Every finding on record at Avir at Golfcrest

Based on observation, interview and record review the facility failed to ensure the food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. 1. The facility failed to ensure that serving utensils, bowls, and cups with dried food particles and water stains were not stored with clean utensils, bowls and cups. 2. The facility failed to ensure that clean pots and pans were free of grease and food particles. 3. The facility failed to ensure the floor tiles in the dry storage room were in good repair and the floor was free of dust. 4. The facility failed to ensure that food in the freezer was labeled and dated.5. The facility failed to ensure that kitchen equipment was clean and in good repair.6. The facility failed to ensure that food was at the correct holding temperature.7. The facility failed to ensure that staff changed gloves and washed hands while serving ready-to-eat foods.These failures place all residents who ate food prepared by the kitchen at risk of foodborne disease and other illnesses. Findings included: Observation on 06/30/2026 at 9:05 am -10 am revealed the following:1. In the dish room were bowls, plates and cups with dried food particles and food stains on them and they were stored with clean bowls, plates and cups.2. Serving utensils were observed with food particles and water stains on them stored with clean utensils. 3. The oven racks and doors had brown greasy stains and burnt food particles in the oven.4. There was a nonfunctioning oven, and the racks had an accumulation of a brown greasy substance on them.Observation of the dry storage room on 6/30/2026 at 9:50 am revealed missing tiles on the floor next to the back of the walk-in freezer. Observation on 6/30/2026 at 9:55 am of the walk-in-freezer was a plain plastic bag with chicken fried steak that was not labeled or dated.Observation on 07/02/2026 at 12:15 pm of lunch revealed the following:Cold Marinated Mixed vegetables with mayonnaise at 55 degrees F, and Marinated cooked mixed vegetables (carrots, green beans and bell peppers) at 45 degrees F. Their menu items were chilled to 41 F and below. Observation on 7/2/2026 at 12:30 pm revealed [NAME] A touching the counter, picking up a bag with carrots, plating food, and picking up rolls with the same gloves to put on a resident's plate. These activities went on multiple times without gloves changing or hand washing. This was pointed out to the Dietary Manager who instructed [NAME] A to change her gloves and use tongs to pick up the rolls. In an interview with [NAME] A on 7/2/2026 at 12:55 pm regarding changing gloves and touching ready eat food she said she should change gloves between tasks. She said not changing gloves could cause cross contamination.In an interview on 7/3/2026 at 9:50am with the said Dietary Manager she said she was going to ensure that the food in the refrigerator was labelled and dated, and she was going to in-service the staff on foodservice sanitation. She said she would also in-service the staff on food temperature and handling of ready-to-eat foods. She said her expectation of the dietary staff was to follow the cleaning schedule and prepare food in a sanitary manner In an interview with the Administrator on 7/3/2026 at 1:30pm he said the expectation of the kitchen staff was to ensure that they follow the sanitization policies and procedures and ensure that they will prepare and store food under sanitary conditions and follow the cleaning schedule. He said moving forward they will be doing daily walk-throughs in the mornings after the morning meeting and in the evening after the stand down meeting. Record review of the policy and procedure for Food Policy dated November 2022 read in part. SanitizationPolicy StatementThe Foodservice areas should be maintained in a clean and sanitary manner.Policy Interpretation and Implementation. 2. All kitchen areas and dining areas should be clean and free from rodent and insect. 3. All utensils, counter tops, shelves, and equipment and maintain in good repairs and from breakage, chips and cracks. 4. All equipment, food contact surfaces and utensils are clean and sanitized using heat and chemicals. 5. Utensils and equipment have been cleaned and sanitized, they should be allowed to air dry. The use of towels or cloth may increase the risk of cross contamination. 10. Ice machine and ice storage containers are drain clean and sanitized. Food Preparation and ServicePolicy Statement: Food and Nutrition services employees prepare, distribute, and service food in a manner that complies with safe food handling practices. Food Distribution and Services.Proper hot and cold temperatures are maintained during food distribution services:Danger Zone means temperature cold food temperature above (41) degrees and hot foods below 135 degrees (F).All food service equipment and utensils will be sanitized according to current guidelines.Food Receiving and Storage:Foods shall be received and stored in a manner that complies with safe food handling practices.Dry Food Storage: Dry foods that are stored in bins are removed are removed from the original packages are labelled and dated.Refrigerator/ Freezer1.All foods stored in the refrigerator or freezer are covered labelled and dated by their used date or discarded. 2.Refrigerators and freezers are kept clean and free of debris.

