Every finding on record at Avir at Granbury

Based on record review and interview, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 5 (1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, and 3/13/2026) of 92 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, and 3/13/2026.This failure could place residents at risk of not having decisions made by a RN to manage residents' healthcare needs and in managing and monitoring the direct care staff. Findings included:Review of the PBJ Staffing Data Report FY Quarter 2 2026 (January 1 - March 31) revealed no RN hours were reported to CMS on 1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, and 3/13/2026. During an interview on 07/16/2026 at 8:53 a.m., the DON stated his expectation was to have RN coverage 8 hours a day. The DON stated he started working at the facility on 3/16/2026 and since then he had worked at the facility every day. He stated the previous DON's last day was on 3/13/2026 and he was unsure why there would not have been any reported RN hours prior to him starting work at the facility for 1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, and 3/13/2026. He stated there was a weekend supervisor who was a RN and he had worked at the facility to assist with making sure there was 8 hours of RN coverage on the weekends.During an interview on 07/16/2026 at 10:45 a.m., the ADMN stated she knew about an email thread with the previous ADMN telling him that he did not report RN hours appropriately. She stated she believed that the facility had RN coverage and would look through the nurse schedules and on a SharePoint site to show RN coverage hours for the days in question. During a follow up interview on 07/16/2026 at 11:24 a.m., the ADMN stated she was unable to find evidence that an RN worked 8 consecutive hours for the days in question. She stated she found a QAPI meeting where the previous ADMN put down the facility had 31 days of RN coverage in January of 2026. She stated she started working at the facility on 6/29/2026 and did not know what occurred prior to her starting to work at the facility. The ADMN did not provide a response to how not having a RN would have affected residents. Record review of facility policy, titled Staffing, Sufficient and Competent Nursing, dated August 2022 revealed: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 10 of 10 confidential resident council members reviewed for resident/group response.The facility failed to provide a grievance log for the January2026, Febuary 2026, March 2026, April 2026, May 2026, and June 2026 indicating a verbal or written response to the Resident Council addressing the grievances reported from their meetings. This failure could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.Findings included:During a confidential group meeting and confidential time, 10 of 10 resident council members stated they did not feel the facility took their views and concerns into account and did not followed up when grievances and complaints were expressed.During an interview on 07/16/2026 at 4:27 PM, the ADMN stated she would expect the facility to have documentation of the grievances including resident council. She stated she would get the grievances and then the managers would discuss them in the morning meetings. She said after the grievances were discussed and completed, she would follow up with who made the grievances. She stated she started working on 06/29/2026 and did not have any documentation from January 2026 to 06/29/2026. She stated there had not been a resident council meeting since she had been the ADMN and moving forward she would make sure she followed up on the Resident Council grievances to make sure the members of the resident council were heard.Record review of facility policy titled Grievances/Complaints, Recording and Investigating revised in 2017 revealed: The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: the date the grievance/complaint was received, the name and room number of the resident filing the grievance/complaint (if available), the name and relationship of the person filing the grievance/complaint on behalf of the resident (if available), the date the alleged incident took place, the name of the person(s) investigating the incident, the date the resident, or interested party was informed of the findings, and the disposition of the grievances (i.e., resolved dispute, etc.). The Resident Grievance/Complaint Investigation Form will be filed with the ADMN within five working days of the incident. A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed in the business office. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure foods were sealed and/or labeled properly in refrigerators, freezers and dry storage.The facility failed to ensure all food was not past expiration date. The facility failed to ensure that staff performed hand hygiene while preparing food.The facility failed to maintain proper food safety and sanitation by allowing a hot pad to fall into the tortilla soup during food preparation.The facility failed to maintain proper food safety and sanitation practices by handling ready-to-eat foods with gloves that were not changed after previous tasks.These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation on 07/14/2026 between 9:27 AM and 9:48 AM the kitchen revealed: Refrigerator #11.One open plastic container with a cracked lid of chicken noodle with an open date of 07/08/2026 and a use by date of 08/07/2026.2.One unopened package of potatoes not labeled with a food item description.Dry Storage #11.One can of cheddar cheese not dated. 2.One can of chicken noodle soup not dated.3.One package of pasta noodles not sealed or dated.4.One open box of powdered sugar with plastic bag holding contents not sealed.5.One open box of creamy wheat with plastic bag holding contents not sealed or dated.6. Three plastic containers of cereal not labeled or dated.Dry Storage #21.Three containers of mustard of a use by date of 10/20/2025.2.Two packages of yellow cake mix without a use by date.3.One package of chocolate frosting of a use by date of 05/15/2026.Freezer #11. One open box of frozen biscuits with plastic bag holding contents not sealed.Freezer #21. One open box of frozen broccoli with plastic bag holding contents not sealed.2.One open box of frozen mango with plastic bag holding contents not sealed.During an observation on 07/14/2026 at 11:40 AM, the DM dropped a hot pad in the prepared soup. The cook was going to pour the remainder of the soup in the pot until questioned of cross contamination. The contaminated soup was discarded by the cook, and the cook prepared an alternative soup.During an observation on 07/14/2026 between 11:27 AM and 12:14 PM, [NAME] E failed to wash his hands after preparing puree food in the blender and preparing food on the stove. The cook used the same gloves to prepare and serve food. The cook picked up ready-to-eat items with gloved hands to plate the food items.During an interview on 07/16/2026 at 3:42 PM, [NAME] E stated that washing hands should happen with every task, between glove changes, and when touching the face. He stated the hot pad that fell into the soup and touching lettuce and tomatoes with gloved hands after doing other tasks was cross contamination that could lead to risk of illness. [NAME] E stated he unloaded the trucks and stored the food and that everything should be labeled, dated, and sealed properly. He stated the food not being sealed in the freezers could cause illness and unlabeled food could cause issues with food being old and mixed up. He stated the cook's monitored storage with the dietary manager and the failure was the need for more education. During an interview on 07/16/2026 at 3:57 PM, the DM stated items that passed their best by date should have been discarded and should have had a label on the item and dated. The DM stated that food items should be sealed and that residents could have been affected by getting food that was not flavorful or could be at-risk of illness due to freezer burn. She stated the cooks and herself were responsible for ensuring items were discarded, sealed and labeled correctly and that the failure was the need to monitor and receive more education.During an interview on 07/16/2026 at 3:59 PM, the DM stated that a hot pad should not have fallen into the soup and the soup should have been discarded right away. She stated that hand hygiene should happen between every task and that gloves should be changed. She stated that utensils should have been used instead of gloved hands to pick up ready-to-eat foods when switching between tasks. She stated the residents could have been affected by being at-risk of illness for cross contamination and that the failure was the need for more education.During a telephone interview on 07/16/2026 at 4:15 PM, the dietician stated that hands should have been washed between every task, especially after touching of the face and touching other items. She stated that utensils should have been used when picking up cold items while doing other tasks. She stated that the hot pad that fell into the soup was cross contamination and the soup should have been discarded immediately. She stated food that entered the kitchen should be labeled, have the entrance date and expiration date on each item, and that food should be sealed so it is not exposed to air. She stated that the negative effects were cross contamination, bacteria issues, and ruining quality of the food when exposed to air. She stated that all kitchen staff, including the DM, monitored food items, and that in-servicing was needed. The dietician stated she comes to the facility once a month and is available by phone.Record review of the facility document titled Matrix, dated 07/14/2026, revealed every resident ate out of the kitchen.Record review of facility policy titled Handwashing/Hand Hygiene dated 2025, revealed: Hand hygiene is indicated after contact with contaminated surfaces and immediately after glove removal. The use of gloves does not replace hand washing/hand hygiene.Record review of facility policy titled Food Receiving and Storage dated 2022, revealed: Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in-first out system. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen or discarded. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing.Record review of facility policy titled Food Preparation and Service dated 2022, revealed: Gloves are worn when handling food directly and changed between tasks. Cross-contamination can occur when harmful substances, i.e., disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned.Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 07/16/2026 revealed: 3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement.(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD.(3) An accurate declaration of the net quantity of contents.(4) The name and place of business of the manufacturer, [NAME], or distributor; and(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.(7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interview and record review the facility failed to maintain a quality assessment and assurance committee consisting at a minimum of the required committee members of 10 of 11 meetings reviewed for QAPI. The facility failed to ensure the MD, or a representative attended the QAPI meetings in September 2025, October 2025, November 2025, December 2025, January 2026, February 2026, March 2026, April 2026, May 2026, and June 2026. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented and no appropriate guidance developed. Findings included: Record review of sign in sheets for QAPI meetings in September 2025, October 2025, November 2025, December 2025, January 2026, February 2026, March 2026, April 2026, May 2026, and June 2026 revealed no evidence that the MD attended QAPI meeting. During an interview on 07.16.2026 at 1:00 pm the ADM stated her expectations were that the MD would attend QAPI meetings. ADM stated it would be beneficial if he attended every QAPI meeting. ADM stated she did not know why the MD had not attended the QAPI meetings. ADM stated she did ot feel that his had any effect on resident care. Record review of facility's policy titled: Quality Assurance and Performance Improvement (QAPI) Program, dated Revised February 2020 Policy StatementThis facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and ImplementationThe objectives of the QAPI program are to: Provide a means to measure current and potential indicators for outcomes of care and quality of life.Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.Reinforce and build upon effective systems and processes related to the delivery of quality care and services.Establish systems through which to monitor and evaluate corrective actions.