Based on observation, interview, 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 4 of 10 residents ( Resident #150, Resident #53, Resident #48, Resident #138 and Resident #1) and 7 of 11 staff (LVN ED, LVN CO, LVN BK, HK H, CNA NH, Staffing Coordinator and CNA Y). 1.LVN BK failed to ensure that sterile technique was maintained during Tracheostomy care to Resident #150 on 7/1/26. 2.LVN ED failed to wash or sanitize hands between Resident #53 and Resident #138 on 7/1/26. 3.LVN CO failed to wear PPE when assisting Resident #48 and did not discard PPE in the hazardous box on 7/1/26. Resident #48 had EBP posted on the door. 4.The facility failed to ensure the dirty section of the laundry room had hand washing soap, and the basket which contained clean socks was not placed on the floor in the clean section of the laundry.5.The facility failed to ensure HK H used appropriate hand hygiene when she washed her hands.6.The facility failed to ensure CNA NH and Staffing Coordinator followed the appropriate procedure for PPE and hand hygiene during Foley care for Resident #1.7. The facility failed to ensure CNA Y followed the appropriate procedure for PPE and hand hygiene before she exited Room G. These failures could place residents at risk for spread of infection, cross contamination, and decrease in quality of life. 1. Record review of Resident #150's facility admission record dated 06/30/2026 revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #150's medical diagnoses included dysphagia (difficulty swallowing), tracheostomy status (also called a tracheotomy, is a procedure where a hole is made at the front of the neck. A tube is inserted through the opening and into the windpipe (trachea) to help you breathe) and gastrostomy status (a surgical opening into the stomach for nutritional support or gastric decompression). Record review of Resident # 150's admission MDS dated 6/22/26, revealed the BIMS score was blank. Resident was documented to be totally dependent for all ADL's. Observation on 07/01/2026 at 6:04 PM revealed Resident #150 was in bed with audible moist breath sounds. The Respiratory Therapy (RT) was at the bedside observing tracheostomy care, and LVN BK stated the resident was not usually moist and they changed the resident's inner cannula every day. LVN BK set up a clean field on the bedside table, checked the oxygen saturation and it was 99%. LVN BK changed his gloves without washing his hands or using hand sanitizer. He then grabbed the sterile suction catheter kit tray, opened it, then doffed (take off) his clean gloves without washing his hands, picked up the sterile gloves, then picked up normal saline at Resident #150's bedside, and poured it in the tray. LVN BK picked up the suction tubing from the sterile suction kit and connected it to the suction machine at Resident #150's bedside. LVN BK removed the inner canula. LVN BK then used his clean gloved right hand to removed the oxygen mask on Resident #150's trach, then inserted the suction catheter into the tracheostomy tube 2 times. The then used the same gloved hands to open the sterile inner cannula kit and picked up the inner cannula and inserted it. LVN BK picked up Trach Care Kit without changing his dirty gloves. LVN BK opened the sterile Trach Care Kit, using the same dirty gloves picked up the sterile 4x4 gauze and sterile gloves placed on the bedside table. LVN BK, using the same dirty gloves, then picked up a bottle of 100 ml normal saline (NS) covered with plastic wrap. LVN BK then poured the NS on the 4x4 gauze, then opened the sterile gloves without washing his hands or using hand sanitizer don sterile gloved. The sterile gloves LVN BK was trying to put on, got toned, he doff the sterile gloves without washing hands or using hand sanitizer, LVN BK don clean gloves and opened two sterile Trach Care kit, using the clean gloves. LVN BK picked up the sterile gloves and placed them on the bedside table and doffed his clean gloves without washing his hands or using hand sanitizer. LVN BK tried donning sterile 2 times and it got toned He picked up the 4x4 gauze and cleaned around Resident #150's stoma site with the toned gloves. In an interview with the RT on 7/1/26 at 6:42 PM regarding tracheostomy care she observed LVN BK perform , she said LVN BK should not have touched the inner cannula with a clean glove; he should have suctioned and then should have sanitized his hands or washed his hands, changed his gloves. The RT said LVN BK should have then opened the stuff, peeled the drain, inner cannula and put it out and he should have opened the gauze; and then he should have reached in with sterile gloves and put everything from inside and put it on the sheet and then put it in trash. The RT said LVN BK did not use proper sterile field and that he was nervous. He was putting gloves on. RT said LVN BK had a couple of education sessions, and had Tracheostomy care demonstration with him and LVN BK perform return demonstration. RT said LVN BK should not use dirty gloves inside a sterile Tracheostomy kit. In an interview on 07/1/2026 at 6:52 PM, LVN BK stated he had one training on trach care 6/30/26 and it was been a while since his last trach care training. He said he did wonderful but not excellent. He said trach care was a sterile procedure. He said after removing the stoma (an opening) that's when sterile started. He said he was supposed to wash his hands before doing anything. He said he tried to have a dominant right hand. He said he opened 1 sterile Trach Kit, when he missed a step with one. LVN BK said he had to think he needed to correct and open another one. He believes he did. LVN BK said he didn't use a clean procedure, and he took clean gloves and put sterile items on there. He forgot sterile gloves. He said he should have used his right hand when he did that. He said he had training before. He said he did a training on Friday and another one yesterday (6/30/26) by the RT. He said the RT watched him and she told him he did good. There was tension today. If staff didn't do it the right way, they could have respiratory distress, infection and sepsis. He said he understood when he went from dirty gloves to touch sterile gloves. He said the facility did training before residents came with tracheostomy care, video, with returned demonstration. Record review of the facility policy and procedure entitled Tracheostomy Care-Suctioning, dated , read in part . Policy: The facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Tracheal suctioning is performed by a licensed nurse to clear the throat and upper respiratory tract of secretions that may block the airway. 2. Resident #53Record review of Resident #53's face sheet, revealed she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe with (acute) exacerbation (a sudden, severe flare-up of these symptom- Like extra coughing)). Record review of Resident #53's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. She needed extensive help from 1 staff with ADLs, and limited assistance with eating. Observation on 7/1/26 at 8:10 a.m. revealed Resident #53 was ambulating from the dining room after eating breakfast to his room. At 8:20 a.m. LVN ED administered 3 medications to Resident #53 by mouth, then moved medication cart to Resident #138 to administer eye drops without washing or sanitizing her hands. Resident #138Record review of Resident #138's face sheet, she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: lack of coordination, other abnormalities of gait and mobility, other reduced mobility, dry eye syndrome of unspecified lacrimal gland, muscle wasting and atrophy, not elsewhere classified, left thigh, muscle wasting and atrophy, not elsewhere classified, right thigh, morbid (severe) obesity (excessive weight that could cause serious health complications) due to excess calories, cognitive communication deficit, Record review of Resident #138's annual MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. She needed extensive help from 2 staff with ADLs, and limited assistance with eating. Observation on 7/1/26 at 8:27 AM. Resident #138 was lying in bed. LVN ED picked Artificial Tears Ophthalmic Solution 0.2-0.2-1 % (Glycerin Hypromellose Polyethylene Glycol 400) Instill 2 drops in both eyes. Interview with LVN ED on 7/2/26 at 1:30 PM, regarding not washing hands between Resident #53 and Resident #138. LVN ED said she was nervous and she knew it could cause cross contamination. 3. Resident #48 Record review of Resident #48's face sheet, dated 03/24/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #48 had diagnoses which included: iron deficiency anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), blurred or impaired vision, anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress), hypertension (blood vessels is too high), heart failure (heart does not pump enough blood for the body's needs), hyperlipidemia (abnormally high fat and lipids) and type 2 diabetes mellitus without complication,( a chronic condition where the body cannot effectively use (insulin resistance) or produce enough of it, leading to high blood sugar levels hyperglycemia). Record review of Resident #48's Significant Change MDS, dated [DATE], reflected the BIMS score was not scored, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on staff for bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #48 was incontinent of bladder and bowel. Observation on 7/1/26 at 3:15 P.M. revealed Resident #48 was standing in his room naked. Resident #48 pulled his brief from his waist down to his feet. LVN CO went in Resident #48's room with an EBP sign posted on the door, without donning PPE or wearing gloves and assisted Resident #48 with pulling up the brief and donning his T-shirt. At 4:05 P.M. LVN CO donned PPE and gloves and administered G-Tube feeding, then went to medication cart with the same gloved hands and PPE and picked up Artificial tear eye drop and administered it to Resident #48. LVN CO doffed PPE and gloves at the medication cart trash instead of the hazardous box in Resident #48's restroom. Interview with LVN CO on 7/2/26 at 1:30PM, regarding not wearing PPE and gloves while assisting Resident #48 in his room and not doffing PPE in the hazardous box, he said he was nervous and he forgot. LVN CO said he did have an in-service about PPE usage to prevent infection every month at least bi-weekly. Interview with DON on 7/2/26 at 5:45 PM, regarding expectations for Resident's on EBP during care. DON said his expectation was for all residents with EBP signs posted on their door, the staff were supposed to don PPE before entering their room to perform any care, to prevent infection and wash or sanitize hands in between residents. 4/5.An observation 07/01/2026 10:36 a.m., revealed the dirty section of the laundry room did not have hand washing soap, the soap dispenser was open on the left side of the sink while the sanitizer was on the right side of the wall. HK H walked to the sink in the dirty section of the laundry room and placed her hand under the dispenser on the right and a clear substance tricked onto her hand. Then she turned on the water faucet and washed her hands. After HK H washed her hands, she shook her hands and turned off the faucet with her wet hand, then took a paper towel and dried her hands. During an interview on 07/01/26 at 10:37 a.m., HK H said she had worked for 2 days and there had not been any hand-washing soap in the soap holder. She said she had used hand sanitizer to wash her hands for the past two days, and she was not sure if it was the right way to wash her hands. HK H said she had always turned off the water tap the same way since she started working in the facility with wet hands. She said she had in-service on infection control and it included hand washing but she could not remember what was educated about how to turn off the water faucet after washing her hand. During an observation on 07/01/26 at 10:40 a.m., the clean side of the laundry revealed a basket filled with socks was placed on the floor. During an interview on 07/01/26 at 10:40 a.m., HK H said there was no space off the floor to place the basket. She said the basket was not supposed to be on the floor because of cross contamination. During an interview on 07/01/26 at 10:45 a.m., Housekeeping Supervisor said the washing area should have soap for staff to wash their hands to prevent cross contamination. He said HK H should not have washed her hands with sanitizer because that was not proper hand washing to prevent cross contamination. He said HK H was supposed to dry her hands with paper towel and dispose of the paper towel and take another dry paper towel to turn off the water faucet to prevent cross contamination. The Housekeeping Supervisor said the basket with socks should not be placed on the floor because of cross contamination, and he asked HK H to place the basket on the lower level of the rack which had clean clothes. HK H placed the basket on the rack, and the basket was touching the clean clothes. The Housekeeping Supervisor said when he asked HK H to place the basket with socks on the rack with clean clothes and the basket touched the clean clothes then the clothes were contaminated, and he was not supposed to ask her to place the basket from the floor with clean clothes and he said it was cross contamination. He said all the clothes and socks would be rewashed.6. Record review of Resident #1's face sheet dated 07/01/26 revealed a [AGE] year-old female who was admitted on [DATE] from the hospital. Resident #1 had diagnoses that included: neuromuscular dysfunction of bladder (lack of bladder control caused by nerve damage), hypertension (when the pressure in the blood vessels is too high), and retention of urine (inability to completely empty the bladder). Record review of Resident #1's admission MDS assessment, dated 05/26/26, revealed the BIMS score was 12, which indicated moderately impaired cognition. Further review of the MDS revealed Resident #1 needed total assistance with ADL care. Further review revealed the resident had an indwelling foley catheter. Record review of Resident #1's care plan initiated on 06/02/26 revealed the resident had 14 French Foley catheter related to Neurogenic bladder. Intervention: Position catheter bag and tubing below the level of the bladder. Record review of Resident #1 order summary report for June 2026 revealed in part . foley catheter 18 French with 10 ML [NAME] DX(diagnosis): neurogenic bladder. During an observation on 07/01/26 at 3:11 p.m., foley care was provided for Resident #1 by CNA NH and Staffing Coordinator. CNA NH changed her gloves three times and she did not sanitize her handss before she donned clean gloves, and on the fourth time she took hand sanitizer from her uniform pocket and after she sanitized her hands, she placed the sanitizer back into her uniform pocket and took gloves from her uniform pocket and continued to provide care for Resident #1's foley care. Staffing Coordinator pulled off the top sheet on Resident#1 before the foley care started and the top sheet had feces on it, and she placed the sheet in the trash bag. She did not remove the dirty gloves but continued to pull wipes from the wipe container and handed them to CNA NH while she provided care for Resident #1. During an interview on 07/01/26 at 3:40 p.m., CNA NH said she changed her gloves three times, but she did not wash or sanitize her hands before she donned clean gloves. CNA NH said she also sanitized her hands with sanitizer from her uniform pocket, and she placed the sanitizer back in her uniform pocket and she contaminated her hands when she placed it back into her uniform pocket. CNA NH said she took gloves from her uniform pocket and donned them and continued to provide care for Resident #1. She said it was infection control issue because it was cross contamination. D During an interview on 07/01/26 at 3:49 p.m., Staffing Coordinator said she should have taken off her gloves and washed her hands and donned clean gloves after she took off Resident #1's top sheet which had feces on it before she took wipes from the clean wipe container and handed the wipes to CNA NH who used the wipes to provide foley care for Resident #1. She said she contaminated the wipes because she used dirty gloves and took wipes from the clean packet. She said when she washed her hands, she had to put her hands inside the paper towel holder because the sensor was not working and it was an infection control issue. During an interview on 07/01/26 at 3:53 p.m., the DON said CNA NH should not have used the sanitizer from her uniform pocket or donned gloves from her uniform pocket while she provided foley care Resident #1 because it was cross contamination. The DON said CNA NH should have washed or sanitized her hands before she donned clean gloves to prevent cross contamination. During an observation on 07/01/26 at 3:55 p.m., CNA Y came out from Room G with gloves on and closed the room door with the same gloves on. She walked to the medication cart by the nursing station and removed the gloves and placed them in the trash can attached to the medication cart. CNA Y took gloves from the nursing station without washing or sanitizing her hands. During an interview on 07/01/26 at 3:59 p.m., CNA Y said she should have taken off the gloves and washed her hands before she exited the resident room to prevent the spread of germs. CNA Y said she should have washed her hands after she took off the used gloves before she took clean gloves from the box because of infection control. During an interview on 07/01/26 at 4:02 p.m., the DON said staff should remove gloves in the resident's room and wash or sanitize her hands before leaving the room, to prevent cross contamination and spread of germs. 7. During an observation on 07/01/26 at 3:55 p.m., CNA Y came out from Room G with gloves on and closed the room door with the same gloves on. She walked to the medication cart by the nursing station and removed the gloves and placed them in the trash can attached to the medication cart. CNA Y took gloves from the nursing station without washing or sanitizing her hands. During an interview on 07/01/26 at 3:59 p.m., CNA Y said she should have taken off the gloves and washed her hands before she exited the resident room to prevent the spread of germs. CNA Y said she should have washed her hands after she took off the used gloves before she took clean gloves from the box because of infection control. During an interview on 07/01/26 at 4:02 p.m., the DON said staff should remove gloves in the resident's room and wash or sanitize her hands before leaving the room, to prevent cross contamination and spread of germs. Record review of the facility's policy on Infection Control, undated, read in part, . 5. Gowns and protective apparel 1. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms in the LTCF. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures.2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environment. 6. Resident care equipment and articles.3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. 7. Although soiled linen may be contaminated with pathogenic microorganisms, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms. Hygienic and common-sense storage and processing of clean and soiled linen is recommended. Record review of the facility's Policy and Procedures title Infection Prevention and Control dated December 2023 read in part. Policy Statement: The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary and comfortable environment and to prevent and manage transmission of disease and infection. Policy Interpretation and Implementation: Infection prevention and control policies and procedures apply to all personnel, consultation, contractors, resident, visitors and volunteers. The objectives of the infection prevention and control policies and procedures are to: A. Monitor, detect, investigate and control infections in the facility. B. Maintain a safe, sanitary and comfortable environment for resident, personnel, visitors and the general public. C. Provide evidence-based guidelines for infection prevention and control based on current practices. Record review of the facility policy on handwashing/hand hygiene date MED-PASS, Inc Revised October 2023 read in part.this facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections.administrative practices to promote hand hygiene #3.hand hygiene products and supplies (soap, towel. ).indication for hand hygiene 1 a. immediately before touching a resident, 1b. before performing an aseptic task. 1f. before moving from a soiled body site to a clean body site on the same resident, 1g. immediately after glove removal.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for four residents (Resident #114, Resident #122, Resident #50 and Resident #1) out of six residents reviewed for ADLs. The facility failed to provide personal hygiene to Resident #114 which resulted in the resident having long fingernails and dark brown substances under the fingernails. The facility failed to provide personal hygiene to Resident #122 which resulted in the resident having facial hair on her chin. The facility failed to provide personal hygiene to Resident #50, which resulted in the resident having long fingernails and dry, flaky, skin from below both knees to his feet. The facility failed to provide incontinent care to Resident #1 which resulted in the resident having incontinent brief saturated with dry and fresh feces and the two draw sheets had dry brown rings. These deficient practices could have placed residents at risk of skin breakdown and reduced feelings of self-worth.Findings included: 1.Record review of Resident #114's face sheet dated 07/01/26 revealed an [AGE] year-old female was initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #114 had diagnoses which included: dementia (a decline in mental abilities ), hypertension (when the pressure in the blood vessels is too high), and myocardial infarction (heart attack). Record review of Resident #114's quarterly MDS assessment, dated 05/30/26, revealed the BIMS score was 10, which indicated moderately impaired cognition. Further review of the MDS revealed Resident #114 needed moderate assistance with personal hygiene. Record review of Resident #114's care plan revision on 02/15/26 revealed the resident had an ADL self-care performance deficit related to paraplegia (not able to move lower part of the body). Intervention: dependent on staff for bathing/shower. Personal hygiene; dependent on staff for personal hygiene as required. Record review of Resident #114's progress notes for June 2026 did not reveal Resident #114 refused personal hygiene. During an observation on 06/30/26 at 9:45 a.m., Resident #114's fingernails on both hands were 0.75 cm long and had dark brown substance under her fingernails. During an interview on 06/30/26 at 9:45 a.m., Resident #114 said she wanted her fingernails cut, and she had asked the aides to cut her fingernails, and they would say they would come back, but they did not. Resident #114 said she could not remember which aides she asked. Resident #114 said the aides were supposed to cut her fingernails and clean them on shower days, but the staff had not cut her fingernails for a while, and she could not remember how long it had been. During an interview on 06/30/26 at 9:47 a.m., ADON A said he observed Resident #114's fingernails on both hands were long and had brown substance under her fingernails. He said none of the staff had told him the resident refused to cut or clean her fingernails. ADON A said Resident #114 could scratch herself with the long fingernails and the fingernails could hide germs which could cause infection. He said the aides cut and clean resident fingernails on shower days and as needed. ADON A said if the resident was diabetic the nurse would cut the resident fingernails. During an interview on 06/30/26 at 9:50 a.m., LVN CR said he observed Resident #114's fingernails on both hands were about 0.75 cm long and the fingernails were dirty and he did not notice the fingernails when he made roundss this morning. He said the aides cut and cleaned resident fingernails on shower days and as needed. LVN CR said Resident #114 could transfer germs from the dirty fingernails to her mouth when she ate with her fingers and that could cause infection for the resident and she could open her skin when she scratched her skin. During an interview on 06/30/26 at 9:53 a.m., CNA D said she was Resident #114's aide and today was the first time she worked with the resident, and she did not observe her fingernails were dirty and long when she made rounds about an hour ago. CNA D said the resident fingernails are cut and cleaned on shower days and as needed and the aide should report to the nurse if the resident refused care. She said Resident #114 could give herself skin tear unintentionally when she scratched herself and germs from the dirty fingernails could cause infection for the resident. During an interview on 07/01/26 at 8:08 a.m., the DON said Resident #114's fingernails should be cleaned daily and as needed. He said Resident #114 could get infection and could scratch her skin. The DON said the aides are supposed to cut resident's fingernails during shower which was at least three times a week and as needed. The DON said if the aide could not cut the resident fingernails, then the aide would tell the nurse, and the nurse would cut the resident fingernails. The DON said CNA D should also report to the nurse if Resident #114 refused to cut her fingernails and the nurse would try to cut Resident #114's fingernails and if the resident refused then she would document it on the progress note. During an interview on 07/01/26 at 2:20 p.m., the Administrator said her expectation was for the aides to cut resident's fingernails during shower and clean resident fingernails daily during ADL care and as needed. She said long and dirty fingernails can hide germs and it was not sanitary, and residents could scratch themselves. 2 Record review of Resident #122's face sheet dated 07/01/26 revealed a [AGE] year-old female was admitted on [DATE] from the hospital. Resident #122 had diagnoses which included: dementia (a decline in mental abilities), hypertension (when the pressure in the blood vessels is too high), and atrioventricular block (a heart rhythm disorder). Record review of Resident #122's quarterly MDS assessment, dated 05/26/26, revealed section 700 read memory problem. Further review of the MDS revealed Resident #122 needed moderate assistance with personal hygiene. Record review of Resident #122's care plan revision on 03/17/26 revealed the resident had an ADL self-care performance deficit related to pain and muscle wasting. Intervention: resident requires partial/moderate assistance with one staff for personal hygiene. Record review of Resident #122's progress notes for June 2026 did not reveal Resident #122 refused personal hygiene. During an observation on 06/30/26 at 10:17 a.m., Resident #122 had black curled hair on her chin. During an interview on 06/30/26 at 10:17 a.m., Resident #122 said it had been a week or two since the staff had shaved the hair on her chin. She said she did not remember her shower days. Resident #122 said she want her facial hair shaved. During an interview on 06/30/26 at 10:37 a.m., CNA D said she did not notice the facial hair on Resident #122's face, and she had quite a few black curled up hairs on her chin. CNA D said a female resident who did not want facial hair could feel embarrassed, and it was a dignity issue. She said residents are shaved or plucked on shower days and as needed. She said she was not given any report Resident #122 refused care and today was her first day working with the resident. During an interview on 07/01/26 at 8:12 a.m., the DON said the aide should shave Resident #122 on shower days and as needed. He said it was dignity issue if Resident #122 did not want any facial hair. He said Resident #122 would feel bad if she did not want facial hair. During an interview on 07/01/26 at 2:25 p.m., the Administrator said residents are shaved during shower days which were three times a week and as needed. She said a female who did not want facial hair would feel different and uncomfortable and it was a dignity issue. 3. Record review of Resident #50's face sheet dated 07/01/26 revealed an [AGE] year-old male was admitted on [DATE] from the hospital. Resident #50 had diagnoses which included: cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (a disease of inadequate control of blood levels of glucose). Record review of Resident #50's quarterly MDS assessment, dated 05/04/26, revealed the BIMS score was 07, which indicated severely impaired cognition. Further review of the MDS revealed Resident #50 needed moderate assistance with personal hygiene. and was dependent on staff assistance with ADL care Record review of Resident #50's care plan revised on 02/27/26 revealed the resident had an ADL self-care performance deficit related to current medical situation, weakness. tremors, and weakness. Intervention: Resident required moderate assistance by 1 staff for personal hygiene. Record review of Resident #50's progress notes for June 2026 did not reveal Resident #50 refused personal hygiene. During an observation on 06/30/26 at 10:28 a.m., Resident #50 had right contracted hand with three long nails, and they were about 1.5 cm, and the left hand 5 fingernails were about 1.5 cm long. Resident #50's skin from below the knees to resident's feet was dry and flaky and some of his skin flaked off when he took off his socks. During an interview on 06/30/26 at 10:28 a.m., Resident #50 said he wanted his fingernails cut and the staff said they would get to it, but he did not know which staff. Resident #50 took off his socks, and said his skin was dry and flaky. During an observation and interview on 06/30/26 at 10:35 a.m. ADON A said he observed Resident #50's fingernails were long. ADON A said the aides are supposed to cut the resident's fingernails on shower day and as needed. ADON A said he was not sure if Resident #50 was a diabetic, then the nurses are responsible for cutting his fingernails. He said Resident #50's skin on his legs was dry and flaky and the aides are supposed to apply lotion or cream on shower days and as needed to prevent the skin breakdown. During an interview on 06/30/26 at 11:00 a.m., CNA D said she was Resident #50's aide and she did not notice the resident's fingernails were long on both hands. She said Resident #50 could scratch himself with the long fingernails. She said the resident fingernails were cut on shower days and as needed and the nurse cut diabetic resident fingernails and she was not sure if Resident #50 was diabetic. She said she would tell the nurse if she could not cut the resident's nails and the nurse would cut the fingernails. She said residents are showered three times a week and the aides are responsible for showering and applying lotion or cream on resident skin on shower days and as needed. CNA D said lotion should be applied to the resident skin on shower days and as needed. She said Resident #50's skin was dry and flaking off and could cause skin break down. During an interview on 07/01/26 at 7:42 a.m., the DON said if Resident #50 was not diabetic the aides would cut the resident fingernails on shower days and as needed and the nurses were responsible to cut his fingernails if he was diabetic. The DON said he was not sure if Resident #50 was diabetic and he would find out if he was diabetic. He said Resident #50 could scratch his skin, and it could become infected. The DON said the aides shower the resident three times a week and they should apply cream on resident skin on shower days, and as needed to prevent the resident skin breakdown. He said the nurse does the skin assessment, and the wound care nurse oversees the skin assessment. The DON said the nurse should document the skin assessment if a resident had long fingernails and if resident refused care. During an interview on 07/01/26 at 2:23 p.m., the Administrator said her expectation was for the aides and the nurses to apply lotion or cream on the resident skin on shower day and as needed to prevent Resident #50's skin from being dry which could cause skin break down. During an interview on 07/03/26 at 3:30 p.m., the Corporate Nurse said the facility protocol was for the staff to document the ADL task where the aide will check off that the resident was provided with a shower. She said there was no area on the task for the aide to document that the resident refused to cut his fingernails, have lotion applied, or be shaved. She said the aide would have to tell the nurse and the nurse would document on the progress note that resident refused to cut fingernails, shave or apply lotion on resident skin. The Corporate Nurse also said the nurses do weekly skin assessments and there was no area in the skin assessment for the nurse to document that the resident had long fingernails or had facial hair. 4. Record review of Resident #1's face sheet dated 07/01/26 revealed a [AGE] year-old female was admitted on [DATE] from the hospital. Resident #1 had diagnoses which included: neuromuscular dysfunction of bladder (lack of bladder control caused by nerve damage), hypertension (when the pressure in the blood vessels is too high), and retention of urine (inability to completely empty the bladder). Record review of Resident #1's admission MDS assessment, dated 05/26/26, revealed the BIMS score was 12, which indicated moderately impaired cognition. Further review of the MDS revealed Resident #1 needed total assistance (dependent on staff) with ADL care. Further review revealed the resident had an indwelling foley catheter. Record review of Resident #1's care plan initiated on 05/22/26 revealed the resident is resistive to care: prefers male nurses related to adjustment to nursing home, and anxiety. Intervention: educate resident/family/caregiver of the possible outcome of not complying with treatment or care. During an observation on 07/01/26 at 3:11 p.m., of foley care and incontinent care provided for Resident #1 by CNA NH and assisted by staffing Coordinator, Resident #1's incontinent brief was saturated with feces, and the incontinent brief had dry and fresh feces. Resident #1's top cover sheet draw sheet, and bed pad had substantial amount feces and dry brown ring. During an interview on 07/01/26 at 3:40 p.m., CNA NH said she was not Resident #1's aide, she was told to go provide foley care for the resident. She said Resident #1's incontinent brief was full of dry and fresh bowel movement. She said the brown rings on the draw sheets and dried bowel movement indicated Resident #1 had not been changed for hours. She said Resident #1 had dry BM stuck on the resident buttocks and inner thigh. CNA NH said aides make rounds every two hours for incontinent care to prevent what happened to Resident #1. During an interview on 07/01/26 at 4:25 p.m. Resident #1 said he could not remember when the staff last changed him. He said he would like to be changed whenever he was dirty. During an interview on 07/01/26 at 4:03 p.m., the DON said the aides are supposed to make rounds every two hours for incontinent care. The DON said if the draw sheets and incontinent brief had brown border , fresh and dry bowel movement on the resident incontinent brief and draw sheet meant Resident #1 had not been changed in more than 2 hours. The DON said if Resident #1 was left on dirty incontinent brief the resident could develop skin break down. During a Telephone interview on 07/03/26 at 3:40 p.m., CNA BT said Resident #1 was her resident on 07/01/26. She said she came to work at 2:00 p.m., and she checked on Resident #1, and she did not notice the resident had any bowel movement. CNA BT said if Resident #1's draw sheets, top sheet had dry BM and brown ring it meant Resident #1 had not been changed for hours. CNA BT said if Resident #1 was left in a dirty incontinent brief the resident could develop skin breakdown. Record review of the facility policy on shaving the resident dated 2001MED - PASS, Inc read in part . the purpose of this procedure is to promote cleanliness and to provide skin care. Interview on 07/03/26 at 3:45 p.m., the corporate nurse said the facility did not have policy on fingernails and skin care. Record review of the facility in service on showers dated 06/02/26 revealed . nail care is to be completed during this time.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 7 residents (Residents #127, 37 and #97) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #127's dental recommendations on 02/25/2026. 2. Resident #7's care plan did not address her Apixaban to prevent blood clot.3. Resident #97's care plan did not address her Clopidogrel Bisulfate hematological agent.4.Resident #12's comprehensive care plan was not revised to reflect the resident's ongoing refusals of ADLs. Interventions were not evaluated for effectiveness, nor were individualized interventions added to address underlying causes of the resident's refusals, based on the resident's current assessed needs. This failure could lead to residents not having their individual, medical and functional needs identified and cause a physical or functional decline in health.1.Record review of Resident #127's facesheet dated 07/03/2026, reflected he was an [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses including chronic kidney disease, dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), need for assistance with personal care, muscle wasting and atrophy (reduction in muscle mass), type 2 diabetes mellitus (high blood sugar) and dysphagia (difficulty swallowing).Record review of Resident #127's Quarterly MDS dated [DATE], reflected he had a BIMS score of 5 out of 15, indicating severe cognitive impairment related to thinking and memory. Resident #127 required moderate assistance with oral hygiene. Record review of Resident #127's care plan dated 06/30/2026, reflected he had focus areas of:-Revised on 03/18/2026: Risk for impaired dentition with interventions including to encourage or assist resident in performing oral hygiene after each meal and as needed. The dental exam recommendations were not in the care plan.Record review of Resident #127's dental exam on 02/25/2026, reflected the resident and SW were on the telehealth visit. Resident #127 said he had discomfort when chewing in the back molars and expressed interest in dentures. Resident #127 would be made a priority at the next scheduled visit for a comprehensive evaluation. The document further read, In the interim, the following recommendations and prescriptions are to be implemented into the pt's daily regimen to manage symptoms until direct dental care can be provided:1)Avoid chewing on the left side. A softer food diet may also be considered to reduce functional pressures when chewing.2) Gently brush and thoroughly clean mouth and teeth 2-3 times/day to reduce oral bacteria.3)Warm saltwater rinses for 30 seconds (and spit out) after every meal and throughout the day, as needed, to flush out excess debris and reduce inflammation.RX1: Amoxicillin 500mg q8hr for 10 daysRX2: 0.12% Chlorhexidine oral rinse; swish for 30 seconds and expectorate (spit out) BID for 14 days.Record review of Resident #127's care plan, reflected he had the following care areas:-Focus: history of dentures, impacted dentition with interventions including needing to be reminded to brush his teeth twice daily. Observation and interview with Resident #127 on 06/30/2026 at 9:08a.m., revealed he was resting in bed and appeared to be well-groomed and comfortable. Resident #127 said he had a dental check-up a while back but wanted to know when his next appointment was because the dentist had more work to do. Resident #127's lower molars on both sides were blackened. Resident #127 said the facility provided a soft diet that was pre-cut so he could eat. He said his teeth did not bother him now and he had no pain.Interview with CNA M on 06/30/2026 at 3:20p.m., she said that Resident #127 was able to brush his own teeth. Resident #127 was quiet and had never complained to her about his teeth. Resident #127 would eat his meals in the dining room.Interview with CNA AJ on 07/01/2026 at 9:25a.m., she said she was an aide for 3 years at this facility. CNA AJ said she assisted Resident #27 with brushing his teeth every day and that she never helped him rinse his mouth with salt water and that Resident #27 was on a soft/puree diet. Interview with the SW on 07/01/2026 at 2:46p.m., the SW said Resident #127 saw a dentist through telehealth and that since his stay was paid through the VA , they would be the one to schedule it for him. The SW said he was last at the hospital in April 2026 for an unrelated complication and when he came back there were no concerns for his teeth.Interview with Resident #127's family member on 07/01/2026 at 3:17p.m., she said she last visited Resident #127 two weeks ago and he was eating well and did not complain about his teeth. The family member said she had no concerns with the care and that Resident #127 had no problems . Interview with MDS A on 07/02/2026 at 3:09p.m., she said that the SW would be the one to update her on dental appointments and the recommendations should have been communicated to the MDS team. MDS A said that there was an IDT that met often and reviewed assessments, sent emails and reviewed appointments. Resident #127 could have had complications in weight loss, infection or sepsis if these recommendations were not added to his orders. 2.Record review of Resident #7's admission face sheet revealed Resident #7 was a [AGE] year-old female who was admitted on [DATE]. Resident #7's diagnoses included essential hypertension (high blood pressure), Type 2 diabetes (high blood sugar) acute embolism and thrombosis of left peroneal vein (blood clot forming deep inside the body usually in the vein), acute embolism and thrombosis of deep vein and unspecified lower extremities (blood clot forming deep inside the body usually in the legs or pelvis), thrombocytopenia (a condition characterized by an abnormally low count of platelets in the blood), peripheral vascular disease (a slow progressive blood disorder that narrows or blocks blood vessels outside the heart or brain), atherosclerosis of native arteries of the right leg (build up of fatty plaque that narrows the arteries and restricts blood flow), acute kidney failure (decreased kidney function), and chronic diastolic congestive heart failure (this happens when the heart muscle becomes stiff and cannot relax normally between beats). Review of Resident #7's annual MDS dated [DATE] revealed she was coded as having a BIMS score of 10 indicating she was moderately impaired cognitively for decision making. She was coded as receiving anticoagulant medication (to help prevent blood clots, potentially leading to a stroke and loss of oxygen to the brain). Record review of Resident #7's Physician's order revealed an order for Apixaban oral tablet 5mg two times a day to prevent blood clot. Record review of Resident #7's care plan dated 5/7/2026 revealed it did not address the anticoagulant medication apixaban. Record review of Resident #7's MAR for June and July 2026 revealed the medication apixaban was given to Resident #7. In an interview on 7/3/2026 at 5:00p.m., the MDS Nurse said she missed doing the service plan. Not updating the care plan to include the anticoagulant apixaban could result in Resident#7 not getting the care and service needed to improve her quality of life. She said she was going to update the care plan to address the anticoagulant.3.Record review of Resident #97's admission face sheet revealed Resident #97 was a [AGE] year-old female who was admitted on [DATE]. Resident #97's diagnoses included chronic venous hypertension (a condition where high blood pressure develops in the leg vein) , Type 2 diabetes (high blood sugar), peripheral vascular disease (a slow progressive blood disorder that narrows or blocks blood vessels outside the heart or brain), atherosclerosis of native arteries of the right leg (build up of fatty plaque that narrows the arteries and restricts blood flow), acute kidney failure (decreased kidney function), and chronic diastolic congestive heart failure (this happens when the heart muscle becomes stiff and cannot relax normally between beats).Review of Resident #97's quarterly MDS dated [DATE] revealed she was coded as having a BIMS score of 10 indicating she was moderately impaired cognitively for decision making. She was coded as receiving antiplatelet medication . Record review of Resident #97's Physician's order revealed an order for Clopidogrel Bisulfates 75mg one time a day for hematological agent .Review of Resident #97's current Care Plan dated 5/7/2026 reflected that her antiplatelet medication was not addressed on her care plan. Record review of the MAR for June and July 2026 revealed the medication Clopidogrel was given to Resident #97. In an interview with MDS A on 7/3/2026 at 5:00pm she confirmed the medication was not care planned. She said she was going to check the reason why it was not addressed on the care plan. She then said the reason it was not done was she was planning to talk to the doctor about the diagnoses. She said she was going to call the doctor. She called the doctor and she was given a more appropriate diagnoses for the medication. She said she just missed following up with the doctor and that was why it was not addressed on the care plan. She said she was going to update the care plan to include the antiplatelet medication. In an interview on 7/3/2026 at 1:05 pm the DON said his expectation of the MDS nurses was to ensure all resident's care areas were addressed in the care plan. He said not addressing the care areas could prevent residents from getting the care and services needed to improve their quality of life. 4. Record review of Resident #12's face sheet, last captured on 7/3/26, reflected a [AGE] year-old female admitted on [DATE] (original admission 1/2/20) diagnosed with acute embolism and thrombosis, hypertension, bipolar disorder, schizophrenia, and unspecified dementia. Record review of the comprehensive care plan dated 4/28/26 for Resident #12 reflected the resident was resistive to care and experienced episodes of refusing care. The interventions addressing ADL refusals were not current despite subsequent annual and quarterly MDS assessments. No evidence was identified that the care plan had been revised to include current goals, individualized interventions, or staff approaches addressing the resident's ongoing refusal of ADLs or promoting maintenance of functional abilities. Record review of the quarterly MDS dated [DATE] for Resident #12 reflected the resident was coded as requiring total assistance for toileting, bathing, upper body dressing, lower body dressing, and personal hygiene. The assessment also reflected that Resident #12 was independent with rolling left and right in bed, always incontinent, did not use a wheelchair or scooter, and was dependent for tub/shower transfers. MDS Section E reflected daily rejection of evaluation and/or care necessary to achieve the resident's health and well-being goals. During an observation and interview conducted with Resident #12 on 6/30/26 at 9:42 a.m., the resident was observed sitting upright in bed watching television. The resident independently operated a television remote control. When approached for interview, the resident stated, I can't answer questions, and declined further interview. During an interview conducted with CNA D on 7/2/26 at 10:35 a.m., it was stated that Resident #12 was physically capable of completing most ADLs independently, including walking, toileting, brushing her teeth, washing her face, and dressing herself. CNA D stated staff routinely provided total assistance because the resident frequently refused to perform those tasks. CNA D stated she did not know why the resident refused but believed it was related to the resident's mental illness. CNA D said she was unaware of any interventions being used to address Resident #12's refusals. CNA D further stated the resident had experienced physical decline (decreased strength, endurance, and mobility) because she rarely got out of bed or participated in physical activity. During an interview conducted with RN AF on 7/2/26 at 10:48 a.m., it was stated that Resident #12 refused to walk despite being physically able to do so. RN AF stated the resident needed to be assessed to determine the reason for the refusals and acknowledged that no interventions were currently being used to encourage independence. RN AF stated she had never attempted interventions to promote participation in ADLs. She further stated the resident enjoyed snacks and believed they could potentially be used as motivation but had not communicated that information to the MDS nurse. RN AF stated she was unaware of any diagnosis that would physically prevent Resident #12 from completing ADLs independently. During an interview conducted with MDS A on 7/2/26 at 3:25 p.m., it was stated that Resident #12 remained in bed most of the day and refused to participate in activities despite being physically capable of performing most ADLs and ambulating. MDS A stated the facility had not assessed the reason for Resident #12's refusals and could not identify any current interventions to encourage participation or maintain function. After reviewing the care plan, MDS A acknowledged the interventions addressing refusals remained from 2020 through 2022 despite the care plan having been revised in April 2026. MDS A further acknowledged there was no current documentation evaluating the effectiveness of interventions or addressing the resident's continued refusal of ADLs and stated the care plan should have been updated to reflect the resident's current needs. During an interview conducted with SW on 7/3/26 at 11:50 a.m., the SW stated documentation of ADL refusals on the care plan was not considered her responsibility. The SW stated she had not discussed refusal of ADLs with Resident #12 and had not documented or revised interventions related to those refusals. During a follow-up interview conducted with MDS A on 7/3/26 at 12:00 p.m., MDS A stated documentation of the refusals was considered the responsibility of the Social Worker because the refusals were viewed as behavioral concerns. MDS A stated she had instructed the Social Worker to complete progress notes and update the care plan following discussions regarding resident behaviors or care concerns. MDS A acknowledged that some of the goals, interventions, and tasks on the care plan were last revised over five years ago and had not been updated. MDS A further stated that even when interventions continued to be appropriate, the care plan should have been reviewed and updated with current information to ensure it accurately reflected the resident's ongoing needs. Record review of the facility's policies and procedures for Care Plans dated 4/2024 read in part. GENERALEach resident will have a care plan that is current, individualized and consistent with their medical regimen.POLICY: 3.The comprehensive care plan is developed within 7 days of CAA completion. A member of the IDT will provide the resident and or representative with a summary of the baseline care plan or a copy of the baseline care plan in writing in a language that can be understood and verbally in a language that can be understood. 5.The care plans are developed by the members of the interdisciplinary team based on their assessments and interaction with the residents and/or resident's significant others.6.The care plans are updated at least every 90 days or with a significant change of resident by the team member initiating the care plan.7.The resident care plans are kept electronically and accessible to the staff caring for the residents.8.If a resident is readmitted to the facility, their care plans are reviewed and updated as needed.9.The care plan consists of the following:a.Problems as identified by reviewing the medical record and discussion with the resident and /or significant others.b.Goals are set in conjunction with the family and resident. Goals are realistic, measurable, behaviorally stated and may be long or short term. Goals should prevent decline or maintain resident function is realistic and appropriate based on the diagnosis.c.Interventions are actions taken to achieve the goal.12These interventions should build on the resident's strengths, be realistic and identify those responsible for the interventions.d.Evaluation of the care plan goals should occur at least every 90 days or with a significant change of the resident. If the goal is continued, a new date of completion should be identified. If the goal has been achieved, it should be discontinued and a new goal, if appropriate, written. If the goal is now unachievable, it should be discontinued and the care plan updated as to why. Record review of the facility's policies and procedures for Care Plans dated 4/2024 read in part. GENERALEach resident will have a care plan that is current, individualized and consistent with their medical regimen.POLICY: 3.The comprehensive care plan is developed within 7 days of CAA completion. A member of the IDT will provide the resident and or representative with a summary of the baseline care plan or a copy of the baseline care plan in writing in a language that can be understood and verbally in a language that can be understood. 5.The care plans are developed by the members of the interdisciplinary team based on their assessments and interaction with the residents and/or resident's significant others.6.The care plans are updated at least every 90 days or with a significant change of resident by the team member initiating the care plan.7.The resident care plans are kept electronically and accessible to the staff caring for the residents.8.If a resident is readmitted to the facility, their care plans are reviewed and updated as needed.9.The care plan consists of the following:a.Problems as identified by reviewing the medical record and discussion with the resident and /or significant others.b.Goals are set in conjunction with the family and resident. Goals are realistic, measurable, behaviorally stated and may be long or short term. Goals should prevent decline or maintain resident function is realistic and appropriate based on the diagnosis.c.Interventions are actions taken to achieve the goal.12These interventions should build on the resident's strengths, be realistic and identify those responsible for the interventions.d.Evaluation of the care plan goals should occur at least every 90 days or with a significant change of the resident. If the goal is continued, a new date of completion should be identified. If the goal has been achieved, it should be discontinued and a new goal, if appropriate, written. If the goal is now unachievable, it should be discontinued and the care plan updated as to why.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13%, based on 4 errors out of 30 opportunities, which involved 3 of 7 residents (Residents #48, #53, #138, and #149) and 3 of 4 staff (LVN DM, LVN ED, and LVN CO) reviewed for medication errors, in that: -LVN DM failed to administer medication Effer K (Potassium is a vital mineral and electrolyte that carries an electrical charge, allowing the body to function) to Resident #149 according to the physician's order on 6/30/26 -LVN ED failed to administer Refresh tear Ophthalmic solution (used to treat dry eyes) to Resident #138 according to the physician's order.-LVN ED failed to administer Budesonide inhalation (is a locally acting steroid medication used to reduce inflammation and suppress the immune system) to Resident # 53 on 7/1/26. LVN ED initialed the MAR as administered. -LVN CO failed to administer Refresh tear Ophthalmic solution (used to treat dry eyes) to Resident #48 according to the physician's order on 7/1/26These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health Findings include: Resident #149 Record review of Resident #149's face sheet, she was an [AGE] year-old female admitted on [DATE]. Her diagnoses included: shortness of breath, pneumonitis( Inflammation of the lung tissue, usually meaning the tiny air sacs in the lung) due to inhalation of food and vomit, hypoxemia( having too little oxygen in the blood), restlessness and agitation(, mixed hyperlipidemia(high fat in the blood, essential (primary) hypertension( high blood)other intervertebral disc (is a soft, round cushion that sits between the small bones of your spine) displacement, lumbar region(lower back) and muscle wasting and atrophy, and hypokalemia(an abnormally low level of potassium in the blood). Record review of Resident #149's admission MDS dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #149's care plan on 6/27/26 revealed in part . diagnosis of hypokalemia . Intervention . give Potassium Chloride medications as ordered . Record review of Resident #149's physician's orders for June 2026 revealed in part: . Potassium Chloride oral packet 10 meq (Potassium Chloride), Give 10 meq by mouth one time a day for hypokalemia . Record review of Resident #149's Medication Administration Record (MAR) dated June 2026 revealed Effer - K 10 meq (Potassium Chloride), Dissolve 1 tablet in 4 ounces water once daily. Pharmacy recommendation had dissolve 10 meq in 4 to 8 ounces water or cold juice and drink slowly Observation on 6/30/26 at 9:10 a.m. revealed LVN DM took Resident #149's Effer - K 10 meq 1 tablet and dissolved it in 4 ounces of water with other medications. Resident #149 drank 2 ounces of the dissolved Effer -K in water. LVN DM discarded the Effer-K . Interview on 6/30/26 at 9:20 a.m. with LVN DM regarding not encouraging Resident #149 to finish the Effer -K medication, revealed LVN DM said he knew Resident #149 was not going to drink the dissolved Effer -K, and Resident #149 always complained of being too full. LVN DM said he had not told the ADON, DON or the doctor about Resident #149 not taking all the Effer-K or changing Effer -K to liquid. LVN DM said Resident #149 could have low potassium in her blood that could affect her heart. Interview with ADON A and DON on 7/1/26 at 2:00PM regarding Resident #149's Effer-K dissolved in water and not able to consume all the medication. DON said they were not aware of it. DON said he was going notify the doctor for start Potassium blood level lab work to be done. The result of Potassium level from the start blood work was low 3.1 MEQ/L. DON said he started in-services to all staff and Effer-K was changed to liquid. Resident #53 Record review of Resident #53's face sheet, revealed she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a long -term lung disease that makes it hard to breathe with (acute) exacerbation (is a sudden, severe flare-up of these symptom- like extra coughing. Record review of Resident #53's quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #53's care plan on 6/27/26 revealed in part . diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation . Intervention . give Budesonide inhalation medications as ordered . Record review of Resident #53's physician's orders for 5/31/2026 revealed in part: Budesonide Inhalation Suspension (Budesonide (Inhalation) 0.5 mg inhale orally one time a day related to chronic obstructive pulmonary disease with (acute) exacerbation. Record review of Resident #53's Medication Administration Record (MAR) dated July 2026, . Budesonide Inhalation Suspension (Budesonide (Inhalation) 0.5 mg inhale orally one time a day and was initialed as given at 9:00AM on 7/1/26. Observation on 7/1/26 at 8:10 a.m. revealed Resident #53 was seen ambulating from the dining , after eating breakfast, to his room. At 8:20 a.m. LVN ED administered 3 medications to Resident #53 by mouth, then moved the medication cart to Resident #138 to administer eye drops. LVN ED did not administer Budesonide (Inhalation) but initialed as given at 9:00AM. Interview with LVN ED on 7/2/26 at 1:30PM about Budesonide (Inhalation) 0.5 mg inhale orally one time a day not given during medication administration on 7/1/26 and was initialed as given at 9:00AM, LVN ED said she thought she gave it. Resident #138 Record review of Resident #138's face sheet, revealed she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: ack of coordination, other abnormalities of gait and mobility, other reduced mobility, dry eye syndrome of unspecified lacrimal gland, muscle wasting and atrophy, not elsewhere classified, left thigh, muscle wasting and atrophy, not elsewhere classified, right thigh, morbid (severe) obesity (excessive weight that could cause serious health complications) due to excess calories, cognitive communication deficit, Record review of Resident #138's annual dated 5/2/26 revealed a BIMS score of 4 indicating severe cognitive impairment. Record review of Resident #138's care plan on 6/27/26 revealed, . Intervention . Artificial Tears Ophthalmic Solution as ordered . Record review of Resident #138's physician's orders for 6/27/2026 revealed in part: Artificial Tears Ophthalmic Solution 0.2-0.2-1 % (Glycerin Hypromellose Polyethylene Glycol 400) Instill 1 drop in both eyes two times a day for Eye Drop. Observation on 7/1/26 at 8:27 a.m. revealed Resident #138 was lying in bed. LVN ED picked Artificial Tears Ophthalmic Solution 0.2-0.2-1 % (Glycerin Hypromellose Polyethylene Glycol 400) Instill 2 drops in both eyes. Interview with LVN ED on 7/2/26 at 1:30PM, regarding not administering Artificial Tears Ophthalmic Solution 0.2-0.2-1 % 1 drop in both eyes as ordered by the doctor, LVN ED said she would be careful. LVN ED said she had in-services on medication administration 2 months ago. Resident #48 Record review of Resident #48's face sheet, dated 03/24/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #48 had diagnoses which included: iron deficiency anemias (not having enough healthy red blood cells to carry oxygen to the body's tissues), blurred or impaired vision, anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress), hypertension (blood vessels is too high), heart failure (heart does not pump enough blood for the body's needs), hyperlipidemia (abnormally high fat and lipids) and type 2 diabetes mellitus without complication,( a chronic condition where the body cannot effectively use (insulin resistance) or produce enough of it, leading to high blood sugar levels hyperglycemia). Record review of Resident #48's significant change MDS, dated [DATE], reflected the BIMS score was not scored out of 15, which indicated the resident had severe cognitive impairment. Record review of Resident #48's care plan on 6/30/26 revealed . Intervention . Artificial Tears Ophthalmic Solution as ordered . Record review of Resident #48's physician's orders for 6/30/2026 revealed in part: Artificial Tears Ophthalmic Solution 0.2-0.2-1 % (Glycerin Hypromellose Polyethylene Glycol 400) Instill 2 drop in both eyes three times a day for Eye Drop. Observation on 7/1/26 at 3:27 P.M. revealed Resident #48 was sitting up in bed. LVN CO picked Artificial Tears Ophthalmic Solution 0.2-0.2-1 % (Glycerin Hypromellose Polyethylene Glycol 400) Instill 1 drops in both eyes. Interview with LVN CO on 7/2/26 at 1:30PM, regarding not administering Artificial Tears Ophthalmic Solution 0.2-0.2-1 % 1 drop in both eyes as ordered by the doctor for Resident #48, LVN CO said he was nervous and he would be more careful. LVN CO said not following physician's order could cause decline in the resident's health. In an interview with the DON and ADON A on 7/2/26 at 5:45 PM, the DON said his expectation for medication administration was for nurses to administer medication as ordered by the physician. The DON said the facility had morning medication pass times for 9:00 a.m.; medications for twice daily were given at 9:00 a.m. and 5:00pm; medications for 3 times daily were given at 9:00 am, 1:00pm and 5:00pm and medications for every 12 hours were given at 9:00 am and 9:00 pm. The DON said he always monitored the staff periodically and the pharmacist also monitored the staff. The DON said the last time the pharmacist monitored staff was in January 2026. During an interview on 7/3/26 at 5:20 p.m., the Administrator said he expected nursing staff to give medications timely, correctly, and according to the physician's orders. Record review of the facility's policies and procedure title Administering Medication dated April 2019 revealed in part. Policy Statement Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation 1. Only persons licensed or permitted by the state to prepare, administer, and document administration of medications may do so. 4. Medications are administered in accordance with the prescriber's order, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication b. Preventing potential medication or food interaction and c. Honoring resident choices and preferences consistent with his 6. Medication errors are documented, reported and reviewed by QAPI committee to inform process changes. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) 8. If a dosage is believed to be inappropriate or excessive for a resident, or the medication has been identified as having potential adverse consequences for a resident or suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident attending physician or facility medical director to discuss the concern. 22. The individual administering the medication initials the resident MAR or appropriate line after giving each medication before administering the next medication.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 8 residents (Residents #57, #71 and #7), 1 of 1 smoking areas, and 2 of 10 rooms (Room B and Room C) observed for accident hazards and environment.1. Resident #57 was observed smoking without supervision on 06/30/2026 and Residents #71 and #7 were observed smoking without supervision on 07/02/2026.2. The smoking area did not have any ashtrays within reach for residents to use.3. Room B's restroom sink's hot water was 115 degrees F on 07/01/2026.4. Room C's restroom sink's hot water was 114 degrees F on 07/01/2026.5. The facility failed to ensure HK Q and Dietary Aide A did not prop open the exit door by the laundry.6. Resident #98's room had damage to the sink faucet and the sheetrock behind the sink and toilet. The failures could result in residents coming into contact with dangerous materials which could place them at risk of injury or death. Resident #57Record review of Resident #57's face sheet dated 07/03/2026, revealed he was a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including systemic lupus erythematosus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues, leading to inflammation and damage across various organs), Wernick's encephalopathy (an acute neurological emergency caused by thiamine (vitamin B1) deficiency, characterized by confusion, eye movement abnormalities, and impaired coordination), rheumatoid arthritis, mild cognitive impairment, and tobacco use. Record review of Resident #57's Comprehensive MDS dated [DATE], revealed he had a BIMS score of 12 out of 15, indicating moderate cognitive impairment related to memory and thinking. Resident #57 was coded for having a wheelchair and required total staff assistance for toileting, showering, dressing and personal hygiene. He required moderate assistance for bed mobility, including transferring from bed to chair or chair to bed. Record review of Resident #57's care plan captured on 07/03/2026, revealed he had the following focus area of behavior problem of smoking without staff present (date initiated 06/05/2026 and last revised 07/01/2026) and disregarding the smoking policy, with interventions including anticipating and meeting resident needs, caregivers providing opportunity for positive interaction, attention. Record review of Resident #57's smoking assessment dated [DATE], revealed he had functional limitations which included contracture, muscle weakness, and need for assistance to get from smoking area and could not independently light his cigarette. Resident #57 was also documented as an unsafe, independent smoker due to cognitive impairment and required direct visual supervision while smoking and the facility stored lighters and cigarettes due to company policy. Record review of Resident #57's skin assessments on 06/22/2026 and 06/29/2026, revealed his skin was warm and dry and there were no issues.Observation of a smoke break sign that was near the patio on 06/30/2026 at 9:00a.m. revealed the departments responsible and the smoke times were 9:00a.m., 11:00 a.m., 1: 00p.m., 4:00p.m. and 7:00p.m.Observation and interview on 06/30/2026 at 3:03p.m., revealed Resident #57 was sitting on the patio smoking a cigarette with Resident #99 sitting next to him. Resident #57 said there was not enough staff to help with him and other residents with their smoke breaks. Resident #57 said he was smoking off hours, and that someone had helped him light his cigarette but he did not want to say who that was. Resident #57 denied having a lighter in his possession. Resident #57 said he was alert and able to smoke safely on his own but that other residents who needed supervision did not always get their smoke break because there was no staff available to assist and sit outside with residents so other residents often went without their breaks. Interview with the Activities Director on 07/01/2026 at 10:47a.m., she said aides were assigned to different smoke break times and that residents smoked outside on 06/30/2026 and she did not know why there was no one out there with Resident #57. The Activities Director said residents who needed assistance were brought out to the patio/smoking area and that no one in the facility was allowed to smoke on their own according to company policy. She said Resident #57 was considered a safe smoker meaning he did not need monitoring, but he would still be at risk of injury and safety concerns. The Activities Director said some of the residents could fall asleep and drop ashes on themselves and some who tried to light their own cigarettes could be hurt by exploding lighters. The Activities Director said the facility should have followed a schedule.Interview with the BOM on 07/01/2026 at 11:50p.m., she said she did not handle smoke breaks. The BOM said everyone knew about Resident #57 going out to smoke on his own and that he was not the only resident to do that. The BOM had told the DON, charge nurses and the Activities Director butDirector but they did not do anything about it. The BOM said about a month ago she saw Resident #57 with a lighter around 9:45p.m. when she was headed home. The BOM said that she had not seen Resident #57 or others smoking alone for some time but smoking alone could put residents at risk of a fire starting or injury. Observation and interview with Resident #57 on 07/01/2026 at 12:50p.m., revealed he was lying in bed and said staff did not respect the allotted times for smoking. Resident #57 said that the DON took his lighter from his room on 06/30/2026 in the afternoon. Resident #57 said he did not feel like the facility cared for or respected residents. Interview with the SW on 07/01/2026 at 2:46p.m., she said staff were not supposed to leave residents to smoke on their own and that residents were educated on not being allowed lighters and smoking without supervision. The SW said Resident #57 usually complied with that request. The SW said residents who smoked on their own could light themselves on fire, burn themselves or get heat exhaustion. The SW said nurses explained that to residents but if the residents were alert, they might not always listen. Resident #71Record review of Resident #71's face sheet dated 07/03/2026, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted on [DATE]. She had medical diagnoses including dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), hypertension (high blood pressure), osteoporosis (bone disease characterized by bone weakness and fragility), need for assistance with personal care, epilepsy (chronic brain disorder characterized by recurring, unprovoked seizures due to abnormal electrical activity in the brain) and nicotine dependence. Record review of Resident #71's Quarterly MDS dated [DATE], revealed she had a BIMS score of 12 out of 15, indicating moderate cognitive impairment related to thinking and memory. Resident #71 required moderate assistance with ADLs such as personal, oral and toileting hygiene, showering and dressing and getting in and out of bed. Record review of Resident #71's care plan captured 07/01/2026, revealed she had a focus area of being a smoker (last revised 02/06/2025) with interventions including being supervised by a visitor or facility staff member at all times, review smoking policy with her as needed or annually with concerns and report smoking related concerns promptly and intervene as appropriate, ensure no oxygen was located in the smoking area while the resident was smoking. Record review of Resident #71's smoking assessment dated [DATE], revealed she was able to understand the facility smoking policy and had functional limitations preventing her from smoking without supervision due to hands shaking a lot when she smoked. Resident #71 was documented as requiring direct visual supervision and the facility stored her lighter and cigarettes.Record review of Resident #71's skin assessments dated 06/16/2026, 06/23/2026, 06/30/2026, revealed she had no concerns with her skin related to smoking. Resident #7Record review of Resident #7's face sheet dated 07/03/2026, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted on [DATE]. She had medical diagnoses including dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), hypertension (high blood pressure), polyneuropathy (nerve damage), osteoarthritis (inflammation of joints), muscle wasting and atrophy (muscle mass loss) and nicotine dependence. Record review of Resident #7's Comprehensive MDS dated [DATE], revealed she had a BIMS score of 10 out of 15, indicating moderate cognitive impairment related to thinking and memory. Resident #7 required total assistance with ADLs such as personal, oral and toileting hygiene, showering and dressing and getting in and out of bed. Record review of Resident #7's care plan captured 07/01/2026, revealed she had a focus area of being a smoker and not complying with the smoking facility policy with interventions including encouraging her to comply with the facility smoking facility and ensuring smoking occurs in designated smoking area and review smoking policy with Resident #7 annually and as needed with concerns and report smoking related concerns promptly and intervene as appropriate. Record review of Resident #7's smoking assessment dated [DATE], revealed she was able to understand the facility smoking policy and needed help getting to the smoking area. Resident #7 was unable to light her cigarette and sometimes dropped ashes on herself and sometimes while she was smoking her hands shook frequently. Resident #7 was documented as requiring direct visual supervision and the facility stored her lighter and cigarettes.Record review of Resident #7's skin assessments dated 06/15/2026, 06/22/2026, 06/29/2026, revealed she had no concerns with her skin related to smoking.Observation and interview on 07/01/2026 at 3:16p.m., revealed Residents #71 and #7 were sitting in their wheelchairs and smoking outside on the patio around a single metal grate about 3 feet by 3 feet in a raised cement bed with cracks along the perimeter. CNA CT assisted both residents with lighting their cigarettes. Resident #7's hands appeared to be shaking and she dropped her cigarette on the ground. CNA CT then left with the cigarette box, opened the patio door and left from view for about a minute. A staff member walking by saw the residents sitting outside without staff supervision and called CNA CT, said something and CNA CT walked back into view, opened the patio door and walked back towards the residents with the cigarette box. Resident #7 called out to CNA CT that her cigarette was on the ground and CNA CT picked it up, threw it away, got another cigarette, lit it, and handed it to Resident #7. Resident #71 said that there were no ashtrays accessible to them while smoking because the ones provided were either on the ground far away or nailed to the nearby tree. Resident #71 and Resident #7 were observed throwing the cigarette into the grate and Resident #71 said that with the grate and cement damage it was hard to roll to the different ashtray spots to put out their cigarettes. CNA CT denied that she left the residents unattended and said she went to call staff to help her watch the residents. CNA CT said the residents threw their cigarettes in the grate in the ground and said that could cause the trash or whatever was in the grate to burn. Resident #71 said that she wanted ashtrays to prevent fires . She said they had someone watch over them during smoke breaks. Interview on 07/01/2026 at 7:09p.m., revealed the DON, Administrator, ADON A and ADON B were in the room. All of them denied taking a lighter from a resident on 06/30/2026. The DON said that the facility's policy said residents could not smoke on their own and that it should not have happened.Interview with Medical Records on 07/03/2026 at 9:29a.m., she said Resident #57 was a safe smoker and had a lighter and was able to go to a nearby store to get cigarettes on his own but lately he did not have any cigarettes nor a lighter. Medical Records said staff would try to monitor Resident #57 but missed him smoking alone sometimes. Medical Records said there were no independent smokers in the facility. Medical Records said the facility had two ashtrays that Medical Records would pass around to staff, but she was unsure why the aide did not use an ashtray. Medical Records said if ashtrays were not used residents or their wheelchairs could get burned and even catch fire especially during times of hot weather.Interview with the DON on 07/03/2026 at 10:33a.m., he said Resident #57 did not listen to staff about smoking with supervision and Resident #57 was educated on this multiple times, and staff would have to continue to monitor and redirect. The DON said it was not okay to leave residents unsupervised like in the two observed instances. The DON said supervision for was for safety and to ensure that someone was there to attend to residents. The DON said staff were aware and were educated on not leaving residents to smoke alone and that Residents #57, #7 and #71 should have been supervised. The DON said ashtrays were used to ensure that the ashes did not drop on the ground.3./4.Record review of the facility's water temperature log revealed the following temperatures for the same 5 rooms (Rooms G, H, J, K and L) in Hall B: - 06/02/2026 111F, 6/4/2026 112F, 06/09/2026 (11 F, 06/12/2026 111F, 06/15/2026 (11 F, 06/16/2026 111 F, 06/17/2026 111 F, 06/18/2026 111 F, 06/24/2026 111 F, 06/25/2026 112 F and 06/26/2026 112F.Observation and interview with CNA AJ on 07/01/2026 at 9:25a.m., the aide said she was an aide for 3 years at the facility. CNA AJ said hot water was used to clean residents in the morning and they might not like having only cold water and she never heard residents complaining about not having hot water. Observation and interview with the Maintenance Director on 07/01/2026 at 11:09a.m., revealed the water temperature of the sink in Room B was 115 F after two minutes, which the Maintenance Director said should be no higher than 110 F. In Room C, the hot water was 114 F. He was aware that his records showed he checked the same five rooms , but he said he never heard of any complaints from staff or residents about the hot water and he checked water temperatures in rooms daily. The Maintenance Director said he did not have records of him checking Rooms B and C. He said he would talk to his corporate counterpart and see what could be done about temperatures out of range. He adjusted the temperature at a central heater which ran through the building, and he tried to adjust it so that all sinks had hot water for use and monitor for relative compliance, but he said he did not check all the rooms for water temperature . The faucet in Room C had an inch long missing chunk of the faucet on the lower left side near the sink bowl, with an unknown white material appearing to ooze out of the gaps in the faucet. There was one gash of missing sheetrock behind the toilet and one gash behind the sink. The Maintenance Director said that the gashes in the wall were not safe for residents and that he was going to have staff work on the faucet. Resident #98 who resided in Room C said she had no issues with the sink or faucet and that she did use it. 5. During an observation and interview on 07/01/26 at 10:20 p.m., with the DON revealed that the exit door by the laundry room was propped open and the door alarm was going off. HK Q wheeled a big gray cart into the facility from the open door. The DON said the door should have been closed as soon as any staff exited the door to prevent residents from eloping and intruders from entering the facility to prevent harm to residents. He said the Maintenance Director was responsible for providing in-services and training for all facility staff. During an observation and interview on 07/01/26 at 10:28 a.m., revealed Dietary Aide A from the kitchen came out of the kitchen and opened the back door and propped it open with a pink basin and went to the dumpster and placed bags of trash. There were resident rooms on the being of the hall way. During an observation and interview on 07/01/2026 at 10:30 a.m., the Housekeeping Supervisor said he could see the back door by the laundry room was propped open with a pink basin. He said the back door should be closed at all times. The Housekeeping Supervisor said the staff should not have left the door open to prevent any resident from leaving the facility, which could put residents in harm's way. He said outsiders could come into the facility and that was not safe for residents. He said there used to be a doorbell for the staff to push when the staff wanted to come back in, but the doorbell was gone and he did not know what happened to it. The Housekeeping Supervisor did not respond when he was asked if he reported the doorbell not outside the back door was not working or lost. During an interview on 07/01/26 at 11:01 a.m., the Account Manager said the staff should have locked the back door after they left to prevent animals, flies, and people that are not supposed to come into the building. The Account Manager said it was a safety issue because residents could leave the facility without the nursing staff knowing and residents could get hurt if residents left the facility premises. The Account Manager also said unwanted personnel could enter the facility and that could place residents at risk of harm. During an interview on 07/01/26 at 11:15 a.m., Dietary Aide A said he was not supposed to leave the back door open because people from the street could come into the facility and residents could get hurt, or residents could leave the facility unattended which was not safe for residents. He also said animals could also come into the building because the door was propped open. During an interview on 07/01/26 at 11:18 a.m., HK Q said he went outside to throw away trash and he propped the door open, but he should not have because it was a safety issue. HK Q said residents could leave the facility without staff knowing or people who do not work for the facility could come into the facility and residents could get harmed depending on who entered the facility. During an interview on 07/01/26 at 1:59 p.m., the Maintenance Director said the staff were not supposed to prop the exit door open because of safety issues. The Maintenance Director said a resident could wander out of the facility through the open door and that could put residents in harm's way. He also said anybody from the street could come into the facility and that would put everybody inside the facility at risk. He said the back door used to have a bell for the staff to ring and a staff from inside the facility would have to open the door for the staff outside. He did not respond when he was asked how long the doorbell was lost. During an interview on 07/01/26 at 2:08 p.m., the Administrator said her expectation from staff was to close any exit door and when the staff wanted to come back in then the staff would ring the doorbell and a staff inside the facility would open the door for the staff. She said it was a safety issue when the exit door was propped open. She said she was not aware that the doorbell by the exit door by the laundry was lost or not functioning. Record review of the facility's policy titled Safety and Supervision of Residents last revised July 2017, revealed in part, Policy StatementOur facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.3. When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:d. Smoking; .g. Electrical Safety. h. Water Temperatures. The policy did not mention exit doors. Record review of the facility's policy on smoking for residents last reviewed October 2022, it read in part,.3. Smoking is only permitted in designated resident smoking areas, which are located outside of the building.5. Metal containers, with self-closing cover devices, are available in smoking areas. 6. Ashtrays are emptied only into designated receptacles. 7. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker or smokeless tobacco user, the evaluate will include:.d) Ability to smoke safety with or without supervision (per a completed Smoking Assessment).12. Any resident with restricted smoking or smokeless tobacco privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking or using smokeless tobacco.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 4 of 10 resident rooms reviewed for environment. -Room A had a live roach crawling on the ground near the restroom on 06/30/2026.-Room B had a dead brown bug in the restroom on 07/01/2026. -Resident #23 had two flies flying around and landing on a resident's pillow on 07/01/2026.-Room E had an a/c unit on 07/01/2026, 07/02/2026 and 07/03/2026 which was not allowed under facility policy. These failures could place residents at risk for disease and infection and a decline in their physical health due to pests in the facility. Findings include:Record review of the pest control binder, the following dates had observations of pests:-2/10/2026: gnats in the kitchen and halls-3/12/2026: roaches in one resident room and the room was sprayed. The Kitchen had gnats.-4/8/2026: There were roaches in the administrative offices, beauty salon, and in the microwave. There were small roaches and gnats most likely due to soiled linens being in holding area. There was no live roach activity. There was little black ant activity.-5/21/2026: roaches -5/24/2026: roaches in the front conference room-5/27/2026: roaches and gnats in the front office and one resident room-6/10/2026: there were a lot of flies and roaches in the front office area. There were 4 dead German roaches found in a monitor on the floor and the trap was replaced. There were 2 dead German roaches near the fridge in the conference room. There were two live roaches observed during the visit. Record review of the facility's pest observation log that staff used to document sightings:-03/12/2026: gnats and roaches in a resident room and gnats in all management front offices.-05/08/2026: spiders, roaches and gnats in resident rooms.-05/11/2026: roaches and gnats in the front office.-05/27/2026: roaches in the kitchen and resident rooms.-05/28/2026: roaches and gnats in resident rooms.-06/10/2026: roaches in resident rooms.-06/17/2026: roaches in resident rooms-07/01/2026: spiders and roaches, staff rooms. Observation and interview on 06/30/2026 at 9:08a.m., revealed there was a live roach in Room A. LVN O was called to the room and said she also saw the roach and that she would contact the maintenance department about it so that pest control could come to the facility. Observation and interview on 06/30/2026 at 11:00a.m., revealed Resident #24 was in her room and there were two houseflies and one gnat flying around her head. Resident #24 said she did not know how pests came into the facility, but she did not like it. Resident #24 said the pests were usually around the nurse's station and she's seen them recently and consistently .During an interview with the Activities Director on 07/01/2026 at 10:47a.m., she said she saw roaches the previous week in the front lobby area. She was aware of pest control coming to the facility but did not know the frequency. During the interview the Activities Director noticed a housefly hovering near the window. The Activities Director said the pest issue was ongoing, and she believed flies came in when residents opened the patio door to go outside and smoke. The Activities Director said interventions included calling pest control to come and leave traps outside the building. During an observation and interview with the Maintenance Director on 07/01/2026 at 11:09a.m., he said he saw pests in the facility and that he saw the round bug in Room B. The bug was about an inch long and a half inch wide and appeared to be dead on its back. The Maintenance Director said he did not know what the bug was but that it was June which was pest season. For residents with infested rooms, the Maintenance Director said he would temporarily move residents out of their rooms, spray the rooms, lock the door and then after a day have Housekeeping do deep cleaning along with regular visits from pest control. The Maintenance Director saw a white a/c unit with a plastic extender in the window of Room E, which also had damage and rips in the plastic where there were quarter-inch gaps and direct sunlight entered the room. The Maintenance Director said he will get one of his staff to remove it. The Maintenance Director said he had been at the facility for a few years and never saw the a/c unit being used and that continuing to have the a/c unit could cause a lot of heat to enter the room and that there was enough space in the gaps for bugs to enter. In a later interview with the Maintenance Director on 07/03/2026, he said he was not aware of the policy on having screens on all windows, but he would work on taking the unit out. Observation and interview on 07/01/2026 at 11:42a.m., HK C said she did not see roaches in her hall. HK C went into Resident #123's room and observed two flies on Resident #123's pillow. Resident #123 was not in her room. HK C said that she seldom saw resident rooms needing pest control but when it happened she would tell nursing staff and the facility would temporarily move residents to another room and spray down rooms. Observation of the patio area on 07/01/2026 at 1:42p.m., revealed the door to the smoking area was left open. During an interview with Receptionist A on 07/01/2026 at 2:33p.m., she said she last saw roaches in the building two weeks ago and she would see baby roaches come after pest control. Receptionist A said she thought pests came in when the door was opened for residents on smoke break. If she saw pests, she would report it to someone in the main office so they could call pest control to come. Receptionist A said residents did not complain about pests to her. During an interview with the DON on 07/03/2026 at 10:33a.m., he said the facility had a binder that staff would document pest sightings. Pest Control were called and came to the facility and treated pests promptly. The DON said that while the building was older and the facility had been periodically renovated which meant the pest issue was ongoing, he had seen pests in the building around three times. He said the window in Room E with the a/c unit was used to meet the needs of residents. The DON said he did not want residents to be hurt by the heat and that it was better to have it for heat exhaustion for temporary need. He said the Maintenance Director will work on removing the unit. Record review of the facility's policy on pest control last revised May 2008, it read in part, Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by [company name]. 3. Windows are screened at all times.6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview and record review the facility failed to ensure that food was prepared by a method that conserved nutritive value, flavor, and appearance in one of one kitchen.The facility failed to ensure that carrots, green beans, and green peas for lunch were not left on the stove at a low temperature for 3 hours prior to lunch. This resulted in the green beans and carrots being overcooked and unattractive.This failure could place all residents who ate meals prepared by the kitchen at risk of not getting the nutrients needed to prevent malnutrition and weight loss. Findings Included: Observation on 6/30/2026 at 9:05 am of the stove in the kitchen revealed cooked green beans, carrots, ham and whipped sweet potatoes were on the stove cooking for lunch. There were two pans on the grill, one with pureed green beans and one with pureed ham for lunch. The grill was hot.In an interview on 6/30/2026 at 9:30 am with [NAME] A revealed she was preparing green beans, carrots, ham and whipped sweet potatoes for lunch. Further interview on 7/4/2026 at 9:15 am regarding cooking menu items 2 -3 hours before lunch she said if menu items were cooked too early and placed on the grill to keep hot it would be overcooked. She said when foods were overcooked, they would lose their nutritive value, color and residents could lose weight. In an interview on 6/30/2026 between 11:55 am and 12:30 pm with 3 unidentified residents revealed the green beans tasted good but it was over cooked. Some residents interviewed did not express any food preferences, they said they just ate whatever was served. They said if they did not like what was served, staff would offer them something else from the always available menu. Observation on 7/4/2026 at 9:10 am of the kitchen revealed the following menu items on the stove: green peas and cabbage cooking for lunch. The color of the peas was olive green and the cabbage bright green in color . In an interview on 7/4/2026 at 9:35 am with the Dietary Manager she said overcooked vegetables could be mushy and would not look good. She they could lose their nutritional value and could result in weight loss. She said she would be in-servicing the dietary staff. She said she was going to ensure that vegetables were cooked a few minutes before meal service so it would not be overcooked. She said they would start cooking vegetables around 10:30 am because lunch service starts at 11:30 am.In an interview on 7/4/2026 at 10:00 am with the Foodservice District Manager she said she will be in-servicing the staff on food service sanitation, food preparation and ware washing. She also said she would ensure that all the issues identified in the kitchen were addressed. Record review of the facility's policy and procedures dated October 2017 title Food and Nutrition Services read in part.Policy Statement:Each resident is provided with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, interview, and record review the facility failed to ensure that residents were free of any significant medication errors for 1 of 7 residents (Resident #149 ) reviewed for medications. -LVN DM failed to administer medication Effer K (Potassium is a vital mineral and electrolyte that carries an electrical charge, allowing the body to function) to Resident #149 according to Physician's order on 6/30/26. Resident #149 did not consume all of the Effer K medication. The failure could place residents with high or low blood pressure at risk of fainting or a stroke due to not getting their blood pressure medication as ordered by their physician Findings included: Record review of Resident #149's face sheet, revealed she was an [AGE] year-old female admitted on [DATE]. Her diagnoses included: shortness of breath, pneumonitis( Inflammation of the lung tissue, usually meaning the tiny air sacs in the lung) due to inhalation of food and vomit, hypoxemia( having too little oxygen in the blood), restlessness and agitation(, mixed hyperlipidemia(high fat in the blood, essential (primary) hypertension( high blood)other intervertebral disc (is a soft, round cushion that sits between the small bones of your spine) displacement, lumbar region(lower back) and muscle wasting and atrophy, and hypokalemia(an abnormally low level of potassium in the blood). Record review of Resident #149's admission MDS dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #149's care plan on 6/27/26 revealed in part . diagnosis of hypokalemia . Intervention . give Potassium Chloride medications as ordered . Record review of Resident #149's physician's orders for June 2026 revealed in part: . Potassium Chloride oral packet 10 meq (Potassium Chloride), Give 10 meq by mouth one time a day for hypokalemia . Record review of Resident #149's Medication Administration Record (MAR) dated June 2026 revealed Effer - K 10 meq (Potassium Chloride), Dissolve 1 tablet in 4 ounces water once daily. Pharmacy recommendation reflected to dissolve 10 meq in 4 to 8 ounces water or cold juice and drink slowly. Observation on 6/30/26 at 9:10 a.m. revealed LVN DM took Resident #149's Effer - K 10 meq 1 tablet and dissolved it 4 ounces of water with other medications. Resident #149 drank 2 ounces of the dissolved Effer -K in water. LVN DM discarded the Effer-K. Interview on 6/30/26 at 9:20 a.m. with LVN DM regarding not encouraging Resident #149 to finish Effer -K dissolved in water. LVN DM said he knew Resident #149 was not going to drink the dissolved Effer -K; Resident #149 always complained of being too full. LVN DM said he had not told the ADON, DON or the doctor about Resident #149 not taking all Effer-K or changing Effer-K to liquid. LVN DM said Resident #149 could have low potassium in her blood that could affect her heart. Interview with the ADON and DON on 7/1/26 at 2:00PM regarding Resident #149's Effer-K dissolved in water and not able to consume all the medication revealed the DON said they were not aware of it. The DON said he was going to notify the doctor to start Potassium blood level lab work to be done. The result of Potassium level from the start blood work was low 3.1 MEQ/L. DON said he started in-services to all staff and Effer-K was changed to liquid.Record review of the facility's policy on medication administration last revised November 2022 revealed in part, Policy Statement Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation 1. Only persons licensed or permitted by the state to prepare, administer, and document administration of medications may do so. 4. Medications are administered in accordance with the prescriber's order, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 2 of 6 residents (Resident #48 and Resident #98) reviewed for resident rights.1. Resident #48's had a missing hot water faucet handle on 06/30/20262. Resident #98's restroom wall and sink were damaged on 07/01/2026. These failures could place residents at risk of injuries, cross-contamination, avoidable infections and a decrease in quality of life.Findings include:1.Record review of Resident #48's face sheet, dated 03/24/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #48 had diagnoses which included: iron deficiency anemias (not having enough healthy red blood cells to carry oxygen to the body's tissues), blurred or impaired vision, anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress), hypertension (high blood pressure), heart failure (heart does not pump enough blood for the body's needs), hyperlipidemia (abnormally high fat and lipids) and type 2 diabetes mellitus without complication ( a chronic condition where the body cannot effectively use (insulin resistance) or produce enough of it, leading to high blood sugar levels hyperglycemia). Record review of Resident #48's significant change MDS, dated [DATE], reflected the BIMS score was not scored out of 15, which indicated that he had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on staff for bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #48 was incontinent of bladder and bowel. Record review of Resident #48's care plan, dated 4/24/26, reflected Resident #48 had an ADL self-care performance deficit and the goal was the resident would improve current level of function. Observation of Resident #48's room on 06/30/2026 at 9:05a.m. revealed the hot water faucet handle on the left side was missing and the hot water was unable to be turned on. There was an EBP sign outside the door. Interview with Resident #48 on 07/01/2026 at 9:00a.m., the resident did not answer questions about the faucet and changed the subject often. Resident #48 did not appear to have any skin injuries and appeared to be well-groomed and comfortable. Observation and interview with CNA AJ on 07/01/2026 at 9:25a.m., she stated she was an aide for 3 years at this facility. CNA AJ said she did not know about the broken faucet in Resident #18's and #48's room, she just came back to work on 06/30/2026 after a week off. CNA AJ said the missing faucet should have been reported to the nurse who would tell the maintenance department. CNA AJ said hot water was used to clean residents in the morning and they might not like having only cold water and said there were no complaints about not having hot water. Interview with the Maintenance Director on 07/01/2026 at 11:07a.m., he said hot water removed germs and if residents did not wash their hands with hot water and then touched their food and ate it, it could cause residents to become sick. He was not aware of the damaged sink and bathroom wall and he did not have any staff report it on the maintenance log. 2. Observation and interview with the Maintenance Director on 07/01/2026 at 11:09a.m., in Room C , revealed the faucet had an inch long missing chunk on the lower left side near the sink bowl, with an unknown white material appearing to ooze out of the gaps in the faucet. There was one gash of missing sheetrock behind the toilet and one gash behind the sink. The Maintenance Director said that the gashes in the wall were not safe for residents and that he was going to have staff work on the faucet.Record review of the facility's policy titled Safety and Supervision of Residents last revised July 2017, it did not cover how to manage damaged resident equipment.

Based on observation, interview and record review, the facility failed to ensure that residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Residents #1) reviewed for incontinent care.The facility failed to ensure Resident #1's Foley catheter bag and tubing was not touching the floor. The facility failed to ensure CNA NH kept Resident #1's Foley catheter bag below Resident #1's bladder level and used appropriate hand hygiene during foley catheter care on 07/01/26., The facility failed to ensure Resident #1 Foley catheter tubing had had Statlock to stabilize the tubing from pulling. The facility failed to ensure CNA H and the Staffing Coordinator used appropriate hand hygiene during foley catheter care for Resident #1 on 07/01/26. These failures could have caused residents to be at risk of infection.Findings included: Record review of Resident #1's face sheet dated 07/01/26 revealed a [AGE] year-old female who was admitted on [DATE] from the hospital. Resident #1 had diagnoses that included: neuromuscular dysfunction of bladder (lack of bladder control caused by nerve damage), hypertension (when the pressure in the blood vessels is too high), and retention of urine (inability to completely empty the bladder). Record review of Resident #1's admission MDS assessment, dated 05/26/26, revealed the BIMS score was 12, which indicated moderately impaired cognition. Further review of the MDS revealed Resident #1 needed total assistance with ADL care. Further review revealed the resident had an indwelling foley catheter. Record review of Resident #1's care plan initiated on 06/02/26 revealed the resident had 14 French Foley catheter related to Neurogenic bladder. Intervention: Position catheter bag and tubing below the level of the bladder. Record review of Resident #1 order summary report for June 2026 revealed in part . foley catheter 18 French with 10 ML [NAME] DX(diagnosis): neurogenic bladder. During an observation on 07/1/26 at 2;59 p.m., revealed that Resident #1's foley bag, privacy bag and tubing were on the floor. During an observation and interview on 07/01/26 at 3:00 p.m., the DON said Resident #1's foley catheter bag, tubing and privacy bag were on the floor because the bed was on the lowest position because the resident was a fall risk. He said it was an infection control issue because if the organism gets into the resident's bladder, it could have caused a UTI (urinary tract infection). He said the staff should have raised the bed up a little bit to prevent the foley form touching the floor. During an observation on 07/01/26 at 3:11 p.m., revealed that Resident #1's foley catheter bag was hung on the bed, but the foley bag, privacy bag and tubing were touching floor. During an observation and interview on 07/01/26 at 3:11 p.m., CNA NH said Resident #1's foley catheter was touching the floor and it was infection control and the resident could get UTI. During an observation on 07/01/26 at 3:11 p.m., revealed foley catheter care was provided for Resident #1 by CNA NH and the Staffing Coordinator. CNA NH placed Resident #1's foley catheter bag on the bed while she provided foley care. She changed her gloves three times and she did not sanitize her hands before she put on a clean gloves, and on the fourth time she took hand sanitizer from her uniform pocket and after she sanitized her hand she placed the sanitizer back into her uniform pocket and took gloves from her uniform pocket and continued to provide care for Resident #1. The Staffing Coordinator pulled off the top sheet on Resident #1 before the foley catheter care started and the top sheet had bowel movement on it. She placed the sheet in the trash bag. She did not remove the dirty glove before she continued to pull wipes from the wipe container and handed them to CNA NH which she was providing care for the resident. During foley catheter care it also revealed Resident #1 did not have a safety lock to hold the foley tube in place. During an interview on07/01/26 at 3:40 p.m., CNA NH said she should not have placed Resident #1's foley catheter bag on the bed because the urine could flow back to the resident's bladder and it could cause infection. She said she also should not place the bag which was on the floor on the bed because of cross contamination. She said she changed her gloves three times, but she did not wash or sanitize her hand before she donned clean gloves. CNA NH said she also sanitized her hand with sanitizer from her uniform pocket, and she placed the sanitizer back in her uniform pocket and she contaminated her hand when she placed her back into her uniform pocket. CNA NH said she took gloves from her uniform pocket and donned them and continued to provide care for Resident #1. She said it was infection control issue because it was cross contamination. CNA NH said Resident #1's foley catheter tubing did not have a sStat lLock to hold the tubing in place, and the foley catheter tubing could be pulled during care, and the foley catheter could be pulled out and it could cause harm to the resident During an interview on 07/01/26 at 3:49 p.m., the Staffing Coordinator said she should have taken off her gloves and washed her hands and donned clean gloves after she took off Resident #1's top sheet which had bowel movement on it before she took wipes from the wipe container and handed the wipes to CNA NH who used the wipes and provided foley catheter care for Resident #1. She said she contaminated the wipes because she used the dirty gloves to take wipes from the clean packet. The Staffing Coordinator said Resident #1's foley catheter was not secured and the foley catheter tubing could pull out during turning and repositioning or during care which could hurt Resident #1. During an interview on 07/01/26 at 402 p.m., the DON said Resident #1's foley catheter should be secured to prevent the foley catheter tubing from pulling during care which could hurt the resident if the foley catheter was pulled. He said the worst case could be the foley catheter could be pulled out of the bladder which could cause serious harm to Resident #1. The DON said CNA NH should not place the foley catheter on the bed during care because the urine could flow back into the resident and it could have caused a UTI for the resident. He said also the foley catheter bag was on the floor and that would transfer the germs from the floor to the resident's linens and the germs could be transferred to the resident which could have caused infection. He said the aide should not have used the sanitizer from her uniform pocket or donned gloves from her uniform pocket because it was cross contamination. Record review of the facility policy on catheter care, urinary care dated 2001 MED-PASS, Inc, updated July 2024 read revealed in part . the purpose of this is to prevent catheter associated urinary tract infection.maintaining unobstructed urine flow #3.the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into urinary bladder. infection control #2b. be sure the catheter tubing and drainage bag are kept off the floor. changing catheter #2. ensure that the catheter remained secured with leg strap to reduce friction and movement at the insertion site. steps in the procedure #2 wash and dry your hands thoroughly. 5. Put on gloves. Record review of the facility policy on handwashing/hand hygiene dated 2001 MED - PASS, Inc. Revised October 2023 read reveaeld in part . indication for hand hygiene #1a .immediately before touching a resident. immediately after glove rem

Based on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for oxygen therapy for 1 of 1 resident (Resident #150) reviewed for respiratory care. -The facility failed to provide tracheal care and suctioning according to professional standards for Resident #150. These deficient practice could result in the residents not receiving the care and services ordered by the physician and a decline in health status and oxygen deprivation. Findings included: Record review of Resident #150's facility admission record dated 06/30/2026 revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #150's medical diagnoses included dysphagia (difficulty swallowing), tracheostomy status (also called a tracheotomy) is a procedure where a hole is made at the front of the neck. A tube is inserted through the opening and into the windpipe (trachea) to help you breathe) and gastrostomy status (a surgical opening into the stomach for nutritional support or gastric decompression). Record review of Resident # 150's admission MDS dated 6/22/26, revealed the BIMS score was blank. Resident #150 was totally dependent for all ADL's. Record review of Resident #150's physician's orders for June 2026 with a start date of/20/2026 revealed the following orders: -Change Shiley (Shiley inner #4 cannulas that twist to lock in place are reusable) disposable inner cannula every 6 hours and PRN (as needed) for Patent airway. -Change trach tie as needed. -The resident is on Enhanced Barrier Precautions regarding tracheostomy care: Use a gown and gloves for high-contact resident care. Every shift for prevention spread of infection. -Trach care every 6 hours for maintenance/infection prevention. -Tracheal suction every 6 hours for Patent airway. Record review of Resident #150's Treatment Administration Record for June 2026 revealed tracheal suction every 6 hours for patent airway was provided on 6/20/2026. Observation of Resident #150 on 6/30/2026 at 9:00AM, revealed the resident was observed lying in bed with the head at a 30-degree angle. Resident #150's oxygen concentrator read 3.5L/min. Observation on 07/01/2026 at 6:04 PM revealed Resident #150 was in bed with audible moist breath sounds. The Respiratory Therapy (RT) was at the bedside observing tracheostomy care, and LVN BK stated the resident was not usually moist and they changed the resident's inner cannula every day. LVN BK set up a clean field on the bedside table, checked the oxygen saturation and it was 99%. LVN BK changed his gloves without washing his hands or using hand sanitizer. He then grabbed the sterile suction catheter kit tray, opened it, then doffed (take off) his clean gloves without washing his hands, picked up the sterile gloves, then picked up normal saline at Resident #150's bedside, and poured it in the tray. LVN BK picked up the suction tubing from the sterile suction kit and connected it to the suction machine at Resident #150's bedside. LVN BK removed the inner canula. LVN BK then used his clean gloved right hand to removed the oxygen mask on Resident #150's trach, then inserted the suction catheter into the tracheostomy tube 2 times. The then used the same gloved hands to open the sterile inner cannula kit and picked up the inner cannula and inserted it. LVN BK picked up Trach Care Kit without changing his dirty gloves. LVN BK opened the sterile Trach Care Kit, using the same dirty gloves picked up the sterile 4x4 gauze and sterile gloves placed on the bedside table. LVN BK, using the same dirty gloves, then picked up a bottle of 100 ml normal saline (NS) covered with plastic wrap. LVN BK then poured the NS on the 4x4 gauze, then opened the sterile gloves without washing his hands or using hand sanitizer don sterile gloved. The sterile gloves LVN BK was trying to put on, got toned, he doff the sterile gloves without washing hands or using hand sanitizer, LVN BK don clean gloves and opened two sterile Trach Care kit, using the clean gloves. LVN BK picked up the sterile gloves and placed them on the bedside table and doffed his clean gloves without washing his hands or using hand sanitizer. LVN BK tried donning sterile 2 times and it got toned He picked up the 4x4 gauze and cleaned around Resident #150's stoma site with the toned gloves. In an interview with the RT on 7/1/26 at 6:42 PM regarding tracheostomy care she observed LVN BK perform , she said LVN BK should not have touched the inner cannula with a clean glove; he should have suctioned and then should have sanitized his hands or washed his hands, changed his gloves. The RT said LVN BK should have then opened the stuff, peeled the drain, inner cannula and put it out and he should have opened the gauze; and then he should have reached in with sterile gloves and put everything from inside and put it on the sheet and then put it in trash. The RT said LVN BK did not use proper sterile field and that he was nervous. He was putting gloves on. RT said LVN BK had a couple of education sessions, and had Tracheostomy care demonstration with him and LVN BK perform return demonstration. RT said LVN BK should not use dirty gloves inside a sterile Tracheostomy kit. In an interview on 07/1/2026 at 6:52 PM, LVN BK stated he had one training on trach care 6/30/26 and it was been a while since his last trach care training. He said he did wonderful but not excellent. He said trach care was a sterile procedure. He said after removing the stoma (an opening) that's when sterile started. He said he was supposed to wash his hands before doing anything. He said he tried to have a dominant right hand. He said he opened 1 sterile Trach Kit, when he missed a step with one. LVN BK said he had to think he needed to correct and open another one. He believes he did. LVN BK said he didn't use a clean procedure, and he took clean gloves and put sterile items on there. He forgot sterile gloves. He said he should have used his right hand when he did that. He said he had training before. He said he did a training on Friday and another one yesterday (6/30/26) by the RT. He said the RT watched him and she told him he did good. There was tension today. If staff didn't do it the right way, they could have respiratory distress, infection and sepsis. He said he understood when he went from dirty gloves to touch sterile gloves. He said the facility did training before residents came with tracheostomy care, video, with returned demonstration. Record review of the facility policy and procedure entitled Tracheostomy Care-Suctioning, updated 01/2026,revealed in part . Policy: The facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Tracheal suctioning is performed by a licensed nurse to clear the throat and upper respiratory tract of secretions that may block the airway.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurse Cart A) reviewed for medication storage. -Nurse Cart A medication cart had medications that were opened and undated. This failure could place residents at risk of receiving expired medication and improperly stored medications, which could result in delayed healing. Findings include:During an observation on [DATE] at 1:06 pm of Nurse Cart A revealed the following opened medications were not dated when they were opened: The following normal saline and nasal drops were open with no date: a, Sodium chloride 0.65% 2 spray in each nostril a day for dryness of the nose - open not dated b, Fluticasone Propionate Nasal spray 1 spray each nostril twice a day -open not dated c, Sterile 0.9% Normal Saline 100 ml bottle open and date Interview with LVN DM on [DATE] at 1:06 PM said he was not aware when the nasal medications were opened and the resident always refused Fluticasone Propionate Nasal spray 1 spray each nostril twice a day and Sodium chloride 0.65% 2 spray in each nostril a day. LVN DM did not know which nurse open those medications.During an interview on [DATE] at 4:38 p.m., the Director of Nurses (DON) said eye drops opened should have an open date. The DON said the medicines would not be effective for the treatment after 30 days. The nurses were responsible for dating normal saline bottle and nasal drops whenever they were opened. Record review of the facility's policy, not dated, Storage of Medication Purpose: Ensure that medications are stored in a safe, secure and orderly manner. Procedure: 11. multi-dose vials that have been opened or accessed should be dated and discarded within 28 days of opening /initial access unless the manufacturer specifies a shorter or longer date.

Based on observation, interview, and record review, the facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 residents (CR #1) reviewed for witnessed falls. The facility failed to ensure 2 staff members remained at bedside on [DATE] during ADL /linen change for CR #1, which resulted in a witnessed fall with major head injury (hematoma [a collection of blood trapped under the skin or inside the body after an injury or damaged blood vessel]), which resulted in hospitalization. CR #1 expired in the hospital on [DATE]. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility corrected the non-compliance before the investigation began. This failure has the potential to place residents at risk for serious harm, hospitalization and death. Findings included: Record review of face sheet dated [DATE] reflected CR #1 was a [AGE] year-old male admitted into the facility on [DATE] and was readmitted on [DATE]. His diagnoses included heart failure (condition where the heart becomes too weak to pump blood through the body properly), thrombocytopenia (condition where a person has a low number of platelets in the blood. Platelets help stop bleeding), intracranial hemorrhage (bleeding inside the skull or brain), hemiplegia (complete paralysis on one side of the body, the person cannot move that side properly), hemiparesis ( weakness on one side of the body), and thrombosis of deep veins (blood clots that forms in the deep veins usually in the legs). Record review of CR #1's Annual Minimum Data Set, dated [DATE] revealed he was coded as Severely impaired - never/rarely made decisions. Section GG, which reflects functional abilities, indicated that CR #1 required dependent, two-person assistance for showers, toileting, hygiene, and bed transfers. Record review of CR #1's care plan initiated [DATE] with a revision date of [DATE] indicated CR #1 was at risk for falls related to poor safety awareness and poor balance. Intervention: CR #1 will be Mechanical lift with staff x 2 to assist with transfers. CR #1 required total assistance x 2 staff assistance for ADLs. Record review of CR #1's progress note dated [DATE] at 8:52 p. m., revealed the following documentation by LVN A .called attention to Resident room, nurse and other staff entered, observed resident on floor lying face down. Per staff that witnessed the fall, during the time of changing resident, I crossed his legs and turned him to side to change linens before changing the diaper. In the process, Resident slid from bed to floor face down. Head to toe assessment done, noted raised area to fore face, open skin sites to right arm, resident nonverbal but can response to verbal stimulus by nodding the head. Assisted resident off the floor to bed. Ice pack applied to raised area to fore face, neuro vital initiated and 911 team called at 8:14 p.m. Record review of EMS report dated [DATE] revealed CR#1 was transported to a local hospital due to a witnessed fall and sustained hematoma (a collection of blood trapped under the skin or inside the body after an injury or damaged blood vessel) on the forehead. Record review of the facility's PIR dated [DATE], revealed the alleged incident occurred on [DATE], at approximately 7:45 p.m. Incident category was documented as witnessed fall. Description of allegation revealed CNA L was in the process of changing CR #1's linen on his bed, when CR #1 slid out of bed on the floor. LVN A assessed CR #1 and noted raised area to forehead, and open skin site to right arm. Cold compress placed on the swelling to the forehead; NP was notified and ordered to send CR #1 to emergency room for further evaluation. Further review of the investigation summary revealed CNA L was suspended pending investigation. Interview with DON on [DATE] at 12:26 p.m., he stated that CR #1 experienced a fall while a CNA L was changing the bed linens. The DON stated that CR #1 was care planned as a two-person assist resident for ADLs. The DON stated that only one CNA was present at the time the incident occurred. The DON performed an immediate assessment of the CR #1 following the fall witnessed, emergency medical services were contacted. LVN A then notified CR#1's NP who ordered to send CR #1 to hospital for evaluation. DON further stated that the facility later received notification that CR #1 expired the following day. The DON said he completed in-service training with all staff on fall prevention, two - person assist residents, care plan, and other related topics after the incident on [DATE] through [DATE]. CNA L was suspended, and he had never returned to work at the facility but had completed training on abuse, neglect, and falls prior to the incident. DON said he contacted the hospital for CR #1's medical record, but the hospital had not provided it to them to date. Interview with Administrator on [DATE] at 1:34 pm. She stated that she was informed the CR #1 slid from the bed to the floor while CNA L was changing the bed linens. According to the Administrator, CNA L was reportedly waiting for another staff member to assist because CR #1 required two-person assistance; however, while waiting, CNA L began changing the bed linen. During the process, CR #1 slid from the bed and fell to the floor. The Administrator stated that CNA L immediately called for assistance and nursing staff responded, assessed the resident, contacted emergency medical services, and transferred CR #1 to the hospital for further evaluation. The Administrator stated that the facility subsequently received notification from the hospital that CR #1 expired the following day. The Administrator stated that she reported the incident to the state, suspended CNA L, and started investigation. She said the facility did a QAPI after the incident, and staff had been retrained and in-serviced on two-person ADL care, fall prevention, abuse and neglect. The facility audited the witnessed falls, and all residents who required two-person ADL care with no adverse findings. The Administrator said CNA L never returned to work and had been removed as an employee at the facility. Interview with CNA L on [DATE] at 1:44 p.m., CNA L, stated that he was the staff member providing care to CR #1 on the day of the witnessed fall incident. He stated that during routine rounds he observed that CR #1 required care and noted that CR #1 was care planned as two-person assist resident. He requested assistance from two other CNAs; however, assistance was not immediately available. He stated that while waiting for assistance, he began changing CR #1's bed linen because the linens were soiled. He stated that CR #1's bed was elevated at the time of care and that CR #1 slid from the bed and landed face down on the floor. He further stated that he could not definitively determine whether the resident's head directly struck the floor because the incident happened rapidly. He said that failure to have two staff members present created a risk for CR #1 to fall from the bed. CNA L stated that the potential risks associated with not utilizing two staff members included falls, injuries, worsening of the resident's condition, and possible death. CNA L said he was suspended on [DATE] and had not returned to work since then. He stated that he had completed training on abuse, neglect, and falls prior to the incident. Interview with LVN A on [DATE] at 2:27 p.m., she said she was called by CNA L that CR #1 slid from the bed to the floor. She stated that she responded following notification of the incident; however, she did not witness the actual fall. She performed a head - to - toe assessment on CR #1 and noted that CR #1 had a raised area to the forehead, and an open skin site to the right arm. She notified CR #1's NP who ordered to send CR #1 to emergency room for further evaluation. LVN A stated that CR #1 was care planned as a two-person assist resident. She stated that if only one staff member attempted to assist a resident requiring a two-person assist, the resident would be at risk for falls and possible injury. LVN A said she and all the nurses and CNAs received in-service education related to fall risk residents, abuse, neglect, care plan review prior to resident's care, Kardex (a summary sheet that tells staff the most important things they need to know about a resident at a glance), two -person assistance, and fall prevention using the acronym CHIPS. The in-services were provided by DON, and the most recent in-service occurred on [DATE]. On [DATE], medical record request was sent to Veteran Affair hospital, where the resident expired, but no record had been received to date. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began.The surveyor confirmed the non-compliance had been corrected by: Interview with Administrator and DON revealed they had identified through their investigation that staff used one-person assistance instead of two-person assistance as stated in the care plan, which caused CR #1 to fall. They implemented training for the nurses and CNAs regarding how to use two-person assistance during ADL care, accessing the care plan/Kardex to determine the resident's individualized care needs, completing fall assessments, implementing fall prevention measures. Record review of the facility in-service dated [DATE] through [DATE] revealed staff were in- serviced on the following topics: Residents at high risk for fall, fall precaution, fall risk factors for residents who are bed bound, review of Kardex and care plan prior to resident care. Fall prevention using the acronyms CHIPS, Abuse and Neglect. Record review of the facility QAPI sign - in sheet meeting held on [DATE] revealed that the following topics were discussed at the meeting: fall prevention, protocol and interventions to minimize and prevent resident falls. Record review of the facility Resident Interview - Safe Survey binder revealed that the facility conducted Residents Safe Survey on 16 residents who were at risk of falling, and residents needing two-person assistance on [DATE] and [DATE] respectfully. Record review of CNA L's personnel file on [DATE] revealed CNA L was suspended on [DATE] and was terminated on [DATE]. During an interview with Resident #5 on [DATE] at 10:56 a.m. Resident #5 stated that she always has two staff members that always assist her with ADLs, repositioning, and transfers because she cannot do it by herself. During interviews on 05/ 21/2026 between 10:27 a.m. through 3:33 p.m., ADON, LVN A, LVN B, LVN C, RN G, RN H, CNA J, CNA K, CNA L, CNA M, and on [DATE] between 12:58 p.m., through 2:53 p.m., LVN D, LVN E, LVN F, RN T, RN U, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, were able to state that they were aware of the fall incident involving CR #1 who was care planned for two - person assistance, but one staff provided the care on [DATE], which resulted in CR #1's fall with injury. They stated that if only one staff member attempted to assist a resident requiring a two-person assistance, the resident would be at risk for falls and possible injury. They stated that they had been reeducated regarding the facility's fall prevention interventions. They stated that they had received in-service education related to fall risk residents, abuse, neglect, care plan review prior to resident's care, Kardex, two -person assistance with ADLs, fall prevention using the acronym CHIPS. Observations of two-person in-bed peri-care of Resident #4 on [DATE] at 2:30 p.m., showed no concern, and staff followed appropriate steps to ensure care and resident safety. Observations of two-person in-bed peri-care of Resident #6 on [DATE] at 2:45 p.m., showed no concern, and staff followed appropriate steps to ensure care and resident safety. Record review of facility's policy on Assessing Falls and their Causes with revision date on [DATE] revealed in parts . The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation: 1. Review the resident care plan to assess for any special needs of the residents. The Facility's policy does not really address the issue to provide adequate supervision and assistive devices to prevent accidents.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there was an accident involving the resident which resulted in injury and required physician intervention for 1 (Resident #1) of 4 residents reviewed for notification of changes. LVN-A failed to notify Resident #1's physician for 24 hours when she complained of pain after a witnessed fall on 06-23-25 which resulted in an acute fracture of the left humerus (the long bone in the upper arm) and soft tissue swelling. The noncompliance was identified as Past Non-Compliance IJ. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. This failure placed dependent residents at risk of not receiving proper care, a decline in health, and pain.Findings included: Record Review of Resident #1's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Primary insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep), lack of coordination (impaired balance or coordination), muscle weakness (decreased strength in the muscles), Hyperlipidemia (abnormally high levels of lipids in the blood), Rheumatoid Arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), and Unspecified Osteoarthritis (a type of arthritis where the specific location is not identified in the medical record). Record review of Resident #1's significant change in status MDS assessment dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment). Record Review of Resident #1's Care Plan dated 06/25/25 revealed she was at risk for falls due to unsteady gait, poor awareness with visual deficit, altered cognition and poor safety awareness. She was a one person assist with her ADL. Observation of Resident #1 on 07/01/2025 at 12:50 p.m. revealed she resided in the facility's locked unit. Resident #1 was in bed with her left arm in a splint to keep it immobilized. Her bed was in the lowest position (the bed frame was adjusted to be as close to the floor as possible), fall mats were in place and her call light was in reach. Record Review of Resident# 1's progress note dated 06/23/25 reflected that the following note was written by LVN A: Nurse witnessed resident on floor in front of room [ROOM NUMBER], laying on her left side, assessment/observation completed with no verbal c/o pain or discomfort, no acute changes at the time of fall, resident assisted up into w/c via nurse and CNA, VS obtained 128/72, 97.0, 97% RA, 18, 67 stable, supplement given, resident up and walking from sitting in w/c, nurse redirected and assisted resident back to w/c, continued with no signs/symptoms of pain during observation, resident assisted to bed via CNA with no complaints of uncontrolled pain. Record Review of CNA-A's witness statement dated 06/30/2025 reflected that CNA-A stated that Resident #1's fall on 06/23/2025 was caused when Resident #1 was getting up from her seat and she accidentally bumped into a resident that CNA-A was assisting. Record review of Resident #1 shower sheet dated 06/24/25 reflected that she refused her shower on 06/24/25. Shower sheet was signed by CNA-GG. Record review of Resident#1 skin assessment dated [DATE] reflected that there wasn't any alterations in skin integrity noted. The Assessment was conducted by LVN-BB. Record review of Resident #1's progress note dated 06/25/25 reflected that she had mild swelling and warmth to touch to her left arm. The NP was notified, and X-ray was ordered, Tylenol 325 mg 2 tabs was given., vitals recorded and was within range. Rp was notified and care was continued. Resident #1 Physician's order dated 08/14/23 reflected that 2 tablets be given by mouth every 8 hours as needed for Pain. Record review of Resident #1 MAR dated 06/25/25 reflected that she was given 2 tabs of Tylenol 325 mg. Record Review of Resident #1's X-Ray report dated 06/25/25 reflected that she had sustained an Acute fracture across the left humerus neck (broken arm)with subtle displacement of bony edges, overlying soft tissue swelling as noted. Record review of Resident #1's progress note dated 06/30/25 reflected that she had one fall in the past three months. Date, time, and how the fall occurred was not documented in the progress note. In an Interview on 07/02/25 at 10:30 am with the DON, Administrator, and Regional Nurse, all stated that when a resident had a fall Head-to-Toe assessment must be done, the NP, the ADON or DON needs to be notified, and the results of the assessment must be documented. They stated that LVN A did not complete a Head-to-Toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. Therefore, due her not following policy, LVN-A was terminated. On 07/02/25 at 11:00 am, an unsuccessful attempt was made to contact LVN-A and CNA-A, but both parties did not answer their phone. In an interview on 07/02/25 at 3:30 PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that she if she had been given a call, she would have given an order for Resident #1 according to the result of the assessment. In an interview on 08/04/25 at 4:20 pm with LVN BB, she stated that on 06/24/25 she was notified by CNA-GG that Resident #1 was complaining of pain to her left arm. LVN-BB stated that she assessed Resident #1's left arm by pulling up Resident#1 sleeve and observed that her arm did not have any redness nor any swelling. LVN BB said that she also conducted a range of motion assessment on Resident#1's arm and Resident#1 did not complain of any pain. However, on 06/25/25, LVN-BB stated that CNA-GG went to get Resident#1 up out of bed, and she complained of pain to her left arm. LVN-BB stated that she assessed Resident#1, and Resident#1 stated that her arm was hurting. LVN-BB said that she notified the NP, and an order was given to have an X-ray performed on Resisdent#1's arm. LVN-BB stated she ordered the X-ray, and she gave Resident#1 two 325 mg Tylenol for pain. On 08/04/25 at 5:35pm, an unsuccessful attempt was made to contact LVN-A and CNA-A, but both parties did not answer their phone. In an interview on 08/04/25 at 6:11pm with CNA-GG, she stated that on 06/24/25 she was trying to get Resident#1 ready for her shower when Resident#1 complained of pain to her left arm. CNA-GG stated that she reported to LVN-BB that Resident#1 was complaining of pain to her left arm. In an interview on 08/04/25 at 6:33pm with CNA-HH, she stated that on 06/23/25, she came to work and Resident#1 was already in bed asleep. In an interview on 08/05/25 at 11:20am with the ADON, he stated that LVN-BB reported to him on 06/25/25 that Resident#1 was experiencing pain in her left arm. The ADON stated that he told LVN-BB to call the NP for an order for an X-ray. The ADON stated that the X-ray was performed and as result of the X-ray Resident#1 was sent to the Hospital. The ADON stated that 06/25/25 was the first time it was reported to him that Resident#1 was having pain. In an interview on 08/05/25 at 11:35am with the Wound Care Nurse, she stated that LVN-BB called her on 06/25/25 to come to station for 4 because Resident#1 was complaining of pain. The Wound Care Nurse stated that she and the ADON both witnessed CNA-GG attempting to put a shirt on Resident#1 when she started showing signs of pain. The Wound Care Nurse stated that LVN-BB was told to call the NP, and get an order for an X-ray. The Wound Care Nurse stated that when the results of the x-ray came back that Resident#1 had an Acute fracture across left humerus neck with subtle displacement of bony edges, overlying soft tissue swelling, as noted, she was sent to the hospital. The Wound Care Nurse stated that 06/25/25 was the first time it was reported to her that Resident#1 was having pain. In an interview on 07/02/25 at 3:30PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that she if she had been given a call, she would have given an order for Resident#1 according to the result of the assessment. Record review of the facility's policy regarding to Accidents and Incidents date 03/2025 revealed in part, All accidents and incidents involving residents, employed, visitors, vendors , etc., occurring on our premises shall be investigated and reported to the administrator The following information also has to be documented in the report , the time the physician was notified and the instructions of the physician, and the date and time the resident's family were notified, the condition of the injured person, including his/her vital signs, the disposition of the injured (i.e., transferred to hospital, or put to bed. Record Review of In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON regarding falls management and changes in resident conditions. Record Review of In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON/ADON regarding Abuse & Neglect/Exploitation, and Who is the Abuse coordinator. Record Review of In-service Training Report dated 06/26/2025 revealed facility administrative staff were educated by the Regional [NAME] President of Operations regarding Reporting Guidelines HHSC Provider Letter #2024-14. Record Review of In-service Training Report dated 06/27/2025 revealed 6am-2pm and 2pm-10pm facility staff were educated by the administrator/ DON regarding resident's rights. Record Review of In-service Training Report dated 06/27/2025 revealed facility 6am-2pm staff were educated by DON/ADON on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of In-service Training Report dated 06/28/2025 revealed facility all staff and all shifts were educated by RN Weekend Supervisor on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of In-service Training Report dated 06/28/2025 revealed all staff and all shifts were educated by RN Weekend Supervisor Fall and incident Protocol. The protocol call being License Nurse assesses resident, notify the MD/NP, RP if needed, DON, Neuro Checks, and implement Doctors orders promptly. Record Review of In-service Training Report dated 06/30/2025 revealed facility 6am-2pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of In-service Training Report dated 06/30/2025 revealed facility 6am-2pm, 2pm-10pm and 10pm-6pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of In-service Training Report dated 07/01/2025 revealed facility leadership staff were educated by Director of Regulatory Compliance on Topic of Abuse & Neglect. Record Review of facility resident interviews-safe review dated 06/27/2025 reflected Residents #2, #3, #4, #5, and #6 were interviewed to ensure that they were feeling safe while living at the facility. Residents were asked the following questions: 1.Do you feel safe here? 2. If you have a concern or compliant, do you feel comfortable reporting It?3. Are you afraid of anyone here?4.When the staff come to your room, do they knock, tell you their name and why they are there? Residents #2, #3, #4, #5, and #6 answered the questions in a manner that assured facility staff that they all felt safe and that they had no concerns with staff or other residents at the facility. Record Review of facility's resident audits for recent falls dated 06/28/2025, and 07/01/2025 reflected Residents #7, #8, #9, & #10 were properly assessed, notifications were made, progress notes were written, SBAR, changes in condition were documented if needed. Record Review of a facility email dated 07/01/2025 reflected the Administrator placed a phone call to LVN-A at 4:52pm on 07/01/2025 informing her that her employment had been terminated. In an interview on 07/02/25 at 10:00am with the DON, Administrator, and Regional Nurse, all stated that when a resident had a fall that a Head-to-Toe assessment must be done, the NP must be notified, the ADON, or DON needs to be notified. And the result of the assessment must be documented. They stated that LVN A did not complete a Head-to-Toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. In an interview on 07/02/25 at 3:40pm with LVN-B, she stated that she was in-serviced on 06/26/25 regarding resident falls. She stated that she was told to complete a head-to-toe assessment, call the facility medical staff, call the ADON, or DON, and the residents RP if the resident isn't their own RP. LVN-B also stated that and SBAR must be performed, and that the assessment must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:45pm with LVN-C, he stated that he was in-serviced on 06/26/25 regarding resident falls. He stated that he must perform a head-to-toe assessment on the resident, call the NP, call the ADON, or DON, and the RP if necessary. He also stated that neuro checks must be conducted if the resident hit their head, an SBAR must be done, and all the information must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:55pm with LVN-D, she stated she was in-serviced on 06/26/25 regarding resident falls. She said the in service pertained to conducting a head-to-toe assessment when a resident has a fall, call the medical staff, RP, if necessary, call the ADON, or DON and let them know that there was a fall. Also document the assessment, and SBAR in the resident's progress notes. In an interview on 07/02/25 at 4:05pm with LVN-E, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated the in service taught her to conduct a head-to-toe assessment, call the facility medical staff, call the ADON, DON, and the residents RP if necessary and perform and SBAR and document the finding in the resident's progress notes. In an interview on 07/02/25 at 4:15pm with CNA-A, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA, her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:20pm with CNA-B, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA, her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:25pm with the Receptionist, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that as a receptionist, his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:35pm with the Director of Therapy, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that if she witnessed a resident fall then her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:40pm with the Director of EVS, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall, then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:45pm with the Director of Maintenance, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall, then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. On 07/03/25 at 4:35 p.m. the facility's Administrator and DON were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 07/03/25 at 4:35 p.m.

Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure LVN-A adequately assessed, monitored, provided appropriate interventions, and contact the physician immediately when Resident #1 complained of pain after a fall which resulted in an acute fracture of her left humerus (the long bone in the upper arm). The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. This failure placed residents who experience falls with injury at risk of not receiving adequate treatment in a timely manner, further injury, and pain.Findings included: Record Review of Resident #1's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Primary insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep), lack of coordination (impaired balance or coordination), muscle weakness (decreased strength in the muscles), Hyperlipidemia (abnormally high levels of lipids in the blood), Rheumatoid Arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), and Unspecified Osteoarthritis (a type of arthritis where the specific location is not identified in the medical record). Record review of Resident #1's significant change in status MDS dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment). Record Review of Resident #1's Care Plan dated 06/25/25 revealed she was at risk for falls due to unsteady gait, poor awareness with visual deficit, altered cognition and poor safety awareness. Interventions included: Anticipate and meet the resident's needs; Be sure the call light is within reach and encourage the resident to use it for assistance as needed; Ensure resident wears appropriate footwear when ambulating or mobilizing in wheelchair; Keep needed items in reach; and Physical Therapy evaluate and treat as ordered or as needed. Observation of Resident #1 on 07/01/2025 at 12:50 p.m. revealed she resided in the facility's locked unit. Resident #1 was in bed. Resident #1 was in bed with her left arm in a splint to keep it immobilized. Her bed was in the lowest position (the bed frame was adjusted to be as close to the floor as possible), fall mats were in place and her call light was in reach. Record Review of Resident #1's progress note dated 06/23/25 reflected that the following note was written by LVN A: Nurse witnessed the resident on floor in front of room [ROOM NUMBER], lying on her left side. An assessment/observation were completed with no verbal c/o pain or discomfort. The resident was assisted to bed with no complaints of uncontrolled pain. Record review Resident#1 progress note dated 06/25/25 reflected that she had mild swelling and warmth to touch to her left arm. The NP was notified, and X-ray was ordered, Tylenol 325mg 2 tabs was given., vitals recorded and was within range. Rp was notified and care was continued. Record review of Resident#1 progress note dated 06/30/25 reflected that she has had one fall in the past three months. Date, time, and how the fall occurred was not documented in the progress note. Record Review of Resident #1's X-Ray report dated 06/25/25 reflected that she had sustained an Acute fracture (a sudden and complete break in a bone) across the left humerus neck (upper arm) with subtle displacement (broken bone fragments are slightly out of alignment) of bony edges, overlying soft tissue swelling as noted. In an interview on 07/02/25 at 10:00am with the DON, Administrator, and Regional Nurse revealed they all stated that when a resident had a fall that a head-to-toe assessment must be done, the NP must be notified, the ADON, or DON needed to be notified. And the result of the assessment must be documented. They stated that LVN A did not complete a head-to-toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. In an interview on 07/02/25 at 3:30PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that if she had been given a call, she would have given an order for Resident#1 according to the result of the assessment. In an interview on 08/11/25 at 11:30am with Resident#1 RP he stated that he was not notified of Resident#1 fall on the 23rd of June until the 25th of June when the facility was getting ready to send her to the hospital. In an interview on 08/05/25 at 11:20am with the ADON he stated that LVN-BB reported to him on 06/25/25 that Resident#1 was experiencing pain in her left arm, The ADON stated that he told LVN-BB to call the NP for an order for an X-ray. The ADON stated that the X-ray was performed and as result of the X-ray Resident#1 was sent to the Hospital. The ADON stated that 06/25/25 was the first time it was reported to him that Resident#1 was having pain. In an interview on 08/05/25 at 11:35am with the Wound Care Nurse she stated that LVN-BB called her on 06/25/25 to come to station for 4 because Resident#1 was complaining of pain. The Wound Care Nurse stated that she and the ADON both witnessed CNA-GG attempting to put a shirt on Resident#1 when she starting sowing signs of pain. The Wound Care Nurse stated that LVN-BB was told to call the NP and get an order for an X-ray. The Wound Care Nurse stated that when the results of the x-ray came back as Resident#1 had an Acute fracture across left humerus neck with subtle displacement of bony edges, overlying soft tissue swelling as noted she was sent to the hospital. The Wound Care Nurse stated that 06/25/25 was the first time it was reported to her that Resident#1 was having pain. Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting revised on 03/27/25 revealed, Policy Statement. All accidents or incidents involving residents, employees, visitors, and vendors occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Record Review of facility's internal investigation documentation dated 06/24/2025 regarding the incident of Resident #1 having a broken arm reflected that the facility interviewed staff beginning on 06/24/2025. Staffed interviewed were staff LVN-A, B, C, D. Record Review of an In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON regarding falls management and changes in resident conditions. Record Review of an In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON/ADON regarding Abuse & Neglect/Exploitation, and Who is the Abuse coordinator. Record Review of an In-service Training Report dated 06/26/2025 revealed facility administrative staff were educated by the Regional [NAME] President of Operations regarding Reporting Guidelines HHSC Provider Letter #2024-14. Record Review of In-service Training Report dated 06/27/2025 revealed 6am-2pm and 2pm-10pm facility staff were educated by the administrator/ DON regarding resident's rights. Record Review of an In-service Training Report dated 06/27/2025 revealed facility 6am-2pm staff were educated by DON/ADON on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of ‘In-service Training Report dated 06/28/2025 revealed all staff and all shifts were educated by RN Weekend Supervisor on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of an In-service Training Report dated 06/28/2025 revealed facility all staff and all shifts were educated by RN Weekend Supervisor Fall and incident Protocol. The protocol call being License Nurse assesses resident, notify the MD/NP, RP if needed, DON, Neuro Checks, and implement Doctor's orders promptly. Record Review of an In-service Training Report dated 06/30/2025 revealed facility 6am-2pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of an In-service Training Report dated 06/30/2025 revealed facility 6am-2pm, 2pm-10pm and 10pm-6pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of an In-service Training Report dated 07/01/2025 revealed facility leadership staff were educated by Director of Regulatory Compliance on the topic of Abuse & Neglect. Record Review of facility resident interviews-safe review dated 06/27/2025 reflected Residents #2, #3, #4, #5, and #6 were interviewed to ensure that they were feeling safe while living at the facility. Residents were asked the following questions:1.Do you feel safe here? 2. If you have a concern or compliant, do you feel comfortable reporting It?3. Are you afraid of anyone here?4.When the staff come to your room, do they knock, tell you their name and why they are there? Residents #2, #3, #4, #5, and #6 answered the questions in a manner that ensured facility staff that they all felt safe and that they had no concerns with staff or other residents at the facility. Record Review of facility resident audits for recent falls dated 06/28/2025, and 07/01/2025 reflected Residents #7, #8, #9, & #10 were properly assessed, notifications were made, progress notes were written, SBAR, changes in condition were documented if needed. Record Review of CNA-A witness statement dated 06/30/2025 reflected that CNA-A stated that Resident #1's fall on o6/23/2025 was caused when Resident #1 was getting up from her seat and she accidentally bumped into a resident that CNA-A was assisting. Record Review of a facility email dated 07/01/2025 reflected the Administrator placed a phone call to LVN-A at 4:52pm on 07/01/2025 informing her that her employment has been terminated. LVN-A was terminated because she failed to follow facility policy regarding a resident's fall. Record Review of facility emailed dated 07/01/2025 reflected the Administrator called CNA-A on 07/01/2025 informing her employment has been terminated. CNA-A was terminated for failing to follow policy regarding a resident's fall. In an interview on 07/02/25 at 3:40pm with LVN-B, she stated that she was in-serviced on 06/26/25 regarding resident falls. She stated that she was told to complete a head-to-toe assessment, call the facility medical staff, call the ADON, or DON, and the resident's RP if the resident wasn't their own RP. LVN-B also stated that a SBAR had to be performed, and that the assessment must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:45pm with LVN-C, he stated that he was in-serviced on 06/26/25 regarding resident falls. He stated that he must perform a head-to-toe assessment on the resident, call the NP, call the ADON, or DON, and the RP if necessary. He also stated that neuro checks must be conducted if the resident hit their head. And a SBAR was to be done, and all the information had to be documented in the resident's progress notes. In an interview on 07/02/25 at 3:55pm with LVN-D, she stated she was in-serviced on 06/26/25 regarding resident falls. She said the in- service pertained to conducting a head-to-toe assessment when a resident has a fall, call the RP if necessary, call the facility medical staff, call the ADON, or DON and let them know that there was a fall. Also document the assessment, and SBAR in the resident's progress notes. In an interview on 07/02/25 at 4:05pm with LVN-E, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated the in-service taught her to conduct a head-to-toe assessment, call the facility medical staff, call the ADON, DON, and the resident's RP if necessary; and perform a SBAR and document the finding in the resident's progress notes. In an interview on 07/02/25 at 4:15pm with CNA-A, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:20pm with CNA-B, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:25pm with the Receptionist, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that as a receptionist his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:35pm with the Director of Therapy she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that if she witnessed a resident fall then her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:40pm with the Director of EVS, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:45pm with the Director of Maintenance, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. Observation of the facility's secure unit on 07/01/2025 from 12:50 p.m. until 1:05 p.m. revealed there were always six staff members inside the locked memory care unit. Observation also revealed that Resident #1 was in her bed, her bed was in the lowest position, fall mats were in place and her call light was in reach. The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. On 07/03/25 at 4:35 p.m. the facility's Administrator and DON were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 07/03/25 at 4:35 p.m.

Based on interview and record review the facility failed ensure that residents requiring respiratory care are provided with necessary services consistent with their care plans for one of three residents reviewed for the use of oxygen. The facility failed to ensure that CR #1's portable oxygen was fully charged before leaving the facility for a clinic appointment. This failure could place residents at risk of not receiving needed services in an emergency. The noncompliance was identified as PNC IJ began on 0328/25 and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of being neglected by not providing necessary care and services. Findings include: Record review of CR #1's admission record face sheet, dated [DATE], revealed a-[AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Chronic obstructive pulmonary disease, (primary) (a progressive lung disease that limit air flow to the lungs) essential hypertension (High blood pressure), obstructive sleep apnea (a condition that prevent air flow to the lungs), type 2 diabetes mellitus (a condition that affect how the body uses blood sugar), post-traumatic stress disorder, depression, anxiety disorder, heart failure and acute kidney failure. Record review of CR#1's progress note, dated [DATE] at 6:50AM, revealed the resident's RP is here to take resident to a local clinic for Doctor's appointment, pt left awake and alert, no SOB /distress noted, left with portable oxygen, no complaint of pain, scheduled morning meds given. Resident left with his walker via a private vehicle. Record review of CR #1'sprogress note did not specify if CR #1 had oxygen on or not, the level of the oxygen concentrator nor how much oxygen CR #1 was receiving at the time of departure. Record review of CR #1's comprehensive care plan, dated [DATE], with a revision date of [DATE], indicated CR #1 was care planed -for Congestive Heart Failure . CR #1 has a Heart Monitor, a small patch, placed on the left side of the chest wall.Goal: Resident will verbalize less difficulty breathing (Dyspnea) and be more comfortable through the review date.-CR #1 had oxygen therapy r/t COPD Date Initiated: [DATE] Revision on: [DATE]Goal- CR #1 will have no s/s of poor oxygen absorption through the review date. Date Initiated: [DATE] Revision on: [DATE] Record review of CR #1's MDS assessment indicated CR #1 had a BIMS score of 14 out of 15, which indicated he was cognitively intact. In an interview with CR #1's RP on [DATE] at 2:00 PM, the RP said she picked up CR #1 for an appointment at about 6:30AM to a local hospital for eye appointment. She said when she got to the clinic, CR #1 requested to have his oxygen but there was no tube to administer the oxygen. She said she asked the nurse at the clinic for an oxygen tube. She said CR#1 said he could not breath and fell before the nurse could place the tube on him. CR #1's RP said the nurse started working on CR # 1 until he was transported to the hospital section of the facility. She said it did not take long before the oxygen tube was brought to CR#1. She said CR #1 did not leave the facility with his oxygen on. She said CR #1 had just finish his treatment when they left the facility. She said she did not remember leaving the facility with tubing, but she had the portable oxygen concentrator in her car. She said she did not know what happened to the oxygen tube. She said she could not recall if the tube was given to her or not. She said one thing she knew was that CR#1 did not have his oxygen prior to leaving the facility. During an interview on [DATE] at 10:30 AM, LVN C said before sending any resident out of the facility, the nurse in charge must complete the assessment complete the form and had it witness by a second nurse before leaving regardless of means of transportation. She said there were serval in-services on assessments, documentation and ensuring that the form was filled out correctly and witnessed by two nurses. She explained that the forms were in a binder at the nurse's station and scanned into the resident's clinical records as soon as possible. During an interview with RN D on [DATE] at 11:50AM, he said before sending any resident out of the facility, he would have a charge nurse with him to assess the resident and document any special treatment and who was responsible for transportation and ensure that the RP know what to do in an emergency. He said he would document time date and what the resident left the with if on any special treatment He would make sure the RP knows what to do. He said if resident was on oxygen, he would make sure that the RP knows how to monitor the oxygen by education the RP. He said Resident on oxygen are always transported out of the facility by EMS. He said there was a form that must be completed by both nurses the are present during the transfer. He said the forms must be signed and scan to resident clinical record. In an interview with facility's DON, and Administrator on [DATE] at 12:00 PM, the DON said the resident's RP called to let the facility know that CR #1was admitted to the hospital. The Administrator said the local Hospital called to inform the facility that CR # 1 died a few days ago. She did not remember but would check her e-mails for the exact time and date. She said as soon as the local hospital explained what happened, herself and the DON started an investigation, called the State Survey Agency and started in-services. The DON said the facility started their own investigation and an in-service on abuse, neglect and exploitation. The DON said training included residents' assessment and proper documentation before transporting residents out to an appointment and outing as well as assessing all residents on Oxygen and on any special treatment. The DON and Administrator said LVN A was immediately suspended awaiting the result of the investigation. The DON said all residents on oxygen or special treatment were usually transported by ambulance to their appointment or by the facility van on regular appointments if there was no special treatment. The DON said in case of CR #1's RP chose to take him to the clinic because that was what she did before admission to the nursing home and did not allow the facility to transport CR #1 to his appointment. During a phone interview on [DATE] at 3:00 PM, CR#1's charge nurse, (LVN #A) said she sent CR #1 to the appointment on [DATE] at about 6:30 AM with his oxygen concentrator and told CR #1's RP to ensure the concentrator was plugged in as soon as they get got to the appointment office, because the concentrator was not fully charged. She said she believed what was left would be enough to get to the Clinic. She said she knew the concentrator was not charged because it was supposed to be charged overnight but CR #1's RP did not return the charger to the facility to charge the concentrator overnight. LVN A said she thought whatever was left on the concentrator would be enough for the trip since the trip was only 30 minutes from the facility. She said she did not know how fully charged the oxygen concentrator was and did not answer to how may liters of oxygen CR #1 was on at the time of departure. She said she did not recall. LVN A said she was suspended for 3 days and had training on abuse, neglect and exploitation, assessment and documentation prior to sending any resident out of the facility regardless of means of transportation. She said all transfers must be assessed, documented, and signed by two nurses. She said there were forms to be completed by both nurses before leaving the facility. During an interview with RN A (local clinic\hospital nurse) on 07/ 23/25 at 9:15 AM, she said the RP brought CR #1 to the clinic between the hour of 7:15 AM to 7:30 AM. and immediately requested for oxygen and stated CR #1 was out of breath. RN A said CR # 1's RP said she needed an oxygen tube for CR #1. RN A said the clinic nurse immediately brought the oxygen tubes and before the nurse could start the oxygen, CR #1 collapsed. RN A said there were always supplies at the clinic and oxygen tubes were readily available and provided to CR #1. RN A said CR #1 was intubated and transported to ICU where he later died. RN A said the administration started an internal investigation. She said she had to look at the records and find out from Medical Records before providing further information. RN A did not get back prior to exit on [DATE]. During an interview with CR#1's physician on [DATE] at 3:00 PM, he said CR #1 was one of his residents at the facility, but his medical treatment was mostly done at the local Hospital and clinic. He said CR #1 had multiple medical conditions which included COPD; and a heart condition. He said he could not speculate the course of death other than he had multiple medical conditions. The facility implemented the following to remove the noncompliance:Interview with LVN B on [DATE] at 3:00PM, he said there was a form in a binder at all nurse's station that must be filled out after assessing the resident being transported out of the facility. He said complete assessment includes all vital signs, and condition. He said the form had specific information such as oxygen, How many liters of oxygen the resident was on at the time of departure, type of portable, if the order is continuous or as needed, educate the RP on the type of equipment with a returned demonstration; if equipment uses batteries or need an electric charger and to ensure all equipment are functioning well before leaving the facility. Record Reviews of in-services and training completed by the facility, which started [DATE]- and ended on [DATE], reflected. training and in-service on Abuse, neglect and exploitation, checklist with the following requirement that must be completed by charge nurse and verified by a manager before a resident could be transported out of the facility:Resident assessment and documentation before leaving the facility. The forms revealed the following process--Do we have the necessary accessories to go with a portable oxygen yes/no-Indicate whether oxygen order is continuous or as needed-continuous/PRN.-Will this resident need a portable concentrator for hospital appointment or day pass-yes/no-Oxygen portable oxygen functional and full- yes/no-Is resident and caregiver education regarding portable oxygen use completed- Yes/No-Is resident owned equipment charged and ready to use-Yes/no.-Can giver demonstrate competency of portable Oxygen Usage-Yes/no.Last in-service was dated [DATE]- Administration of oxygen therapy:-How to read oxygen on oxygen concentrator-How to connect properly with different oxygen devices. -If a resident goes out on appointment or with family: make sure resident has sufficient oxygen in cylinders, make sure oxygen cylinder is secured properly.-If a resident uses home personal portable oxygen concentrator, then make sure battery is full and adapter is attached. Record review of facility's, undated, policy on Abuse, Neglect and Exploitation undated revealed Neglect' the failure of the facility, its employee or service providers to provide goods, and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on observation, interview, and record review the facility failed to ensure the resident's environment remained as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for transfers. Resident #1 was transferred from her motorized wheelchair to the bed with a sit to stand hoyer lift using a sling that was too small to secure around her waist and had a broken buckle. This could place residents who utilize the sit to stand hoyer lift at risk for falls and serious injury. Findings included: Record review of Resident #1's facesheet revealed an eighty-two year old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were dementia, lack of coordination, disorientation, abnormalities of gait and mobility, morbid obesity, and encephalopathy (brain disease or disorder that effects brain function). Record review of Resident #1's MDS (minimum data set) Section C- Cognitive Patterns completed 04/24/25 revealed a BIMS (brief interview mental status) revealed a score of 11 out of 15, signifying moderate impairment. Section G- Functional Status documented that for transfers, Resident #1 required extensive assistance where staff provided weight bearing assistance and was a one-person physical assistance. Record review of Resident #1's care plan revised 04/22/25 documented the following focus areas:* impaired visual function related to glaucoma [TT1] (eye disease that damages the optic nerve) and she was at risk for falls. * ADL self-care performance deficit and detailed that she required partial/moderate assistance during transfers. *On 02/06/25, Resident #1 had a fall with no injury related to lower extremity weakness. During a transfer with a CNA from the bed to her motorized wheelchair, care plan stated her knees went out and she was assisted to sit on the floor. Intervention listed was to consult with PT for strength and mobility. [TT2] In an interview on 06/25/25 at 10:13 am, CNA C stated the facility had a sit to stand hoyer lift that they used to transfer Resident #1 in and out of bed. When they would perform a transfer, aides would tie the belt that secured the resident during a transfer because it could not fit around her due to her size. CNA C [TT3] explained she did not know where they kept this hoyer, but if you looked at the belt, there were several knots in the belt where you can see where it's been tied. She could not give an exact time frame for how long the belt had been broken, but she estimated at least one month. CNA C stated she was worried when Resident #1 would use the sit to stand hoyer because she felt she could slip off and fall. In an observation and interview on 06/25/25 at 1:12 pm, CNA A stated the facility had two traditional mechanical lifts and a sit to stand hoyer lift that was primarily used by Resident #1. She walked the investigator to the sit to stand hoyer life and explained the sit to stand was only utilized by residents who could grab the handle bars. CNA A gave a demonstration on how it was used. She stepped her feet on the platform at the bottom of the machine and grabbed the handles bars. She stated that at her feet, there was a strap that would fasten around both of her legs and there was a strap that would fasten around her lower back/waist. The machine had an up and down button that raised the handle bars up for comfortability as the resident raised from a sitting to standing position. There was a seatbelt attached to a sling that she stated fit around the small of their back and the loops attached to the hooks on the machine. The belt had several knots that had been tied on it. CNA A stated that the knots had been tied on the belt because the belt was too big and the aides were trying to keep it from sliding. When asked if Resident #1 used the belt during transfers, she stated Resident #1 didn't need it because she was able to stand. CNA A could not recall how long the belt on the sit to stand lift had been broken and stated that she had only used it a few times because Resident #1 use to walk more. In an interview on 06/25/25 at 1:46 pm with Resident #1, she stated that when she used the sit to stand lift, she made sure her feet were secured and if they were not, she would ask one of the aides to help her. She explained that there was a burgundy belt attached to the hoyer's sling that was supposed to snap around her, however the buckle was not secured and needed some adjustment and this made her feel unsteady. She explained the aides usually tied it but they needed another belt so that it could be adjusted correctly. She stated that although she was not nervous using the sit to stand lift, she knew that it needed to be fixed. In an observation and interview on 06/25/25 at 2:59 pm, Resident #1 rolled herself into her room accompanied by CNA A and CNA B. Resident #1 lifted her legs out of the leg rests on her motorized wheelchair and placed them on the foot rest of the sit to stand hoyer lift. CNA A removed her glasses and the pouch she was wearing and strapped her legs into the lift. Resident #1 grabbed the handle bars and CNA attempted to fasten the buckle on the sling but it could not fit around Resident #1's body. She tried to buckle it but it would not stay. CNA A finished the transfer with Resident #1, safety lowering her back to a sitting position on the bed. When asked why did she use the seatbelt attached to the sling, she stated that one of the prongs were broken and it could not clasp. The investigator viewed the buckle and noticed that 1 out of the 3 prongs was missing. In an interview on 06/25/25 at 4:08 pm with the DON, he stated he honestly was not aware of the strap on the lift. The DON showed the investigator and email and explained that yesterday he made a request to Corporate Central Supply requesting new lifts at the facility. He stated his expectation was for staff to inform him of malfunctioned equipment and if he would have known, he would have gotten on it immediately. In an observation on 07/08/25 at 9:15 am, the sit to stand lift had been removed from the previous space across from Resident #1's room. The lift had been moved to a storage room and the attachable belt and sling had been removed from the lift. Review of the maintenance calibration displayed that the last service date was 04/25/25 and it was due for maintenance on 10/25/25. In an interview on 07/08/25 at 11:22 am, CNA C stated in the past, she had used the sit to stand lift with Resident #1 and she was aware the belt on the sling was broken. She stated at one point, the facility had ordered a new sling/belt, but it went missing, so staff had been utilizing the broken belt for about a year and a half. She stated t when equipment was not functional, staff were supposed to notify the DON, however, she did not let the DON know the belt was broken because the lift operated fine. CNA C recalled in a morning meeting a few months prior, administration was informed that aides needed new belts and slings. She also stated staff were instructed to no longer to use the sit to stand lift because it was dangerous to operate the machine with a broken belt. In an interview on 07/08/25 at 12:49 pm, Resident #1 stated she was not using the lift for transfers and she had been getting in an out of bed using the walker instead. She stated staff informed her that they would not use the sit to stand lift because the broken belt made it dangerous for transfers. Resident #1 explained she had also restarted therapy and felt she was getting stronger. In therapy she worked on walking, riding the bike, using the walker, and walking with the parallel bars. In an interview on 07/08/25 at 12:55 pm with PTA, she stated that Resident #1 was picked up for physical therapy on 06/30/25. In PT, Resident #1 was working on her balance, functional goals, functional limitations, bed mobility, and weakness and balance deficient. PTA explained that since Resident #1 had just started, there were no progress notes entered in the system because they are to be completed every 4 weeks. In an interview on 07/08/25 at 1:02 pm, the MD stated that prior to the previous State visit on 06/25/25, no one had mentioned to him that the belt to the sit to stand lift was broken. He explained that if there was a problem with equipment, they should report it to the DON and log it into the maintenance log located at each nurse's station. On the evening of 06/25/25, he joined the DON, ADM, and other staff to discuss the sit to stand lift. The MD stated that they ordered new belts and slings for the hoyers from central supply, and he discarded the broken belt. In an interview on 07/08/25 at 1:27 pm, the DON stated that after the State visit on 06/25/25, a meeting was called and the first thing staff did was pull the sit to stand hoyer lift off of the floor. CNA's and nurses were immediately in serviced that before they use any equipment, they were to check it before use to satisfy that it was safe and there must always be two people. The DON also stated that he ordered new slings and belts in bulk for all the hoyers. He explained that he pulled it off the floor because he did not want it to be used and he was intentionally asking staff daily when was the last they used the sit to stand hoyer lift to makes sure staff were not sneaking to use it without permission. The DON explained Resident #1 used to walk with her walker and since she restarted therapy, she has been able to utilize the walker again for transfers. He stated that he could confidently say that since the last visit, no one at the facility had used the sit to stand hoyer. In an observation on 07/08/25 at 1:45 pm, a transfer was completed by Resident #1, CNA B, and CNA E. Resident #1 sat in her mobilized chair near the front wall of the room and aides went into the bathroom to wash their hands and put on gloves. CNA B and CNA E removed the cross pouch on Resident #1's body and they asked her to sit forward so that they could fasten the gait belt around her waist. Resident #1 let staff know that she has it, and she began to lift herself up from the chair to a standing position while aides stood close by. Using her walker, Resident #1 slowly walked herself from the chair to the bed. Aides helped Resident #1 pivot and she sat down on the bed. Record review revealed an in-service was completed 12/20/24 titled [mechanical]Lift: Proper Use; Do's and Don'ts when transferring resident's. Sign in sheet reflected that 16 nursing staff and CNA's were in attendance. Record review of facility in-services revealed that an inservice was completed on 06/29/25 titled safe transfer techniques and another in-service was completed on 06/30/25 titled Sit to Stand Lift, properly checking slings. Record review of the facility's policy titled Lifting Machine, Using Mechanical revised 07/2017 reflected that under the subsection Steps in the Procedure staff should:1) Make sure that all necessary conditions (slings, hooks, chains, straps, and supports) is on hand and in good condition.2) Double check the sling.3) Place the sling under the resident. Visually check the size to ensure it is not too large or too small.4) Lower the sling bar closer to the resident.5) Attach sling straps to sling bar, according to manufacturer's instructions. a) Make sure the sling is securely attached to the clips and that it is properly balanced.b) Check to make sure the resident's head, neck, and back are supported.c) Before resident is lifted, double check the security of the sling attachment.d) Examine all hooks, clips or fasteners.e) Check the stability of the straps.f) Ensure that the sling bar is securely attached and sound.Sling Care:a) Disinfect slings between residents (unless disposable).b) Discard any worn, frayed or ripped slings.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 4 (Resident#31, #71, 77 and 82) of 18 residents reviewed for accuracy of assessments. The facility failed to ensure Resident#31's annual MDS assessment 08/02/24 accurately reflected her lack of natural teeth in her oral cavity. The facility failed to ensure Resident#71's annual MDS assessment dated [DATE] accurately reflected his continuous dental problems. The facility failed to ensure Resident#77's annual MDS assessment dated [DATE] accurately reflected her mental illness condition. The facility failed to ensure Resident#82's annual MDS assessment accurately reflected his continuous dental problems. These failures could place residents at risk for receiving inadequate care and services due to inaccurate assessments. The findings included: Record review of Resident #31's face sheet dated 03/26/25 revealed a-[AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Essential hypertension (Highblood Pressure)(Primary diagnosis), dementia with behavior, bipolar (disorder, which causes extreme changes in mood and behavior), anxiety (mental health condition charaterized by fear), depression, muscle wasting, Cerebral infraction, (known as stroke limited blood flow to the brain), muscle weakness and pain. Review of Resident #31's annual MDS assessment dated [DATE], revealed her BIMS score was 11 out of 15 reflective of moderate cognitive impairment. Review of section on oral dentures indicated she had all her natural teeth without problem. Observation on 03/24/25 at 12: 20PM revealed Resident #31 was on puree diet . Observation indicated she was served puree diet. During an attempted interview, Resident said she had no teeth. She said she eats what she can and did not answer further question. Record review of Resident #31's Dental examination dated 12/24/24 revealed Resident #31 had no natural teeth in her oral cavity. Dentist note indicated inflame\swollen, bleeding gums. Review of Resident #31's Care Plan updated 03/26/25 revealed he was care-plan for potential for oral/dental health problem (no tooth) r/t Poor oral hygiene, initiated: 03/26/2025 Revision on: 03/26/2025. Resident #71 Record review of Resident #71's face sheet dated 03/25/25 revealed a-[AGE] year-old male admitted to the facility on [DATE]/2023 and readmitted on [DATE]. His diagnoses included Essential hypertension (high blood pressure) (Primary diagnosis), dementia with behavior, cellulitis (a bacterial infection of your skin and the tissue beneath the skin), anxiety, depression, and muscle weakness, depression, Infection of amputation of right lower extremities. Review of Resident #71's annual MDS assessment, dated 10/03/24, revealed his BIMS score was 15 out of 15 reflective of intact cognition. Review of section on oral dentures indicated he had all his natural teeth without problem. Observation and interview on 03/24/25 at 8:40 AM revealed Resident #71 was in bed alert and oriented. During an interview, he said he was in pain and had been in pain for a while. He said he has been at the facility for almost 2 years and had lost 4 teeth. He said he was in constant pain and had told the nurse about his pain when unbearable. He reached out to his bed side table and brought out his tube of oral gel. He said he had to order the oral gel online to help with the pain from time to time. He said he gets his medical treatment from the local hospital and that was of no good. In an interview with LVN E on 03/24/25 at 11:00 AM she said she was not aware that Resident #71 had oral dental pain. She said this was her first time of knowing about Resident #71's dental concerns. LVN said Resident #71 was in pain most of the time due to his disease process but did not specify dental pain and he always verbalize relief after 30 minutes of post medication. In an interview with MDS Coordinator A on 03/24/25 at 10:30 AM, She said she was not aware that Resident #71 had dental pain. She said she did not complete Resident #71's MDS assessment. She said Resident #71's MDS assessment was done before her time by another staff that no longer work at the facility. She said she would reassess Resident #71 and refer him to the social worker for immediate referral for his dental problem. In an interview with Facility's social worker on 03/25/25 at 11:00am, she said Resident #71 had sign his dental referral paperwork and she would follow up with the dentist. Observation and interview on 04/10/25 at 12:20pm, revealed Resident #71 had his meal and consumed all served meal 2 slices of [NAME] and vegetables. He said he was doing well and reported no concern. Interview about his pain, he said he had pain from time to time but not current. He said he had pain all over his body and when he had pain, whatever medication that was given for pain, should take care of the pain. He did not tell the staff was specifially his teeth. He said his teeth fell out over a period of one year at different times and not all at once. He also stated he would order his own items like the stuff for his teeth without telling staff. During an interview with CNA G and CNA H on 04/10/25 at 1:50PM, both said they would tell the nurse in charge if a resident complained of pain. CNA G said she has been working with Resident #71 on and off for about a year and had not had any complaint. CNA H said she was new but would tell any nurse about residents complaining about pain. Record review of Resident #71's MAR indicated he was on the following medication for pain- Tramadol 100 mg every 8 hours for pain start date 12/07/24 Acetaminophen 325 mg 2 tablets every 6 hours for pain. Nitroglycerin oral PRN for chest pain. Further review revealed he requested pain medications PRN, but his pain level was not above 6 (only 2 times in February 2025) out of 10 being the highest. Record review of Resident #71's weight revealed no evidence of weight loss. His weight was as followed - 01/02/25 was 267.7 Ibs, 2/1/25 was 268.5 lbs and 03/01/25 was 261.5Ibs. Weights were completing using a mechanical lift. Record review of Resient #71's current care plan dated April 2025. This care plan revealed resident was seen by the dentist on 3/25/25. A plan was put into place to address his issues. Resident refused care at this time. Resident #77 Record review of Resident #77's face sheet dated 03/26/25 revealed a-[AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Essential hypertension (Primary diagnosis), bipolar disorder, schizophrenia, anxiety, and depression. Review of Resident #77's annual MDS assessment, dated 4/11/24, revealed her BIMS score was coded as 0 indicated sever cognitive impartment. Review of section on PASRR indicated no mental condition Mental illness was left blank. Review of section I - Active diagnoses, psychiatric \mood disorder was check for bipolar disorder and schizophrenia. Record review of Resident #77's PASRR evaluation dated 12/30/1919 indicated she had serious mental illness. Observation and interview on 03/24/25 at 11:00 AM, revealed Resident #77 was in bed. Resident #77 asked if snacks were available. She said she wanted some snacks. Snacks was requested for her. She said she was doing well and did not answer further question. Record review of Resident #82's electronic face sheet dated 03/26/25 revealed a-[AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included. Absence of right leg Above the knee amputation, type 2 diabetes, (Adult onset of diabetes) dementia, depression, and anxiety dementia behavior, bipolar, anxiety, depression, muscle wasting, essential hypertension (High blood pressure), anxiety and depression. Review of Resident #82's annual MDS assessment, dated 08/02/24, revealed her BIMS score was 11 out of 15 reflective of moderate cognitive impairment. Review of section on oral\dentures status indicated she was assessed as no natural teeth or tooth fragment(s) (edentulous). Observation and interview on 03/25/25 revealed Resident was in her room, alert and oriented, she was on mechanical altered diet . In an interview, she said she had about 5 or 6 teeth in her mouth and the dentist wanted them out, but she was not ready to take them out. Record review of Resident #82's Dental note dated 12/10/24 read in part .Patient treated in room of nursing home. Patient tolerated x-rays well. I recommend an annual exam.; I recommend upper and lower full dentures for teeth replacement as medically necessary to restore proper mastication and nutrition.; I recommend extraction of teeth due to non-restorability as medically necessary to resolve chronic/acute dental infection.; Patient tolerated X-rays well.; Extraction of teeth 6, 7, 8, 20, 22-28 due to decay. During an interview with facility social worker on 03/25/25 at 2:15 pm, she said Resident #71 was not on the dental list, She said she was not aware of Resident #71's dental pain. She said she would follow up with Resident #71. She said Resident #81 had seen the dentist and she would follow up with Resident #81's RP for final decision. She said she was not responsible for completing section L (oral dental) of the MDS. During an interview with MDS Coordinator A on 03/25/25 at 3:30Pm, she looked at all identified MDS and said She was not present at the facility during the time when the identified MDS were completed. She said she was new to the facility and would ensure that all MDS assessment accurately reflected Resident's condition. She said inaccurate assessments could delay\prevent residents from getting needed services to maintain their health. She said she was responsible for ensuring that all assessment reflected resident's health status. Record review of facility's policy titled MDS 3.0 completion, Policy revealed in part Residents are assessed using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: I. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10% based on 3 out of 30 opportunities, which involved 3 of 3 residents (Resident #25, Resident #54, and Resident #93) and 2 of 2 staff (LVN and MA A) observed during medication administration reviewed for medication error. 1. The facility failed to ensure that Resident #25's aspirin was administered as ordered as chewable on 3/25/25 at 8:50 a.m. as the aspirin was swallowed whole. 2. The facility failed to ensure that Resident #54's Cholecalciferol Oral Tablet 50 mcg was administered as ordered on 3/25/25 at 9:02 a.m. as D3 125 mcg (5000 IU) was administered. 3. The facility failed to ensure that Resident #93's aspirin was administered as ordered as chewable on 3/25/25 at 8:38 a.m. as the aspirin was swallowed whole. The failure could place residents at risk of not receiving therapeutic dosage and/or effects of medications. Findings included: Resident #25 Record Review of Resident #25's face sheet dated 3/26/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (chronic lung condition causing restricted airflow), Atherosclerotic Heart Disease of Native Coronary Artery (buildup of plaque in arteries that supply blood to the heart), and Essential Hypertension (High Blood Pressure). Record review of Resident's #25's quarterly MDS dated [DATE] revealed a BIMS score of 5 that suggested severe cognitive impairment. Record review of Resident #25's Order Summary Report as of 3/25/25 revealed order for Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for Blood thinner. Record review of Resident #25's MAR printed 3/25/25 revealed Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day. Observation on 3/25/25 at 8:50 a.m. revealed LVN H administered Chewable Aspirin 81 mg with Resident #25's other medications which he swallowed and was not chewed. LVN H did not instruct Resident #25 to chew the aspirin. Resident #54 Record Review of Resident #54's face sheet dated 3/26/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities), Osteitis Deformans (chronic bone disorder with excessive breakdown and regrowth of bone). Record review of Resident #54's quarterly MDS dated [DATE] revealed a BIMS score of 1 that suggested severe cognitive impairment. Record review of Resident #54's Order Summary Report as of 3/25/25 revealed order for Cholecalciferol (Vitamin D3) Oral Tablet 50 mcg (2000 UT ) Give1 tablet by mouth one time a day for vitamin d deficiency. Record review of Resident #54's MAR printed 3/25/25 revealed Cholecalciferol Oral tablet 50 mcg (2000 UT) Give 1 tablet by mouth one time a day. Observation on 3/25/25 at 9:02 a.m. revealed that LVN H administered D3 125 mcg (5000 IU) to Resident #54. Resident #93 Record Review of Resident #93's face sheet dated 3/26/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease (disorder of the blood vessels), Atherosclerosis (plaque buildup in blood vessels that carry blood through the body) and Congestive Heart Failure (disorder where the heart does not pump blood as well as it should). Record review of Resident's #93's quarterly MDS dated [DATE] revealed a BIMS score of 6 that suggested severe cognitive impairment. Record review of Resident #93's Order Summary Report as of 3/25/25 revealed order for Aspirin 81mg Oral Tablet Chewable 81 mg (Aspirin) Give 1 tablet by mouth one time a day for prevent blood clot. Record review of Resident #93's MAR printed 3/25/25 revealed Aspirin 81 Oral Tablet Chewable 81 mg (Aspirin) Give 1 tablet by mouth one time a day for prevent blood clot. Observation on 3/25/25 at 8:38 a.m. revealed LVN H administered Chewable Aspirin 81 mg with Rresident #93's other medications which he swallowed and was not chewed. LVN H did not instruct Resident #93 to chew the aspirin. Interview on 3/27/25 at 9:56 a.m., ADON said staff have continuing education training regarding medications. Interview on 3/27/25 at 10:02 a.m., MA A said there is was a class yearly for continuing education regarding medication with a written exam. Interview on 3/27/25 at 10:07 a.m., the DON said that the facility uses a computer- based training system with medication education done quarterly with competency- based check offs and further education done as needed. The DON said that the pharmacist observes medication pass at the facility. The DON said that if aspirin or other medications is was not administered correctly or at the correct dosage, then the resident might not get the therapeutic effects of the medication. Interview on 3/27/25 at 10:34 a.m., the Pharmacist said she does medication training quarterly and monthly during the facility's survey window to all nursing staff. Record Review of policy Medication Administration with implementation date of 3/2022 revealed that medications are to be administered as ordered.