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 (CNA B & CNA C) staff and 1 of 3 (Resident #58) reviewed for infection control procedures.The facility failed to ensure CNA B and CNA C followed EBP, provided incontinent care and foley catheter care (a flexible tube inserted into the bladder for urination) appropriately, and performed hand hygiene appropriately while providing incontinent care and foley catheter care for Resident #58 on 07/14/2026. These failures could place residents at risk for the transmission of communicable diseases.Findings included:Record review of Resident #58's electronic face sheet, dated 07/16/2026, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE] with diagnosis including: retention of urine and UTI (infection in urine). Record review of Resident #58's 5-day Medicare MDS assessment, dated 05/27/2026, reflected a BIMS score of 09 indicating moderate cognitive impairment. Further review reflected he was dependent on staff for toileting hygiene and utilized an indwelling catheter for urination. Record review of Resident #58's electronic physician's order, dated 07/15/2026, reflected EBP: Staff must use gown and gloves during high-contact resident care activities that could possibly to result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). Every shift for EBP Precautions.Record review of Resident #58's comprehensive care plan, dated 07/15/2026, reflected Resident is at risk for recurrent urinary tract infections related to the presence of an indwelling urinary catheter.Educate the resident and family, as appropriate, on catheter care, infection prevention, hydration, and symptoms that should be reported promptly.During an observation and interview on 07/14/2026 at 11:01 a.m., Resident #58 received incontinent care and foley catheter care from CNA B and CNA C. Both CNAs gathered supplies and entered the room with supplies in see-through plastic bag. CNA B asked Resident #58 if she could put the bag of supplies on his bedside table and he agreed. CNA B and CNA C sanitized their hands and put on gloves, no gowns were applied. Resident #58 had a foley catheter bag connected to the right side of his bed in a privacy bag. There was a EBP sign on the door and there was PPE in a bin to the right of the room with EBP sign on top. The CNAs pulled down his brief and CNA B got an incontinent wipe and wiped his left inner thigh. CNA B folded the wipe and wiped his right inner thigh. CNA B asked CNA C to get a bag out of her pocket and CNA C did. CNA C opened up the bag for soiled trash disposal. CNA C put the unused bags back into CNA B's pocket. CNA B then got another wipe and wiped the top of the penal shaft down to the scrotal area. CNA B disposed of the wipe and got another wipe to the scrotal area and kept going over the area multiple times with the same wipe touching the catheter tubing with the part of the wipe that touched the skin in the process. She disposed of that wipe and got another wipe for the catheter tubing and started wiping from the end of the shaft away from the skin down the tubing. With the same wipe she went back to the tubing and rubbed multiple times to and from the skin. She disposed of the wipe and asked CNA C to help resident roll to his left side. CNA C helped him roll to his side. CNA B got another wipe and began to scrub his buttock area that had cream on it multiple times with same wipe. CNA B disposed of wipe and got another wipe and wiped multiple times with same wipe getting skin clean from cream that CNA B stated was to help prevent rash. CNA B stated the nurse put on the cream and Resident #58's skin was looking better from the rash. CNA B removed the soiled brief and rolled the soiled draw sheet up to the resident's left side. CNA B did not remove gloves or perform hand hygiene and gathered clean brief. CNA B placed the clean brief on top of clean draw sheet and pushed under Resident #58's left side. CNA B helped Resident #58 roll to his back and to his right. CNA B removed the soiled draw sheet and unfolded the clean draw sheet flat under the resident. CNA B reached into her pocket for a see-through plastic bag for the soiled linen without removing her gloves or performing hand hygiene. CNA B put the bags that were unused back into her front left pocket with dirty gloved hand. Resident #58 rolled back onto his back and was covered with sheet and blanket. CNA B and CNA C removed their gloves and sanitized their hands with hand sanitizer before leaving the room with the soiled linen and trash in bags.During an interview on 07/14/2026 at 11:11 a.m., CNA C stated she had been trained on infection control and that it was not appropriate to wipe an area with the same wipe multiple times. She stated she should have worn a gown during catheter care and just forgot to put one on. She stated she should have changed gloves and performed hand hygiene to help prevent infection spread when going from dirty to clean environments. During an interview on 07/14/2026 at 11:11 a.m., CNA B stated it was appropriate to use the same wipe multiple times since she folded it. CNA B stated it was not okay to rub the area back and forth with the same part of the wipe. She stated she should have worn a gown during catheter care and did not remember to put one on. She stated she had been trained on infection control.During an interview on 07/14/2026 at 4:02 p.m., LVN D stated the EBP sign meant staff should wear PPE including gown and gloves when performing foley catheter care. She stated she had been trained on infection control at least yearly on computer and then in-services as needed. She stated she did not know why staff may not have used PPE during foley catheter care. She stated staff originally would learn what EBP was on hire and that all staff had been trained. She stated using a wipe multiple times could cause infection spread from one area to the other. She stated gloves should be changed from going from dirty to clean area and hands sanitized to help reduce infection spread. During an interview on 07/16/2026 at 10:20 a.m., the DON stated that staff should be looking at EBP signs and wearing gowns when providing high contact care such as incontinent care for a resident. He stated all staff were trained on EBP and infection control including hand hygiene. He stated he expected staff to change their gloves and perform hand hygiene when they were moving from a dirty to clean area like placing clean linen and brief or reaching into their pocket. He stated staff should not be going over the same skin multiple times with the same wipe and should not be touching the catheter tubing with the same wipe that was used to wipe the resident's skin. He stated not wearing the PPE could potentially cause infection spread. He stated not performing hand hygiene and reusing the same wipe over multiple areas could potentially cause infection spread. He stated he monitored that nursing staff were following infection control protocol multiple times a day as he monitored them performing care to the residents. He stated he felt that staff were just nervous and forgot to follow infection control protocols during observation.Review of facility policy titled, Handwashing/Hand Hygiene, dated 01/2025, reflected Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.Review of facility policy titled, Enhanced Barrier Precautions, dated 03/2024, reflected 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing. b. bathing/showering. c. transferring. d. providing hygiene. e. changing linens. f. changing briefs or assisting with toileting. g. device care or use.Review of facility policy titled, Perineal Care, dated 02/2018, reflected MALE 1. Follow steps below: Take the wipe in one hand and gently grasp the penis shaft. If, the resident is uncircumcised gently pull back the foreskin and wipe the head of the penis beginning at the urethral opening working outward and away from the penis head (circular motion). Use a new wipe with each stroke. After cleaning is complete gently move the foreskin back into its natural position if uncircumcised. Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum. Using a new wipe with each stroke clean from the upper part of the leg to the hip. Repeat on the other side and then once from hip bone to hip bone. Turn the resident over and repeat on the back side. 2. Take off gloves, put them into the trash bag with the soiled brief and wipes. 3. WASH/SANITIZE your hands. If indwelling urinary catheter is present: a. Hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum. B. When cleaning the urethral area; Gently wipe around the juncture of the catheter and meatus. Then wipe the catheter from the meatus down the tube about 4 inches.

Based on observation, interviews and reviews, the facility failed to ensure that the MDS assessment accurately reflected the resident's status for 1 of 12 (Resident #39) residents reviewed for accuracy of assessments. The facility failed to accurately code the presence of a condom (external) urinary catheter for Resident #39 on 2 consecutive quarterly assessments on 04/27/2026 and 05/04/2026. This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate MDS assessments.Findings included: During record review of Resident #39's electronic face sheet, dated 07/15/2026, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses of flaccid hemiplegia affecting left nondominant side (inability to use his left arm), acute kidney failure, weakness, psychotic disorder (a set of symptoms involving a loss of touch with reality), stroke (a medical emergency when blood flow to the brain is interrupted), depression (persistent sadness, loss of interest and physical fatigue), anxiety (feelings of fear, tension and worry), heart failure (heart muscle is too weka or stiff to pump blood effectively), and pain. During record review of Resident #39's Quarterly MDS Assessment, dated 04/27/2026, revealed in Section C - Cognitive Patterns, subsection C0500, a BIMS score of 13 out of 15, indicating mild cognitive impairment. Section H - Bowel & Bladder, subsection H0100 Appliances, A. Indwelling (inside the body) and B. External were entered indicating Resident #39 had an indwelling and external urinary catheter. Resident #39's Quarterly MDS Assessment, dated 05/04/2026, revealed in Section H - Bowel & Bladder, subsection H0100 Appliances, Z. None of the Above was entered. During record review of Resident #39's comprehensive care plan dated 07/28/2025, revealed Problem: Resident requires an external catheter (condom Catheter) R/T personal preference and dignity concerns. During an observation on 07/14/2026 at 2:45 p.m., a urine collection bag was noted hanging under Resident #39's bed frame in a privacy bag. During an interview on 07/14/2026 at 2:45 p.m., Resident #39 stated he wore a condom (external) urinary catheter to keep his clothing and bed linens dry. He stated he required staff assistance with changing the catheter. During an interview on 07/16/2026 at 3:16 p.m., the DON stated Resident #39 used a condom catheter and the MDS should have been coded to indicate the catheter. He stated he did not know why the catheter was not coded correctly, corporate staff completed the MDS. The DON stated his expectation was for the MDS to accurately reflect the resident's status. Record review of the Policy titled Resident Assessment date revised March 2026, stated in part. 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:a. OBRA required assessments - conducted for all residents in the facility:(1) admission Assessment (Comprehensive);(2) Quarterly Assessment;(3) Annual Assessment (Comprehensive);(4) Significant Change in Status Assessment (SCSA) (Comprehensive);(5) Significant Correction to Prior Comprehensive Assessment (SCPA) (Comprehensive);(6) Significant Correction to Prior Quarterly Assessment (SCQA); and(7) Discharge Assessment (return anticipated and return not anticipated).b. PPS required assessments - conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF benefits:(1) 5-day Assessment;(2) Interim Payment Assessment; and(3) Part A PPS Discharge Assessment.2. The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments.3. A comprehensive assessment includes:a. completion of the Minimum Data Set (MDS);b. completion of the care area assessment (CAA) process; andc. development of the comprehensive care plan.

Based on interviews and record review, the facility failed to refer residents with newly evident or possible serious mental illness or a related condition for PASRR evaluation for 1 of 18 resident (Resident #9) reviewed for PASRR. The facility failed to follow up with the LA for PASRR level II determination when Resident #9's PASRR level I screening reflected she was positive for mental illness This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included:Record review of Resident #9's electronic face sheet dated 7.16.2026 revealed [AGE] year-old male admitted to the facility 05.14.2026 with the diagnoses of bipolar disorder (mental health condition), Major Depressive Disorder, Morbid Obesity (chronic disease of severely overweight). Post Traumatic Stress Disorder Record review of Resident #9's PASRR Level I Screening dated 5.14.2026 Section C PASRR screening was negative for Primary Diagnosis of Dementia, Mental Illness, Intellectual Disability, and Developmental Disability. Record review of Resident #9's physician orders dated 7.16.2026 revealed Depakote two times a day, Sertraline daily, may be seen by psychiatric and psychological services to evaluate and treat as needed, Amantadine at bedtime, Fluoxetine daily, Prazosin at bedtime. Record review of Resident #9's Quarterly MDS dated 06.23.2026 revealed Section C-Cognitive Patterns BIMS score-15 (cognitively intact). Section I-Active Diagnosis Seizure Disorder or Epilepsy, Bipolar Disorder, Post Traumatic Stress Disorder. Record review of Resident #9's Care Plan dated 7.13.2026 revealed Resident is at risk for adverse drug effects due to use of psychotropic medications for treatment of depression. There was no evidence in the care plan that the bipolar diagnosis was being addressed. During an interview on 07.16.2026 at 3:20 pm, the DON stated his expectations were that all residents PASRR information be accurate. The DON stated if a resident had a diagnosis that could potentially qualify them for specialized services the PE should be completed and sent to the LA (local authority). The DON stated he did not feel this failure affected the residents care. The DON stated this failure occurred due to human error. Record review of facility's policy titled: PASRR dated 01.20.2026:The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. The facility's Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL 1 upon admission.2. LIDDA submits PL1 in portal3. LIDDA performs PE withing 72 hours of receipt of PL1.4. LIDDA submits PE on Portal within 7 days of receipt of PL 1.The MDS coordinator or designee will input all other PL1s into the online portal on admission. This includes negative preadmission PL1s and PL1s for resident who qualify for exempted or expedited services.