Based on observation, interview and record review, the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to correct the assessed problem and/or attain the highest practicable mental and psychosocial well-being, for one (Resident#122) of 24 sampled residents reviewed for behavioral heath. The facility failed to ensure that Resident #122 had individualized behavioral health needs addressed through a person-centered care plan. The facility failed to ensure that Resident #122's suicidal ideation was addressed and followed up on. An Immediate Jeopardy (IJ) was identified on 02/16/24 at 6:30 PM. While the IJ was removed on 02/18/24 at 5:15PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of not receiving care and services to address their mental health condition such as PTSD. Finding included Record review of Resident #122's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admitted [DATE]. He had diagnoses of facial weakness after a stroke, dysphagia (trouble swallowing), muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, PTSD, and hemiplegia and hemiparesis (weakness and paralysis) after a stroke affecting the dominant side. Record review of Resident #122's Admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. The Admission MDS revealed he was diagnosed with PTSD. Record review of Resident #122's care plan dated 9/12/23 read in part- Behavior Management (Initiated: 8/30/23). *Focus: Resident #122 has depression r/t admission (Initiated: 8/3/23, Revised: 8/3/23). *Goal: Resident #122 will exhibit indicators of depression, anxiety, or sad mood less than daily by review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). Resident #122 will remain free of s/sx of distress, symptoms of depression, anxiety, or sad mood by/through review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). *Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness (Initiated: 8/3/23). The care plan did not mention anything about his PTSD Record review of Resident #122's medical records from the hospital on 8/29/23 revealed he presented to the hospital for dysuria (trouble urinating) and SI. He also had suicidal ideation at his nursing home with plan to hang himself with call bell. He only had these ideas because he wanted to get out of nursing home. He currently denies suicide ideation here. Record review of Resident #122's psychiatric note from 12/27/23 revealed he stopped the Psychiatrist in the dining room to tell him he was having nightmares of war combat mostly when he heard other residents yelling out of help. In an interview with Psychiatric Nurse Practitioner on 2/15/24 at 1:45 pm, she stated seeing Resident #122 every month and evaluates him. She knew he had PTSD and had talked to staff about it and what to do if he was in crisis. She said he told her in the hall in August that he thought about wrapping the call light cord around his neck, but he never did since he did not know how to do it. He told her then he felt trapped and did not want to be here. He wanted to live with his [family member]. She said she immediately recommended to send him to VA for further evaluation because of suicidal thoughts. She said he had never said anything about symptoms or suicidal thoughts since that one time, and she asked him about it at every visit and evaluation., and he had no thoughts of suicide. She said she put him on a low dose of Melatonin in December since he told her he was having nightmares, but on further visits, he said he was not having nightmares anymore. She said she always talked to staff about Trauma Informed Care and to be aware of resident's conditions and be there if they are in crisis because of past events. Record review of Resident #122's medical record revealed a Trauma Informed Care Assessment-PTSD on 1/18/24 given by the Social Worker, that was scored a 5 out of 5 of probable PTSD. The assessment indicated he had PTSD. Record review of Resident #122's progress notes written by the the Social Worker on 1/18/24 stated, Resident approached SW to discuss his increased depression. Per [Resident] he is unable to sleep at night due to continuous noises. Per [Resident] the noise reminds him of his time in the Vietnam War. Per [Resident] the noise triggers his PTSD badly. He is requesting discharge home since his [family member] circumstances have changed. SW and resident called [family member]and she plans on moving to a larger house and will be working in [local] vs [out of town]. SW to send email request to VA to request discharge orders. In an interview with the Social Worker on 2/1/24 at 1:03pm, she said she did not care plan suicidal ideations unless the resident was actively suicidal. She said she checked Resident #122 daily to see how he was and performed a Trauma Screen on him. Observation and interview with Resident #122 on 2/15/24 at 11:25 am the resident was in his room in bed, watching TV bringing his lunch. Resident #122 told me he does not want to be here, he would rather be at home with his family member. He said he was living with his family member, but he had a stroke and had to go to the hospital, then came here. He said one time after he came here in the summer, he felt trapped and did not like being here, he thought about wrapping the call light cord around his neck, but he did not do it since he could not figure out how. He said he does not want to do that anymore but he still wants to go live with his family member. In an interview with Social Worker on 2/15/24 at 12:05 pm, she said she looks out for Resident #122 because of his PTSD, and she sees him every week, often every day. She said she can re-direct him if he is feeling anxious, and sometimes he will come to her office to talk if something is bothering him. She said he is being seen by an NP with Team Health that is part of Deer Oaks, and VA has quarterly meetings with him, as well as SW and RN from VA every month. She said she has talked to the nurses and aides about his PTSD and triggers that might agitate him, and interventions such as re-direct, talking, distractions from the triggers. She said she updates the progress notes with her visits with him. She said he is in a VA NH to Home program where the VA helps him with the transition, and his daughter is moving back to Houston and will buy a house so he can live with her. She said she asks him every time she sees him about any suicidal thoughts, and he says no. Observation on 02/16/24 at 5:00PM, revealed Resident #122 was in bed sleeping. He was clean and dry. His face was covered with his sheet. During an interview with LVN K at 5:15PM, he said Resident #122 usually go to bed after dinner and he sleeps through the night. He said not to disturb him because noise irritate him. LVN K said Resident #122 was a post war veteran and gets irritated when he hears noises. LVN K said he had an in-serviced on 02/15/24 to reduce noise at the nurse's station during shift change. He said he had not observed resident #122 with any sign of behavior. During an interview with the DON on 02/16/24 at 6:00PM, he said Resident #122 had not shown any sign of suicidal ideation since he came back from the hospital around August. He said all active staff were in-serviced on suicidal precaution sometime in August. He said he had initiated an in-service on 02/15/24 when the issue of suicide was brought to his attention. Observation and interview on 02/17/23 at 12:30PM, revealed Resident #122 in his wheelchair in the dining room socializing with other residents. During an interview he said he was waiting for his lunch. Observation revealed no sign of depression. Observation on 02/17/24 from 1:30 to 3:00PM, revealed no concerns. Observation revealed there were two staff nurses on each station (2,3, & 4). Observation and interview on 02/17/24 at 4:30 PM revealed Resident #122 in bed and said he was doing fine. He said he was looking forward to going home as soon as he gets better. He said he was not ready to go home until he was strong enough to transfer himself from his wheelchair to bed. He said he was receiving therapy and working on being strong. He said the only thing he hated was the noise that remind him of the war. He said all he heard during the war were people crying for help and in pain. He said noise brought bad memories to him. He said that was one of the reasons why he had to sleep with his head covered. He denied suicidal ideation. Record review of facility policy on Suicidal Threats (undated) stated: If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Observation on 02/18/24 at 12:30PM revealed Resident #122 was in church activities in the dining room. He was clean and dry. No concern on observation. Observation at 1:30PM revealed he was observed in his room with his call light on. During an interview, he said he needed to be changed and assisted back to bed. CNA G. Administrator was notified an Immediate Jeopardy situation was identified on 2/16/24at 6:36 pm a template was provided. Facility's Plan of removal was accepted on 02/18/24 at 2:00PM and included: [facility] - Plan of Removal F 740 Resident #122's Care Plan and behavioral health concerns and needs were reviewed again on 02/16/2024 by the Interdisciplinary Care Team. The Director of Nursing initiated Safety Rounds for Resident #122 at 7:00 p.m. on 02/16/2024. Resident #122 was interviewed and assessed by the Director of Nursing at 7:15 p.m. and found to have no suicidal ideations and no active suicidal behaviors. Resident #122 was found to be stable and in good mood. A Clinical Chart review of Resident #122 was conducted by the Interdisciplinary Care Team. The Interdisciplinary Care Team updated Resident #122's to add specificity to individualizing the Care Plan to state resident's name instead of using the word resident, added Monitor for Safety, Monitor for Target Behaviors, Behavior Management of PTSD and monitoring Target Behaviors, Monitor for mood due to PTSD, risk for Visual Impairment due history of CVA, ADL Self Care deficit due to history of CVA Completion Date: 02/16/2024 Resident #122's Care Plan was reviewed again on 02/16/2024. Review of Resident #122's Care Plan confirmed that the Care Plan was updated on 09/12/2023 and 02/15/2024 to identify history of PTSD and suicidal ideations. The trauma informed care assessments that were completed 08/03/2023, 01/18/2024 and 02/17/2024 were used to update Resident #122's Care Plan. The facility did determine how to lessen the likelihood of Resident #122's triggers by relocating him closer to the nursing station for safety, closer observation and decreased environmental noise. Information was added to the Resident's Care Plan to address how to lessen the likelihood of triggers on 02/15/2024. Completion Date 02/17/2024 Head to Toe Assessment of Resident #122 - Completed 02/16/2024. Psychiatric Nurse Practitioner was contacted and notified by Director of Nursing concerning Immediate Jeopardy F 740 regarding Resident #122's needs and assessment. Completion Date: 2/16/2024 and 02/17/2024. Resident's attending physician and the Medical Director were notified of the Immediate Jeopardy related to F740 regarding Resident #122. Completion Date: 02/16/2026 and 02/17/2024 QAPI Meeting - A Called Ad Hoc QAPI Meeting was held on the evening of 2/16/2024 to review and address the Immediate Jeopardy citation. Completion Date: 02/16/2024 In-services - The Director of Nursing re-educated and in serviced all staff on Managing Residents with Behaviors, Suicide Ideations, Dementia, and other Behaviors. The Objective of the In-Services is to educate staff on (1) Reporting residents who express Suicide Ideations to the licensed charge nurse, Director of Nursing, one of the Assistant Director of Nursing, Weekend Supervisor, Administrator, or other management staff immediately. (2) Educating staff on understanding persons with Dementia, (3) Understanding post-traumatic stress disorder (PTSD), (4) Understanding the importance of keeping residents calm when exhibiting behaviors, (5) The need to provide trauma informed care and culturally sensitive care. Direct care staff will not allowed to provide direct resident care until they have completed Inservice Training on the aforementioned topics. Completion 02/17/2024 Staff were Inservice on using the individualized plan of care to assist with person-centered intervention for each resident. Staff will not be able to provide direct resident care until they have completed Inservice training on using the individualized plan of care to assist with person-centered interventions for each resident. Trauma Informed Care Assessment has been completed on Resident #122. The Trauma Informed Care Assessment looks for psychological symptoms or triggers that prompt recall of a previous traumatic event. The primary purpose is to address the needs of trauma survivors by minimizing triggers or re-traumatization. Completed 02/17/2024 Facility Plan to Ensure Compliance All Residents were reviewed for Diagnosis of PTSD. Four (4) of 125 Residents were identified to have diagnosis of PTSD. The four residents identified Care Plans were reviewed and updated to ensure they are individualized to identify and meet the needs of each resident. The Care Plans of all four residents with a history of PTSD were updated and individualized to add behavior management / risk for behaviors related to PTSD. No other residents were identified with a history of SI. Completion Date: 02/17/2024 Social Worker and/or Registered Nurse completed updated PHQ-9 Assessments on all four (4) Residents with diagnosis of PTSD. (Residents were in bed asleep on 02/16/2024). Social Worker completes a Resident Mood Interview, also known as PH Q-9, on all residents quarterly or as per MDS schedule. The PHQ-9 is a psychological assessment tool to measure depression. No other residents with a history of SI were identified. Completion Date: 02/17/2024 Administrator will inform and Inservice Interdisciplinary Team regarding Care Plan Policy including residents with diagnosis of PTSD and updating residents' Care Plans to identify and address the individualized behavioral health needs and person-centered concerns and interventions for all residents. Administrator and Director of Nursing reviewed the Care Plan policy and confirmed that it includes that review of residents who are readmitting from the hospital and includes that person-centered care plans include care planning for physical, mental, and psychosocial well-being of each resident. Care plans are revised relating to behavioral and mental health based on initial assessments, quarterly and as information about the resident and the residents' condition change. Completion: 02/17/2024 Director of Nursing will continue to Inservice all facility staff on Managing Residents with Dementia, PTSD, Suicide Ideation and Other Behaviors. Resident Care Plans are archived in Point Click Care, and all nursing staff have access to Point Click Care. Completion Date: 02/17/2024 Trauma Informed Care Assessment has been completed on all residents identified to have a diagnosis of PTSD. The Trauma Informed Care Assessment looks for psychological symptoms or triggers that prompt recall of a previous traumatic event. The primary purpose is to address the needs of trauma survivors by minimizing triggers or re-traumatization. Completed 02/17/2024 Administrator shall create a Monitoring Tool to monitor Care Plans for residents with diagnosis of PTSD and Suicide Ideations to confirm they have been updated. Completion 02/17/2024 The surveyor confirmed the plan of removal had been implemented sufficiently from 02/17/24 to 02/18/24 by During an interview with facility Administrator and the DON on 02/17/23 at 1:00PM, the Facility Administrator said the facility had initiated training and in-services since the incident was brought to the attention of the facility. She said the DON had in-services with all available staff and will continue to provide in-services till all staff are trained to implement resident's behavior on care plan and the attention of staff during morning meetings. The DON said some of the residents are post war veterans. He said the facility had identified 4 out of 17 residents with the diagnoses of PTSD. He said the facility had gone through all care plans, reviewed and revised their care plan to reflect their diagnoses. The DON said he would continue to provide in service and training to minimize noise during shift change. During an interview with LVN E on 02/17/24 at 5:00PM, she said she had just had an in-services on documentation, answering call lights and paying attention to resident's verbalized concerns. During an interview with CNA G on 02/18/24 at 1:45PM, CNA G said she had an in-service communication with residents and ensuring that their needs are being met and paying attention to their verbal communication. She said she would stay with any resident with suicidal ideation and find out if they have a plan on how. She said she would remain with the residents and notify the nurse in charge and the DON. She said she would the conversation on the resident chart. Record review on 02/17/24 revealed Resident #118, #122, #209, and 314's clinical record care plan had been updated to include their diagnoses of PTSD. Interview on 02/18/24 at 3:34PM RN H said he worked at the facility double on weekend 6AM-10PM shift and was in serviced on suicidal ideation and threats to take the following steps: place the resident on 1 on 1 supervision never leaving the resident, remove any objects in the resident room that the resident could use to try and harm themselves, call the RP, doctor, and Administration. To ensure that all communication with the resident were documented on the resident's clinical record and followed up on. Interview on 02/18/24 at 3:45PM, RN M said he worked the weekends and as needed 6AM-10PM shift. He said he was in-serviced on suicide precautions on 02/17/24 that if a resident expressed suicide ideation to not leave the resident alone, place the resident on to one supervision, remove any objects that resident could use to harm himself, notify the family, doctor, and Administrator. RN K said resident had to remain on one-to-one supervision until sent out for psychiatric evaluation\further notice. Interview on 02/18/24 at 3:50PM CNA F said she was a fulltime staff and had been at the facility for almost a year. She said she remember having an in-service on suicidal threats if a resident expressed harm to themselves. She said that was long time ago when she first started and had just had one yesterday 02/17/24. She said to stay with the resident do not leave them alone, inform the charged nurse, and continue to monitor the residents. She said she would tell the charge nurse, the administrator and continue conversation with the resident till further action is taken. Interview on 02/18/24 at 4:00 PM CNA I said she worked regular full time she said she had been in-serviced on suicidal attempts. CNA I said that if a resident expressed that they wanted to harm themselves she was not to leave the resident alone, have someone to go and inform the nurse, make sure that she removed any objects from the resident room to prevent the resident from harming themselves. She would make sure that she engages the resident in conversation through her shift. She said she had been working at the facility for over a year and had not witness any resident talked about hurting themselves. Interview on 02/18/24 at 4:15 PM LVN T said he worked the 2:00 PM-10:00 PM shift full time. LVN T said she received in-serve on suicidal precautions to never to leave the resident alone and to remove any objects that the resident might use to harm themselves, and to send for the DON and ask a CNA to remain with the resident. She said the last in-services she had was on 02/18/24 this morning to keep noise down during shift change and to pay attention to resident's call light. All resident identified with PTSD diagnoses were observed from 12:00PM to 5:00pm observation revealed no sign of distress. Records review revealed all were updated to reflect monitoring, reporting and documentation. On 2/18/24 at 5:30PM, the Administrator was informed that the Immediate Jeopardy (IJ) was removed, however, the facility remained out of compliant at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm , the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 4 residents , (Residents # 1 and #2), reviewed for supervision in that: Resident #1 was assaulted by his roommate, Resident #2,who had a history of [REDACTED].#1 sustained blackened eyes, a bloody nose and a swollen lip. This failure affected 2 residents and placed 145 additional residents at risk of physical, emotional and mental harm. Findings include: Intakes: # 5, 5, 5, 4 Resident #1 Record review of the clinical chart for Resident #1 revealed the [AGE] year-old male resident was originally admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Further review of the clinical chart revealed Resident #1 was a resident of the secure unit due to wandering behaviors Record review of Resident #1's care plan dated 6/15/18 revealed he resided in the secure unit due to risk of elopement. Interventions included, .Monitor whereabouts when wandering and redirect as needed, approach in a calm manner .avoid confrontation when agitated. Record review of Resident #1's quarterly MDS with an ARD of 7/20/18 revealed the resident could not participate in the BIMS interview indicating he is severely cognitively impaired. He was usually understood and could usually understand others. He did not exhibit behaviors. The review also revealed the resident is 5 ft. 4 inches and weighs 150 pounds and has had no behavioral issues. Observation and attempted interview with Resident #1 conducted on 8/24/18 at 12:50 PM revealed Resident #1 to be a small man with a slight build who was on top of the covers on his bed. Observations revealed dark bruising underneath both eyes. When questioned as to what happened to him and what caused his injuries he attempted to verbalize but could not be understood. He did however, demonstrate to the surveyor what occurred by balling up his fist and acting like he was throwing punches. Resident #2 Record review of the clinical chart for Resident #2 revealed the [AGE] year-old male resident was originally admitted to the facility on [DATE] to the secure unit and moved into general population on 3/26/18. His [DIAGNOSES REDACTED].), other specified depressive episodes, mood disorder due to known physiological condition, unsp, cough. Record review of Resident #2's care plan dated 2/15/18 revealed he had episodes of verbal aggression towards other resident and resided in the secure unit for safety due to elopement. Interventions included, Educate resident regarding acceptable alternatives to identified behaviors .positive reinforcement, monitor whereabouts when wandering and redirect as needed .avoid confrontation when agitated. Resident #2's care plan was updated on 3/8/18 to include an incident in which he pushed another resident causing him to fall. No new interventions were put in place. Resident #2's care plan was updated 8/9/18 to include an incident in which he became upset in the main dining room because he could not sit at a certain table. Interventions included increasing anti-anxiety medication. Record Review of Resident #2's quarterly MDS with an ARD of 7/27/18 revealed Resident #2 had a BIMS score of 06 indicating he had severe cognitive limitations. He did not exhibit behaviors. The review revealed the resident was on hospice services due to his terminal illness, was independently ambulatory and was 5 ft. 6 inches tall and weighed 212 pounds. Record review of incident log revealed a previous assaultive incident involving Resident #2 that occurred on the secure unit on 3/8/18 at 11:07 AM. Review of the incident revealed that a resident from another room wandered into Resident #2's room at the time (room [ROOM NUMBER] A), and opened Resident #2's drawer. The review revealed Resident #2 walked up to the other resident and shoved him, causing the resident to fall backwards hitting his head on wall and caused skin tears to bilateral elbowes, (sic) and laceration to parietal . Record review of physician's progress notes dated 3/15/18 read in part, .room [ROOM NUMBER] .Patient was examined and nurses have reported that his cervical (unknown term used in this context) was recently increased because of behavioral problems. He states he becomes aggravated because of his loud roommate. Nursing staff are working on getting him another room. Record review of the document entitled, ROOM CHANGE NOTIFICATION revealed Resident #2 was admitted to the secure unit 413 A on 8/16/18 at 12:30 PM. The document read in part, .Resident is being moved because he has been talking about making the great escape this weekend and he has also posted it on his facebook account . Record review of the document entitled, Provider Investigation Report', revealed that an incident involving Residents #1 and #2 occurred 8/22/18 at 7:40 PM and was reported to the State Agency on 8/23/18 10:56 PM. The review revealed Resident #1 was going through Resident #2's drawer when the nurse heard a noise, went to the room and separated both residents. Both residents were sent to the hospital for further evaluation and treatment. Tests conducted for Resident #1 revealed no fractures. The review further revealed that upon Resident #2's return to the facility, he was placed on 1-1 supervision with no roommate. Record review of the facility's incident report dated 8/23/18 read in part, Writer heard someone yellin', (sic) When I went into the room resident was on top of his roommate in roommates bed. I noted that room mates face was bleeding. This writer separated, (sic), the two residents. Resident stated that his roommate was going into his drawer and hit him when he tried to stop him so he hit the roommate back . Observations could not be conducted of Resident #2 during the investigation as the resident was at a local hospital pending admission to their in-house palliative care unit. Interview with LVN A on 8/24/18 at 2:40 PM revealed she heard someone yelling nurse' and she immediately went to the room occupied by Residents #1 and #2--room [ROOM NUMBER]. She stated she observed Resident #2 on top of Resident #1 who had blood on his face. She assessed the resident and took his vitals. He was sent out to the hospital. LVN A stated she asked Resident #1 if Resident #2 had hit him and he stated yes LVN A stated she has just started working at the facility and has only been there about a week and a half. She stated she notified the Harris County Guardian and administration and wrote up the incident. She also stated she really didn't get a chance to work with the residents very long. When Resident #2 returned last night (8/23/18), she provided 1 to 1 supervision of him until he was sent out again for further evaluation. Interview with CNA C on 8/24/18 at 2:15 PM revealed she did not see the incident but was present at the time the injured resident was assessed. She stated the resident was crying, had blood on his eye and it was puffed up. Record review of consult regarding Resident #1 from the Nurse Practitioner dated 8/23/18 read in part, Urgent consult from facility re: aggressive behaviors .Last night Pt was in a physical altercation with another resident, who was also his roommate.Pt has a hx of physical violence, tends to be very territorial, easily agitated and quick to anger. Pt is currently on 1-1 due to aggressive/violent behaviors . RP states PT has a hx of physical violence and is hot tempered.Currently calm with intermittent [MEDICAL CONDITION]/o Pt with recent assault on another male resident, hx of physical violence, Pt is at a high risk of harming others, including residents and staff members despite the injuries caused to his roommate, he does not appear to have any remorse or regret for hurting his roommate. When asked what happens when another resident comes into his room, Pt responded, I will beat his a** . Record review of undated document entitled, Abuse and Neglect Inservice read in part, Each resident has the right to be free from verbal, sexual, physical and mental abuse The following standards of practice will be operationalized in order that resident's, (sic), will not be subject to abuse by anyone, including but not limited to, facility staff, other residents, consultants, contractors, , volunteer or staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrator's designee. Local law enforcement, the state survey agency, and the Department of Family and Protective services, (if appropriate) will be notified in accordance with federal and state law . Record review of the document entitled, Resident -to-Resident Altercations, read in part, If two residents are involved in an altercation staff will: Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation .Review the events .including interventions to try to prevent additional incidents .Report incidents, finding and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy .Revised (MONTH) 2007. According to the facility's CMS Form 672, the census was 147.

Based on observation, interview, and record review, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 3 of 10 residents (Residents #1, #2 and CR #1) reviewed for administration in that: - The Administrator and DON failed to follow their abuse policy and failed to recognize the possible sexual abuse between Residents #1 and #2 and between Resident #1 and CR #1. - The Administrator and DON failed to ensure residents were appropriately assessed for consensual sexual activity and failed to recognize the resident's capacity to consent. - The DON failed to ensure facility staff were aware of the incidents between Resident #1 and Resident #2 and provided adequate supervision to cognitively impaired residents in the secure unit. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE], 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 pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 2 residents and 1 former resident and placed the other 39 residents who resided in the secure unit at risk of unwanted sexual advances, abuse, mistreatment and neglect. Findings included: In an interview on [DATE] at 11:20am, the Administrator said she monitored facility staff, including the DON. She said she monitored incidents and staffing daily, reviewed documentation, conducted a meeting every morning and reviewed the 24 hour report. She said she was aware of the incident that occurred between Resident #1 and Resident #2. She said she relied on her department heads to gather information and investigate the incident. She said she did not see how or why this incident was an immediate jeopardy. In an interview on [DATE] at 2:20pm, the DON said the incident between Resident #1 and Resident #2 was consensual. She said she was not sure why the incident was an immediate jeopardy. She said if residents had sexual behaviors, they separate the residents and redirect them. She said they are constantly redirecting residents on the secure unit. She said they in-serviced staff frequently on abuse and neglect. Resident #1 Record review of Resident #1's medical record revealed he as admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. He had a court-appointed guardian. Record review of Resident #1's History and Physical completed by his physician dated [DATE] revealed he was admitted to the facility from the hospital after he had increasing agitation at previous nursing home. The physician reports the resident was very confused and cannot give any history. Record review of Resident #1's care plan dated [DATE] revealed he had behaviors of wandering, difficulty to redirect and episodes of aggression. Interventions included educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 when unable to participate in group activities .1:1 as needed, refer to psych services as needed with exacerbation or inability to effectively redirect behaviors, remove resident from common areas during times of unacceptable behavior . The care plan was updated on [DATE] to include behaviors related to being in a female resident's room stripping and displaying sexual behavior. No new interventions were added to the care plan after the update. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he was usually understood and could usually understand others. He had a BIMS score of 0, indicating severe cognitive impairment. A staff assessment for cognition was not completed. Resident had other behavioral symptoms not directed toward others daily. He had wandering behaviors daily. He required supervision for transfers and was independent for walking and locomotion. Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 4:08pm written by LVN A: Resident wandered in another room was alone with female resident, female resident was stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract this residents attention no physical contact made staff intervened and separated resident . Record review of a Progress Note completed by NP A dated [DATE] revealed the nurse practitioner received a call from a facility staff member who reported Resident #1 was found in bed with another resident, about to have sexual relations. Redirected, but found a second time, almost the point of penetration. NP A gave a [DIAGNOSES REDACTED]. In an interview on [DATE] at 1:00pm, ADON said NP A was not available for interview because he was out of the country. Record review of Resident #1's physician's orders [REDACTED]. Record review of an Informed Consent for Psychoactive Medications dated [DATE] revealed Resident #1's guardian consented to the use of [MEDICATION NAME], an antimanic medication, used to treat sexual disorder. Record review of a physician's orders [REDACTED]. Record review of Resident #1's MAR indicated [REDACTED]. CR #1 Record review of CR #1's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. She was discharged to the hospital on [DATE]. Record review of CR #1's admission MDS assessment dated [DATE] revealed she was usually understood and could usually understand others. She had a BIMS score of 8, indicating moderate cognitive impairment. She demonstrated physical and verbal behaviors ,[DATE] days out of 7 days and had other behaviors not directed toward others ,[DATE] days out of 7 days. She required supervision and setup for locomotion on unit, walking and transfers. Record review of CR #1's Care Plan dated [DATE] revealed she had behavioral issues related to dementia, mood disorder and [MEDICAL CONDITION] disorder. Interventions included, Offer schedule of activities for resident to select choices, engage resident in group activities .offer activity programs directed toward specific interests of resident. Further review of CR #1's care plan revealed she had sexual behaviors toward others, including stripping and displaying sexual behaviors in male resident's room. Interventions included, educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 activity programming 3 x/week when unable to participate in group activities .remove resident from common areas during times of unacceptable behavior . Record review of CR #1's nursing progress notes revealed the following: - [DATE] at 3:59pm written by LVN A: Resident wandered in another room was alone with male resident stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract male resident's attention no physical contact made staff intervened and separated resident . - [DATE] at 5:51pm written by Unit Manager A: Called (family member) informed her that resident observed in another room with a male resident both residents were stripping and displaying sexual behavior, no contact was made due to staff walking in room and directed both resident to redress and go to common area for activities. (Family member) informed me she was told that there might be some heighted (sic) sexual behavior that she has never displayed before, she had always been quiet and reserved . - [DATE], [DATE] and [DATE] notes that Resident displaying sexual behavior rolling hips, rolling tongue. - [DATE] at 9:20pm: Resident stable at the time, laying in bed .Resident has been slightly agitated today .resident got upset about staff getting another resident out of her room that she stated she wanted to have sex with. Resident came out of room naked yelling and screaming she was going to call the police because staff won't let her have sex. Redirection finally successful . -[DATE] at 2:24pm: Resident was displaying physically aggressive behavior towards nurses, CNAs and Resident #1. 911 was called and she was discharged to the hospital. In an interview on [DATE] at 3:25pm, the ADON said the incident on Feburary 23, (YEAR) that occurred between CR #1 and Resident #1 did not have an incident report. When asked about the progress note completed by NP A on [DATE], he said NP A must have been mistaken. He said there was no evidence that the incident NP A described occurred. In an interview on [DATE] at 10:20am, LVN A said she did not recall the incident between CR #1 and Resident #1. She said she did not think they had any physical contact. She said CR #1 had some sexual behaviors. She said Resident #1 usually stayed out of his room and talked to the female residents. Resident #1 continued- Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 9:41am written by RN A: It was reported to nurse that resident was noticed leaving a female residents room adjusting his pants at 9:15am. Nurse immediately assessed female resident noticed her pant were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to assessment. Female denied any involvement with male resident and stated that she pulled her own pants off. Unable to redirect male resident x3, resident yelling at staff and displaying aggressive verbal behavior. Resident denies any involvement with foul play and walks towards his room. Q 15 minute checks initiated. At 9:30am staff attempted to redirect resident to common area, but resident being continuously defiant to staff and was unable to redirect to main area. Resident began to walk towards room. At 9:36am nurse was called again when a staff member (MDS Nurse) reported the same female resident was noticed in his room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female was on toilet in his room. Immediately redirected both residents. Nurse assessed both resident no apparent injuries noted at this time. Female resident currently in her room and male resident in main area. Will continue 15 min checks. - Addendum: [DATE] at 11:41am SW A notified and assessed resident. One on one care initiated by staff. No further redirection necessary at this time. - [DATE] at 1:28pm written by LVN B: Resident continued to pace and wander up and down the unit, going room to room, frequently redirected back to his room, in 0 distress . - [DATE] at 6:39pm written by SW B: SW interview (Resident #1) in day room after resident was reported in female resident room. (Resident #1) could not recall inappropriate behavior with female resident. Resident says, 'NO I would not do that because I have a wife and when I leave here I am going to pick her up from work.' (Resident #1) coach on appropriate and inappropriate behavior and touching Resident denies having attraction to female resident. Cannot recall if he or female resident were visiting each other's room. Record review of Resident #1's care plan for behaviors was updated on [DATE] to include the following behavior: resident observed in 'sexual inappropriate behavior, was touching female vaginal area. No new interventions were added to the care plan after the update. Record review of an incident report dated [DATE] revealed Resident #1 was observed walking out of a female resident's room adjusting his pants. Resident #1 denied involvement and placed on Q 15 minute checks. At 9:36am, the MDS Nurse reported to the same residents were in his room with Resident #1 touching female resident inappropriately. Immediate actions taken were to separate residents and initiate Q 15 minute checks. Record review of a witness statement dated [DATE] completed by CNA A revealed at 9:15am, she was monitoring residents in the dining room. I then noticed that some of the them that wander in other rooms was not present, so I went to make rooms checks only to see (Resident #1) come out of (Resident #2's room) pulling his pants up. Then I went behind the curtain I saw (Resident #2) laying on A bed with pants and pull-ups off beside her, I then asked her what was wrong she said nothing . Record review of a witness statement dated [DATE] at 9:30am completed by MDS Nurse revealed the following: I observed in (Resident #1's room) in the secure unit Resident standing over other resident who was on the bed with bottom half of clothing down to her knees, male resident was penetrating female resident's vagina with his fingers. When I called out to (RN A) male resident came out of room and female resident went into restroom . Record review of a physician's orders [REDACTED]. Record review of 1:1 documentation for Resident #1 dated [DATE] revealed staff documented 1:1 supervision from 11:22am to 1:05pm. Record review of a document provided for every 15 minute checks revealed Resident #1 was checked on every 15 minutes on [DATE] starting at 9:15am and ending on [DATE] at 4:30pm. In an observation and interview on [DATE] at 4:30pm, Resident #1 said he had been at the facility for one week and was ready to go home. He said he was married and did not have to be in the facility for long. When asked about having a sexual relationship in the facility, he said Oh, no. I am married. I stick with her. She makes me so happy .2 weeks I haven't talked to her. I love putting my arms around her and squeezing her and saying 'I love you!' He said he was not sure why he was at the facility. He said he did not know Resident #2. Resident #2 Record review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed was understood and could understand others. She had a BIMS score of 0, indicating severe cognitive impairment. She did not display any behaviors. She required supervision and setup for transfers, walking and locomotion on the unit. Record review of Resident #2's care plan dated [DATE] revealed she had impaired cognition and long-term memory loss due to dementia. Interventions included Keep instructions simple and short, reorient as appropriate, however do not argue or agitate resident .observe for changes in cognitive status . The care plan was updated on [DATE] due to resident observed in sexual inappropriate behavior and allowed male resident to touch her vaginal area. Updated interventions included head to toe assessment, psych review and medication adjustment. Record review of Resident #2's Nurse Progress Notes revealed the following: - [DATE] at 11:44am completed by RN A: It was reported to nurse that a male resident was noticed leaving resident's room adjusting his pants at 9:15m. Nurse immediately assessed resident noticed her pants were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to toe assessment. Resident denied any involvement with male resident and stated that she pulled her own pants of. Female resident was laying in her bed when staff left room. Q 15 minute checks initiated on resident .At 9:36am nurse was called again when staff member reported resident was noticed in the same male's room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female resident was on toilet in his room. Immediately redirected both residents .Will continue Q 15 min checks. - [DATE] 6:33pm completed by Unit Manager A: Called (Resident #2's responsible party) .I informed him of the compromising incident his (family member) was found in today with a male resident twice. No injury occurred and resident admitted she let male resident touch her willingly and when I went back about a half hour later she had know (sic) idea what I was talking about . - [DATE] at 6:38am completed by SW B: Was informed of sexual behavior between two residents .SW mentioned the incident between her and male resident, (Resident #2) said 'no, nothing happened.' SW then ask were you in a male resident room or was he in your room and (Resident #2) denied room visit .Resident: 'No I didn't touch anybody, nobody touched me, and I didn't have my pants down.' Record review of Resident #2's Behavioral Medicine Progress Note dated [DATE] revealed staff reported to Psychiatric NP that Resident #2 had a history of [REDACTED]. Facility staff reported asking the resident is she was forced or hurt, but she could not remember. Psychiatric NP stated, (Resident #2's) dementia can trigger inappropriate behaviors, increase loss of inhabitation and self-control .Will initiate [MEDICATION NAME] to target libido, reduce hypersexuality and impulsivity . Record review of a physician's orders [REDACTED].#2 was ordered [MEDICATION NAME] 50mg (an antidepressant medication), one tablet by mouth every day for anxiety and inappropriate sexual behavior. In an interview on [DATE] at 10:30am, ADON said the psychiatrist ordered [MEDICATION NAME] for Resident #2 to decrease her libido. He said they were going to try it and then attempt a gradual dose reduction if needed. In an interview on [DATE] at 4:00pm, Resident #2 said she liked staying at the facility. She said her husband died a few years ago and she has been here since then. When asked about sexual relationships at the facility, she said she has not had any type of relationship with anyone. She said she would like to. I hope it happens soon. Record review of Resident #2's MDS assessment dated [DATE] revealed she had a BIMS score of 10, indicating moderate cognitive impairment. Record review of a e-mailed statement completed by the Regional Quality Manager dated [DATE] revealed she completd the updated BIMS assessment on [DATE] at 10:00am. The statement read in part . I asked all of the questions on the BIMS assessment, and then marked her responses on the form. After that portion was over, I asked her if she remembered any particular incident that had occurred between her and any other residents. She said 'no, not really'. I asked her if she remembered that she had been in a male resident's room. When I said that, her face lit up and she replied 'yes'. I asked her what she was doing in his room. She said 'I was sitting on his bed and we did some talking'. And then she looked at me and said 'we didn't have sex!' I told her that I didn't think that she had, but there would be no shame if she had. I asked her if she knew what to do if someone wanted to have sex with her and she didn't want that, and she said 'yes, I would kick in between the legs' I asked her if she enjoyed sex, and she said 'well of course!' and laughed out loud .Had I not known better, I would have assumed she had no memory issues. Based on that conversation, I believe she was well aware of the sexual activity that had occurred and was very much in agreement with what happened. In an interview on [DATE] at 5:15pm, SW A, when asked about sexual abuse, said there was something that occurred yesterday. She said the Administrator was aware of the incident. She said Resident #1 was seen walking out of Resident #2's room. She said when she became aware of it, she interviewed the residents about 20 minutes after the incident. She said Resident #2 consented to the behavior. She let her know if that was something she wanted to do they could talk about it. She said she also notified the resident's families. In an observation on [DATE] between 6:40pm and 7:20pm, Resident #1 was sitting in a chair in the corner by an exit door, alone. All staff were assisting other residents or at the nurse's station. In an observation and interview on [DATE] at between 6:40pm and 7:20pm, Resident #2 was lying in bed, watching television. There were no staff members in her room. She was alert and oriented to self. She said she could not recall witnessing abuse at the facility. She said no one had touched her inappropriately. In an Interview on [DATE] at 7:15pm, Unit Manager A said in the secure unit there were 2 CNAs, 1 nurse, 1 med aide, activity aide on the 10am to 6pm shift and the unit manager during the day. She said if there is an incident, they do every 15 minute checks for 72 hours. She said Resident #1 was observed walking out of Resident #2's room. Resident #2 was in her room with her pants down, her brief off. She said she did a head to toe assessment and there was no sign of penetration. She said 30 minutes later they were found in his room and he was touching her vaginal area. She said when Resident #2 was interviewed, she said she consented to the activity. When asked if she could consent, she said it was a thin line, because she could not remember what happened shortly after the incident. When asked if it was possible sexual abuse, she said it was a 'catch 22' because Resident #2 said she consented right after. She said she did not think to send either resident to the hospital. She said about 2 to 3 months ago, Resident #1 was found in another female resident's room, but she was not aware of physical contact. In an interview on [DATE] at 6:00pm, Unit Manager A said CR #1 had some behaviors. She said CR #1 was oriented to the unit. She said CR #1 tried to entice Resident #1 at least two times but was not aware of sexual contact. In an interview on [DATE] at 6:45pm, CNA C was working on the secure unit. He said he was not aware of abuse or neglect. He said there were no recent incidents in the facility. When asked about residents that require extra supervision, he said Resident #2 was monitored frequently because she wandered into male resident's rooms. In an Interview on [DATE] at 7:20pm, CNA B said she had worked on the secure unit for 4 months. She said she worked the 2pm-10pm shift. She said she worked on the secure unit [DATE] to [DATE]. When asked if she checked on any residents more frequently, she said when she did rounds she checked in every room. She said all the residents require supervision. She said she checked Resident #2 every 30 minutes because she goes in and out of male resident's rooms. She said she heard about sexual behaviors that occurred yesterday. She said Resident #2 was found with a male resident in her room. She said she could not remember the name of the male resident. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #1 was sitting in a chair in the corner by an exit door, alone. He got up and walked around the hall, looking into other resident's rooms. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #2 was in the dining room for lunch. In an interview on [DATE] at 12:15pm, CNA D said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she was not aware of the details, but knew it involved Resident #1 and Resident #2. She said right after the incident, Resident #1 was on 1:1 supervision. She said she was not sure when it ended. She said she was not aware if either resident required special supervision. She said she completed rounds on all residents. She said she was not aware if Resident #1 or Resident #2 had past sexual behaviors. In an interview on [DATE] at 12:20pm, CNA A said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she saw Resident #1 walking out of Resident #2's room, adjusting his pants. She said she went in the room and noticed Resident #2 was in bed with her pants and brief off. She said she called for RN A. She said she was not sure what the nurse did, but later, CNA A changed the sheets Resident #2 was laying on. She said Resident #2 was laying on a bed that was not hers. She said she did not see anything on the sheets. She said she was not aware of past sexual behaviors. When asked if she would consider the incident sexual abuse, she said yes, maybe. In a telephone interview on [DATE] at 1:45pm, the MDS nurse stated on the day of the incident, she was on the secure unit looking at medical charts. She said when she was leaving the secure unit, she noticed movement in a resident's room. She said she entered Resident #1's room and saw him standing above Resident #2, her knees were up, and his fingers were in her vagina. She said she yelled for RN A. She said when she called for help, both residents reacted and got up real fast. She said when RN A arrived, Resident #2 was sitting on the toilet and Resident #1 walked out into the hallway. She said she did not think the incident was sexual abuse because didn't see anything that would indicate either resident was coerced or uncomfortable. She said they acted like she interrupted. She said Resident #2 was confused but accurate. She said Resident #1 was pleasantly confused. She said after the incident, she did not update their care plans. In an interview on [DATE] at 2:00pm, when asked about Resident #1's [MEDICATION NAME]'s medication, SW A said they were trying to reduce medications such as [MEDICATION NAME]. She said the medication was discontinued to see if the behavior would reoccur. She said in this case, it did. She said she was not sure why he was put on the medication in March. She said the incident that occurred between Resident #1 and Resident #2 was not considered sexual abuse because no one appeared upset or mistreated, and no one complained about the incident. She said they would have considered it an allegation of sexual abuse if it had not been consensual. When asked about consenting to sexual behavior, she said everyone had the right to consent. She said when she interviewed the residents after the incident, they did not appear distressed, they were pleasant and they both acted like nothing happened. She said they did not have an assessment to determine whether a resident had the capacity to consent to sexual behavior. She said after the incident, interventions included to monitor and keep them separated. She acknowledged that both residents had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:20pm, SW B said after the incident that occurred between Resident #1 and Resident #2, she interviewed them separately. She said Resident #2 was able to consent to sexual activity because during the interview she said she could not remember. She said Resident #2 denied the whole incident. She said Resident #2 stated she was attracted to Resident #1. She said Resident #1 could not recall the incident. Resident #1 told her, I have a wife, I will pick her up later. She said 1:1 supervision was put in place but did not know when it ended. When asked how she would determine whether a resident had the capacity to consent, she said if a resident was alert and oriented and was a good historian. She said she would not consider the incident a sexual abuse allegation because the residents could not remember anything, they were not aware, and it did not affect them. She said their mood did not change. She said interventions put in place after the incident included every 15 minute checks and psych consult. In an interview on [DATE] at 9:43am, RN A said the day of the incident, it was reported to her by the CNA that Resident #1 was seen exiting Resident #2's room adjusting his pants. She said when she went in the room, Resident #2 was lying on the bed with her pants and brief off. She said when she asked what happened, Resident #2 said she took them off herself and denied any sexual activity. She said both residents were placed on Q 15 minute checks. She said when she asked Resident #1 what happened, he said he was not sure what she was talking about. She said a little while later, they were found in his room. She said Resident #1 was placed on 1:1 supervision. She said for any sexual activity, she would investigate and monitor. She said if consent was given, she would give them privacy. When asked if Resident #1 or Resident #2 had the capacity to consent, she said Resident #1 was more confused than Resident #2. In an interview on [DATE] at 2:50pm, the DON said a few months ago, there was another incident with Resident #1 and CR #1. She said CR #1 had a history of [REDACTED]. She said they were seen together a lot. She said there was an incident when CR #1's legs were open, her clothes were on and it seemed Resident #1 was trying to get himself erect. She said they put Resident #1 on [MEDICATION NAME] for a short period to see if it would decrease the behaviors. She said Resident #1 was pleasantly confused and does not have good recall. She said when the incident occurred between Resident #1 and Resident #2, she asked the social workers for guidance. She said she thought consent should be assessed after a sexual incident. She said when Unit Manager A assessed the residents, at that moment they were consenting to the behavior. She said both residents could not remember the incident shortly afterward. She said residents with dementia still have sexual needs. She did not think the incident was sexual abuse because there was not a clear aggressor. She said there was no one taking advantage of someone else. She said interventions put in place included social work involvement, psych assessment, close observation and the family was notified. She said she didn't think either resident was a threat to other residents. In an interview on [DATE] at 3:30pm, the Administrator, who is the abuse coordinator, said she was notified of the incident between Resident #1 and Resident #2 by Unit Manager A. She said the Unit Manager A reported that Resident #1 had a history of [REDACTED]. When they asked again, the residents could not remember. She said after the incident, the social workers and psychologist assessed the resident and added medications. She said the physician and family were notified. She said when Resident #2's family member was notified, he was not surprised by the behavior. She said Resident #1 denied the incident occurred by saying he was married. She said after she heard the details of the incident, she thought that both residents were consenting. She said she thinks they are both denying the incident occurred, rather than them not remembering. She said both residents can carry a conversation and they know what is going on. She said neither resident resisted the other. When asked if either resident had the capacity to consent, she said yes. She said they did not have a policy for sexual contact between residents. In an interview on [DATE] at 4:40pm, when asked about Resident #1's wife, SW A said it was possible that while engaging in sexual activity, Resident #1 could have thought Resident #2 was his wife. When asked if someone with a BIMS score of 0, with severe cognitive impairment, could