Based on observation, and interview, and record review, the facility failed to store drugs and biologicals in locked compartments during medication storage inspection for 1 (West Hall Medication Cart) of 3 medication carts reviewed for storage.The facility failed to ensure the [NAME] Hall Medication Cart was locked and secured while unattended.This failure could place residents at risk of drug diversion.Findings included:During an observation on 07/15/2026 at 12:43 p.m., the [NAME] Hall Medication Cart sitting by entrance to the hallway was unlocked. There were two residents sitting in wheelchairs at the nurses' station by the unlocked medication cart. No nurse was observed on the hall. The top drawer of the medication cart had OTC medications including diphenhydramine (generic Benadryl for allergies) and acetaminophen (generic Tylenol for fever or pain). The top drawer had prescription antiemesis (for nausea) topical medication and prescription eye drops. There were alcohol swabs in the top drawer. Next drawer down from top had gloves and prescription tablets in bubble packaging. The second from top drawer had prescription breathing treatments, liquid Maalox (for indigestion) and over the counter topical cream. Bottom drawer had lancet sharps insulin needles, and disinfecting wipes. There was a locked drawer that had narcotic medication in it. During an interview on 07/15/2026 at 12:50 p.m. the DON stated his expectation would be for the medication cart to be locked when a nurse was not present. He stated the nurses were responsible for locking their own carts and he monitored that they locked the carts when he was walking down the halls. He stated that not locking the cart could potentially cause residents to ingest medications that were not theirs or hurt themselves or others with sharp items. He stated that LVN A was responsible for the [NAME] Hall Medication Cart.During an interview on 07/15/2026 at 1:27 p.m., LVN A stated the medication carts should be locked when not attended. She stated she had to go help a resident that fell and forgot to lock her cart in the moment. She stated not locking the cart could cause residents to have access to medications and sharps that could hurt them or others. Record Review of facility policy Medication Labeling and Storage dated February 2023 revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Medication Storage.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.4. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on interview and record review, the facility's QAPI committee failed to implement an appropriate action plan to address identified quality deficiencies for 1 of 1 facility. The QAPI committee failed to implement the corrective actions outlined on the Plan of Correction, dated 12/12/2025, for deficient practice F727. This failure could place residents at risk for substandard quality of care due to the failure of the facility to take action on an identified problem affecting resident safety, respiratory treatment, and employee training. Findings included: Record review of a CMS 2567, dated 12/05/2025, reflected that based on interview, and record review, a deficient practice was cited at F727 (RN 8 hours a day seven days a week) during the 12/05/2025 SSA recertification survey. Interview and record review reflected the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 1 of 1 (11/01/2025, 11/02/2025, 11/08/2025, 11/29/2025, and 11/30/2025) month reviewed for RN coverage. Record review of the facility's Plan of Correction, dated 9/5/2024, which was submitted in response to the 7/31/2024 SSA CHOW survey reflected the facility's plan as 1. The facility has corrected the issue by hiring a weekend Registered Nurse to ensure compliance with CMS and or HHSC requirements for RN coverage. 2. Resident of the facility could be affected by this deficient practice. 3. Systemic changes to prevent recurrence, the facility has hired a new RN weekend supervisor. The new weekend RN supervisor started on 12/12/25. Facility now has RN coverage eight hours a day, seven days per week. The DON or designee will monitor compliance by reviewing the staffing schedule daily. The audit for RN coverage will be held during morning meetings Monday through Friday for the first four weeks, then once per month for one month. 4. The matter of not having RN coverage eight hours per day will be brought before the QAPI committee for the next two months, if no further issues arise, the matter will be considered resolved.Review of the PBJ Staffing Data Report FY Quarter 2 2026 (January 1 - March 31) revealed no RN hours were reported to CMS on 1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, and 3/13/2026. During an interview on 07/16/2026 at 11:24 a.m., the ADMN stated she started working for the facility on 06/29/2026. She stated she was able to look up the QAPI meeting in January where the previous ADMN documented that there was RN coverage 31 days in January 2026. She stated she could not provide evidence that an RN was working eight consecutive hours on 1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, or 3/13/2026. She stated she would expect that the plan of correction to be followed and reviewed during the QAPI meetings to monitor that the issue had been resolved. Review of the facility's policy titled, Quality Assurance and Performance Improvement Changes to QAPI Program, dated February 2023, reflected 1. The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee.2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #55) reviewed for care plans . The facility failed to ensure Resident #55 had a care plan in place to address his smoking status. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Findings included: During record review of Resident #55's electronic face sheet, dated 07/14/2026, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses of stroke, right side paralysis, rheumatoid arthritis (a chronic disease that causes the immune system to attack the lining of the joints), schizophrenia (a brain disorder that causes individuals to struggle with distinguishing reality from imagination), seizures, and blindness. During record review of Resident #55's admission MDS Assessment, dated 06/23/2026, revealed in Section C - Cognitive Patterns, subsection C0500, a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #55's admission MDS Assessment, dated 06/23/2026, revealed in Section J - Health Conditions, subsection J1300 - Current Tobacco Use, 0 indicating No was selected. During an observation on 07/15/2026 at 10:38 a.m., Resident #55 was in the designated smoking area smoking a cigarette. During record review of Resident #55's comprehensive care plan dated 06/18/2026 and reviewed/revised 07/14/2026, revealed tobacco use was not addressed on the care plan. During an interview on 07/16/2026 at 1:55 p.m., LVN A stated the social worker, administrator and department heads were responsible for creating and updating care plans. She stated the DON was responsible for monitoring care plan accuracy. LVN A stated staff utilized the care plans to make sure proper care was provided. She stated the smoking status of a resident should be care planned so that staff were aware. She stated R # 55 was a smoker. LVN A stated she did not know why a resident's smoking status would not be included in the care plan. During an interview on 07/16/2026 at 2:08 p.m., NA B stated he reviewed the resident's care plans, so he would know their needs. He stated resident needs should be on the care plan. NA B stated failure to include individualized needs on the care plan could result in poor resident care. He stated he was aware that R #55 was a smoker. During an interview on 07/16/2026 at 2:28 p.m., the DON stated the MDS Coordinator and IDT were responsible for the care plans, but he was ultimately responsible for accuracy and completeness. The DON stated his expectations were for the care plans to be accurate. He stated incomplete or inaccurate care plans may have a negative psychosocial effect on a resident. The DON stated the reason resident's need may not be included in their care plan would be human error and it was overlooked. During an interview on 07/16/2026 at 3:16 p.m., the Admn stated the DON and regional nurse were responsible for care plans. She stated nursing staff input was welcome. She stated consequences of failing to produce an accurate care plan could affect how staff approached care and communication the residents. The Admn stated the smoking status should be on the care plan. She stated the reason it could have been missed was human error. She stated her expectations were for anything to do with resident care be included on the care plan for staff to follow. Review of facility's policy titled Care Plans - Comprehensive Person Centered revised March 2022, revealed:Policy statement A care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy interpretation and implementation7. The person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 3 (Resident #5, Resident #25, and Resident #48) of 18 residents reviewed for food and nutrition services. The facility failed to ensure Resident #5, Resident #25, and Resident #48 received items listed on the lunch menu on 7/14/2026. This failure could place residents at risk of poor intake, chemical imbalance, and/or weight loss.Findings included:Record review of Resident #5's electronic face sheet, dated 07/16/2026, reflected an [AGE] year-old male admitted on [DATE] and most recent readmission on [DATE] with diagnoses including: unspecified protein-calorie malnutrition (insufficient intake or absorption of protein and calories leading to impaired body function and tissue loss). Record review of Resident #5's Quarterly MDS assessment, dated 06/11/2026, reflected a BIMS score of 12 indicating moderate cognitive impairment. Further review reflected Resident #5 did not have weight loss in the last 6 months. During an observation and interview on 07/14/2026 at 12:43 p.m., Resident #5 was sitting at a table in the dining room. He did not receive tortilla soup and received tomato soup. Resident #5 stated he was not told that the soup would be different. Record review of Resident #25's electronic face sheet, dated 07/16/2026, reflected a [AGE] year-old male admitted on [DATE] with diagnoses including: type 2 diabetes mellitus (excess blood sugar levels related to body not producing enough insulin).Record review of Resident #25's Quarterly MDS assessment, dated 06/26/2026, reflected a BIMS score of 15 indicating intact cognition. Further review reflected Resident #25 did not have weight loss in the last 6 months. During an observation and interview on 07/14/2026 at 1:01 p.m., Resident #25 received his lunch tray in his room. The ticket stated that he was to receive tortilla soup and he received tomato soup. Resident #25 stated he would not eat tomato soup because he does not like cooked vegetables. He stated he was not informed that he would not get tortilla soup. He covered the soup and began to eat other items on his tray.Record review of Resident #48's electronic face sheet, dated 07/16/2026, reflected a [AGE] year-old male admitted on [DATE] with diagnosis of anemia (low blood iron levels).Record review of Resident #48's Quarterly MDS assessment, dated 06/11/2026, reflected a BIMS score of 06 indicating severe cognitive impairment. Further review reflected Resident #48 did not have weight loss in the last 6 months. During an observation and interview on 07/14/2026 at 12:43 p.m., Resident #48 was sitting at a table in the dining room. He was served tomato soup. In a confidential group interview at an undisclosed date at an undisclosed time, 10 of 10 group members stated the facility kitchen would change the menu frequently. They stated they did not get notified when a menu change had occurred until they received their food and saw that the items were not what they expected. They stated that they would like to know what was going to be served prior to meal service.During an observation on 07/14/2026 at 12:02 p.m., the lunch menu on the dining room wall outside of the kitchen had the menu items: Tortilla Soup, Soft Beef Taco, Refried Beans, Shred Lettuce & Chop Tomato, Chocolate Brownie, and Beverage.During an interview on 07/16/2026 at 8:57 a.m., the DM stated she expected for residents to get all of the menu items. She stated there was a problem with the soup during lunch service on 7/14/2026 and the remaining tortilla soup had to be disposed of. She stated that was why some residents did not get the tortilla soup. She stated she did not tell the residents or the nursing staff that there was going to be a switch in menu items. She stated the kitchen staff looked at the resident's food tickets and if there were no food preferences about tomato soup listed, those residents received the tomato soup. She stated someone who did not like cooked vegetables should not have gotten tomato soup and did not know why Resident #25 had gotten the tomato soup instead of something else. She stated that she wrote down the substitution of tomato soup for tortilla soup on the substitution log for the dietitian to review on her next visit to the facility. She stated she did not notify the dietitian about the substitution when it occurred. She stated the residents not being told about substitutions could make them unhappy. She stated sometimes she needed to make substitutions due to items not being available, but that issue had been corrected now that the new ADMN had increased the dollar amount per day for each resident and she could get all of the items needed for food service on the food delivery truck.During a telephone interview on 07/16/2026 at 4:05 p.m., the dietitian stated ideally the menu should be followed. She stated if a food item had to be substituted, she would expect for the residents to be notified of the substitution. She stated she was unsure if she had been notified of the substitution of tomato soup for the tortilla soup. She stated negative effect would depend on the soup recipe and if the tortilla soup was broth based then it should have been replaced with another broth based soup to be equivalent. She stated the menu should match what was being served but the ticket may not match if there was a food substitution. She stated the DM was responsible for making sure food served matched the menu. She stated she had just started supervising the facility and came to the facility monthly. She stated she was always available on the phone when needed. She stated she did monitor some of food service when she was present among doing other tasks such as reviewing resident records and diet orders. Record review of facility policy, titled Menu Planning, dated 2003, revealed 5. Menus will be posted in areas that are accessible to patients/residents and at heights where all individuals can easily view them.6. Temporary changes in the menu will be noted on the menu substitution sheets and posted so that facility staff are aware of changes.