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 3 of 10 residents (Residents #1, #2 and CR #1) reviewed for supervision in that: - The facility failed to monitor Resident #1 and Resident #2, who were cognitively impaired, after alleged inappropriate sexual conduct. Resident #1 was seen walking out of Resident #2's room, and Resident #2 was in bed naked below the waist. Shortly afterwards, Resident #2 was found in Resident #1's room engaging in sexual activity. - The facility failed to monitor Resident #1 and Resident #2 after 2 reported incidents of sexual conduct. - The facility failed to ensure staff on the secure unit were aware of the incidents that occured between Resident #1 and Resident #2. - The facility failed to monitor Resident #1 and CR #1, two cognitively impaired residents, after inappropriate sexual conduct was reported. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE], 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 pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 2 residents and 1 former resident and placed the other 39 residents who resided in the secure unit at risk of unwanted sexual advances, abuse, mistreatment and neglect. Findings included: Resident #1 Record review of Resident #1's medical record revealed he as admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. He had a court-appointed guardian. Record review of Resident #1's History and Physical completed by his physician dated [DATE] revealed he was admitted to the facility from the hospital after he had increasing agitation at previous nursing home. The physician reports the resident was very confused and cannot give any history. Record review of Resident #1's care plan dated [DATE] revealed he had behaviors of wandering, difficulty to redirect and episodes of aggression. Interventions included educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 when unable to participate in group activities .1:1 as needed, refer to psych services as needed with exacerbation or inability to effectively redirect behaviors, remove resident from common areas during times of unacceptable behavior . The care plan was updated on [DATE] to include behaviors related to being in a female resident's room stripping and displaying sexual behavior. No new interventions were added to the care plan after the update. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he was usually understood and could usually understand others. He had a BIMS score of 0, indicating severe cognitive impairment. A staff assessment for cognition was not completed. Resident had other behavioral symptoms not directed toward others daily. He had wandering behaviors daily. He required supervision for transfers and was independent for walking and locomotion. Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 4:08pm written by LVN A: Resident wandered in another room was alone with female resident, female resident was stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract this residents attention no physical contact made staff intervened and separated resident . Record review of a Progress Note completed by NP A dated [DATE] revealed the nurse practitioner received a call from a facility staff member who reported Resident #1 was found in bed with another resident, about to have sexual relations. Redirected, but found a second time, almost the point of penetration. NP A gave a [DIAGNOSES REDACTED]. In an interview on [DATE] at 1:00pm, ADON said NP A was not available for interview because he was out of the country. Record review of Resident #1's Physician's Orders dated (MONTH) (YEAR) revealed [MEDICATION NAME] 10mg, 1 tablet by mouth daily had an order date of [DATE]. Record review of an Informed Consent for Psychoactive Medications dated [DATE] revealed Resident #1's guardian consented to the use of [MEDICATION NAME], an antimanic medication, used to treat sexual disorder. Record review of a physician's order for Resident #1 dated [DATE] revealed the [MEDICATION NAME] medication was discontinued. Record review of Resident #1's MAR indicated [REDACTED]. CR #1 Record review of CR #1's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. She was discharged to the hospital on [DATE]. Record review of CR #1's admission MDS assessment dated [DATE] revealed she was usually understood and could usually understand others. She had a BIMS score of 8, indicating moderate cognitive impairment. She demonstrated physical and verbal behaviors ,[DATE] days out of 7 days and had other behaviors not directed toward others ,[DATE] days out of 7 days. She required supervision and setup for locomotion on unit, walking and transfers. Record review of CR #1's Care Plan dated [DATE] revealed she had behavioral issues related to dementia, mood disorder and [MEDICAL CONDITION] disorder. Interventions included, Offer schedule of activities for resident to select choices, engage resident in group activities .offer activity programs directed toward specific interests of resident. Further review of CR #1's care plan revealed she had sexual behaviors toward others, including stripping and displaying sexual behaviors in male resident's room. Interventions included, educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 activity programming 3 x/week when unable to participate in group activities .remove resident from common areas during times of unacceptable behavior . Record review of CR #1's nursing progress notes revealed the following: - [DATE] at 3:59pm written by LVN A: Resident wandered in another room was alone with male resident stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract male resident's attention no physical contact made staff intervened and separated resident . - [DATE] at 5:51pm written by Unit Manager A: Called (family member) informed her that resident observed in another room with a male resident both residents were stripping and displaying sexual behavior, no contact was made due to staff walking in room and directed both resident to redress and go to common area for activities. (Family member) informed me she was told that there might be some heighted (sic) sexual behavior that she has never displayed before, she had always been quiet and reserved . - [DATE], [DATE] and [DATE] notes that Resident displaying sexual behavior rolling hips, rolling tongue. - [DATE] at 9:20pm: Resident stable at the time, laying in bed .Resident has been slightly agitated today .resident got upset about staff getting another resident out of her room that she stated she wanted to have sex with. Resident came out of room naked yelling and screaming she was going to call the police because staff won't let her have sex. Redirection finally successful . -[DATE] at 2:24pm: Resident was displaying physically aggressive behavior towards nurses, CNAs and Resident #1. 911 was called and she was discharged to the hospital. In an interview on [DATE] at 3:25pm, the ADON said the incident on Feburary 23, (YEAR) that occurred between CR #1 and Resident #1 did not have an incident report. When asked about the progress note completed by NP A on [DATE], he said NP A must have been mistaken. He said there was no evidence that the incident NP A described occurred. In an interview on [DATE] at 10:20am, LVN A said she did not recall the incident between CR #1 and Resident #1. She said she did not think they had any physical contact. She said CR #1 had some sexual behaviors. She said Resident #1 usually stayed out of his room and talked to the female residents. Resident #1 continued- Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 9:41am written by RN A: It was reported to nurse that resident was noticed leaving a female residents room adjusting his pants at 9:15am. Nurse immediately assessed female resident noticed her pant were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to assessment. Female denied any involvement with male resident and stated that she pulled her own pants off. Unable to redirect male resident x3, resident yelling at staff and displaying aggressive verbal behavior. Resident denies any involvement with foul play and walks towards his room. Q 15 minute checks initiated. At 9:30am staff attempted to redirect resident to common area, but resident being continuously defiant to staff and was unable to redirect to main area. Resident began to walk towards room. At 9:36am nurse was called again when a staff member (MDS Nurse) reported the same female resident was noticed in his room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female was on toilet in his room. Immediately redirected both residents. Nurse assessed both resident no apparent injuries noted at this time. Female resident currently in her room and male resident in main area. Will continue 15 min checks. - Addendum: [DATE] at 11:41am SW A notified and assessed resident. One on one care initiated by staff. No further redirection necessary at this time. - [DATE] at 1:28pm written by LVN B: Resident continued to pace and wander up and down the unit, going room to room, frequently redirected back to his room, in 0 distress . - [DATE] at 6:39pm written by SW B: SW interview (Resident #1) in day room after resident was reported in female resident room. (Resident #1) could not recall inappropriate behavior with female resident. Resident says, 'NO I would not do that because I have a wife and when I leave here I am going to pick her up from work.' (Resident #1) coach on appropriate and inappropriate behavior and touching Resident denies having attraction to female resident. Cannot recall if he or female resident were visiting each other's room. Record review of Resident #1's care plan for behaviors was updated on [DATE] to include the following behavior: resident observed in 'sexual inappropriate behavior, was touching female vaginal area. No new interventions were added to the care plan after the update. Record review of an incident report dated [DATE] revealed Resident #1 was observed walking out of a female resident's room adjusting his pants. Resident #1 denied involvement and placed on Q 15 minute checks. At 9:36am, the MDS Nurse reported to the same residents were in his room with Resident #1 touching female resident inappropriately. Immediate actions taken were to separate residents and initiate Q 15 minute checks. Record review of a witness statement dated [DATE] completed by CNA A revealed at 9:15am, she was monitoring residents in the dining room. I then noticed that some of the them that wander in other rooms was not present, so I went to make rooms checks only to see (Resident #1) come out of (Resident #2's room) pulling his pants up. Then I went behind the curtain I saw (Resident #2) laying on A bed with pants and pull-ups off beside her, I then asked her what was wrong she said nothing . Record review of a witness statement dated [DATE] at 9:30am completed by MDS Nurse revealed the following: I observed in (Resident #1's room) in the secure unit Resident standing over other resident who was on the bed with bottom half of clothing down to her knees, male resident was penetrating female resident's vagina with his fingers. When I called out to (RN A) male resident came out of room and female resident went into restroom . Record review of a physician's order for Resident #1 dated [DATE] revealed an order to start [MEDICATION NAME] 10mg, 1 tablet by mouth daily. Record review of 1:1 documentation for Resident #1 dated [DATE] revealed staff documented 1:1 supervision from 11:22am to 1:05pm. Record review of a document provided for every 15 minute checks revealed Resident #1 was checked on every 15 minutes on [DATE] starting at 9:15am and ending on [DATE] at 4:30pm. In an observation and interview on [DATE] at 4:30pm, Resident #1 said he had been at the facility for one week and was ready to go home. He said he was married and did not have to be in the facility for long. When asked about having a sexual relationship in the facility, he said Oh, no. I am married. I stick with her. She makes me so happy .2 weeks I haven't talked to her. I love putting my arms around her and squeezing her and saying 'I love you!' He said he was not sure why he was at the facility. He said he did not know Resident #2. Resident #2 Record review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed was understood and could understand others. She had a BIMS score of 0, indicating severe cognitive impairment. She did not display any behaviors. She required supervision and setup for transfers, walking and locomotion on the unit. Record review of Resident #2's care plan dated [DATE] revealed she had impaired cognition and long-term memory loss due to dementia. Interventions included Keep instructions simple and short, reorient as appropriate, however do not argue or agitate resident .observe for changes in cognitive status . The care plan was updated on [DATE] due to resident observed in sexual inappropriate behavior and allowed male resident to touch her vaginal area. Updated interventions included head to toe assessment, psych review and medication adjustment. Record review of Resident #2's Nurse Progress Notes revealed the following: - [DATE] at 11:44am completed by RN A: It was reported to nurse that a male resident was noticed leaving resident's room adjusting his pants at 9:15m. Nurse immediately assessed resident noticed her pants were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to toe assessment. Resident denied any involvement with male resident and stated that she pulled her own pants of. Female resident was laying in her bed when staff left room. Q 15 minute checks initiated on resident .At 9:36am nurse was called again when staff member reported resident was noticed in the same male's room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female resident was on toilet in his room. Immediately redirected both residents .Will continue Q 15 min checks. - [DATE] 6:33pm completed by Unit Manager A: Called (Resident #2's responsible party) .I informed him of the compromising incident his (family member) was found in today with a male resident twice. No injury occurred and resident admitted she let male resident touch her willingly and when I went back about a half hour later she had know (sic) idea what I was talking about . - [DATE] at 6:38am completed by SW B: Was informed of sexual behavior between two residents .SW mentioned the incident between her and male resident, (Resident #2) said 'no, nothing happened.' SW then ask were you in a male resident room or was he in your room and (Resident #2) denied room visit .Resident: 'No I didn't touch anybody, nobody touched me, and I didn't have my pants down.' Record review of Resident #2's Behavioral Medicine Progress Note dated [DATE] revealed staff reported to Psychiatric NP that Resident #2 had a history of [REDACTED]. Facility staff reported asking the resident is she was forced or hurt, but she could not remember. Psychiatric NP stated, (Resident #2's) dementia can trigger inappropriate behaviors, increase loss of inhabitation and self-control .Will initiate [MEDICATION NAME] to target libido, reduce hypersexuality and impulsivity . Record review of a physician's order dated [DATE] revealed Resident #2 was ordered [MEDICATION NAME] 50mg (an antidepressant medication), one tablet by mouth every day for anxiety and inappropriate sexual behavior. In an interview on [DATE] at 10:30am, ADON said the psychiatrist ordered [MEDICATION NAME] for Resident #2 to decrease her libido. He said they were going to try it and then attempt a gradual dose reduction if needed. In an interview on [DATE] at 4:00pm, Resident #2 said she liked staying at the facility. She said her husband died a few years ago and she has been here since then. When asked about sexual relationships at the facility, she said she has not had any type of relationship with anyone. She said she would like to. I hope it happens soon. Record review of Resident #2's MDS assessment dated [DATE] revealed she had a BIMS score of 10, indicating moderate cognitive impairment. Record review of a e-mailed statement completed by the Regional Quality Manager dated [DATE] revealed she completd the updated BIMS assessment on [DATE] at 10:00am. The statement read in part . I asked all of the questions on the BIMS assessment, and then marked her responses on the form. After that portion was over, I asked her if she remembered any particular incident that had occurred between her and any other residents. She said 'no, not really'. I asked her if she remembered that she had been in a male resident's room. When I said that, her face lit up and she replied 'yes'. I asked her what she was doing in his room. She said 'I was sitting on his bed and we did some talking'. And then she looked at me and said 'we didn't have sex!' I told her that I didn't think that she had, but there would be no shame if she had. I asked her if she knew what to do if someone wanted to have sex with her and she didn't want that, and she said 'yes, I would kick in between the legs' I asked her if she enjoyed sex, and she said 'well of course!' and laughed out loud .Had I not known better, I would have assumed she had no memory issues. Based on that conversation, I believe she was well aware of the sexual activity that had occurred and was very much in agreement with what happened. In an interview on [DATE] at 5:15pm, SW A, when asked about sexual abuse, said there was something that occurred yesterday. She said the Administrator was aware of the incident. She said Resident #1 was seen walking out of Resident #2's room. She said when she became aware of it, she interviewed the residents about 20 minutes after the incident. She said Resident #2 consented to the behavior. She let her know if that was something she wanted to do they could talk about it. She said she also notified the resident's families. In an observation on [DATE] between 6:40pm and 7:20pm, Resident #1 was sitting in a chair in the corner by an exit door, alone. All staff were assisting other residents or at the nurse's station. In an observation and interview on [DATE] at between 6:40pm and 7:20pm, Resident #2 was lying in bed, watching television. There were no staff members in her room. She was alert and oriented to self. She said she could not recall witnessing abuse at the facility. She said no one had touched her inappropriately. In an Interview on [DATE] at 7:15pm, Unit Manager A said in the secure unit there were 2 CNAs, 1 nurse, 1 med aide, activity aide on the 10am to 6pm shift and the unit manager during the day. She said if there is an incident, they do every 15 minute checks for 72 hours. She said Resident #1 was observed walking out of Resident #2's room. Resident #2 was in her room with her pants down, her brief off. She said she did a head to toe assessment and there was no sign of penetration. She said 30 minutes later they were found in his room and he was touching her vaginal area. She said when Resident #2 was interviewed, she said she consented to the activity. When asked if she could consent, she said it was a thin line, because she could not remember what happened shortly after the incident. When asked if it was possible sexual abuse, she said it was a 'catch 22' because Resident #2 said she consented right after. She said she did not think to send either resident to the hospital. She said about 2 to 3 months ago, Resident #1 was found in another female resident's room, but she was not aware of physical contact. In an interview on [DATE] at 6:00pm, Unit Manager A said CR #1 had some behaviors. She said CR #1 was oriented to the unit. She said CR #1 tried to entice Resident #1 at least two times but was not aware of sexual contact. In an interview on [DATE] at 6:45pm, CNA C was working on the secure unit. He said he was not aware of abuse or neglect. He said there were no recent incidents in the facility. When asked about residents that require extra supervision, he said Resident #2 was monitored frequently because she wandered into male resident's rooms. In an Interview on [DATE] at 7:20pm, CNA B said she had worked on the secure unit for 4 months. She said she worked the 2pm-10pm shift. She said she worked on the secure unit [DATE] to [DATE]. When asked if she checked on any residents more frequently, she said when she did rounds she checked in every room. She said all the residents require supervision. She said she checked Resident #2 every 30 minutes because she goes in and out of male resident's rooms. She said she heard about sexual behaviors that occurred yesterday. She said Resident #2 was found with a male resident in her room. She said she could not remember the name of the male resident. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #1 was sitting in a chair in the corner by an exit door, alone. He got up and walked around the hall, looking into other resident's rooms. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #2 was in the dining room for lunch. In an interview on [DATE] at 12:15pm, CNA D said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she was not aware of the details, but knew it involved Resident #1 and Resident #2. She said right after the incident, Resident #1 was on 1:1 supervision. She said she was not sure when it ended. She said she was not aware if either resident required special supervision. She said she completed rounds on all residents. She said she was not aware if Resident #1 or Resident #2 had past sexual behaviors. In an interview on [DATE] at 12:20pm, CNA A said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she saw Resident #1 walking out of Resident #2's room, adjusting his pants. She said she went in the room and noticed Resident #2 was in bed with her pants and brief off. She said she called for RN A. She said she was not sure what the nurse did, but later, CNA A changed the sheets Resident #2 was laying on. She said Resident #2 was laying on a bed that was not hers. She said she did not see anything on the sheets. She said she was not aware of past sexual behaviors. When asked if she would consider the incident sexual abuse, she said yes, maybe. In a telephone interview on [DATE] at 1:45pm, the MDS nurse stated on the day of the incident, she was on the secure unit looking at medical charts. She said when she was leaving the secure unit, she noticed movement in a resident's room. She said she entered Resident #1's room and saw him standing above Resident #2, her knees were up, and his fingers were in her vagina. She said she yelled for RN A. She said when she called for help, both residents reacted and got up real fast. She said when RN A arrived, Resident #2 was sitting on the toilet and Resident #1 walked out into the hallway. She said she did not think the incident was sexual abuse because didn't see anything that would indicate either resident was coerced or uncomfortable. She said they acted like she interrupted. She said Resident #2 was confused but accurate. She said Resident #1 was pleasantly confused. She said after the incident, she did not update their care plans. In an interview on [DATE] at 2:00pm, when asked about Resident #1's [MEDICATION NAME]'s medication, SW A said they were trying to reduce medications such as [MEDICATION NAME]. She said the medication was discontinued to see if the behavior would reoccur. She said in this case, it did. She said she was not sure why he was put on the medication in March. She said the incident that occurred between Resident #1 and Resident #2 was not considered sexual abuse because no one appeared upset or mistreated, and no one complained about the incident. She said they would have considered it an allegation of sexual abuse if it had not been consensual. When asked about consenting to sexual behavior, she said everyone had the right to consent. She said when she interviewed the residents after the incident, they did not appear distressed, they were pleasant and they both acted like nothing happened. She said they did not have an assessment to determine whether a resident had the capacity to consent to sexual behavior. She said after the incident, interventions included to monitor and keep them separated. She acknowledged that both residents had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:20pm, SW B said after the incident that occurred between Resident #1 and Resident #2, she interviewed them separately. She said Resident #2 was able to consent to sexual activity because during the interview she said she could not remember. She said Resident #2 denied the whole incident. She said Resident #2 stated she was attracted to Resident #1. She said Resident #1 could not recall the incident. Resident #1 told her, I have a wife, I will pick her up later. She said 1:1 supervision was put in place but did not know when it ended. When asked how she would determine whether a resident had the capacity to consent, she said if a resident was alert and oriented and was a good historian. She said she would not consider the incident a sexual abuse allegation because the residents could not remember anything, they were not aware, and it did not affect them. She said their mood did not change. She said interventions put in place after the incident included every 15 minute checks and psych consult. In an interview on [DATE] at 9:43am, RN A said the day of the incident, it was reported to her by the CNA that Resident #1 was seen exiting Resident #2's room adjusting his pants. She said when she went in the room, Resident #2 was lying on the bed with her pants and brief off. She said when she asked what happened, Resident #2 said she took them off herself and denied any sexual activity. She said both residents were placed on Q 15 minute checks. She said when she asked Resident #1 what happened, he said he was not sure what she was talking about. She said a little while later, they were found in his room. She said Resident #1 was placed on 1:1 supervision. She said for any sexual activity, she would investigate and monitor. She said if consent was given, she would give them privacy. When asked if Resident #1 or Resident #2 had the capacity to consent, she said Resident #1 was more confused than Resident #2. In an interview on [DATE] at 2:50pm, the DON said a few months ago, there was another incident with Resident #1 and CR #1. She said CR #1 had a history of [REDACTED]. She said they were seen together a lot. She said there was an incident when CR #1's legs were open, her clothes were on and it seemed Resident #1 was trying to get himself erect. She said they put Resident #1 on [MEDICATION NAME] for a short period to see if it would decrease the behaviors. She said Resident #1 was pleasantly confused and does not have good recall. She said when the incident occurred between Resident #1 and Resident #2, she asked the social workers for guidance. She said she thought consent should be assessed after a sexual incident. She said when Unit Manager A assessed the residents, at that moment they were consenting to the behavior. She said both residents could not remember the incident shortly afterward. She said residents with dementia still have sexual needs. She did not think the incident was sexual abuse because there was not a clear aggressor. She said there was no one taking advantage of someone else. She said interventions put in place included social work involvement, psych assessment, close observation and the family was notified. She said she didn't think either resident was a threat to other residents. In an interview on [DATE] at 3:30pm, the Administrator, who is the abuse coordinator, said she was notified of the incident between Resident #1 and Resident #2 by Unit Manager A. She said the Unit Manager A reported that Resident #1 had a history of [REDACTED]. When they asked again, the residents could not remember. She said after the incident, the social workers and psychologist assessed the resident and added medications. She said the physician and family were notified. She said when Resident #2's family member was notified, he was not surprised by the behavior. She said Resident #1 denied the incident occurred by saying he was married. She said after she heard the details of the incident, she thought that both residents were consenting. She said she thinks they are both denying the incident occurred, rather than them not remembering. She said both residents can carry a conversation and they know what is going on. She said neither resident resisted the other. When asked if either resident had the capacity to consent, she said yes. She said they did not have a policy for sexual contact between residents. In an interview on [DATE] at 4:40pm, when asked about Resident #1's wife, SW A said it was possible that while engaging in sexual activity, Resident #1 could have thought Resident #2 was his wife. When asked if someone with a BIMS score of 0, with severe cognitive impairment, could consent to sexual activity, she said there was a thin line and she did not know the right answer. Record review of the facility policy for Abuse Prohibition Standards of Practice dated ,[DATE] read in part . Each resident has the right to be free from verbal, sexual, physical and mental abuse .Training employees: In addition to the freedom from abuse, neglect and exploitation requirements facilities must also provide training to their staff that at a minimum educates staff on- activities that constitute abuse .dementia management and resident abuse prevention .Prohibition of Abuse: The facility will consider utilization of the following tips for prevention of abuse .Assess, monitor and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents .When suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploit(TRUNCATED)

Based on observation, interview, and record review, the facility, in response to allegations of abuse or neglect, failed to have evidence that all alleged violations are thoroughly investigated for 3 of 10 residents (Residents #1, #2 and CR #1) reviewed for abuse in that: - The facility failed to conduct a thorough investigation after alleged inappropriate sexual conduct between two cognitively impaired residents. Resident #1 was seen walking out of Resident #2's room, and Resident #2 was in bed naked below the waist. - The facility failed to conduct a thorough investigation after inappropriate sexual conduct between CR #1 and Resident #1, two cognitively impaired residents, was reported. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE], 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 pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 2 residents and 1 former resident and placed the other 39 residents who resided in the secure unit at risk of unwanted sexual advances, abuse, mistreatment and neglect. Findings included: Resident #1 Record review of Resident #1's medical record revealed he as admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. He had a court-appointed guardian. Record review of Resident #1's History and Physical completed by his physician dated [DATE] revealed he was admitted to the facility from the hospital after he had increasing agitation at previous nursing home. The physician reports the resident was very confused and cannot give any history. Record review of Resident #1's care plan dated [DATE] revealed he had behaviors of wandering, difficulty to redirect and episodes of aggression. Interventions included educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 when unable to participate in group activities .1:1 as needed, refer to psych services as needed with exacerbation or inability to effectively redirect behaviors, remove resident from common areas during times of unacceptable behavior . The care plan was updated on [DATE] to include behaviors related to being in a female resident's room stripping and displaying sexual behavior. No new interventions were added to the care plan after the update. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he was usually understood and could usually understand others. He had a BIMS score of 0, indicating severe cognitive impairment. A staff assessment for cognition was not completed. Resident had other behavioral symptoms not directed toward others daily. He had wandering behaviors daily. He required supervision for transfers and was independent for walking and locomotion. Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 4:08pm written by LVN A: Resident wandered in another room was alone with female resident, female resident was stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract this residents attention no physical contact made staff intervened and separated resident . Record review of a Progress Note completed by NP A dated [DATE] revealed the nurse practitioner received a call from a facility staff member who reported Resident #1 was found in bed with another resident, about to have sexual relations. Redirected, but found a second time, almost the point of penetration. NP A gave a [DIAGNOSES REDACTED]. In an interview on [DATE] at 1:00pm, ADON said NP A was not available for interview because he was out of the country. Record review of Resident #1's Physician's Orders dated (MONTH) (YEAR) revealed [MEDICATION NAME] 10mg, 1 tablet by mouth daily had an order date of [DATE]. Record review of an Informed Consent for Psychoactive Medications dated [DATE] revealed Resident #1's guardian consented to the use of [MEDICATION NAME], an antimanic medication, used to treat sexual disorder. Record review of a physician's order for Resident #1 dated [DATE] revealed the [MEDICATION NAME] medication was discontinued. Record review of Resident #1's MAR indicated [REDACTED]. CR #1 Record review of CR #1's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. She was discharged to the hospital on [DATE]. Record review of CR #1's admission MDS assessment dated [DATE] revealed she was usually understood and could usually understand others. She had a BIMS score of 8, indicating moderate cognitive impairment. She demonstrated physical and verbal behaviors ,[DATE] days out of 7 days and had other behaviors not directed toward others ,[DATE] days out of 7 days. She required supervision and setup for locomotion on unit, walking and transfers. Record review of CR #1's Care Plan dated [DATE] revealed she had behavioral issues related to dementia, mood disorder and [MEDICAL CONDITION] disorder. Interventions included, Offer schedule of activities for resident to select choices, engage resident in group activities .offer activity programs directed toward specific interests of resident. Further review of CR #1's care plan revealed she had sexual behaviors toward others, including stripping and displaying sexual behaviors in male resident's room. Interventions included, educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 activity programming 3 x/week when unable to participate in group activities .remove resident from common areas during times of unacceptable behavior . Record review of CR #1's nursing progress notes revealed the following: - [DATE] at 3:59pm written by LVN A: Resident wandered in another room was alone with male resident stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract male resident's attention no physical contact made staff intervened and separated resident . - [DATE] at 5:51pm written by Unit Manager A: Called (family member) informed her that resident observed in another room with a male resident both residents were stripping and displaying sexual behavior, no contact was made due to staff walking in room and directed both resident to redress and go to common area for activities. (Family member) informed me she was told that there might be some heighted (sic) sexual behavior that she has never displayed before, she had always been quiet and reserved . - [DATE], [DATE] and [DATE] notes that Resident displaying sexual behavior rolling hips, rolling tongue. - [DATE] at 9:20pm: Resident stable at the time, laying in bed .Resident has been slightly agitated today .resident got upset about staff getting another resident out of her room that she stated she wanted to have sex with. Resident came out of room naked yelling and screaming she was going to call the police because staff won't let her have sex. Redirection finally successful . -[DATE] at 2:24pm: Resident was displaying physically aggressive behavior towards nurses, CNAs and Resident #1. 911 was called and she was discharged to the hospital. In an interview on [DATE] at 3:25pm, the ADON said the incident on Feburary 23, (YEAR) that occurred between CR #1 and Resident #1 did not have an incident report. When asked about the progress note completed by NP A on [DATE], he said NP A must have been mistaken. He said there was no evidence that the incident NP A described occurred. In an interview on [DATE] at 10:20am, LVN A said she did not recall the incident between CR #1 and Resident #1. She said she did not think they had any physical contact. She said CR #1 had some sexual behaviors. She said Resident #1 usually stayed out of his room and talked to the female residents. Resident #1 continued- Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 9:41am written by RN A: It was reported to nurse that resident was noticed leaving a female residents room adjusting his pants at 9:15am. Nurse immediately assessed female resident noticed her pant were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to assessment. Female denied any involvement with male resident and stated that she pulled her own pants off. Unable to redirect male resident x3, resident yelling at staff and displaying aggressive verbal behavior. Resident denies any involvement with foul play and walks towards his room. Q 15 minute checks initiated. At 9:30am staff attempted to redirect resident to common area, but resident being continuously defiant to staff and was unable to redirect to main area. Resident began to walk towards room. At 9:36am nurse was called again when a staff member (MDS Nurse) reported the same female resident was noticed in his room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female was on toilet in his room. Immediately redirected both residents. Nurse assessed both resident no apparent injuries noted at this time. Female resident currently in her room and male resident in main area. Will continue 15 min checks. - Addendum: [DATE] at 11:41am SW A notified and assessed resident. One on one care initiated by staff. No further redirection necessary at this time. - [DATE] at 1:28pm written by LVN B: Resident continued to pace and wander up and down the unit, going room to room, frequently redirected back to his room, in 0 distress . - [DATE] at 6:39pm written by SW B: SW interview (Resident #1) in day room after resident was reported in female resident room. (Resident #1) could not recall inappropriate behavior with female resident. Resident says, 'NO I would not do that because I have a wife and when I leave here I am going to pick her up from work.' (Resident #1) coach on appropriate and inappropriate behavior and touching Resident denies having attraction to female resident. Cannot recall if he or female resident were visiting each other's room. Record review of Resident #1's care plan for behaviors was updated on [DATE] to include the following behavior: resident observed in 'sexual inappropriate behavior, was touching female vaginal area. No new interventions were added to the care plan after the update. Record review of an incident report dated [DATE] revealed Resident #1 was observed walking out of a female resident's room adjusting his pants. Resident #1 denied involvement and placed on Q 15 minute checks. At 9:36am, the MDS Nurse reported to the same residents were in his room with Resident #1 touching female resident inappropriately. Immediate actions taken were to separate residents and initiate Q 15 minute checks. Record review of a witness statement dated [DATE] completed by CNA A revealed at 9:15am, she was monitoring residents in the dining room. I then noticed that some of the them that wander in other rooms was not present, so I went to make rooms checks only to see (Resident #1) come out of (Resident #2's room) pulling his pants up. Then I went behind the curtain I saw (Resident #2) laying on A bed with pants and pull-ups off beside her, I then asked her what was wrong she said nothing . Record review of a witness statement dated [DATE] at 9:30am completed by MDS Nurse revealed the following: I observed in (Resident #1's room) in the secure unit Resident standing over other resident who was on the bed with bottom half of clothing down to her knees, male resident was penetrating female resident's vagina with his fingers. When I called out to (RN A) male resident came out of room and female resident went into restroom . Record review of a physician's order for Resident #1 dated [DATE] revealed an order to start [MEDICATION NAME] 10mg, 1 tablet by mouth daily. Record review of 1:1 documentation for Resident #1 dated [DATE] revealed staff documented 1:1 supervision from 11:22am to 1:05pm. Record review of a document provided for every 15 minute checks revealed Resident #1 was checked on every 15 minutes on [DATE] starting at 9:15am and ending on [DATE] at 4:30pm. In an observation and interview on [DATE] at 4:30pm, Resident #1 said he had been at the facility for one week and was ready to go home. He said he was married and did not have to be in the facility for long. When asked about having a sexual relationship in the facility, he said Oh, no. I am married. I stick with her. She makes me so happy .2 weeks I haven't talked to her. I love putting my arms around her and squeezing her and saying 'I love you!' He said he was not sure why he was at the facility. He said he did not know Resident #2. Resident #2 Record review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed was understood and could understand others. She had a BIMS score of 0, indicating severe cognitive impairment. She did not display any behaviors. She required supervision and setup for transfers, walking and locomotion on the unit. Record review of Resident #2's care plan dated [DATE] revealed she had impaired cognition and long-term memory loss due to dementia. Interventions included Keep instructions simple and short, reorient as appropriate, however do not argue or agitate resident .observe for changes in cognitive status . The care plan was updated on [DATE] due to resident observed in sexual inappropriate behavior and allowed male resident to touch her vaginal area. Updated interventions included head to toe assessment, psych review and medication adjustment. Record review of Resident #2's Nurse Progress Notes revealed the following: - [DATE] at 11:44am completed by RN A: It was reported to nurse that a male resident was noticed leaving resident's room adjusting his pants at 9:15m. Nurse immediately assessed resident noticed her pants were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to toe assessment. Resident denied any involvement with male resident and stated that she pulled her own pants of. Female resident was laying in her bed when staff left room. Q 15 minute checks initiated on resident .At 9:36am nurse was called again when staff member reported resident was noticed in the same male's room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female resident was on toilet in his room. Immediately redirected both residents .Will continue Q 15 min checks. - [DATE] 6:33pm completed by Unit Manager A: Called (Resident #2's responsible party) .I informed him of the compromising incident his (family member) was found in today with a male resident twice. No injury occurred and resident admitted she let male resident touch her willingly and when I went back about a half hour later she had know (sic) idea what I was talking about . - [DATE] at 6:38am completed by SW B: Was informed of sexual behavior between two residents .SW mentioned the incident between her and male resident, (Resident #2) said 'no, nothing happened.' SW then ask were you in a male resident room or was he in your room and (Resident #2) denied room visit .Resident: 'No I didn't touch anybody, nobody touched me, and I didn't have my pants down.' Record review of Resident #2's Behavioral Medicine Progress Note dated [DATE] revealed staff reported to Psychiatric NP that Resident #2 had a history of [REDACTED]. Facility staff reported asking the resident is she was forced or hurt, but she could not remember. Psychiatric NP stated, (Resident #2's) dementia can trigger inappropriate behaviors, increase loss of inhabitation and self-control .Will initiate [MEDICATION NAME] to target libido, reduce hypersexuality and impulsivity . Record review of a physician's order dated [DATE] revealed Resident #2 was ordered [MEDICATION NAME] 50mg (an antidepressant medication), one tablet by mouth every day for anxiety and inappropriate sexual behavior. In an interview on [DATE] at 10:30am, ADON said the psychiatrist ordered [MEDICATION NAME] for Resident #2 to decrease her libido. He said they were going to try it and then attempt a gradual dose reduction if needed. In an interview on [DATE] at 4:00pm, Resident #2 said she liked staying at the facility. She said her husband died a few years ago and she has been here since then. When asked about sexual relationships at the facility, she said she has not had any type of relationship with anyone. She said she would like to. I hope it happens soon. Record review of Resident #2's MDS assessment dated [DATE] revealed she had a BIMS score of 10, indicating moderate cognitive impairment. Record review of a e-mailed statement completed by the Regional Quality Manager dated [DATE] revealed she completd the updated BIMS assessment on [DATE] at 10:00am. The statement read in part . I asked all of the questions on the BIMS assessment, and then marked her responses on the form. After that portion was over, I asked her if she remembered any particular incident that had occurred between her and any other residents. She said 'no, not really'. I asked her if she remembered that she had been in a male resident's room. When I said that, her face lit up and she replied 'yes'. I asked her what she was doing in his room. She said 'I was sitting on his bed and we did some talking'. And then she looked at me and said 'we didn't have sex!' I told her that I didn't think that she had, but there would be no shame if she had. I asked her if she knew what to do if someone wanted to have sex with her and she didn't want that, and she said 'yes, I would kick in between the legs' I asked her if she enjoyed sex, and she said 'well of course!' and laughed out loud .Had I not known better, I would have assumed she had no memory issues. Based on that conversation, I believe she was well aware of the sexual activity that had occurred and was very much in agreement with what happened. In an interview on [DATE] at 5:15pm, SW A, when asked about sexual abuse, said there was something that occurred yesterday. She said the Administrator was aware of the incident. She said Resident #1 was seen walking out of Resident #2's room. She said when she became aware of it, she interviewed the residents about 20 minutes after the incident. She said Resident #2 consented to the behavior. She let her know if that was something she wanted to do they could talk about it. She said she also notified the resident's families. In an observation on [DATE] between 6:40pm and 7:20pm, Resident #1 was sitting in a chair in the corner by an exit door, alone. All staff were assisting other residents or at the nurse's station. In an observation and interview on [DATE] at between 6:40pm and 7:20pm, Resident #2 was lying in bed, watching television. There were no staff members in her room. She was alert and oriented to self. She said she could not recall witnessing abuse at the facility. She said no one had touched her inappropriately. In an Interview on [DATE] at 7:15pm, Unit Manager A said in the secure unit there were 2 CNAs, 1 nurse, 1 med aide, activity aide on the 10am to 6pm shift and the unit manager during the day. She said if there is an incident, they do every 15 minute checks for 72 hours. She said Resident #1 was observed walking out of Resident #2's room. Resident #2 was in her room with her pants down, her brief off. She said she did a head to toe assessment and there was no sign of penetration. She said 30 minutes later they were found in his room and he was touching her vaginal area. She said when Resident #2 was interviewed, she said she consented to the activity. When asked if she could consent, she said it was a thin line, because she could not remember what happened shortly after the incident. When asked if it was possible sexual abuse, she said it was a 'catch 22' because Resident #2 said she consented right after. She said she did not think to send either resident to the hospital. She said about 2 to 3 months ago, Resident #1 was found in another female resident's room, but she was not aware of physical contact. In an interview on [DATE] at 6:00pm, Unit Manager A said CR #1 had some behaviors. She said CR #1 was oriented to the unit. She said CR #1 tried to entice Resident #1 at least two times but was not aware of sexual contact. In an interview on [DATE] at 6:45pm, CNA C was working on the secure unit. He said he was not aware of abuse or neglect. He said there were no recent incidents in the facility. When asked about residents that require extra supervision, he said Resident #2 was monitored frequently because she wandered into male resident's rooms. In an Interview on [DATE] at 7:20pm, CNA B said she had worked on the secure unit for 4 months. She said she worked the 2pm-10pm shift. She said she worked on the secure unit [DATE] to [DATE]. When asked if she checked on any residents more frequently, she said when she did rounds she checked in every room. She said all the residents require supervision. She said she checked Resident #2 every 30 minutes because she goes in and out of male resident's rooms. She said she heard about sexual behaviors that occurred yesterday. She said Resident #2 was found with a male resident in her room. She said she could not remember the name of the male resident. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #1 was sitting in a chair in the corner by an exit door, alone. He got up and walked around the hall, looking into other resident's rooms. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #2 was in the dining room for lunch. In an interview on [DATE] at 12:15pm, CNA D said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she was not aware of the details, but knew it involved Resident #1 and Resident #2. She said right after the incident, Resident #1 was on 1:1 supervision. She said she was not sure when it ended. She said she was not aware if either resident required special supervision. She said she completed rounds on all residents. She said she was not aware if Resident #1 or Resident #2 had past sexual behaviors. In an interview on [DATE] at 12:20pm, CNA A said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she saw Resident #1 walking out of Resident #2's room, adjusting his pants. She said she went in the room and noticed Resident #2 was in bed with her pants and brief off. She said she called for RN A. She said she was not sure what the nurse did, but later, CNA A changed the sheets Resident #2 was laying on. She said Resident #2 was laying on a bed that was not hers. She said she did not see anything on the sheets. She said she was not aware of past sexual behaviors. When asked if she would consider the incident sexual abuse, she said yes, maybe. In a telephone interview on [DATE] at 1:45pm, the MDS nurse stated on the day of the incident, she was on the secure unit looking at medical charts. She said when she was leaving the secure unit, she noticed movement in a resident's room. She said she entered Resident #1's room and saw him standing above Resident #2, her knees were up, and his fingers were in her vagina. She said she yelled for RN A. She said when she called for help, both residents reacted and got up real fast. She said when RN A arrived, Resident #2 was sitting on the toilet and Resident #1 walked out into the hallway. She said she did not think the incident was sexual abuse because didn't see anything that would indicate either resident was coerced or uncomfortable. She said they acted like she interrupted. She said Resident #2 was confused but accurate. She said Resident #1 was pleasantly confused. She said after the incident, she did not update their care plans. In an interview on [DATE] at 2:00pm, when asked about Resident #1's [MEDICATION NAME]'s medication, SW A said they were trying to reduce medications such as [MEDICATION NAME]. She said the medication was discontinued to see if the behavior would reoccur. She said in this case, it did. She said she was not sure why he was put on the medication in March. She said the incident that occurred between Resident #1 and Resident #2 was not considered sexual abuse because no one appeared upset or mistreated, and no one complained about the incident. She said they would have considered it an allegation of sexual abuse if it had not been consensual. When asked about consenting to sexual behavior, she said everyone had the right to consent. She said when she interviewed the residents after the incident, they did not appear distressed, they were pleasant and they both acted like nothing happened. She said they did not have an assessment to determine whether a resident had the capacity to consent to sexual behavior. She said after the incident, interventions included to monitor and keep them separated. She acknowledged that both residents had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:20pm, SW B said after the incident that occurred between Resident #1 and Resident #2, she interviewed them separately. She said Resident #2 was able to consent to sexual activity because during the interview she said she could not remember. She said Resident #2 denied the whole incident. She said Resident #2 stated she was attracted to Resident #1. She said Resident #1 could not recall the incident. Resident #1 told her, I have a wife, I will pick her up later. She said 1:1 supervision was put in place but did not know when it ended. When asked how she would determine whether a resident had the capacity to consent, she said if a resident was alert and oriented and was a good historian. She said she would not consider the incident a sexual abuse allegation because the residents could not remember anything, they were not aware, and it did not affect them. She said their mood did not change. She said interventions put in place after the incident included every 15 minute checks and psych consult. In an interview on [DATE] at 9:43am, RN A said the day of the incident, it was reported to her by the CNA that Resident #1 was seen exiting Resident #2's room adjusting his pants. She said when she went in the room, Resident #2 was lying on the bed with her pants and brief off. She said when she asked what happened, Resident #2 said she took them off herself and denied any sexual activity. She said both residents were placed on Q 15 minute checks. She said when she asked Resident #1 what happened, he said he was not sure what she was talking about. She said a little while later, they were found in his room. She said Resident #1 was placed on 1:1 supervision. She said for any sexual activity, she would investigate and monitor. She said if consent was given, she would give them privacy. When asked if Resident #1 or Resident #2 had the capacity to consent, she said Resident #1 was more confused than Resident #2. In an interview on [DATE] at 2:50pm, the DON said a few months ago, there was another incident with Resident #1 and CR #1. She said CR #1 had a history of [REDACTED]. She said they were seen together a lot. She said there was an incident when CR #1's legs were open, her clothes were on and it seemed Resident #1 was trying to get himself erect. She said they put Resident #1 on [MEDICATION NAME] for a short period to see if it would decrease the behaviors. She said Resident #1 was pleasantly confused and does not have good recall. She said when the incident occurred between Resident #1 and Resident #2, she asked the social workers for guidance. She said she thought consent should be assessed after a sexual incident. She said when Unit Manager A assessed the residents, at that moment they were consenting to the behavior. She said both residents could not remember the incident shortly afterward. She said residents with dementia still have sexual needs. She did not think the incident was sexual abuse because there was not a clear aggressor. She said there was no one taking advantage of someone else. She said interventions put in place included social work involvement, psych assessment, close observation and the family was notified. She said she didn't think either resident was a threat to other residents. In an interview on [DATE] at 3:30pm, the Administrator, who is the abuse coordinator, said she was notified of the incident between Resident #1 and Resident #2 by Unit Manager A. She said the Unit Manager A reported that Resident #1 had a history of [REDACTED]. When they asked again, the residents could not remember. She said after the incident, the social workers and psychologist assessed the resident and added medications. She said the physician and family were notified. She said when Resident #2's family member was notified, he was not surprised by the behavior. She said Resident #1 denied the incident occurred by saying he was married. She said after she heard the details of the incident, she thought that both residents were consenting. She said she thinks they are both denying the incident occurred, rather than them not remembering. She said both residents can carry a conversation and they know what is going on. She said neither resident resisted the other. When asked if either resident had the capacity to consent, she said yes. She said they did not have a policy for sexual contact between residents. In an interview on [DATE] at 4:40pm, when asked about Resident #1's wife, SW A said it was possible that while engaging in sexual activity, Resident #1 could have thought Resident #2 was his wife. When asked if someone with a BIMS score of 0, with severe cognitive impairment, could consent to sexual activity, she said there was a thin line and she did not know the right answer. Record review of the facility policy for Abuse Prohibition Standards of Practice dated ,[DATE] read in part . Each resident has the right to be free from verbal, sexual, physical and mental abuse .Training employees: In addition to the freedom from abuse, neglect and exploitation requirements facilities must also provide training to their staff that at a minimum educates staff on- activities that constitute abuse .dementia management and resident abuse prevention .Prohibition of Abuse: The facility will consider utilization of the following tips for prevention of abuse .Assess, monitor and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents .When suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .Definitions .sexual abuse- any touching or exposure of the anus, breast or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or