Based on interview and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) residents reviewed for comprehensive person-centered care plans. For Resident #1, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measurable objectives in the focus areas of decreased functional abilities r/t impaired cognition and impaired mobility, resistive to care at times r/t new to nursing facility and adjustment to nursing facility, impaired daily decisions making and rejecting of necessary care at times r/t Dx Dementia and Encephalopathy, resident wishes to remain in the nursing facility, risk for cardiac complications r/t diagnoses of HLD, ASHD, and HTN, risk of adverse drug effects r/t use of psychotropic medications use for Depression and Psychosis, at risk for adverse reaction r/t Polypharmacy (antidepressant and antipsychotic medications), at risk for weight changes r/t Dx of Depression and new to this NF, at risk for decline in psychosocial well-being r/t new SNF, frequent pain r/t migraines and impaired mobility, decreased visual acuity r/t aging progress, and (risk for respiratory distress r/t Dx of Asthma. For Resident #2, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the focus areas of resident is at high risk for falls related to quadriplegia, wheelchair dependence, bladder, and impaired mobility, resident has gastroesophageal reflux disease requiring ongoing management, resident is at increased risk for infection related to chronic UTI, incontinence, neuromuscular bladder, COPD, and frequent hospital visits, resident has atrial fibrillation and hypertension requiring ongoing monitoring to prevent cardiac complications, resident is quadriplegic and wheelchair dependent, requiring total assistance with mobility and ADLs, resident requires ongoing long-term care due to complex medical and functional needs, resident has COPD and respiratory failure requiring PRN oxygen therapy and has a history of nicotine dependence, resident has bladder and BPH with a history of chronic UTIs, resident has depression, anxiety, mood disorder and insomnia, affecting overall wellbeing and participation in care, resident has an ADL self-care performance deficit r/t Quadriplegia, resident is verbally aggressive to staff during care due to ineffective copy skills, poor impulse control, resident has a history of false accusations, making unfounded claims due to mistrust of others, resident uses antidepressants medication r/t Depression, resident is on anticoagulant therapy r/t Atrial fibrillation, resident uses anti-anxiety medications r/t Anxiety Disorder, resident is on diuretic therapy r/t hypertension, resident receives anticonvulsant medication r/t anxiety, MDD, Mood Disorder, resident has oxygen therapy r/t COPD, and resident has SOB r/t COPD. For Resident #3, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the focus areas of: resident has an ADL self-care performance deficit r/t mobility impairment, resident has a behavior problem/self-harm (Schizophrenia) r/t yelling, refuses care, hitting himself on objects, curses, hits hand on wall/door/window, attempts to pull fire extinguisher, resident will be able to make basic needs know on a daily basis through the review date, resident has impaired thought processes r/t Schizophrenia, psychosis, and IDD, resident has hypertension, resident had an actual fall with no injury r/t poor communication/comprehension, resident uses antidepressant medication r/t insomnia, resident receives anticonvulsant medication r/t Schizophrenia and Psychosis, resident has potential nutritional problem r/t cognitive impairment, and resident has potential for psychosocial well-being problem r/t recent admission. For Resident #4, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of : resident has difficulty making self-understood r/t Dx of Dementia, Discharge Plan: resident does not have plans/wishes to discharge from SNF, resident has hx of Major Depression and Anxiety, (resident is at risk for nutritional decline r/t Hx of Depression, Hx of Dysphagia, Diuretic use, and GERD, resident has impaired abilities r/t weakness and impaired cognition, resident is incontinent of bowel and bladder r/t impaired mobility and impaired cognition, resident is at risk for pain r/t to diabetic neuropathy, disease process, and Dx of chronic pain, potential for adverse reaction to drug Sulfa and Tramadol, resident uses medication Lexapro r/t depression, (resident will receive diet as ordered by MD. For Resident #5, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of resident requires staff supervision when using tobacco products, Hypertension, wound management, documented pressure ulcer, resident has decreased functional abilities r/t lung cancer with tongue and lymph, terminal Dx, resident has congestive heart failure, resident has anemia, resident is at risk for wt. changes and/or potential aspiration r/t terminal condition and Dx Dysphagia, resident has chronic pain r/t cancer, resident has a terminal prognosis r/t lung cancer with tong and lymph cancer, and resident is at risk for bowel and bladder incontinence r/t terminal condition. For Resident #6, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives in the areas of wound management. These failures could place residents at risk for not receiving care and services to meet their needs and deficits.The findings include: 1. Record review of Resident #1 Face Sheet, dated 04/21/2026, revealed a [AGE] year-old female, with an admission date of 04/01/2026. Resident #1 had diagnoses which included Hypothyroidism (condition where the thyroid gland is underactive and fails to produce sufficient hormones to meet the body's needs), Unspecified Dementia diagnosis used when symptoms of cognitive decline, such as memory loss, confusion, and impaired thinking, are present, but the underlying cause cannot be definitely determined or does not fit a specific pattern), Unspecified Psychosis (mental health symptom including hallucinations, and delusions), Migraine, unspecified, Metabolic Encephalopathy (serious, often reversible brain dysfunction caused by systemic illness, such as liver failure, kidney failure, or severe infection), Essential (primary) hypertension (high blood pressure), and Unspecified asthma. Record review of Resident #1s admission MDS assessment, dated 04/07/2026, revealed Resident #1 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #1 Care Plan, with a recent review date of 04/10/2026, revealed the objectives that were not person-centered and lacked the ability to be evaluated, quantified, and verified were: The resident will maintain current level of function through the review date (decreased functional abilities r/t impaired cognition and impaired mobility), the resident will cooperate with care through next review date (resistive to care at times r/t new to nursing facility and adjustment to nursing facility), the resident will maintain current level of cognitive function through the review date (impaired daily decisions making and rejecting of necessary care at times r/t Dx Dementia and Encephalopathy), Care needs will be met daily and PRN while residing in the nursing facility (resident wishes to remain in the nursing facility), the resident will be free from complications of cardiac problems through the review date (risk for cardiac complications r/t diagnoses of HLD, ASHD, and HTN), the resident will be free of falls through the next review date (risk of adverse drug effects r/t use of psychotropic medications use for Depression and Psychosis), the resident will be free of adverse drug reactions through the review date (at risk for adverse reaction r/t Polypharmacy [antidepressant and antipsychotic medications]), the resident will maintain stable weight through next review period (a risk for weight changes r/t Dx of Depression and new to this NF), the resident will demonstrate adjustment to nursing home placement by/through review date (at risk for decline in psychosocial well-being r/t new SNF), the resident will not have discomfort related to analgesia through the review date (frequent pain r/t migraines and impaired mobility), the resident will show no decline in visual function through review date (decreased visual acuity r/t aging progress), the resident will remain free from complications of asthma (risk for respiratory distress r/t Dx of Asthma). 2. Record review of Resident #2's Facesheet, dated 04/21/2026, revealed a [AGE] year-old male, with an admission date of 07/2//2023. Resident #2 had diagnoses which included Chronic Obstructive Pulmonary Disease (progressive, preventable inflammatory lung disease causing restricted airflow and breathing difficulties), Polyneuropathy (widespread damage to multiple peripheral nerves often causing numbness, burning pain, or muscle weakness), unspecified, Urinary Tract Infection, Unspecified Atrial fibrillation (heart rhythm disorder where the heart's upper chambers beat rapidly and irregularly, increasing risks for stroke, blood clots, and heart failure), Nicotine dependence, Major Depressive Disorder, Quadriplegia (paralysis affecting all four limbs and the torso, caused by cervical spinal cord injury), Essential (Primary) Hypertension (high blood pressure), and Generalized anxiety disorder. Record review of Resident #2's Quarterly MDS assessment, dated 03/04/2026, revealed Resident #2 had a BIMS score of 13, which indicated intact cognitive response. Record review of Resident #2's Care Plan, with a recent review of date of 02/03/2026, revealed the objectives that were not person-centered and lacked the ability to be evaluated, quantified, and verified were: Resident will remain free from falls and fall-related injuries (resident is at high risk for falls related to quadriplegia, wheelchair dependence, bladder, and impaired mobility), resident will remain free from GERD-related discomfort or complications (resident has gastroesophageal reflux disease requiring ongoing management), resident will remain free from signs and symptoms of infection (resident is at increased risk for infection related to chronic UTI, incontinence, neuromuscular bladder, COPD, and frequent hospital visits), resident will maintain stable cardiovascular status without acute events (resident has atrial fibrillation and hypertension requiring ongoing monitoring to prevent cardiac complications), resident will maintain skin integrity an highest practicable level of comfort and function (resident is quadriplegic and wheelchair dependent, requiring total assistance with mobility and ADLs), resident will maintain the highest practicable quality of life in LTC setting (resident requires ongoing long-term care due to complex medical and functional needs), resident will maintain adequate oxygenation and remain free from respiratory distress (resident has COPD and respiratory failure requiring PRN oxygen therapy and has a history of nicotine dependence), resident will maintain urinary elimination and remain free from UTI symptoms (resident has bladder and BPH with a history of chronic UTIs), Resident will demonstrate stable mood and improved sleep patterns (resident has depression, anxiety, mood disorder and insomnia, affecting overall wellbeing and participation in care), Resident will maintain current level of function through the review date (resident has an ADL self-care performance deficit r/t Quadriplegia), Resident will demonstrate effective coping skills through the review date (resident is verbally aggressive to staff during care due to ineffective copy skills, poor impulse control), resident will have fewer episodes of false accusations and outburst by the review date (resident has a history of false accusations, making unfounded claims due to mistrust of others), resident will be free from discomfort or adverse reactions related to antidepressants (resident uses antidepressants medication r/t Depression), resident will be free from discomfort or adverse reactions related to anticoagulant use (resident is on anticoagulant therapy r/t Atrial fibrillation), resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date (resident uses anti-anxiety medications r/t Anxiety Disorder), resident will be free from discomfort or adverse reactions related to diuretic therapy through the review date (resident is on diuretic therapy r/t hypertension), resident will be free from discomfort or adverse reactions related to anticonvulsant medications through the review date (resident receives anticonvulsant medication r/t anxiety, MDD, Mood Disorder), resident will have no s/sx of poor oxygen absorption through the review date (resident has oxygen therapy r/t COPD), and resident will have complications relate to SOB through the review date (resident has SOB r/t COPD), 3. Record review of Resident #3's Face Sheet, dated 04/21/2026, revealed a [AGE] year-old male, with an original admission date into the facility of 02/27/2026. Resident #3 was most recent admission date was 04/10/2026. Resident #5 had diagnoses which included Post traumatic seizures (convulsions resulting from traumatic brain injury), Schizoaffective disorder (a chronic mental condition characterized by a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, including mania or depression), Generalized Anxiety, and Schizophrenia (a severe brain disorder characterized by hallucinations, delusions, disorganized speech, and impaired social/occupational functioning). Record review of Resident #3's admission MDS, dated [DATE], revealed Resident #3 had a BIMS score of 99, which indicated the Resident #3 was unable to complete the interview. Record review of Resident #3's Care Plan, with recent review of date of 03/09/2026, revealed the objectives that were not person-centered and lacked the ability to be evaluated, quantified, and verified were: Resident will maintain current level of function in ADL's through the next review date (resident has an ADL self-care performance deficit r/t mobility impairment), (Resident) will have fewer episodes of yelling, refuses care, hitting himself on objects daily by review date (resident has a behavior problem/self-harm (Schizophrenia) r/t yelling, refuses care, hitting himself on objects, curses, hits hand on wall/door/window, attempts to pull fire extinguisher), resident will be able to make basic needs know on a daily basis through the review date, (resident will be able to make basic needs know on a daily basis through the review date), Resident will be able to communicate basic needs on a daily basis through the next review date (resident has impaired thought processes r/t Schizophrenia, psychosis, and IDD), resident will remain free of complications related to hypertension through review date (resident has hypertension), resident will resume usual activities without further incident through the review date (resident had an actual fall with no injury r/t poor communication/comprehension), resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (resident uses antidepressant medication r/t insomnia), resident will be free from side effects of anticonvulsant medication through review date (resident receives anticonvulsant medication r/t Schizophrenia and Psychosis), resident will comply with recommended daily diet through review date (resident has potential nutritional problem r/t cognitive impairment) and resident will have no indications of psychosocial will being problems by/through review date (the resident has potential for psychosocial well-being problem r/t recent admission. 4. Record review for Resident #4's Face Sheet, dated 04/22/2026, revealed an [AGE] year-old female, with an admission date of 07/13/2018. Resident #4 had diagnoses which included Unspecified combined systolic (congestive) and diastolic (congestive) heart failure, Major Depressive Disorder, Acute respiratory failure, Unspecified dementia (progressive syndrome characterized by severe cognitive decline), Generalized anxiety, and GERD (chronic condition where stomach acid flows back into the esophagus causing persisting heartburn, regurgitation, chest pain, and damage to the esophageal lining). Record review of Resident #4's Quarterly MDS assessment, dated 03/20/2026, revealed Resident #4's had a BIMS score of 12, which indicated moderate cognitive impairment Record review of Resident #4's Care Plan, with recent review of date of 12/09/2025, revealed the objectives that were not person-centered and lacked the ability to be evaluated, quantified, and verified were: Resident will maintain ability to make basic needs/wants known daily through next review date (resident has difficulty making self-understood r/t Dx of Dementia), resident's care needs will be met daily and PRN while residing in the SNF (Discharge Plan: resident does not have plans/wishes to discharge from SNF), resident will be free from s/sx of increased depression or anxiety (resident has hx of Major Depression and Anxiety), Resident will be free from nutritional decline and will maintain stable weight (resident is at risk for nutritional decline r/t Hx of Depression, DM, Hx of Dysphagia, Diuretic use, and GERD), resident will maintain or improve current functional abilities without significant functional decline over the next 90-days (resident has impaired abilities r/t weakness and impaired cognition), resident will be clean and dry and will maintain dignity daily (resident is incontinent of bowel and bladder r/t impaired mobility and impaired cognition), resident will function on an acceptable level with minimal interference from pain and medication side effects through the review date (resident is at risk for pain r/t to diabetic neuropathy, disease process, and Dx of chronic pain), resident will have no allergic reactions (potential for adverse reaction to drug Sulfa and Tramadol), resident will be free from discomfort or adverse reactions related to antidepressants (resident uses medication Lexapro r/t depression), and resident will comply with recommended diet daily through review date (resident will receive diet as ordered by MD). 5. Record review of Resident #5's Face Sheet, dated 04/22/2026, revealed a [AGE] year-old male, with an admission date of 03/18/2026. Resident #5's diagnoses included Malignant (cancer) neoplasm of unspecified part of lung, Essential (Primary) Hypertension, Secondary and unspecified malignant neoplasm of lymph node, and Chronic systolic heart failure. Record review of Resident #5's admission MDS assessment, dated 03/25/2026, revealed Resident #5 had a BIMS score of 14, which indicated intact cognitive response. Record review of Resident #5's Care Plan, with recent review of date of 04/01/2026, revealed the objectives that were not person-centered and lacked the ability to be evaluated, quantified, and verified were: Resident will follow tobacco policy of facility without injury to self or others (resident requires staff supervision when using tobacco products), resident blood pressure will be within normal limits (Hypertension), wound will show signs of improvement (wound management), management of pressure ulcer (documented pressure ulcer), resident will maintain current level of function through the review date (resident has decreased functional abilities r/t lung cancer with tongue and lymph, terminal Dx), resident will have clear lung sounds, heart rate, and rhythm within normal limits through the review date (resident has congestive hear failure), resident will remain free of s/sx or complications related to anemia through review date (resident has anemia), resident will maintain stable wt. as able and be free from s/sx of aspiration through next review (resident is at risk for wt. changes and/or potential aspiration r/t terminal condition and Dx Dysphagia), resident will not have discomfort related to side effects of analgesia through the review date (resident has chronic pain r/t cancer), resident's comfort will be maintained through the review date (resident has a terminal prognosis r/t lung cancer with tong and lymph cancer), resident will be continent at all times through the review date (resident is at risk for bowel and bladder incontinence r/t terminal condition) 6. Record review of Resident #6's Face Sheet, dated 04/22/2026, revealed a [AGE] year-old male with an admission date of 04/18/2026. Resident #6's diagnoses included Displaced fracture of lesser Trochanter (long bony prominence on the upper femur that acts as an anchor for hip and thigh muscles, crucial for movement) of right femur. Record review of Resident #6's admission MDS assessment, dated 04/22/2026, revealed Section C - Cognitive Patterns was not completed, and a BIMS score was not determined Record review of Resident #6's Care Plan, with recent review of date of 04/29/2026, revealed the objectives that were not person-centered and lacked the ability to be evaluated, quantified, and verified were: Wound will show signs of improvement (wound management). During an interview on 04/22/2026 at 1:48 p.m., the MDS Coordinator said she was responsible for ensuring the MDS assessments were completed and entered into the electronic platform. The MDS Coordinator said the person who completed the MDS was responsible for the objectives and the IDT would be responsible to ensure the objectives and goals were measurable. The MDS Coordinator said the nursing and therapy department were able to update objectives prior to the IDT's final approval. The MDS Coordinator said she was aware the objectives were not person-centered and measurable. The MDS Coordinator said the positive outcome of measurable objectives would be to ensure the resident was making progress and not declining and objectives were met. During an interview on 04/22/2026 at 3:00 p.m. the Social Worker said the IDT reviewed all care plans and reviewed the objectives and goals. The Social Worker said the MDS nurse was in charge of coordinating the care plan and ensuring the objectives were person-centered and measurable. The Social Worker said in the facility, the MDS Coordinator would be responsible to change the generic objectives that populated the care plan after the MDS assessment was entered into the electronic platform. The Social Worker agreed the majority of the objectives in the care plans were not person-centered or measurable. She said objectives should be measurable to see if the resident was progressing or declining. On 04/23/2026 at 10:19 a.m., the Administrator said he was a member of the IDT and would attend care plan meetings. The Administrator said the MDS Coordinator and nurses were responsible for updating the care plan and ensuring the objectives were person-centered and measurable. The Administrator said objectives should be measurable to gauge the level of improvement including behavioral and track the needs to ensure the resident was receiving appropriate services. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 03/2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to met the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes;

Based on observation, interviews and record reviews, the facility failed to ensure Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability was performed prior to admission for 1 of 4 (Resident #3) reviewed for PASRR, in that: The facility admitted Resident #3, whose admission was a Pre-admission category and who had a suspicion of mental illness, prior to receiving the required PASRR II evaluation assessment and PASRR determination. This failure could affect all new residents admitted into the facility as a Preadmission with a mental condition at risk for inappropriate admissions and the inability to be evaluated and receive services in the most integrated setting appropriate to their needs.Findings included:Record review of Resident #3's Face Sheet, dated 04/21/2026, revealed a [AGE] year-old male, with an original admission date into the facility of 02/27/2026. Resident #3 was most recent admission date was 04/10/2026. Resident #5 had diagnoses which included Post traumatic seizures (convulsions resulting from traumatic brain injury), Schizoaffective disorder (a chronic mental condition characterized by a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, including mania or depression), Generalized Anxiety, and Schizophrenia (a severe brain disorder characterized by hallucinations, delusions, disorganized speech, and impaired social/occupational functioning). Record review of Resident #3's admission MDS, dated [DATE], revealed Resident #3 had a BIMS score of 99, which indicated the Resident #3 was unable to complete the interview. Section 1 - Active Diagnoses, Section I8000 revealed Resident #3 had the diagnosis of Post traumatic seizures, Unspecified Intellectual Disabilities, and Schizophrenia. Record review of Resident #3's PASRR Level 1 Screening, dated 02/26/2026, revealed Resident #3 was categorized as a Preadmission admission due to Section A0900A marked as #7, which indicated the referring entity was other. Section A0900B indicated the type of entity for Resident #3 was the Texas Department of Criminal Justice. Review of Section C - PASRR Screening, Section C0100 revealed a code of 1, which indicated there was a suspicion Resident #3 had evidence or an indicator of a Mental Illness. Section C0200 was coded 1, which indicated there was suspicion Resident #3 had evidence or an indicator of an Intellectual Disability. During an interview on 04/21/2026 at 2:05 p.m., Resident #3 confirmed he had been in the hospital and said he would not bang his head or be mean to others. During an interview on 04/23/2026 at 10:01 p.m., the Regional Nurse Consultant said the facility was currently going through a CHOW since September or October of 2025 and the facility had received correspondence from the local LMHA/LIDDA that they would be unable to proceed with the PASRR process in TMHP LTC Online Portal due to the CHOW and due to the lack of a provider number. The Regional Nurse Consultant said this meant the LHMA could not entered the PL1s into the state electronic portal to initiate the PASRR process. The Regional Nurse Consultant said the PL1s for residents who were admitted after the initiation of the CHOW were completed on a paper form that the facility had kept hard copies to provide to the LMHA/LIDDA to be entered into the portal once the facility received a provider number and the CHOW was completed. The Regional Nurse Consultant said the LMHA/LIDDA had not completed Level II PASRR Assessments since the CHOW had been initiated in September 2025. The Regional Nurse Consultant said she was aware that the facility could not admitted a Preadmission category PASRR positive individual until after the PASRR Level II assessment was completed and a determination was made. During an interview on 04/23/2026 at 10:19 a.m., the Administrator said he was not aware the LMHA/LIDDA was not completing the PASRR Level II assessments. The Administrator said he was not aware of that the facility had admitted a resident who was a PASRR Preadmission and PL1 positive for Mental Illness. During an interview on 04/23/2026 at 11:16 a.m., the Marketing Director said she was responsible for admitting new residents and ensured the PASRR PL1 was completed prior to admission. She said she would obtain a copy of PL1 for the facility. The Marketing Director said she would gather all the information for the admission packet when she admitted a new resident and send the information to admissions. The Market Director said she was unaware of the process with the LMHA/LIDDA after that point. The Marketing Director said she was not responsible for sending the PL1s to the LMHA/LIDDA. She said the medical team would reach out the LMHA/LIDDA if the PL1 was positive. During an interview on 04/23/2026 at 11:33 a.m., the MDS Coordinator said she was guided by TMHP to keep a list of all PL1 positives that were admitted after the initiation of CHOW until provider number was received. The MDS Coordinator said after the CHOW was approved, the facility would be required to submit a new PL1 for all residents who resided in the facility within 90 days after the approval of the CHOW. The MDS Coordinator said she was under the impression that Preadmissions who were PASRR positive and newly admitted would be included in the list and she had not been informed to not admit a resident as Preadmission and PASRR positive. The MDS Coordinator said she knew that a PASRR Preadmission who had a suspicion of mental health or intellectual disabilities could not be admitted until after the PASRR Level II Assessment was completed and the facility determined that they could meet his/her needs. Record Review of the facility's policy, PASRR, dated 01/20/2026, revealed the aim of the PASRR program was to identify residents with Mental Illness (MI), Intellectual Disability (ID), or Developmental Disability (DD), Related Conditions (RC) and to ensure they are properly placed, whether from the community or Nursing Facility an to ensure they receive the services they require for their MI, or ID/DD. The PASRR Level Screen (PL1)In the event the facility is considering an admission from the community (home, homeless shelter, jail, group home, off the street, etc.) and the facility Interdisciplinary Team (IDT) suspects any MI, ID, or DD, the community Admissions Coordinator prior to admission will contact the LIDDA and follow the preadmission process.