Based on observation, interview, and record review, the facility failed to ensure residents have the right to be free from sexual abuse for 3 of 10 residents (Residents #1, #2 and CR #1) reviewed for abuse. - The facility failed to follow their abuse policy and identify an allegation of sexual abuse between Residents #1 and #2 and between Resident #1 and CR #1. - The facility failed to appropriately assess for consensual sexual activity. Resident #1 was seen walking out of Resident #2's room, and Resident #2 was in bed naked below the waist. Shortly afterwards, Resident #2 was found in Resident #1's room engaging in sexual activity. Residents #1 and #2 had a severe cognitive impairment and could not recall the incident after it occurred. - The facility failed to monitor Resident #1 and Resident #2 after alleged inappropriate sexual conduct. Resident #2 was found in Resident #1's room engaging in sexual activity shortly after the first incident. - The facility failed to monitor Resident #1 and Resident #2 after 2 reported incidents of sexual conduct. - The facility failed to ensure staff on the secure unit were aware of the incidents that occured between Resident #1 and Resident #2. - The facility failed to monitor Resident #1 and CR #1, two cognitively impaired residents, after inappropriate sexual conduct was reported. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE], 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 pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 2 residents and 1 former resident and placed the other 39 residents who resided in the secure unit at risk of unwanted sexual advances, abuse, mistreatment and neglect. Findings included: Resident #1 Record review of Resident #1's medical record revealed he as admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. He had a court-appointed guardian. Record review of Resident #1's History and Physical completed by his physician dated [DATE] revealed he was admitted to the facility from the hospital after he had increasing agitation at previous nursing home. The physician reports the resident was very confused and cannot give any history. Record review of Resident #1's care plan dated [DATE] revealed he had behaviors of wandering, difficulty to redirect and episodes of aggression. Interventions included educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 when unable to participate in group activities .1:1 as needed, refer to psych services as needed with exacerbation or inability to effectively redirect behaviors, remove resident from common areas during times of unacceptable behavior . The care plan was updated on [DATE] to include behaviors related to being in a female resident's room stripping and displaying sexual behavior. No new interventions were added to the care plan after the update. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he was usually understood and could usually understand others. He had a BIMS score of 0, indicating severe cognitive impairment. A staff assessment for cognition was not completed. Resident had other behavioral symptoms not directed toward others daily. He had wandering behaviors daily. He required supervision for transfers and was independent for walking and locomotion. Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 4:08pm written by LVN A: Resident wandered in another room was alone with female resident, female resident was stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract this residents attention no physical contact made staff intervened and separated resident . Record review of a Progress Note completed by NP A dated [DATE] revealed the nurse practitioner received a call from a facility staff member who reported Resident #1 was found in bed with another resident, about to have sexual relations. Redirected, but found a second time, almost the point of penetration. NP A gave a [DIAGNOSES REDACTED]. In an interview on [DATE] at 1:00pm, ADON said NP A was not available for interview because he was out of the country. Record review of Resident #1's Physician's Orders dated (MONTH) (YEAR) revealed [MEDICATION NAME] 10mg, 1 tablet by mouth daily had an order date of [DATE]. Record review of an Informed Consent for Psychoactive Medications dated [DATE] revealed Resident #1's guardian consented to the use of [MEDICATION NAME], an antimanic medication, used to treat sexual disorder. Record review of a physician's order for Resident #1 dated [DATE] revealed the [MEDICATION NAME] medication was discontinued. Record review of Resident #1's MAR indicated [REDACTED]. CR #1 Record review of CR #1's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. She was discharged to the hospital on [DATE]. Record review of CR #1's admission MDS assessment dated [DATE] revealed she was usually understood and could usually understand others. She had a BIMS score of 8, indicating moderate cognitive impairment. She demonstrated physical and verbal behaviors ,[DATE] days out of 7 days and had other behaviors not directed toward others ,[DATE] days out of 7 days. She required supervision and setup for locomotion on unit, walking and transfers. Record review of CR #1's Care Plan dated [DATE] revealed she had behavioral issues related to dementia, mood disorder and [MEDICAL CONDITION] disorder. Interventions included, Offer schedule of activities for resident to select choices, engage resident in group activities .offer activity programs directed toward specific interests of resident. Further review of CR #1's care plan revealed she had sexual behaviors toward others, including stripping and displaying sexual behaviors in male resident's room. Interventions included, educate resident regarding acceptable alternatives to identified behaviors and document response/understanding .monitor whereabouts when wandering and redirect as needed, approach in calm manner .avoid confrontation when agitated, provide 1:1 activity programming 3 x/week when unable to participate in group activities .remove resident from common areas during times of unacceptable behavior . Record review of CR #1's nursing progress notes revealed the following: - [DATE] at 3:59pm written by LVN A: Resident wandered in another room was alone with male resident stripping and displaying sexual behavior, sticking out tounge (sic) and waving hands to attract male resident's attention no physical contact made staff intervened and separated resident . - [DATE] at 5:51pm written by Unit Manager A: Called (family member) informed her that resident observed in another room with a male resident both residents were stripping and displaying sexual behavior, no contact was made due to staff walking in room and directed both resident to redress and go to common area for activities. (Family member) informed me she was told that there might be some heighted (sic) sexual behavior that she has never displayed before, she had always been quiet and reserved . - [DATE], [DATE] and [DATE] notes that Resident displaying sexual behavior rolling hips, rolling tongue. - [DATE] at 9:20pm: Resident stable at the time, laying in bed .Resident has been slightly agitated today .resident got upset about staff getting another resident out of her room that she stated she wanted to have sex with. Resident came out of room naked yelling and screaming she was going to call the police because staff won't let her have sex. Redirection finally successful . -[DATE] at 2:24pm: Resident was displaying physically aggressive behavior towards nurses, CNAs and Resident #1. 911 was called and she was discharged to the hospital. In an interview on [DATE] at 3:25pm, the ADON said the incident on Feburary 23, (YEAR) that occurred between CR #1 and Resident #1 did not have an incident report. When asked about the progress note completed by NP A on [DATE], he said NP A must have been mistaken. He said there was no evidence that the incident NP A described occurred. In an interview on [DATE] at 10:20am, LVN A said she did not recall the incident between CR #1 and Resident #1. She said she did not think they had any physical contact. She said CR #1 had some sexual behaviors. She said Resident #1 usually stayed out of his room and talked to the female residents. Resident #1 continued- Record review of Resident #1's Nursing Progress Notes revealed the following: - [DATE] at 9:41am written by RN A: It was reported to nurse that resident was noticed leaving a female residents room adjusting his pants at 9:15am. Nurse immediately assessed female resident noticed her pant were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to assessment. Female denied any involvement with male resident and stated that she pulled her own pants off. Unable to redirect male resident x3, resident yelling at staff and displaying aggressive verbal behavior. Resident denies any involvement with foul play and walks towards his room. Q 15 minute checks initiated. At 9:30am staff attempted to redirect resident to common area, but resident being continuously defiant to staff and was unable to redirect to main area. Resident began to walk towards room. At 9:36am nurse was called again when a staff member (MDS Nurse) reported the same female resident was noticed in his room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female was on toilet in his room. Immediately redirected both residents. Nurse assessed both resident no apparent injuries noted at this time. Female resident currently in her room and male resident in main area. Will continue 15 min checks. - Addendum: [DATE] at 11:41am SW A notified and assessed resident. One on one care initiated by staff. No further redirection necessary at this time. - [DATE] at 1:28pm written by LVN B: Resident continued to pace and wander up and down the unit, going room to room, frequently redirected back to his room, in 0 distress . - [DATE] at 6:39pm written by SW B: SW interview (Resident #1) in day room after resident was reported in female resident room. (Resident #1) could not recall inappropriate behavior with female resident. Resident says, 'NO I would not do that because I have a wife and when I leave here I am going to pick her up from work.' (Resident #1) coach on appropriate and inappropriate behavior and touching Resident denies having attraction to female resident. Cannot recall if he or female resident were visiting each other's room. Record review of Resident #1's care plan for behaviors was updated on [DATE] to include the following behavior: resident observed in 'sexual inappropriate behavior, was touching female vaginal area. No new interventions were added to the care plan after the update. Record review of an incident report dated [DATE] revealed Resident #1 was observed walking out of a female resident's room adjusting his pants. Resident #1 denied involvement and placed on Q 15 minute checks. At 9:36am, the MDS Nurse reported to the same residents were in his room with Resident #1 touching female resident inappropriately. Immediate actions taken were to separate residents and initiate Q 15 minute checks. Record review of a witness statement dated [DATE] completed by CNA A revealed at 9:15am, she was monitoring residents in the dining room. I then noticed that some of the them that wander in other rooms was not present, so I went to make rooms checks only to see (Resident #1) come out of (Resident #2's room) pulling his pants up. Then I went behind the curtain I saw (Resident #2) laying on A bed with pants and pull-ups off beside her, I then asked her what was wrong she said nothing . Record review of a witness statement dated [DATE] at 9:30am completed by MDS Nurse revealed the following: I observed in (Resident #1's room) in the secure unit Resident standing over other resident who was on the bed with bottom half of clothing down to her knees, male resident was penetrating female resident's vagina with his fingers. When I called out to (RN A) male resident came out of room and female resident went into restroom . Record review of a physician's order for Resident #1 dated [DATE] revealed an order to start [MEDICATION NAME] 10mg, 1 tablet by mouth daily. Record review of 1:1 documentation for Resident #1 dated [DATE] revealed staff documented 1:1 supervision from 11:22am to 1:05pm. Record review of a document provided for every 15 minute checks revealed Resident #1 was checked on every 15 minutes on [DATE] starting at 9:15am and ending on [DATE] at 4:30pm. In an observation and interview on [DATE] at 4:30pm, Resident #1 said he had been at the facility for one week and was ready to go home. He said he was married and did not have to be in the facility for long. When asked about having a sexual relationship in the facility, he said Oh, no. I am married. I stick with her. She makes me so happy .2 weeks I haven't talked to her. I love putting my arms around her and squeezing her and saying 'I love you!' He said he was not sure why he was at the facility. He said he did not know Resident #2. Resident #2 Record review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed was understood and could understand others. She had a BIMS score of 0, indicating severe cognitive impairment. She did not display any behaviors. She required supervision and setup for transfers, walking and locomotion on the unit. Record review of Resident #2's care plan dated [DATE] revealed she had impaired cognition and long-term memory loss due to dementia. Interventions included Keep instructions simple and short, reorient as appropriate, however do not argue or agitate resident .observe for changes in cognitive status . The care plan was updated on [DATE] due to resident observed in sexual inappropriate behavior and allowed male resident to touch her vaginal area. Updated interventions included head to toe assessment, psych review and medication adjustment. Record review of Resident #2's Nurse Progress Notes revealed the following: - [DATE] at 11:44am completed by RN A: It was reported to nurse that a male resident was noticed leaving resident's room adjusting his pants at 9:15m. Nurse immediately assessed resident noticed her pants were pulled off and diaper was off at 9:16am. There was no apparent injuries noted on head to toe assessment. Resident denied any involvement with male resident and stated that she pulled her own pants of. Female resident was laying in her bed when staff left room. Q 15 minute checks initiated on resident .At 9:36am nurse was called again when staff member reported resident was noticed in the same male's room and he was touching her inappropriately on his bed. When nurse arrived male was in hallway and female resident was on toilet in his room. Immediately redirected both residents .Will continue Q 15 min checks. - [DATE] 6:33pm completed by Unit Manager A: Called (Resident #2's responsible party) .I informed him of the compromising incident his (family member) was found in today with a male resident twice. No injury occurred and resident admitted she let male resident touch her willingly and when I went back about a half hour later she had know (sic) idea what I was talking about . - [DATE] at 6:38am completed by SW B: Was informed of sexual behavior between two residents .SW mentioned the incident between her and male resident, (Resident #2) said 'no, nothing happened.' SW then ask were you in a male resident room or was he in your room and (Resident #2) denied room visit .Resident: 'No I didn't touch anybody, nobody touched me, and I didn't have my pants down.' Record review of Resident #2's Behavioral Medicine Progress Note dated [DATE] revealed staff reported to Psychiatric NP that Resident #2 had a history of [REDACTED]. Facility staff reported asking the resident is she was forced or hurt, but she could not remember. Psychiatric NP stated, (Resident #2's) dementia can trigger inappropriate behaviors, increase loss of inhabitation and self-control .Will initiate [MEDICATION NAME] to target libido, reduce hypersexuality and impulsivity . Record review of a physician's order dated [DATE] revealed Resident #2 was ordered [MEDICATION NAME] 50mg (an antidepressant medication), one tablet by mouth every day for anxiety and inappropriate sexual behavior. In an interview on [DATE] at 10:30am, ADON said the psychiatrist ordered [MEDICATION NAME] for Resident #2 to decrease her libido. He said they were going to try it and then attempt a gradual dose reduction if needed. In an interview on [DATE] at 4:00pm, Resident #2 said she liked staying at the facility. She said her husband died a few years ago and she has been here since then. When asked about sexual relationships at the facility, she said she has not had any type of relationship with anyone. She said she would like to. I hope it happens soon. Record review of Resident #2's MDS assessment dated [DATE] revealed she had a BIMS score of 10, indicating moderate cognitive impairment. Record review of a e-mailed statement completed by the Regional Quality Manager dated [DATE] revealed she completd the updated BIMS assessment on [DATE] at 10:00am. The statement read in part . I asked all of the questions on the BIMS assessment, and then marked her responses on the form. After that portion was over, I asked her if she remembered any particular incident that had occurred between her and any other residents. She said 'no, not really'. I asked her if she remembered that she had been in a male resident's room. When I said that, her face lit up and she replied 'yes'. I asked her what she was doing in his room. She said 'I was sitting on his bed and we did some talking'. And then she looked at me and said 'we didn't have sex!' I told her that I didn't think that she had, but there would be no shame if she had. I asked her if she knew what to do if someone wanted to have sex with her and she didn't want that, and she said 'yes, I would kick in between the legs' I asked her if she enjoyed sex, and she said 'well of course!' and laughed out loud .Had I not known better, I would have assumed she had no memory issues. Based on that conversation, I believe she was well aware of the sexual activity that had occurred and was very much in agreement with what happened. In an interview on [DATE] at 5:15pm, SW A, when asked about sexual abuse, said there was something that occurred yesterday. She said the Administrator was aware of the incident. She said Resident #1 was seen walking out of Resident #2's room. She said when she became aware of it, she interviewed the residents about 20 minutes after the incident. She said Resident #2 consented to the behavior. She let her know if that was something she wanted to do they could talk about it. She said she also notified the resident's families. In an observation on [DATE] between 6:40pm and 7:20pm, Resident #1 was sitting in a chair in the corner by an exit door, alone. All staff were assisting other residents or at the nurse's station. In an observation and interview on [DATE] at between 6:40pm and 7:20pm, Resident #2 was lying in bed, watching television. There were no staff members in her room. She was alert and oriented to self. She said she could not recall witnessing abuse at the facility. She said no one had touched her inappropriately. In an Interview on [DATE] at 7:15pm, Unit Manager A said in the secure unit there were 2 CNAs, 1 nurse, 1 med aide, activity aide on the 10am to 6pm shift and the unit manager during the day. She said if there is an incident, they do every 15 minute checks for 72 hours. She said Resident #1 was observed walking out of Resident #2's room. Resident #2 was in her room with her pants down, her brief off. She said she did a head to toe assessment and there was no sign of penetration. She said 30 minutes later they were found in his room and he was touching her vaginal area. She said when Resident #2 was interviewed, she said she consented to the activity. When asked if she could consent, she said it was a thin line, because she could not remember what happened shortly after the incident. When asked if it was possible sexual abuse, she said it was a 'catch 22' because Resident #2 said she consented right after. She said she did not think to send either resident to the hospital. She said about 2 to 3 months ago, Resident #1 was found in another female resident's room, but she was not aware of physical contact. In an interview on [DATE] at 6:00pm, Unit Manager A said CR #1 had some behaviors. She said CR #1 was oriented to the unit. She said CR #1 tried to entice Resident #1 at least two times but was not aware of sexual contact. In an interview on [DATE] at 6:45pm, CNA C was working on the secure unit. He said he was not aware of abuse or neglect. He said there were no recent incidents in the facility. When asked about residents that require extra supervision, he said Resident #2 was monitored frequently because she wandered into male resident's rooms. In an Interview on [DATE] at 7:20pm, CNA B said she had worked on the secure unit for 4 months. She said she worked the 2pm-10pm shift. She said she worked on the secure unit [DATE] to [DATE]. When asked if she checked on any residents more frequently, she said when she did rounds she checked in every room. She said all the residents require supervision. She said she checked Resident #2 every 30 minutes because she goes in and out of male resident's rooms. She said she heard about sexual behaviors that occurred yesterday. She said Resident #2 was found with a male resident in her room. She said she could not remember the name of the male resident. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #1 was sitting in a chair in the corner by an exit door, alone. He got up and walked around the hall, looking into other resident's rooms. In an observation on [DATE] between 12:10pm and 12:20pm revealed Resident #2 was in the dining room for lunch. In an interview on [DATE] at 12:15pm, CNA D said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she was not aware of the details, but knew it involved Resident #1 and Resident #2. She said right after the incident, Resident #1 was on 1:1 supervision. She said she was not sure when it ended. She said she was not aware if either resident required special supervision. She said she completed rounds on all residents. She said she was not aware if Resident #1 or Resident #2 had past sexual behaviors. In an interview on [DATE] at 12:20pm, CNA A said she worked in the secure unit. She said she was at the facility the day of the incident, working the 6am-2pm shift. She said she saw Resident #1 walking out of Resident #2's room, adjusting his pants. She said she went in the room and noticed Resident #2 was in bed with her pants and brief off. She said she called for RN A. She said she was not sure what the nurse did, but later, CNA A changed the sheets Resident #2 was laying on. She said Resident #2 was laying on a bed that was not hers. She said she did not see anything on the sheets. She said she was not aware of past sexual behaviors. When asked if she would consider the incident sexual abuse, she said yes, maybe. In a telephone interview on [DATE] at 1:45pm, the MDS nurse stated on the day of the incident, she was on the secure unit looking at medical charts. She said when she was leaving the secure unit, she noticed movement in a resident's room. She said she entered Resident #1's room and saw him standing above Resident #2, her knees were up, and his fingers were in her vagina. She said she yelled for RN A. She said when she called for help, both residents reacted and got up real fast. She said when RN A arrived, Resident #2 was sitting on the toilet and Resident #1 walked out into the hallway. She said she did not think the incident was sexual abuse because didn't see anything that would indicate either resident was coerced or uncomfortable. She said they acted like she interrupted. She said Resident #2 was confused but accurate. She said Resident #1 was pleasantly confused. She said after the incident, she did not update their care plans. In an interview on [DATE] at 2:00pm, when asked about Resident #1's [MEDICATION NAME]'s medication, SW A said they were trying to reduce medications such as [MEDICATION NAME]. She said the medication was discontinued to see if the behavior would reoccur. She said in this case, it did. She said she was not sure why he was put on the medication in March. She said the incident that occurred between Resident #1 and Resident #2 was not considered sexual abuse because no one appeared upset or mistreated, and no one complained about the incident. She said they would have considered it an allegation of sexual abuse if it had not been consensual. When asked about consenting to sexual behavior, she said everyone had the right to consent. She said when she interviewed the residents after the incident, they did not appear distressed, they were pleasant and they both acted like nothing happened. She said they did not have an assessment to determine whether a resident had the capacity to consent to sexual behavior. She said after the incident, interventions included to monitor and keep them separated. She acknowledged that both residents had a [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:20pm, SW B said after the incident that occurred between Resident #1 and Resident #2, she interviewed them separately. She said Resident #2 was able to consent to sexual activity because during the interview she said she could not remember. She said Resident #2 denied the whole incident. She said Resident #2 stated she was attracted to Resident #1. She said Resident #1 could not recall the incident. Resident #1 told her, I have a wife, I will pick her up later. She said 1:1 supervision was put in place but did not know when it ended. When asked how she would determine whether a resident had the capacity to consent, she said if a resident was alert and oriented and was a good historian. She said she would not consider the incident a sexual abuse allegation because the residents could not remember anything, they were not aware, and it did not affect them. She said their mood did not change. She said interventions put in place after the incident included every 15 minute checks and psych consult. In an interview on [DATE] at 9:43am, RN A said the day of the incident, it was reported to her by the CNA that Resident #1 was seen exiting Resident #2's room adjusting his pants. She said when she went in the room, Resident #2 was lying on the bed with her pants and brief off. She said when she asked what happened, Resident #2 said she took them off herself and denied any sexual activity. She said both residents were placed on Q 15 minute checks. She said when she asked Resident #1 what happened, he said he was not sure what she was talking about. She said a little while later, they were found in his room. She said Resident #1 was placed on 1:1 supervision. She said for any sexual activity, she would investigate and monitor. She said if consent was given, she would give them privacy. When asked if Resident #1 or Resident #2 had the capacity to consent, she said Resident #1 was more confused than Resident #2. In an interview on [DATE] at 2:50pm, the DON said a few months ago, there was another incident with Resident #1 and CR #1. She said CR #1 had a history of [REDACTED]. She said they were seen together a lot. She said there was an incident when CR #1's legs were open, her clothes were on and it seemed Resident #1 was trying to get himself erect. She said they put Resident #1 on [MEDICATION NAME] for a short period to see if it would decrease the behaviors. She said Resident #1 was pleasantly confused and does not have good recall. She said when the incident occurred between Resident #1 and Resident #2, she asked the social workers for guidance. She said she thought consent should be assessed after a sexual incident. She said when Unit Manager A assessed the residents, at that moment they were consenting to the behavior. She said both residents could not remember the incident shortly afterward. She said residents with dementia still have sexual needs. She did not think the incident was sexual abuse because there was not a clear aggressor. She said there was no one taking advantage of someone else. She said interventions put in place included social work involvement, psych assessment, close observation and the family was notified. She said she didn't think either resident was a threat to other residents. In an interview on [DATE] at 3:30pm, the Administrator, who is the abuse coordinator, said she was notified of the incident between Resident #1 and Resident #2 by Unit Manager A. She said the Unit Manager A reported that Resident #1 had a history of [REDACTED]. When they asked again, the residents could not remember. She said after the incident, the social workers and psychologist assessed the resident and added medications. She said the physician and family were notified. She said when Resident #2's family member was notified, he was not surprised by the behavior. She said Resident #1 denied the incident occurred by saying he was married. She said after she heard the details of the incident, she thought that both residents were consenting. She said she thinks they are both denying the incident occurred, rather than them not remembering. She said both residents can carry a conversation and they know what is going on. She said neither resident resisted the other. When asked if either resident had the capacity to consent, she said yes. She said they did not have a policy for sexual contact between residents. In an interview on [DATE] at 4:40pm, when asked about Resident #1's wife, SW A said it was possible that while engaging in sexual activity, Resident #1 could have thought Resident #2 was his wife. When asked if someone with a BIMS score of 0, with severe cognitive impairment, could consent to sexual activity, she said there was a thin line and she did not know the right answer. Record review of the facility policy for Abuse Prohibition Standards of Practice dated ,[DATE] read in part . Each resident has the right to be free from verbal, sexual, physical and mental abuse .Training employees: In addition to the freedom from abuse, neglect and exploitation requirements facilities must also provide training to their staff that at a minimum educates staff on- activities that constitute abuse(TRUNCATED)

Based on observation, interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 1of 25 residents (Resident #14) reviewed for falls and coordination of care with hospice. The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent neglect. --Ensure that resident ' s hospice clinical records were kept in the facility --supervise the DON to ensure nursing staff completed accurate care plans to address resident's that complain of pain after a fall. --supervise the DON to ensure that nursing staff were trained on fall prevention and fall management. --supervise the DON to ensure that nursing staff are trained to accurately document follow up and assessments of residents after a change of condition. --Failed to ensure that Resident that pass level 1 screening were apropriatly followed up and results are documented on resident's clinical records. The DON failed to: --Train and supervise staff on management of residents that complain of pain after a fall --Train staff to identify residents' risk factors after falls. --Train and monitor staff ' s clinical documentation on residents after falls. --to ensure that all resident ' s clinical records were available in resident ' s file for review. An immediate jeopardy (IJ) was identified on 01/06/16. While the IJ was removed on 01/08/16 the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected 1 residents and placed 5 residents also on Hospice care at risk for delay in service and decline in health status and a decreased quality of life. Findings include: Record review of Resident #14 ' s clinical record face sheet revealed she was [AGE] year old female admitted to the facility on [DATE] her [DIAGNOSES REDACTED]. Record revealed no information on hospice. Observation on 01/05/16 at 8:00am revealed Resident # 14 was in bed sleeping, Catheter to her bed side with 50cc of yellow urine. Observation at 10:00am revealed PT\OT staff dressing resident up for therapy catheter to bed side with about 80cc of yellow urine. Resident was not interview able. Resident murmurs to verbal communication. In an interview with the facility administrator on 01/06/16 at 3:45 pm,She said the facility staffs did follow policy and procedure and all care was taken in regard to caring for Resident #14. She said Resident #14 was on hospice and hospice was properly notified. Record review of Resident #14's Nurse's notes dated 12/17/15 at 9:15pm revealed Resident observed falling while walking in hallway. Resident lifted onto chair assessed. Neuro checked initiated; Resident complaint of right hip and anterior pelvis pain, able to transfer self onto bed while bilateral weight bearing; Resident able to position self on bed by lifting hips and sliding across bed. No apparent injury noted; Resident self-ambulatory, Tylenol given as ordered. Responsible Party (RP) notified Local Hospice notified awaiting orders. Call light within reach will continue to monitor resident. Nurses notes dated 12/18/15 revealed Resident woke up at getup time this morning and started crying for pain from fall, Hospice was notified and X-ray of right hip\leg was ordered community portable was called for services. Record review revealed no documentation of physician notification, no documentation of pain assessment from 9:00pm 12/17/15 to 6:57am on 12/18/15. Records revealed no pain assessment throughout the night shift and no information on hospice assessment. Record review of facility ' s 24 hour report dated 12/17/15 no time title Change of condition revealed Resident #14 fall no head injury observed. Record review of facility ' s accident & incident report revealed 12/17/15 4:02pm fall no head injury, location was hallway on unite; disposition in-house treatment. Inter-disciplinary team (IDT) notes dated 12/18/15 at 11:19am revealed fall follow up for 12/17/15- Resident self-ambulating, (did not hit head) . assisted with 2 staff, self-transferred to bed, Neuro v\s initiated PRN pain med given. MD ordered X-Ray result pending. Nurses notes dated 12/18/15 1:08pm revealed- Follow up fall: Resident hospice organization contacted for evaluation and orders. No new orders.10:00pm Hospice Nurse P present to evaluate resident on X-ray request due to fall. Hospice Nurse P concluded no new orders required at the time and would prefer to have resident reassessed by nurse on following day to determine if an X-ray warranted. Overnight nurse communicated resident complain of pain, communicated once again to hospice with new orders for X ray. Hospice Nurse Q present at facility to reassessed resident - . X-ray result obtained with fracture of right hip reported. Hospice nurse ordered sent resident to local hospital .left facility at 12:55pm. RP notified by Hospice nurse. Record review of Medication flow sheet revealed Tylenol [MEDICATION NAME] was given on 12/17/15 at 4:00pm and Tylenol 500 mg was administrated on 12/18/15 at 5:55am. Record review of facility ' s pain monitoring scale revealed resident was on routine when necessary (PRN) pain assessment; records revealed no pain on 6am-2pm and 2pm-10pm shift. 10-6pm shift indicated a pain level of 10. Record review of telephone orders dated 12/17/15 no time and no signature revealed pt. discharged from Hospice sent to none contracture hospital for aggressive treatment . Record review of telephone orders dated 12/18/15 at 6:55am no signatures revealed - X-ray. No documentation of physician's notification. Record review of clinical notification log revealed an entry dated 12/17/15 no time revealed Fall please follow up no apparent injury. Record review of radiology report dated 12/18/15 signed 12:16 pm revealed moderately displaced sub capital fracture of right hip noted. No associated discoloration is seen. No bonny destructive lesion is identified . seen no bony destructive . Records revealed no hospice documentation, No pain assessment and no time of physician notification. Record review of Hospital record dated 12/28/15 4:13pm revealed [DIAGNOSES REDACTED]. Record review of resident # 14 care plan up dated 12/17/15-Fall: approach :- rule out medical complication with increase falls; Notify MD(Medical doctor, medical director and family of falls or injuries PRN ( when Necessary) . Record review of Resident #14 ' s last MDS assessment dated [DATE] revealed section C- cognition level was coded 00 severely impaired. It documented that her cognitive skills for decision making was severely impaired and required staff assistance in part with activity of daily living. Resident was assessed as mobile un-assisted. In an interview on 01/05/16 at 11:00am, LVN-D said she was told of the incident the next day on 12/18/15. She said Resident #14 as on hospices and it was the facility ' s policy to notify Hospice first. She said Hospice was notified. When asked what she did she said she was waiting for hospice nurse. In an interview with Hospice Nurse Q on 01/05/16 at 2:00pm she said Hospice Nurse P who was covering for her came to check on Resident #14 when the call came to the agency. She said Hospice Nurse P did not leave her with any documentation but asked her to check on Resident #14. Hospice Nurse Q clarified that orders dated 12/17/15 discharge from hospice was her orders for 12/18/15. She said she was not at the facility on 12/17/15. At this time she started calling Hospice Nurse P for her documentation. She said Hospice Nurse P told her that she did not assess Resident #14 on 12/17/15 at 10pm. Hospice Nurse Q said there was no documentation from Hospice Nurse P in reference to Resident #14 ' s assessment. She said she would call Hospice Nurse P to see if there was documentation on Resident #14. After the phone call she said there was no documentation of the visit. When asked about coordination of service without medical records she said it depends on what the facility wants. She said sometimes the records are kept at the facility or at the hospice office. She said she keeps her records with her at the office.Further interview, Hospice Nurse said she came to visit Resident # 14 that morning at about 10:00am. She provided her notes and said she keeps her notes. Reviewed of Hospice Nurse Q'snotes dated 12/18/15 10:00am revealed Resident # 14 who was pleasantly confused and in severe pain on right hip movement awaiting X-ray. 12/18/15 8:00pm Pt. discharged from hospices for aggressive treatment . Several attempt was made to contact LVN C-night nurse who worked the night shift and initiated the X-ray. Her phone could not accept any message. In an interview on 01/06/16 at 11:30am with RN B who was on duty when Resident #14 fell , she said she worked the 6-2 and 2-10 shifts. She said Resident #14 fell on the hallway from the dining room. She assessed Resident #14, herself and the Medication Aide G (MA-G) on duty assisted Resident #14 onto her wheel chair after assessments. Neuro checked was initiated; Resident #14 complained of right hip and anterior pelvis pain, able to transfer self onto bed while bilateral weight bearing; She said Resident # 14 was able to scoot self on to the bed by lifting hips and sliding across bed. She said she gave Resident #14 her pain medication gave report to the night Nurses. No answer was provided when asked about her pain assessment. She said she started her Neuro check. When asked about Notification, she said she called Hospice nurse per facility protocol.She said prior to the end of her shift at about 9:30ish pm, Hospice Nurse P (RN P) came in went into Resident ' s room for few minutes and left. RN B said RN P told her that another nurse would assess her in the morning if Resident # 14 needs an X-ray or not.RN B said not form of assessment documentation was given to her by RN P upon exit.RN B said when she came the next morning on 12/08/15, the night Nurse LVN C told her that Resident # 14 was crying of severe pain this morning and she called for an X-ray and notified her hospice and her physician.When asked about the time Hospice arrived RN Q, she said RN Q arrived at the facility almost at the same time with the Ambulance was taking resident #14 to the Hospital. She indicated that things were going so fast and she may not be accurate with the exat time but she know Nurse Q came in about the same time Resident #14 left the facility. Interview with DON on 01/06/16 at 1:30pm, he said Residents RP, Physician are notified of any fall. The initial thing was to assess resident and document, notify the physician and the responsible party. He said all process was followed during the time of Resident # 14 ' s fall. When asked what time Resident physician was called, he said it at the time of fall. He said Resident # 14 was a hospice resident and hospice was notified. No information was provided on when Resident's physician was notified.When asked about hospice records he said Hospice records were on Resident ' s clinical records. Records reviewed together with surveyor revealed no evidence of hospice records. Records review of Hospice binder on station #2 revealed no records for resident #14. He said there is always an ongoing communication with hospice. He said he would call Hospice to fax in their records for Resident #14. During a telephone interview with Resident's responsible party on 01/11/16 at 8:40am, she indicated that the facility called her on 12/18/15 that her mother had a fall and was being sent to the hospital. She said she does not remember the time but the hospital and the facility called her almost at the same time on the same day. Prior to exit on 01/08/16, Facility Administrator said she has no further information to provide. she said all her additional information would be included in her IDR process. Record review of the facility's written policy entitled, Abuse program; prevention\training identification page 2 Neglect Policy define neglect as failure to provide goods and services to avoid harm, mental, anguish or mental illness. Neglect occurs when facility staff fails to monitor and supervise residents. Neglect occurs when facility fails to provide necessary care for residents Record review of facility ' s provided policy on falls; revised October 2010 Page 7 Falls Risk Management After a Fall read in part- A- If a resident has just fallen , or is found .Nursing staff will record vital sign and evaluate for possible injuries to head, neck spine and extremities. B- If there is evidence of significant injuries such as fracture or bleeding, nursing staff will provide appropriate first aid . C- Once an assessment rules out significant injuries, nursing staff will help the resident to a comfortable sitting, lying or standing position D- Nursing staff will notify the resident ' s attending physician and family in an appropriate time frame. When a fall result in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Interview with the Administrator on 1/7/16 at 3:55pm revealed that the PASRR Level 2 Evaluation was done by MHMR. She said that the facility was not responsible for getting Level 2 PASRR Evaluations. An immediate jeopardy (IJ) was identified on 01/06/16 at 3:45 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/06/168/14/15 at 4:48pm and after several revisions were made it was accepted on 01/07/15 at 6:20pm. The POR included in part: 1. Immediate Corrective action was- on all fall\incidents\accidents notify DON\ADON or nurse on call as feasible possible but not later than 1 hour after incident occurs: however if the patient is being transferred to hospital the DON\ADON\Nurse on call and the Administrator must be notified immediately. 2. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and visual observation of any limb shortening or internal or external rotation of any obvious sign of fracture. a. Take vital signs - temperatures, BP, pulse, b. If vital signs- critical is not met per (care path) then proceed with initial nursing evaluation for injuries and \ or mental status change. Do not move off the floor until complete exam has been performed. c. Determine if suspected fracture or new bone deformity, head trauma, altered manta, ( decrease LOC, unresponsiveness, suspicious of [MEDICAL CONDITION] new or worsen cognitive impairment), laceration required sutures\staples if yes notify MD\NP\PA and transfer via EMS. 3 If resident falls and has any complaints of [MEDICAL CONDITION] or spinal injury, head trauma, perform Neurological assessment at the scene of fall If any abnormalities call EMS and send resident out. Do not move resident A complete report and notify MD via telephone. If no answer within one hour,, the Medical Director will be contacted. The RP\facility will be notified Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change on fall policies on 01/07/16 by 3:00pm by the Director of Nursing (DON.) The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 01/07/16 until 01/08/16. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment. Observations were made from 01/07/06 until 01/08/16 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 01/07/16-01/08/16 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 01/08/16 at 10:00pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. According to the CMS-672, listed 6 residents on Hospice.