Based on interview and record review the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 1 of 1((11/01/2025,11/02/2025,11/08/2025,11/29/2025, and 11/30/2025) month reviewed for RN coverage.The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 5 of 30 days (11/01/2025,11/02/2025,11/08/2025,11/29/2025, and 11/30/2025).This failure could place residents at risk of not having decisions made, that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings include:Record review of the facility's RN nursing schedule for the month of November 2025 revealed there was no evidence of 8 hour RN coverage on 11/01/2025,11/02/2025,11/08/2025,11/29/2025, and 11/30/2025. During an interview on 12/05/2025 at 2:15 PM, the DON stated she started working as the interim DON on 9/18/2025. The DON stated she could not cover every shift with RN coverage. The DON stated there was no RN coverage on 11/1, 11/2, 11/8, 11/29 and 11/30. The DON stated her expectation was to have 8-hour RN Coverage daily. The DON stated the ADON was responsible for completing the staffing schedule, and she monitored the schedule. The DON stated she did not think there was a negative effect on residents, because staff had access to her any time, she could be at the facility in timely manner, and the nursing had a group chat with corporate staff. The DON stated what led to the failure was it's hard to hire an RN who would work with the facility's cliental, which were most residents from the penal system and/or sex offenders.During an interview on 12/05/2025 at 3:20 PM, the ADMN stated his first day as the administrator was 11/01/2025. The ADMN stated his expectation was the facility follow the regulations and have 8-hour RN coverage 7 days per week. The ADMN stated the ADON was responsible for making the daily schedule. The AMMN stated the DON was responsible for monitoring the schedule and ensuring there was 8 hours of RN coverage daily. The ADMN stated he and the DON monitored the schedule during their daily staffing meetings and their Friday staffing meeting they discussed the weekend coverage. The AMDN stated the DON worked the weekends to cover but could not work every weekend. The ADMN stated he did not think there was a negative effect on residents. The ADMN stated he felt they had competent nursing staff, and staff had access to the DON, and he had not had any complaints from residents regarding their care. The ADMN stated he did not have a reason for the failure. The ADMN stated the facility did not have a policy, that the facility followed the federal and state regulations.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 4 (Resident #32, Resident #25, Resident #21, and Resident #39) of 18 Residents reviewed for accuracy of assessments. The facility failed to ensure MDS dated [DATE] reflected the use of oxygen for Resident #32. The facility failed to ensure MDS dated [DATE] reflected hospice services for Resident #25. The facility failed to ensure MDS dated [DATE] reflected hospice services for Resident #21. The facility failed to ensure MDS dated [DATE], reflected the use of anti-anxiety medications for Resident #39. This failure could residents at risk of inaccurate assessments and not receiving appropriate care according to their status. Findings include: Resident #32 Review of Resident #32's electronic face sheet reflected a [AGE] year-old male originally admitted on [DATE] re-admitted on [DATE] with diagnoses that included: fusion of spine (surgery to fuse spine), quadriplegia (loss of motor and sensory function in all limbs and the trunk), weakness, pneumonia (infection in the lungs), and chronic obstructive pulmonary disease (disorder that effects air flow in and out of the lungs). Review of Resident #32's quarterly MDS assessment dated [DATE] reflected: BIMS score of 13 meaning his cognition was intact. Further review of MDS reflected resident was not on oxygen therapy. Review of Resident #32's comprehensive care plan initiated 12/11/2024 reflected: Problem: resident has an as needed oxygen therapy order related to emphysema/COPD and personal history of smoking .Approach: Administer oxygen at as needed 1-4 l/min via nasal cannula. Observe oxygen precautions. Record review of Resident #32's electronic physician order dated 07/30/2024 reflected: oxygen to be administered via nasal cannula as needed at 1-4 l/min for quadriplegia (loss of motor and sensory function in all limbs and the trunk). Further review of order reflected physician order was discontinued on 05/29/2025. Record review of Resident #32's electronic physician order dated 05/29/2025 reflected: oxygen to be administered via nasal cannula as needed at 1-4 l/min for quadriplegia (loss of motor and sensory function in all limbs and the trunk). During an observation on 06/02/2025 at 11:32 a.m., Resident #32 was sitting up in a wheelchair in his room. Oxygen was being administered at 4 l/min via nasal cannula, and there was no oxygen sign on his door indicating oxygen in use. During an observation on 06/03/2025 at 9:25 a.m., Resident #32 was sitting in his room in wheelchair and the oxygen concentrator was on and being administered to resident at 4 l/min via nasal cannula. Resident #25 Review of Resident #25's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: brain bleed, prostate cancer, and dementia. Review of Resident #25's quarterly MDS dated [DATE] reflected: BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS reflected resident was not on hospice services. Review of Resident #25's comprehensive care plan initiated 12/10/2024 reflected: Problem: Terminal Care (Hospice) .Approach: Pain management, Comfort measures. Review of Resident #25's electronic physicians reflected: Admit to Hospice diagnosis heart disease, dated 05/29/2025 and Admit to Hospice, dated 12/10/2024 and discontinued 05/29/2025. Resident #21 Review of Resident #21's electronic face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: urinary tract infection, anxiety, and dementia. Review of Resident #21's quarterly MDS dated [DATE] reflected: BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS reflected resident was not on hospice services. Review of Resident #21's comprehensive care plan initiated 10/10/2024 reflected: Problem: resident is on Hospice .Approach: Hospice will follow resident's needs; resident's rights will be respected. Review of Resident #21's electronic physicians reflected: Admit to Hospice diagnosis degeneration of the brain, dated 05/27/2025 and Admit to Hospice, dated 01/09/2025 and discontinued 05/27/2025. Resident #39 Review of Resident #39's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart failure, anxiety, and diabetes. Review of Resident #39's Quarterly MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #39 was not receiving anti-anxiety medication. Review of Resident #39's Comprehensive Care Plan last revised 05/30/2025 revealed no evidence of resident medication for anxiety. Review of Resident #39's electronic Physicians Orders revealed: hydroxyzine tablet; 10 mg; amt: 1 tab; oral Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime for anxiety, start date 03/11/2025 discontinued 05/29/2025 and hydroxyzine tablet; 10 mg; amt: 1 tab; oral Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime start date 05/29/2025 with no stop date. Review of Resident #39's May 2025 MAR revealed 12 doses of hydroxyzine was administered. Review of Resident #39's June 2025 MAR up until 06/03/2025, revealed 3 doses of hydroxyzine was administered. During an interview on 06/04/25 at 03:17 PM, the MDS Coordinator stated anyone receiving hospice services should have been claimed on the MDS. She stated anyone receiving oxygen or taking anti-anxiety medications should have been claimed on the MDS. She stated she just started in May and these MDS were completed prior to that. During an interview on 06/04/25 at 03:31 PM, the DON stated he was responsible for ensuring that the MDS's were completed accurately. He stated they were completed by the MDS Coordinator and then reviewed by him. He stated the hospice, and the oxygen just must have been missed. He stated the facility did not have an MDS policy, the facility follows the RAI.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 2 (West Hall medication cart and East Hall medication cart) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure the [NAME] Hall and East Hall medication carts, with prescription medications and biologicals, were secured while unattended. This failure could place residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. The findings included: During an observation on 06.02.2025 at 10:01 AM, the [NAME] Hall Medication cart had prescription heart medications (amiodarone, amlodipine, metoprolol), prescription depression medications (trazodone), prescription diuretics (metolazone), prescription antinausea (meclizine, ondansetron), prescription diabetes medications (glucagon, insulin), prescription inhalation medications (albuterol, ipratropium bromide, budesonide), prescription anti-yeast medication. (nystatin powder and cream), OTC pain medication (aspirin, Tylenol), OTC constipation medication (MiraLAX). During an observation on 06.02.2025 at 11:28 AM East Hall Medication cart had prescription heart medications (amiodarone, amlodipine, metoprolol), prescription depression medications (trazodone), prescription diuretics (metolazone), prescription antinausea (meclizine, ondansetron), prescription diabetes medications (glucagon, insulin), prescription inhalation medications (albuterol, ipratropium bromide, budesonide), prescription anti-yeast medication. (nystatin powder and cream), OTC pain medication (aspirin, Tylenol), OTC constipation medication (MiraLAX). During an observation on 06.02.2025 at 10:01 AM medication cart on [NAME] Hall was unlocked and unattended for 15 minutes. There were no residents in the hall. During an observation on 06.02.2025 at 11:28 AM medication cart on East Hall was unlocked and unattended for 15 minutes. There were no resident in the hall. During an interview on 06.02.2025 at 10:05 AM, LVN A stated the medication cart (West Hall medication cart) should not have been left unlocked and unattended. LVN A stated residents could get medications that did not belong to them, and this could possibly cause harm to the resident. LVN A stated she had been trained when she was hired on use and medication carts and the keep it locked when not in use by the DON. LVN A stated she just got busy and forgot to lock the medication cart. During an interview on 06.02.2025 at 11:30 AM, RN B stated the medication cart (East Hall medication cart) should be locked when not in use or in line of sight. RN B stated if the medication cart was not locked, other people or residents could take something out of the cart that they did not need. RN B stated this could cause a resident to possibly take a medication not intended for them. RN B stated if a resident took a medication not intended for them, it could possibly cause a health issue for that resident. RN B stated that she left the medication cart to get a resident some ice. RN B stated she had been trained on the use of the medication cart when she was hired by DON. During an interview on 06.04.2025 at 2:49 PM, the DON stated the medication carts should have been locked when not in use. The DON stated the harm could be if a resident took a medication off the cart that was not for them, it could cause an adverse reaction. The DON stated she was not sure why this occurred. The DON stated she and the ADMIN made rounds in the morning and several times a day and check to see the medication carts are locked if not in use. The DON stated nurses and medication aides are trained on hire and PRN, on the use of medication carts. Review of the facility's undated policy titled: Security of Medication Cart The medication cart shall be secured during medications passes. Policy Interpretation and Implementation 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry . Medication carts must be securely locked at all times when out of the nurse's view.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #8, Resident #25, and Resident #40) of 18 residents reviewed for hospice services. 1. The facility failed to maintain required hospice forms and documentation, that included certificate of terminal illness to ensure that the needs of the resident were addressed and met 24 hours per day to ensure Resident #8, Resident #25, and Resident #40 received adequate end-of-life care. 2. The facility failed to have a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day and to have a physician certification and recertification of the terminal illness for Resident #8, Resident #25, and Resident #40. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, depression, and schizoaffective disorder. Review of Resident #8's quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of Section O: revealed Resident #8 was on hospice care. Review of Resident #8's Comprehensive Care Plan last revised 04/03/2025, revealed: Problem: Resident is on Hospice .Approach .Report decline in condition to hospice agency. Review of Resident #8's electronic Physicians Orders revealed: Admit to Hospice diagnosis moderate protein calorie malnutrition, dated 05/29/2025 and Admit to Hospice, dated 03/20/2025 and discontinued 05/29/2025. Review of Resident #8's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #8. Resident #25 Review of Resident #25's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: brain bleed, prostate cancer, and dementia. Review of Resident #25's quarterly MDS dated [DATE] reflected: BIMS of 11 which indicated moderate cognitive impairment. Further review of MDS reflected resident was not on hospice services. Review of Resident #25's comprehensive care plan initiated 12/10/2024 reflected: Problem: Terminal Care (Hospice) .Approach: Pain management, Comfort measures. Review of Resident #25's electronic physicians reflected: Admit to Hospice diagnosis heart disease, dated 05/29/2025 and Admit to Hospice, dated 12/10/2024 and discontinued 05/29/2025. Review of Resident #25's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #25. Resident #40 Review of Resident #40's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: kidney disease, depression, and renal failure. Review of Resident #40's quarterly MDS dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment. Review of Section O: revealed Resident #40 was on hospice care. Review of Resident #40's Comprehensive Care Plan last revised 05/30/2025, revealed: Problem: Resident requires Hospice .Approach .Report decline in condition to hospice agency. Review of Resident #40's electronic Physicians Orders revealed: Admit to Hospice, dated 05/27/2025 and Admit to Hospice, dated 03/06/2025 and discontinued 05/27/2025. Review of Resident #40's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #8. During an interview on 06/04/25 at 03:00 PM, the DON stated that communication between hospice staff and facility staff was done verbally, but the facility did not have any written documentation of communication. He stated he was not aware that communication needed to be documented. He stated he did not know why the facility did not have the certifications of terminal illness on file for these 3 residents. Review of the facility's policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure that spoiled food items were disposed of properly. 2. The facility failed to ensure foods were labeled properly. 3. The facility failed to ensure that food items were disposed of properly. 4. The facility failed to ensure cans that were dented were removed from food storage. 5. The facility failed to ensure staff wore beard and hair coverings, that secured all hair. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 06/02/2025 between 9:30 AM and 9:50 AM of the kitchen revealed Dietary Aide was wearing a hair net that failed to have all hair covered, and dietary aide was not wearing a beard covering over his beard. The Dietary Aide stated he was new and was not told he needed to wear a covering over his beard. The Dietary Aide stated he did not realize he did not have all his hair restrained in his hair covering. Further observation of kitchen revealed: Refrigerator: 1. 1 package of salad mix out of the original container that was not labeled with a use by date. 2. 1 package of lettuce out of the original container that was not labeled with a use by date. 3. 1 package of ham out of the original container that was labeled with a use by date. 4. 1 metal container covered in foil that contained gravy, that was hot to touch. 5. 1 metal container covered in foil that contained oatmeal, that was hot to touch. The Dietary Aide took the temperature of the gravy when it was removed from the refrigerator the temperature of gravy was 140 degrees and the oatmeal temperature was 130 degrees. The Dietary Aide stated he did not put them in the refrigerator and did not know why they were in the refrigerator. The Dietary aide stated he did not know the cooling process. During an observation on 06/02/25 between 9:55 AM to 10:10 AM of the storage building revealed: Dry Storage: 1. 3 unopened boxes of bran flakes cereal with a use by date of 04/19/2025 2. 1 can of chicken noodle soup that was dented. 3. 1 can of cream of mushroom soup that was dented. 4. 1 can of solid packed apples that was dented. 5. 4 bags of tortilla chips out of the original container not labeled with a description or a date. Freezer: 1. 15 packages of vegetables out of the original container that were not labeled with a use by date. During an interview on 06/02/2025 at 11:30 AM, the DM stated she had put the gravy and the oatmeal in the refrigerator when she saw state come in the building. The DM stated she had gotten nervous and was trying to make sure the kitchen looked clean. The DM stated the gravy and oatmeal were too hot to be put into the refrigerator. The DM stated the gravy and oatmeal needed to be cooled to 70 degrees before putting into the refrigerator. The DM stated it was the cooks' and the DM's responsibility to ensure food was cooled prior to placing in the refrigerator. The DM stated it was ultimately her responsibility. The DM stated the effect on residents could have been residents could have gotten sick. The DM stated what led to failure was her being overwhelmed that state was in the building. The DM stated she did not realize male staff needed to wear coverings over their beards. The DM stated staff needed to make sure all their hair was contained in a hair net. The DM stated she did not realize that Dietary Aide did not have all his hair in the hair covering. The DM stated her expectation was staff have all hair covered properly per policy. The DM stated staff were responsible to ensure they used hair and beard coverings. The DM stated she was ultimately responsible to ensure that staff used hair and beard coverings properly. The DM stated what led to failure was she overlooked and assumed it was good enough. The DM stated the affect on residents could have been hair in a resident's food. The DM stated food should have been labeled with a receive date, an open date and a use by date. The DM stated she did not realize the frozen vegetables needed a use by date on them, she assumed there was a manufacture date on each package. The DM stated all staff who stocked food or opened food were responsible to label food. The DM stated she was ultimately responsible for ensuring food was labeled. The DM stated residents could have gotten sick if receiving food that was spoiled or out of date. The DM stated she monitored food storage by making rounds each morning. The DM stated what led to the failure was oversight on her part and being overwhelmed with state in the building. During an interview on 06/04/2025 at 3:17 PM, the ADMN stated her expectation was dietary staff needed to follow the kitchen policies. The ADMN stated the DM and herself were responsible to ensure policy was being followed in the kitchen. The ADMN stated she and the DM should have been making rounds in the kitchen to ensure policy was being followed. The ADMN stated residents could have been exposed to food borne illness or cross contamination. The ADMN stated what led to failures the DM being new and was still learning. Record review of the facility's policy titled, Cooling and Reheating Foods dated 2018, revealed Chill methods place food in 2-inch-deep pans, chill from 140 degrees to 70 degrees in two hours. Record review of the facility's policy titled, Employee Sanitation dated 2018, revealed Employee Cleanliness Requirements .Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Record review of the facility's policy titled, Food Storage dated 2018, revealed To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes . All containers by be labeled and dated. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/04/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided respiratory care received care consistent with professional standards of practice for 1 of 18 residents (Resident #32) and 1 of 1 oxygen storage room reviewed for oxygen administration. 1. The facility failed to post No Smoking sign in resident doorway for Resident #32 on 06/02/2025 & 06/03/2025 who used oxygen. 2. The facility failed to post No Smoking sign on doorway for room that oxygen was stored on 06/02/2025. These failures could place residents at risk of people not being notified of no smoking in oxygen storage or oxygen in use and prohibit smoking in any room, ward, or compartment where oxygen was in use or stored. Findings included: Resident #32 Record review of Resident #32's electronic face sheet dated 06/03/2025 reflected the resident was a [AGE] year-old male originally admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: fusion of spine (surgery to fuse spine), quadriplegia (loss of motor and sensory function in all limbs and the trunk), weakness, pneumonia (infection in the lungs), and chronic obstructive pulmonary disease (disorder that effects air flow in and out of the lungs). Record review of Resident #32's quarterly MDS assessment dated [DATE] reflected: BIMS score of 13 meaning his cognition was intact. Further review of MDS reflected the resident was not on oxygen therapy. Record review of Resident #32's care plan with start date of 12/11/2024 reflected: Problem: [resident name] has an as needed oxygen therapy order related to emphysema/COPD and personal history of smoking .Approach: Administer oxygen at as needed 1-4 l/min via nasal cannula. Observe oxygen precautions. Record review of Resident #32's physician order dated 07/30/2024 reflected oxygen to be administered via nasal cannula as needed at 1-4 l/min for quadriplegia (loss of motor and sensory function in all limbs and the trunk). Record review of Resident #32's progress note dated 05/21/2025 reflected day one of three after roommate change, seems to be tolerating well so far. During an observation on 06/02/2025 at 11:32 a.m., Resident #32 was sitting up in a wheelchair in his room. Oxygen was being administered at 4/l/min and there was no oxygen sign on his door indicating oxygen in use. During an observation on 06/03/2025 at 9:25 a.m., Resident was sitting in his room in his wheelchair and his oxygen concentrator was on. During an observation on 06/02/2025 at 10:01 a.m., empty oxygen cylinders and full oxygen cylinders were stored in a building adjacent to the facility. There was no evidence of an oxygen sign on the door to the building which opened to the room where oxygen was being stored. There were 10 empty cylinders and 25 full canisters. During an interview on 06/03/2025 at 10:52 a.m., the ADON stated residents with oxygen being administered should have an oxygen sign on the door to their rooms. She stated Resident #32 had been on oxygen for a while. She stated she felt him moving rooms recently may have led to failure of no sign on his doorway. During an interview on 06/03/2025 at 11:03 a.m., the DON stated all staff were responsible for making sure no smoking signs were posted outside of resident's rooms. He stated he, the ADON, and the ADMN monitored that appropriate oxygen signs were posted outside of the resident's rooms twice a week. He stated that the resident moving rooms may have led to failure of sign not being posted outside of his room. He stated not having an oxygen sign could be hazardous and may not alert people that oxygen was being used in the room. During an interview on 06/03/2025 at 11:07 a.m., the ED stated she did not know why oxygen in use sign was not posted outside of Resident #32's room. She stated not posting could lead to people not knowing that oxygen was in use inside of the room. She stated she expected that oxygen storage area to have oxygen sign in place on the door, but she never thought of placing a sign on the door leading to where oxygen was stored in building adjacent to facility. She stated not having signs were a safety hazard and would lead to not alerting people that oxygen was stored in that area. During an interview on 06/03/2025 at 12:36 p.m., the RNC stated her expectation would be that areas that store oxygen or oxygen was used, would have a sign outside the door notifying people that oxygen was in use or being stored. She stated the ADMN and DON were responsible for making sure signs were posted when corporate was not in the building. She stated she expected for staff to follow policies about oxygen use and storage. She stated she felt the sign on Resident #32's room could have been removed by another resident or had fallen off the door. She stated not having signs posted could lead to people not knowing that oxygen was in use or being stored. Record review of the facility policy's titled Resident Smoking Policy with no date reflected: No smoking signs will be maintained on doors or gates where oxygen is used or stored. Record review of the facility policy's titled Fire Safety and Prevention with revision date November 2021 reflected: Use visible 'No Smoking' signs where oxygen is stored or being administered.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 2 (Resident #8 and Resident #39) of 18 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #8's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. 2. The facility failed to ensure Resident #39's PRN Hydroxyzine (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, depression, and schizoaffective disorder. Review of Resident #8's quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of Section N: Medications revealed Resident #8 was receiving anti-anxiety medications. Review of Resident #8's Comprehensive Care Plan last revised 04/03/2025, revealed: Problem: Resident has the potential for complications related to antianxiety medication use .Approach: Administer medication per MD orders, monitor for any side effects. Review of Resident #8's electronic Physicians Orders revealed: lorazepam tablet; 0.5 mg; amt: 1 tab; oral Special Instructions: May administer 1-2 tabs Every 2 Hours, start date 03/19/2025 with no stop date. Review of Resident #8's May 2025 MAR revealed no doses of Lorazepam were administered. Review of Resident #8's June 2025 MAR up until 06/03/2025, revealed no doses of Lorazepam were administered. Review of Resident #8's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. Review of Drugs.com for Lorazepam accessed on 06/04/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #39 Review of Resident #39's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart failure, anxiety, and diabetes. Review of Resident #39's Quarterly MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #39 was not receiving anti-anxiety medication. Review of Resident #39's Comprehensive Care Plan last revised 05/30/2025 revealed no evidence of resident medication for anxiety. Review of Resident #39's electronic Physicians Orders revealed: hydroxyzine tablet; 10 mg; amt: 1 tab; oral Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime for anxiety, start date 03/11/2025 discontinued 05/29/2025 and hydroxyzine tablet; 10 mg; amt: 1 tab; oral Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime start date 05/29/2025 with no stop date. Review of Resident #39's May 2025 MAR revealed 12 doses of hydroxyzine was administered. Review of Resident #39's June 2025 MAR up until 06/03/2025, revealed 3 doses of hydroxyzine was administered. Review of Resident #39's physician progress notes revealed no evidence of documented rationale to order PRN hydroxyzine for more than 14 days. Review of Drugs.com for Hydroxyzine accessed on 06/04/2025 at https://www.drugs.com/ hydroxyzine.html revealed: hydroxyzine also reduces activity in the central nervous system, it can be used as a sedative to treat anxiety and tension. During an interview on 06/04/25 at 03:31 PM, the DON stated prn psychotropic medications cannot be given for longer than 14 days without a new order or physician documentation for the need to continue past 14 days. He stated this could lead to over-sedation or possible seclusion. He stated he just overlooked and missed these orders. He stated he was responsible for reviewing orders. Review of the facility's policy titled; Psychoactive Medication Use dated July 2024 revealed in part: Policy Statement: Residents are not given psychotropic medications unless the drug is necessary to treat a specific condition, as diagnoses and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Guidelines: .7. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e 14 days).