Based on record review and interview, the facility failed to implement its written policy and procedures that prohibit neglect for 1 of 25 residents (Resident #14) reviewed for neglect: Resident #14 had a fall and a change in condition on 12/17/15 between 3:30-4:00pm. Resident #14 was allowed to self-transfer from the wheelchair to the bed immediately after the fall while she complained of pain to her hip and pelvic area. Resident #14 ' s physician was not immediately notified of her fall or complaints of pain. Resident #14 did not have an x-ray of the hip and pelvic area until 11:40am on 12/18/15. She was then sent to the hospital on [DATE] at 12:55pm for a [MEDICAL CONDITION] and surgical repair. There was no documentation of a pain assessment for Resident #14 after the fall. An IJ was identified on 01/06/2016. While the IJ was removed on 01/08/2016, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected 1 resident and placed an additional 5 residents on Hospice at risk of not receiving care and services, delay in treatment and possible complications. Complaint # 0 Findings Include: Record review of Resident #14 ' s clinical record face sheet revealed she was [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #14 ' s clinical record revealed no information on hospice to indicate hospice visits, assessments or coordination. Record review of Resident #14 ' s last MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 00 which indicated she had severe cognitive impairment. It was documented that her daily decision making skills were severely impaired and required staff assistance in part with activity of daily living. Resident #14 was assessed as not needing staff assistance for mobility. Record review of Resident #14's care plan dated 07/30/2015 updated on 10/15/15 with a note to continue read in part: Problem-Resident has Terminal/ End stage [DIAGNOSES REDACTED].goal .Pain will be well managed through end of life .approaches included .coordinate care with Hospice provider, Contact .with changes in condition .Notify MD, family, responsible party of changes as needed. Problem .potential to experience an alteration in level of comfort. DX [MEDICAL CONDITION] (OA) .goal will voice relief from pain interventions within 1 hour from administration .approaches included: pain assessment per protocol, identify location and rate of pain prior to and after any interventions, medication as ordered, attempt and document effectiveness of non pharmacological interventions . Problem- At risk for injury related to falls per [MEDICAL CONDITION] medications, weakness with lack of coordination and gait abnormal .there was three falls documented, 9/30, 10/15/15 and 12/17/15 .goal was to have no significant injury related to falls .approaches .Notify MD and family of falls and injuries . Record review of Resident # 14's care plan dated 12/17/15 for a problem of Fall read in part . approach . rule out medical complication with increase falls . Notify MD (medical director and family of falls or injuries as necessary . Record review of Resident #14 ' s Nurse ' s notes dated 12/17/15 at 9:15pm revealed Resident observed falling while walking in hallway. Resident lifted onto chair assessed. Neuro checked initiated; Resident complaint of right hip and anterior pelvis pain, able to transfer self onto bed while bilateral weight bearing; Resident able to position self on bed by lifting hips and sliding across bed. No apparent injury noted; Resident self-ambulatory, Tylenol given as ordered. Responsible Party (RP) notified Local Hospice notified awaiting orders. Call light within reach will continue to monitor resident. Record review of Resident #14's Hospital History & Physical dated 12/28/15 at 1:25pm read in part .Review of Systems .She is awake, moans to pain . X-ray of the femur shows a right femoral fracture. Impression: 1. Right femoral neck fracture. 2. Advance dementia. 3. Urinary tract infection. In an interview on 01/06/16 at 11:30am with Registered Nurse (RN) B on duty during the fall, she said she worked the 6am-2pm and 2pm-10pm shifts. RN B said Resident #14 fell in the hallway while coming from the dining room. RN B said she assessed Resident #14 and then Medication Aide (MA) G on duty assisted Resident #14 into her wheel chair after the assessment. RN B said Neuro checks were initiated and Resident #14 complained of right hip and anterior pelvis pain. She said Resident #14 was able to transfer self onto bed while bearing weight on both legs. She said Resident #14 was able to scoot on to the bed by lifting her hips and sliding across the bed. She said she gave Resident #14 her pain medication and gave report to the night Nurse. No answer was provided when asked about conducting a pain assessment for Resident #14. RN B said she started her Neuro check. When asked about consulting with Resident #14 ' s physician, she said she called the Hospice nurse per facility protocol. She said prior to the end of her shift at about 9:30ish pm, Hospice Nurse P came in, went into Resident #14 ' s room for few minutes and left. RN B said Hospice Nurse P told her that another nurse would assess Resident #14 in the morning to see if she needed an X-ray or not. RN B said Hospice Nurse P did not give her any form of assessment documentation before he left the night of 12/17/15. RN B said when she came to work the next morning on 12/18/15, the night Nurse; LVN C told her that Resident # 14 was crying of severe pain this morning. LVN C said she called for an X-ray and notified her hospice and physician. When asked about the time Hospice Nurse Q arrived at the facility RN B said Hospice Nurse Q arrived almost at the same time as the Ambulance was taking Resident #14 to the Hospital. She indicated that things were going so fast and she could not give the exact time but she knew Hospice Nurse Q came in about the same time as Resident #14 left the facility. In an interview with Resident #14 ' s physician on 01/07/16 at 8:10am revealed that he had not been contacted by the facility on 12/17/15 regarding Resident #14 ' s fall and complaints of pain. He said that they put it on the log for him to see her. He said this was the system he and the facility used for non-emergency situations, such as when a resident has a fall with no injury. Record review of facility form titled Clinical Notification Log read in part: List any resident incidents that have occurred or concerns to be addressed at the time of the Physician or Nurse Practitioner ' s next visit .Resident Name: Resident 14 .Date of Occurrence: 12/17/15 .Concern/Assessment/Actions: Fall please follow-up- no apparent injury. Several attempts were made to contact LVN C who worked the night shift and initiated the X-ray. Her phone would not accept any messages. Nurse ' s notes dated 12/18/15 at revealed Resident woke up at getup time this morning and started crying for pain from fall, Hospice was notified and X-ray of right hip\leg was ordered Record review of the facility's Inter-disciplinary team (IDT) notes dated 12/18/15 at 11:19am for Resident #14 revealed fall follow up for 12/17/15- Resident self-ambulating, (did not hit head) . assisted with 2 staff, self-transferred to bed, Neuro v\s initiated PRN pain med given. MD ordered X-Ray result pending. Observation on 01/05/16 at 8:00am revealed Resident # 14 was in bed sleeping, she had a catheter to her bed side with 50cc of yellow urine. Observation at 10:00am revealed PT\OT staff dressing resident up for therapy. Resident was not interviewable due to cognitive status. Resident mumbles to verbal communication. Record review of Resident #14's Nurses notes dated 12/18/15 at 1:08pm revealed- Follow up fall: Resident hospice organization contacted for evaluation and orders. No new orders. Record review of Resident #14's Nurse's notes dated 12/18/15 at 1:08pm read in part, Follow Up fall. Resident ' s hospice organization was contacted for resident evaluation and orders for x-ray 12/17/15 (no time provided) .unable to send a nurse to current unavoidable events with staff. No new orders. Hospice Nurse P present on 12/17/18 (SIC) at 10:00pm to evaluate resident for x-ray request due to fall. Hospice Nurse P concluded .no x-ray was required at the time. Hospice Nurse P said he would prefer to have Resident #14 reassessed by nurse on following day to determine if an X-ray was warranted. LVN C communicated Resident #14 ' s complaint of pain once again to the hospice organization with new order for X- ray obtained (No date and time provided). Hospice Nurse Q present at facility to reassess resident. X-ray result obtained with fracture of right hip reported. Hospice Nurse Q ordered Resident #14 to be sent to local hospital .left facility at 12:55pm. RP notified by Hospice Nurse Q. Record review of Resident #14 ' s Progress Note dated 12/18/15 read in part . Chief complaint: Evaluation of patient for hypertension and fall with resultant right [MEDICAL CONDITION] . Musculoskeletal: Lying in bed complains of right hip pain and there was noted shortening of the right leg. In an interview on 01/05/16 11:00am, LVN-D said she was told of the incident the next day on 12/18/15. She said Resident #14 was on hospice and it was the facility ' s policy to notify Hospice first. She said Hospice was notified. When asked what she did she said she was waiting for hospice nurse to complete the assessment. Record review of an email sent to the Facility ' s Administrator from Hospice Nurse Q regarding the overnight report for 12/17/15 read in part .2300 (11:00pm) Visit Resident #14 related to fall earlier in the day. At the time of visit . unable to fully assess hip/pelvic area . This note was signed by Hospice Nurse P. In an interview with Hospice Nurse Q on 01/06/16 at 2:00pm she said Hospice Nurse P, who was covering for her came to check on Resident #14 when the call came to the agency. She said Nurse P did not leave her with any documentation but asked her to check on Resident #14. Hospice Nurse Q said there was no documentation from Nurse P in reference to Resident #14 ' s assessment. She said she would call Hospice Nurse P to see if there was documentation on Resident #14. After the phone call she said there was no documentation of the visit. Further interview, Hospice Nurse Q said she came to visit Resident # 14 that morning (12/18/15) at about 10:00am. Hospice Nurse Q provided her notes at the time of the interview and said she kept her notes with her. When asked about coordination of service without medical records she said it depends on what the facility wants. She said sometimes the records are kept at the facility or at the hospice office. She said she kept her records with her at the office. Record reviewed of Hospice Nurse Q notes dated 12/18/15 10:00am read in part, Resident # 14 was resting in bed with her eyes open, pleasantly confused .has severe pain on right hip movement Appetite was poor this morning related to pain . awaiting X-ray results . Record review of a separate Hospice note dated 12/18/15 at 10:00am revealed a verbal order obtained from Resident #14 ' s physician to send her to the hospital for fracture of right femur. Record review of Resident #14 ' s clinical record revealed no documentation of physician notification, no documentation of pain assessment from 9:00pm 12/17/15 to 6:57am on 12/18/15. Records revealed no pain assessment throughout the night shift and no hospice assessment. Record review of facility ' s 24 hour report dated 12/17/15 no time title Change of condition revealed Resident #14 fall no head injury observed. Record review of the facility ' s Incident report dated 12/17/15 at 4:02pm read in part Incident Type: Fall/no head injury .Type of Injury: None Apparent .Location: Hallway on unit .Incident Level: Non-witnessed .Narrative of Incident: Resident was observed falling onto right side while walking in hallway .Resident lifted onto chair and assessed .Disposition was in-house treatment. Record review of Medication flow sheet revealed Tylenol [MEDICATION NAME] (milligrams) was given on 12/17/15 at 4:00pm and Tylenol 500 mg was administrated on 12/18/15 at 5:55am. Record review of facility ' s pain monitoring scale revealed resident was on routine when necessary (PRN) pain assessment; records revealed no pain on 6am-2pm and 2pm-10pm shift. 10-6pm shift indicated a pain level of 10. Record review of telephone orders dated 12/17/15 (no time and no signature documented) read pt. discharged from Hospice sent to none contracture hospital for aggressive treatment. Record review of telephone orders dated 12/18/15 at 6:55am no signatures revealed an order to obtain an X-ray. Record review of radiology report dated 12/18/15 signed 12:16 pm revealed moderately displaced sub capital fracture of right hip noted. No associated discoloration is seen . Records revealed no hospice documentation, No pain assessment and no time of physician notification. Interview with Director of Nurses (DON) on 01/06/16 at 1:30pm, he said the Resident ' s Responsible party (RP), Hospice and Physician should be notified of any fall. The initial thing was to assess resident and document, notify the physician and the responsible party and hospice if resident was on hospice care. He said all processes were followed during the time of Resident # 14's fall. When asked what time Resident #14 ' s physician was called, he said it should be on the resident's clinical records. He said Resident #14 was a hospice resident and hospice was notified. No information was provided on when Resident's physician was notified. Records for Resident #14 were reviewed together with the surveyor and revealed no evidence of the facility consulting with Resident #14 regarding her fall and pain. When asked about hospice records the DON said Hospice records were on Resident #14' s clinical records. Records reviewed together with surveyor revealed no evidence of hospice records. Record review of Hospice binder on station #2 revealed no records for Resident #14. He said there is always an ongoing communication with hospice. He said he would call Hospice to fax in their records for Resident #14. During a telephone interview with Resident #14's responsible party on 01/11/16 at 8:40am, she indicated that the facility called her on 12/18/15 that her mother had a fall and was being sent to the hospital. She said she does not remember the time but the hospital and the facility called her almost at the same time on the same day. Record review of the facility's written policy entitled, Abuse program; prevention\training identification page 2 Neglect Policy define neglect as failure to provide goods and services to avoid harm, mental, anguish or mental illness. Neglect occurs when facility staff fails to monitor and supervise residents. Neglect occurs when facility fails to provide necessary care for residents Record review of facility ' s provided policy on falls; revised October 2010 Page 7 Falls Risk Management After a Fall read in part- A- If a resident has just fallen , or is found .Nursing staff will record vital sign and evaluate for possible injuries to head, neck spine and extremities. B- If there is evidence of significant injuries such as fracture or bleeding, nursing staff will provide appropriate first aid . C- Once an assessment rules out significant injuries, nursing staff will help the resident to a comfortable sitting, lying or standing position D- Nursing staff will notify the resident ' s attending physician and family in an appropriate time frame. When a fall result in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Prior to exit on 01/08/16, Facility Administrator said she has no further information to provide. she said all her additional information would be included in her IDR process. An immediate jeopardy (IJ) was identified on 01/06/16 at 3:45 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/06/16 at 4:48pm and after several revisions were made it was accepted on 01/07/16 at 6:20pm. The POR included in part: 1. Immediate Corrective action was- on all fall\incidents\accidents notify DON\ADON or nurse on call as feasible possible but not later than 1 hour after incident occurs: however if the patient is being transferred to hospital the DON\ADON\Nurse on call and the Administrator must be notified immediately. 2. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and visual observation of any limb shortening or internal or external rotation of any obvious sign of fracture. a. Take vital signs - temperatures, BP, pulse, b. If vital signs- critical is not met per (care path) then proceed with initial nursing evaluation for injuries and \ or mental status change. Do not move off the floor until complete exam has been performed. c. Determine if suspected fracture or new bone deformity, head trauma, altered manta, ( decrease LOC, unresponsiveness, suspicious of [MEDICAL CONDITION] new or worsen cognitive impairment), laceration required sutures\staples if yes notify MD\NP\PA and transfer via EMS. 3 If resident falls and has any complaints of [MEDICAL CONDITION] or spinal injury, head trauma, perform Neurological assessment at the scene of fall If any abnormalities call EMS and send resident out. Do not move resident. A complete report and notify MD via telephone. If no answer within one hour,, the Medical Director will be contacted. The RP\facility will be notified Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change on fall policies on 01/07/16 by 3:00pm by the Director of Nursing (DON.) The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 01/07/16 until 01/08/16. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment. Observations were made from 01/07/16 until 01/08/16 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 01/07/16-01/08/16 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 01/08/16 at 10:00am that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The CMS Form 672 listed 6 residents receiving hospice care.

Based on observation, interview and record review the facility failed to ensure 1 of 25 residents (#14) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: Resident #14 had a fall and a change in condition on 12/17/15 at 4:02pm. Resident #14 was allowed to self-transfer from the wheelchair to the bed immediately after the fall while she complained of pain to her hip and pelvic area. Resident #14 ' s physician was not immediately notified of her fall or complaints of pain. Resident #14 did not have an x-ray of the hip and pelvic area until 11:40am on 12/18/15. She was then sent to the hospital on [DATE] at 12:55pm for a [MEDICAL CONDITION] and surgical repair. There was no pain assessment conducted for Resident #14 after the fall. An IJ was identified on 01/06/2016. While the IJ was removed on 01/08/2016, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected 1 resident and placed an additional 6 residents on Hospice at risk of not receiving care and services, delay in treatment and possible complications. Complaint # 0 Findings Include: Record review of Resident #14 ' s clinical record face sheet revealed she was [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #14 ' s clinical record revealed no information on hospice to indicate hospice visits, assessments or coordination. Record review of Resident #14 ' s last MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 00 which indicated she had severe cognitive impairment. It was documented that her daily decision making skills were severely impaired and required staff assistance in part with activity of daily living. Resident #14 was assessed as not needing staff assistance for mobility. Record review of Resident #14's care plan dated 07/30/2015 updated on 10/15/15 with a note to continue read in part: Problem-Resident has Terminal/ End stage [DIAGNOSES REDACTED].goal .Pain will be well managed through end of life .approaches included .coordinate care with Hospice provider, Contact .with changes in condition .Notify MD, family, responsible party of changes as needed. Problem .potential to experience an alteration in level of comfort. DX OA .goal will voice relief from pain interventions within 1 hour from administration .approaches included: pain assessment per protocol, identify location and rate of pain prior to and after any interventions, medication as ordered, attempt and document effectiveness of non pharmacological interventions . Problem- At risk for injury related to falls per [MEDICAL CONDITION] medications, weakness with lack of coordination and gait abnormal .there was three falls documented, 9/30, 10/15/15 and 12/17/15 .goal was to have no significant injury related to falls .approaches .Notify MD and family of falls and injuries . Record review of Resident # 14's care plan dated 12/17/15 for a problem of Fall read in part . approach . rule out medical complication with increase falls . Notify MD (medical director and family of falls or injuries as necessary . Record review of Resident #14 ' s Nurse ' s notes dated 12/17/15 at 9:15pm revealed Resident observed falling while walking in hallway. Resident lifted onto chair assessed. Neuro checked initiated; Resident complaint of right hip and anterior pelvis pain, able to transfer self onto bed while bilateral weight bearing; Resident able to position self on bed by lifting hips and sliding across bed. No apparent injury noted; Resident self-ambulatory, Tylenol given as ordered. Responsible Party (RP) notified Local Hospice notified awaiting orders. Call light within reach will continue to monitor resident. In an interview on 01/06/16 at 11:30am with Registered Nurse (RN) B on duty during the fall, she said she worked the 6am-2pm and 2pm-10pm shifts. RN B said Resident #14 fell in the hallway while coming from the dining room. RN B said she assessed Resident #14 and then Medication Aide (MA) G on duty assisted Resident #14 into her wheel chair after the assessment. RN B said Neuro checks were initiated and Resident #14 complained of right hip and anterior pelvis pain. She said Resident #14 was able to transfer self onto bed while bearing weight on both legs. She said Resident #14 was able to scoot on to the bed by lifting her hips and sliding across the bed. She said she gave Resident #14 her pain medication and gave report to the night Nurse. No answer was provided when asked about conducting a pain assessment for Resident #14. RN B said she started her Neuro check. When asked about consulting with Resident #14 ' s physician, she said she called the Hospice nurse per facility protocol. She said prior to the end of her shift at about 9:30ish pm, Hospice Nurse P came in, went into Resident #14 ' s room for few minutes and left. RN B said Hospice Nurse P told her that another nurse would assess Resident #14 in the morning to see if she needed an X-ray or not. RN B said Hospice Nurse P did not give her any form of assessment documentation before he left the night of 12/17/15. RN B said when she came to work the next morning on 12/18/15, the night Nurse; LVN C told her that Resident # 14 was crying of severe pain this morning. LVN C said she called for an X-ray and notified her hospice and physician. When asked about the time Hospice Nurse Q arrived at the facility RN B said Hospice Nurse Q arrived almost at the same time as the Ambulance was taking Resident #14 to the Hospital. She indicated that things were going so fast and she could not give the exact time but she knew Hospice Nurse Q came in about the same time as Resident #14 left the facility. In an interview with Resident #14 ' s physician on 01/07/16 at 8:10am revealed that he had not been contacted by the facility on 12/17/15 regarding Resident #14 ' s fall and complaints of pain. He said that they put it on the log for him to see her. He said this was the system he and the facility used for non-emergency situations, such as when a resident has a fall with no injury. Record review of facility form titled Clinical Notification Log read in part: List any resident incidents that have occurred or concerns to be addressed at the time of the Physician or Nurse Practitioner ' s next visit .Resident Name: Resident 14 .Date of Occurrence: 12/17/15 .Concern/Assessment/Actions: Fall please follow-up- no apparent injury. Nurse ' s notes dated 12/18/15 at revealed Resident woke up at getup time this morning and started crying for pain from fall, Hospice was notified and X-ray of right hip\leg was ordered Record review of the facility's Inter-disciplinary team (IDT) notes dated 12/18/15 at 11:19am for Resident #14 revealed fall follow up for 12/17/15- Resident self-ambulating, (did not hit head) . assisted with 2 staff, self-transferred to bed, Neuro v\s initiated PRN pain med given. MD ordered X-Ray result pending. Observation on 01/05/15 at 8:00am revealed Resident # 14 was in bed sleeping, she had a catheter to her bed side with 50cc of yellow urine. Observation at 10:00am revealed PT\OT staff dressing resident up for therapy. Resident was not interviewable due to cognitive status. Resident mumbles to verbal communication. Record review of Resident #14's Nurses notes dated 12/18/15 at 1:08pm revealed- Follow up fall: Resident hospice organization contacted for evaluation and orders. No new orders. Record review of Resident #14's Nurse's notes dated 12/18/15 at 1:08pm read in part, Follow Up fall. Resident ' s hospice organization was contacted for resident evaluation and orders for x-ray 12/17/15 (no time provided) .unable to send a nurse to current unavoidable events with staff. No new orders. Hospice Nurse P present on 12/17/18 (SIC) at 10:00pm to evaluate resident for x-ray request due to fall. Hospice Nurse P concluded .no x-ray was required at the time. Hospice Nurse P wanted to have Resident #14 reassessed by nurse on the following day to determine if an X-ray was warranted. LVN C communicated Resident #14 ' s complaint of pain once again to the hospice organization with new order for X- ray obtained (No date and time provided). Hospice Nurse Q present at facility to reassess resident. X-ray result obtained with fracture of right hip reported. Hospice Nurse Q ordered Resident #14 to be sent to local hospital .left facility at 12:55pm. RP notified by Hospice Nurse Q. Record review of Resident #14 ' s Progress Note dated 12/18/15 read in part . Chief complaint: Evaluation of patient for hypertension and fall with resultant right [MEDICAL CONDITION] . Musculoskeletal: Lying in bed complains of right hip pain and there was noted shortening of the right leg. In an interview on 01/05/16 11:00am, LVN-D said she was told of the incident the next day on 12/18/15. She said Resident #14 was on hospice and it was the facility ' s policy to notify Hospice first. She said Hospice was notified. When asked what she did she said she was waiting for hospice nurse to complete the assessment. Record review of an email sent to the Facility ' s Administrator from Hospice Nurse Q regarding the overnight report for 12/17/15 read in part .2300 (11:00pm) Visit Resident #14 related to fall earlier in the day. At the time of visit . unable to fully assess hip/pelvic area . This note was signed by Hospice Nurse P. In an interview with Hospice Nurse Q on 01/06/15 at 2:00pm she said Hospice Nurse P, who was covering for her came to check on Resident #14 when the call came to the agency. She said Nurse P did not leave her with any documentation but asked her to check on Resident #14. Hospice Nurse Q said there was no documentation from Nurse P in reference to Resident #14 ' s assessment. She said she would call Nurse P to see if there was documentation on Resident #14. After the phone call she said there was no documentation of the visit. Further interview, Hospice Nurse Q said she came to visit Resident # 14 that morning (12/18/15) at about 10:00am. She provided her notes at the time of the interview and said she kept her notes with her. When asked about coordination of service without medical records she said it depends on what the facility wanted. She said sometimes the records are kept at the facility or at the hospice office. She said she kept her records with her at the office. Record reviewed of Hospice Nurse Q notes dated 12/18/15 10:00am read in part, Resident # 14 was resting in bed with her eyes open, pleasantly confused .has severe pain on right hip movement Appetite was poor this morning related to pain . awaiting X-ray results . Record review of a separate Hospice note dated 12/18/15 at 10:00am revealed a verbal order obtained from Resident #14 ' s physician to send her to the hospital for fracture of right femur. Record review of Resident #14 ' s clinical record revealed no documentation of physician notification, no documentation of pain assessment from 9:00pm 12/17/15 to 6:57am on 12/18/15. Records revealed no pain assessment throughout the night shift and no hospice assessment. Record review of facility ' s 24 hour report dated 12/17/15 no time title Change of condition revealed Resident #14 fall no head injury observed. Record review of the facility ' s Incident report dated 12/17/15 at 4:02pm read in part Incident Type: Fall/no head injury .Type of Injury: None Apparent .Location: Hallway on unit .Incident Level: Non-witnessed .Narrative of Incident: Resident was observed falling onto right side while walking in hallway .Resident lifted onto chair and assessed .Disposition was in-house treatment. Record review of Medication flow sheet revealed Tylenol [MEDICATION NAME] (milligrams) was given on 12/17/15 at 4:00pm and Tylenol 500 mg was administrated on 12/18/15 at 5:55am. Record review of facility ' s pain monitoring scale revealed resident was on routine when necessary (PRN) pain assessment; records revealed no pain on 6am-2pm and 2pm-10pm shift. 10-6pm shift indicated a pain level of 10. Record review of telephone orders dated 12/17/15 (no time and no signature documented) read pt. discharged from Hospice sent to none contracture hospital for aggressive treatment. Record review of telephone orders dated 12/18/15 at 6:55am no signatures revealed an order to obtain an X-ray. Record review of radiology report dated 12/18/15 signed 12:16 pm revealed moderately displaced sub capital fracture of right hip noted. No associated discoloration is seen . Records revealed no hospice documentation, No pain assessment and no time of physician notification. Interview with Director of Nurses (DON) on 01/06/16 at 1:30pm, he said the Resident ' s Responsible party (RP), Hospice and Physician should be notified of any fall. The initial thing was to assess the resident and document, notify the physician and the responsible party; and hospice if the resident was on hospice. He said all processes were followed during the time of Resident # 14's fall. When asked what time Resident #14 ' s physician was called, he said it should be on the resident's clinical records. The DON said Resident #14 was a hospice resident and hospice was notified. No information was provided on when Resident's physician was notified. Records for Resident #14 were reviewed together with the surveyor and revealed no evidence of the facility consulting with Resident #14's physician regarding her fall and pain. When asked about hospice records the DON said the Hospice records were on Resident #14' s clinical records. Records reviewed together with surveyor revealed no evidence of hospice records. Record review of Hospice binder on station #2 revealed no records for Resident #14. He said therewas always an ongoing communication with hospice. He said he would call Hospice to fax in their records for Resident #14. During a telephone interview with Resident #14's responsible party on 01/11/16 at 8:40am, she indicated that the facility called her on 12/18/15 that her mother had a fall and was being sent to the hospital. She said she does not remember the time but the hospital and the facility called her almost at the same time on the same day. Record review of Resident #14's Hospital History & Physical dated 12/28/15 at 1:25pm read in part .Review of Systems .She is awake, moans to pain . X-ray of the femur shows a right femoral fracture. Impression: 1. Right femoral neck fracture. 2. Advance dementia. 3. Urinary tract infection. Record review of the facility's written policy entitled, Abuse program; prevention\training identification page 2 Neglect Policy define neglect as failure to provide goods and services to avoid harm, mental, anguish or mental illness. Neglect occurs when facility staff fails to monitor and supervise residents. Neglect occurs when facility fails to provide necessary care for residents Record review of facility ' s provided policy on falls; revised October 2010 Page 7 Falls Risk Management After a Fall read in part- A- If a resident has just fallen , or is found .Nursing staff will record vital sign and evaluate for possible injuries to head, neck spine and extremities. B- If there is evidence of significant injuries such as fracture or bleeding, nursing staff will provide appropriate first aid . C- Once an assessment rules out significant injuries, nursing staff will help the resident to a comfortable sitting, lying or standing position D- Nursing staff will notify the resident ' s attending physician and family in an appropriate time frame. When a fall result in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Prior to exit on 01/08/16, Facility Administrator said she has no further information to provide. she said all her additional information would be included in her IDR process. Several attempts were made to contact LVN C who worked the night shift and initiated the X-ray. Her phone would not accept any messages. An immediate jeopardy (IJ) was identified on 01/06/16 at 3:45 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/06/168/14/15 at 4:48pm and after several revisions were made it was accepted on 08/17/15 at 8:30am. The POR included in part: 1. Immediate Corrective action was- on all fall\incidents\accidents notify DON\ADON or nurse on call as feasible possible but not later than 1 hour after incident occurs: however if the patient is being transferred to hospital the DON\ADON\Nurse on call and the Administrator must be notified immediately. 2. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and visual observation of any limb shortening or internal or external rotation of any obvious sign of fracture. a. Take vital signs - temperatures, BP, pulse, b. If vital signs- critical is not met per (care path) then proceed with initial nursing evaluation for injuries and \ or mental status change. Do not move off the floor until complete exam has been performed. c. Determine if suspected fracture or new bone deformity, head trauma, altered manta, ( decrease LOC, unresponsiveness, suspicious of [MEDICAL CONDITION] new or worsen cognitive impairment), laceration required sutures\staples if yes notify MD\NP\PA and transfer via EMS. 3 If resident falls and has any complaints of [MEDICAL CONDITION] or spinal injury, head trauma, perform Neurological assessment at the scene of fall If any abnormalities call EMS and send resident out. Do not move resident. A complete report and notify MD via telephone. If no answer within one hour,, the Medical Director will be contacted. The RP\facility will be notified 3. Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change on fall policies on 01/07/16 by 3:00pm by the Director of Nursing (DON.) The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 01/07/16 until 01/08/16. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment. Observations were made from 01/07/06 until 01/08/16 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 01/07/16-01/08/16 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 01/08/16 at 10:00am that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The CMS Form 672 listed 6 residents receiving hospice care.

Based on interview and record review, the facility failed to consult the physician regarding an incident for 1 of 25 residents (Resident #14) reviewed for physician notification. Resident #14 had a fall and a change in condition on 12/17/15 between 3:30-4:00pm. The facility did not consult with the physician on 12/17/15 when Resident #14 had a fall and complained of hip and pelvic pain. The physician was not immediately consulted regarding Resident #14's fall or complaints of pain. There was a note put in his box for him to see the resident the next day. Resident #14 did not have an x-ray of the hip and pelvic area until 11:40am on 12/18/15. She was then sent to the hospital for a [MEDICAL CONDITION] and surgical repair. The facility did not notify Resident #14's Responsible Party (RP) until 12/18/15, the day after the fall. An IJ was identified on 01/06/15. While the IJ was removed on 01/08/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected 1 resident and placed an additional 5 residents on Hospice at risk of not receiving care and services, delay in treatment and possible complications. Intake # 0 Findings Include: Record review of Resident #14 ' s clinical record face sheet revealed she was [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #14 ' s clinical record revealed no information on hospice. Record review of Resident #14 ' s last MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 00 which indicated she had severe cognitive impairment. It was documented that her daily decision making skills were severely impaired and required staff assistance in part with activity of daily living. Resident #14 was assessed as not needing staff assistance for mobility. Record review of Resident #14's care plan dated 07/30/2015 updated on 10/15/15 with a note to continue read in part Problem-Resident has Terminal/ End stage [DIAGNOSES REDACTED].goal .Pain will be well managed through end of life .approaches included .coordinate care with Hospice provider, Contact .with changes in condition .Notify MD, family, responsible party of changes as needed. Problem .potential to experience an alteration in level of comfort. DX OA ([MEDICAL CONDITION]) .goal will voice relief from pain interventions within 1 hour from administration .approaches included: pain assessment per protocol, identify location and rate of pain prior to and after any interventions, medication as ordered, attempt and document effectiveness of non-pharmacological interventions . Problem- At risk for injury related to falls per [MEDICAL CONDITION] medications, weakness with lack of coordination and gait abnormal .there was three falls documented, 9/30, 10/15/15 and 12/17/15 .goal was to have no significant injury related to falls .approaches .Notify MD and family of falls and injuries . Record review of Resident # 14's care plan dated 12/17/15 for a problem of Fall read in part . approach . rule out medical complication with increase falls . Notify MD (medical director and family of falls or injuries as necessary . Record review of Resident #14 ' s Nurse ' s notes dated 12/17/15 at 9:15pm revealed Resident observed falling while walking in hallway. Resident lifted onto chair assessed. Neuro checked initiated; Resident complaint of right hip and anterior pelvis pain, able to transfer self onto bed while bilateral weight bearing; Resident able to position self on bed by lifting hips and sliding across bed. No apparent injury noted; Resident self-ambulatory, Tylenol given as ordered. Responsible Party (RP) notified Local Hospice notified awaiting orders. Call light within reach will continue to monitor resident. Record review of Resident #14's Hospital History & Physical dated 12/28/15 at 1:25pm read in part .Review of Systems .She is awake, moans to pain . X-ray of the femur shows a right femoral fracture. Impression: 1. Right femoral neck fracture. 2. Advance dementia. 3. Urinary tract infection. In an interview on 01/06/16 at 11:30am with Registered Nurse (RN) B on duty during the fall, she said she worked the 6am-2pm and 2pm-10pm shifts. RN B said Resident #14 fell in the hallway while coming from the dining room. RN B said she assessed Resident #14 and then Medication Aide (MA) G on duty assisted Resident #14 into her wheel chair after the assessment. RN B said Neuro checks were initiated and Resident #14 complained of right hip and anterior pelvis pain. She said Resident #14 was able to transfer self onto bed while bearing weight on both legs. She said Resident #14 was able to scoot on to the bed by lifting her hips and sliding across the bed. She said she gave Resident #14 her pain medication and gave report to the night Nurse. No answer was provided when asked about conducting a pain assessment for Resident #14. RN B said she started her Neuro check. When asked about consulting with Resident #14 ' s physician, she said she called the Hospice nurse per facility protocol. She said prior to the end of her shift at about 9:30ish pm, Hospice Nurse P came in, went into Resident #14 ' s room for few minutes and left. RN B said Hospice Nurse P told her that another nurse would assess Resident #14 in the morning to see if she needed an X-ray or not. RN B said Hospice Nurse P did not give her any form of assessment documentation before he left the night of 12/17/15. RN B said when she came to work the next morning on 12/18/15, the night Nurse; LVN C told her that Resident # 14 was crying of severe pain this morning. LVN C said she called for an X-ray and notified her hospice and physician. When asked about the time Hospice Nurse Q arrived at the facility RN B said Hospice Nurse Q arrived almost at the same time as the Ambulance was taking Resident #14 to the Hospital. She indicated that things were going so fast and she could not give the exact time but she knew Hospice Nurse Q came in about the same time as Resident #14 left the facility. In an interview with Resident #14 ' s physician on 01/07/16 at 8:10am revealed that he had not been contacted by the facility on 12/17/15 regarding Resident #14 ' s fall and complaints of pain. He said that they put it on the log for him to see her. Record review of facility form titled Clinical Notification Log read in part: List any resident incidents that have occurred or concerns to be addressed at the time of the Physician or Nurse Practitioner ' s next visit .Resident Name: Resident 14 .Date of Occurrence: 12/17/15 .Concern/Assessment/Actions: Fall please follow-up- no apparent injury. Several attempts were made to contact LVN C who worked the night shift and initiated the X-ray. Her phone would not accept any messages. Nurse ' s notes dated 12/18/15 at revealed Resident woke up at getup time this morning and started crying for pain from fall, Hospice was notified and X-ray of right hip\leg was ordered. Record review of the facility's Inter-disciplinary team (IDT) notes dated 12/18/15 at 11:19am for Resident #14 revealed fall follow up for 12/17/15- Resident self-ambulating, (did not hit head) . assisted with 2 staff, self-transferred to bed, Neuro v\s initiated PRN pain med given. MD ordered X-Ray result pending. Record review of Resident #14's Nurses notes dated 12/18/15 at 1:08pm revealed- Follow up fall: Resident hospice organization contacted for evaluation and orders. No new orders. Record review of Resident #14's Nurse's notes dated 12/18/15 at 1:08pm read in part, Follow Up fall. Resident ' s hospice organization was contacted for resident evaluation and orders for x-ray 12/17/15 (no time provided) .unable to send a nurse to current unavoidable events with staff. No new orders. Hospice Nurse P present on 12/17/18 (SIC) at 10:00pm to evaluate resident for x-ray request due to fall. Hospice Nurse P concluded .no x-ray was required at the time. Hospice Nurse P said he would prefer to have Resident #14 reassessed by nurse on following day to determine if an X-ray was warranted. LVN C communicated Resident #14 ' s complaint of pain once again to the hospice organization with new order for X- ray obtained (No date and time provided). Hospice Nurse Q present at facility to reassess resident. X-ray result obtained with fracture of right hip reported. Hospice Nurse Q ordered Resident #14 to be sent to local hospital .left facility at 12:55pm. RP notified by Hospice Nurse Q. In an interview on 01/05/16 11:00am, LVN-D said she was told of the incident the next day on 12/18/15. She said Resident #14 was on hospice and it was the facility ' s policy to notify Hospice first. She said Hospice was notified. When asked what she did she said she was waiting for hospice nurse to complete the assessment. In an interview with Hospice Nurse Q on 01/06/15 at 2:00pm she said Hospice Nurse P, who was covering for her came to check on Resident #14 when the call came to the agency. She said Nurse P did not leave her with any documentation but asked her to check on Resident #14. Hospice Nurse Q said there was no documentation from Nurse P in reference to Resident #14 ' s assessment. She said she would call Nurse P to see if there was documentation on Resident #14. After the phone call she said there was no documentation of the visit. Further interview, Hospice Nurse said she came to visit Resident # 14 that morning (12/18/15) at about 10:00am. She provided her notes at the time of the interview and said she kept her notes with her. When asked about coordination of service without medical records she said it depends on what the facility wants. She said sometimes the records are kept at the facility or at the hospice office. She said she kept her records with her at the office. Record reviewed of Hospice Nurse Q notes dated 12/18/15 10:00am read in part, Resident # 14 was resting in bed with her eyes open, pleasantly confused .has severe pain on right hip movement Appetite was poor this morning related to pain . awaiting X-ray results . Record review of a separate Hospice note dated 12/18/15 at 10:00am revealed a verbal order obtained from Resident #14 ' s physician to send her to the hospital for fracture of right femur. Record review of Resident #14 ' s Hospice note dated 12/18/15 at 8:00pm read, Resident #14 was discharged from hospice for aggressive treatment . Record review revealed no documentation of physician notification, no documentation of pain assessment from 9:00pm 12/17/15 to 6:57am on 12/18/15. Records revealed no pain assessment throughout the night shift and no hospice assessment. Record review of facility ' s 24 hour report dated 12/17/15 no time title Change of condition revealed Resident #14 fall no head injury observed. Record review of the facility ' s Incident report dated 12/17/15 at 4:02pm read in part Incident Type: Fall/no head injury .Type of Injury: None Apparent .Location: Hallway on unit .Incident Level: Non-witnessed .Narrative of Incident: Resident was observed falling onto right side while walking in hallway .Resident lifted onto chair and assessed . Record review of radiology report dated 12/18/15 and signed at 1:16pm revealed moderately displaced sub capital fracture of right hip noted. No associated discoloration was seen . Record review of Resident #14 ' s clinical record revealed no hospice documentation, no pain assessment and no time of physician notification. Interview with Director of Nurses (DON) on 12/06/16 at 1:30pm, he said the Resident ' ss Responsible party (RP), Hospice and Physician should be notified of any fall. The initial thing was to assess resident and document, notify the physician and the responsible party; hospice if resident was on hospice. He said all processes were followed during the time of Resident # 14's fall. When asked what time Resident #14 ' s physician was called, he said it should be on the resident's clinical records. He said Resident #14 was a hospice resident and hospice was notified. No information was provided on when Resident's physician was notified. Records for Resident #14 were reviewed together with the surveyor and revealed no evidence of the facility consulting with Resident #14 regarding her fall and pain. Record review of the facility's written policy entitled, Abuse program; prevention\training identification page 2 Neglect Policy define neglect as failure to provide goods and services to avoid harm, mental, anguish or mental illness. Neglect occurs when facility staff fails to monitor and supervise residents. Neglect occurs when facility fails to provide necessary care for residents Record review of facility ' s provided policy on falls; revised October 2010 Page 7 Falls Risk Management After a Fall read in part . Nursing staff will notify the resident ' s attending physician and family in an appropriate time frame. When a fall result in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Prior to exit on 01/08/16, Facility Administrator said she has no further information to provide. she said all her additional information would be included in her IDR process. An immediate jeopardy (IJ) was identified on 01/06/16 at 3:45 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/06/16 at 4:48pm and after several revisions were made it was accepted on 01/07/16 at 6:20pm. The POR included in part: 1. Immediate Corrective action was- on all fall\incidents\accidents notify DON\ADON or nurse on call as feasible possible but not later than 1 hour after incident occurs: however if the patient is being transferred to hospital the DON\ADON\Nurse on call and the Administrator must be notified immediately. 2. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and visual observation of any limb shortening or internal or external rotation of any obvious sign of fracture. a. Take vital signs - temperatures, BP, pulse, b. If vital signs- critical is not met per (care path) then proceed with initial nursing evaluation for injuries and \ or mental status change. Do not move off the floor until complete exam has been performed. c. Determine if suspected fracture or new bone deformity, head trauma, altered manta, ( decrease LOC, unresponsiveness, suspicious of [MEDICAL CONDITION] new or worsen cognitive impairment), laceration required sutures\staples if yes notify MD\NP\PA and transfer via EMS. 3 If resident falls and has any complaints of [MEDICAL CONDITION] or spinal injury, head trauma, perform Neurological assessment at the scene of fall If any abnormalities call EMS and send resident out. Do not move resident. A complete report and notify MD via telephone. If no answer within one hour, the Medical Director will be contacted. The RP\family will be notified 3. Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change on fall policies on 01/07/16 by 3:00pm by the Director of Nursing (DON.) The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 01/07/16 until 01/08/16. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment. Observations were made from 01/07/06 until 01/08/16 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 01/07/16-01/08/16 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 01/08/15 at 10:00am that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. CMS 672 listed 6 residents receiving hospice care.