Based on observation, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 3 residents reviewed for quality of care. When Resident #1 obtained a skin tear on 05/17/24 that reopened on 05/25/24, the facility failed to obtain treatment orders and provide wound care treatment. After the wound reopened on 5/25/24, the facility did not provide wound care until 5/30/24 when a family member changed the dressing. On 06/01/24 maggots were found in the wound and dressing. The facility did not obtain treatment orders until 06/02/24. An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 5:13 p.m. While the IJ was removed on 06/08/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems These failures placed residents of having unidentified skin conditions leading to delays in necessary medical interventions, pain, worsening conditions, and decline in health. Findings included: Based on observation, interviews, and record reviews the facility failed to ensure residents were free from neglect for 1 of 3 residents (Resident #1) reviewed for abuse. When Resident #1 obtained a skin tear on 05/17/24 that reopened on 05/25/24, the facility failed to obtain treatment orders and provide wound care treatment. After the wound reopened on 5/25/24, the facility did not provide wound care until 5/30/34 when a family member changed the dressing. On 06/01/24 maggots were found in the wound and dressing. The facility did not obtain treatment orders until 06/02/24. An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 5:13 p.m. While the IJ was removed on 06/08/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, mental anguish, emotional distress, diminished quality of life, and serious physical harm. Findings included: Record review of Resident #1's Face Sheet, dated 06/04/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with of diagnoses Chronic (persisting) obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), unspecified, Unspecified dementia (impaired ability to remember, think, or make decisions that interfere with completing daily activities), Spinal stenosis (occurs when the space inside the backbone was to small and can put pressure on the spinal cord), Essential Hypertension (high blood pressure), and Dysphagia (difficulty swallowing), oropharyngeal phase (affects the oral and pharyngeal [swallowing food or liquid through the pharynx and esophagus] of swallowing). Record review of Resident #1's Doctor Visit Progress Note with Physician D, dated 05/17/2024, revealed Resident #1 had profound hearing impairment and he had an otoplasty (procedure to change the shape, position, or size of the ear using permanent sutures) in the past and had his right ear removed as part of his surgery. Record review revealed diagnoses included a cerebrovascular accident (a stroke) and Degenerative joint disease (another name for osteoarthritis). Record review revealed Physician D noted Resident #1 had no infections or acute issues over the past four to six weeks. Skin and integument was noted as no acute changes. Record review of Resident #1's Admission MDS Assessment, dated 04/14/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which indicated intact cognitive response. Section B - Hearing, Speech, and Vision, under B0200 - Hearing, revealed Resident #1 had moderate hearing difficulty in which the speaker had to increase volume and speak distinctly. Under B1000 - Vision, revealed Resident #1 was highly impaired with object identification in question, but eyes appeared to follow objects. Review of Section J1700 - History of Falls on Admission/Entry or Reentry revealed Resident #1 had no falls in the last two (2) to six (6) months prior to admission. Record review of Resident #1's Care Plan, dated 05/17/2024, revealed the plan was updated to identify Resident #1 had a fall with a laceration to the back of head of 5/17/24 and a fall on 5/25/24 with skin tear to rt elbow. Record review of Resident #1's Event Report, dated 05/17/2024 at 11:45 a.m., and completed by LVN M, revealed Resident #1 fell , sustained a head injury and skin tear to left upper extremity, and was transported to the hospital. Record review of Resident #1's Progress Note, dated 05/17/2024 at 11:50 a.m., revealed Resident #1 was found on the floor in his room by Maintenance Director and had an abrasion on the top of his head and a skin tear to left upper extremity. Resident #1 was sent out by 911. Note documented by LVN M. Record review of Resident #1's Progress Note, dated 05/17/2024 at 6:03 p.m., revealed Resident #1 arrived back from the ER with the presence of a laceration of right forearm, wrapped with ace bandages and a laceration of the scalp. Review revealed there was no documentation LVN M contacted the facility doctor when Resident #1 returned from the emergency room to discuss the discharge orders or confer about orders for Resident #1's laceration on his right forearm. Record review of Resident #1's hospital discharge records, dated 05/17/2025, revealed Resident #1 wound Care to be: care for the wound with soap and water; wound cleanser, saline or germ-free water, gauze, and dressing; use mild soap and water and pat wound dry. Record review of Resident #1's Progress Note, dated 05/25/2024 at 2:15 p.m., revealed Resident #1 returned from the ER and LVN M notified the on-call for Physician G and would continue current care plan. Record review of Resident #1's clinical Medication Orders, dated 06/04/2024, revealed Resident #1's medication order history from 04/08/2024 - 06/02/2024 did not include an order for wound care until 06/02/2024. Record review of Resident #1 eMar for 05/17/2024 - 05/31/2024, revealed Resident #1 had no wound care orders in place. Record review of Resident #1's nursing progress notes from 05/25/2024 to 06/01/2024 revealed no evidence of nursing care provided wound care. During an interview on 06/05/2024 at 10:15 a.m., Resident #1's family member said she had a video camera in Resident #1's room. Resident #1's family member said she witnessed Resident #1 as he sat on the side of his bed on 05/17/2024 at 11:30 a.m. drop his med cup, bent over, reach toward the floor, and fell forward. Resident #1's family member said Resident #1 fell to the floor and hit his head on the nightstand by his bed. Resident #1's family member said she immediately called the facility to let them know Resident #1 had fell . Resident #1's family member said she went to the ER and met Resident #1 when he arrived and said he had a skin tear on his right elbow. Resident #1's family member said Resident #1 fell again on 05/25/2024 when Resident #1 was found on the floor and sent to the ER for the second time. Resident #1's family member said she went to the ER and met Resident #1 when he arrived and said he had reopened the skin tear on his right elbow. Resident #1's family member said she was at the facility with Resident #1 visiting at approximately 8:15 p.m., on 06/01/2024. Resident #1's family member said she was sitting to the left of Resident #1 and put her arm around his shoulders and Resident #1 said, ouch, that hurts. Resident #1's family member said she asked Resident #1 what hurt, and he told her his right elbow. Resident #1's family member said she looked at the bandage on Resident's elbow and saw movement of approximately 50 maggots on the outside of the bandage. Resident #1's family member said she moved the top layer of the bandage and underneath was approximately 100 to 150 baby maggots. Resident #1's family member said the bandage was saturated in bloody drainage. Resident #1's family member said she immediately called LVN A who came in and changed and cleaned the bandage. Resident #1's family member said she watched as LVN A cleaned the area and she said she saw maggots on the wound. Resident #1's family member said she did not tell Resident #1 about the maggots because she was afraid Resident #1 would freak out. Resident #1's family member said Resident #1 was nearly blind and he could not see the larvae. During a follow-up interview on 06/05/2024 at 11:58 a.m., Resident #1's family member said she was at the facility on 05/30/2024 at 6:00 p.m., and at approximately 6:15pm, noticed Resident #1's bandaged on his elbow had not been removed since he returned from theER on [DATE]. Resident #1's family member said she removed the dressing and saw the area was soaked in dark, black colored drainage and had a bad smell. Resident #1's family member said she reported the wound to the nurse who was in the hall outside Resident #1's door. Review of video evidence submitted by Resident #1's family member, dated 06/01/2024 at 8:36 p.m., revealed an up-close view of the wound. Resident #1's arm laid on unwrapped cotton gauze and was wrapped in woven gauze bandage with small white larvae wiggling on the inside of the top layer of the gauze. The second layer of gauze had an area approximately 4 inches by 4 inches saturated in red blood with dark red colored drainage around the edges. The area was moist, the gauze was stretched, and small white larvae could be seen moving under the second layer. Review of two (2) photos, submitted by Resident #1's family member, dated 05/30/2024 at 6:17 p.m. and 6:23 p.m., revealed Resident #1's wound on his right elbow was uncovered and laid on white bandage that covered the wound. The bandage was saturated in black and thick, dark red drainage and the gauze was stuck to Resident #1 skin. The wound, which was approximately 1 1/2 inches by 1 1/2 inches, was pink, soft, and raw. The skin around the outer edge of the bandage was dry and cracked, with large scales of dry skin present. Based on the photo image, Resident #1's family member was contacted by phone. During an interview on 06/06/2024 at 9:27 a.m., LVN A said on 05/30/2024, during daily head-to-toe assessments, she observed changed the bandage on Resident #1's left elbow at approximately 7:45pm. LVN A said Resident #1 did not have orders for wound care, but she saw the bandage and did not know when the bandage had been changed. LVN A said she had been off duty for a week and 05/30/2024 was her first shift upon return. LVN A said Resident #1 had fallen prior to her return and she was not aware if Resident #1 had wound care orders or not. Review of video evidence submitted by Resident #1's family member, dated 06/01/2024 at 8:39 p.m., revealed an up-close view of the wound. The video showed a bandage that was saturated with a circle of bloody drainage and multiple small white larvae could be seen moving under the gauze. Review of photograph evidence provided by Resident #1's family member, dated 06/01/2024 at 8:40 p.m., revealed an up-close view of the wound of Resident #1's bandage on his right elbow. The area was covered in woven gauze that was stretch and small, white larvae was seen between the fibers of the gauze. The gauze was observed saturated in red drainage with dark edges. During an observation on 06/04/2024 at 7:42 a.m., Resident #1 was observed with a gauze wrapped around his right elbow, with the gauze approximately an inch above and under the elbow. Observed a spot of bright red substance in the middle of the gauze about the size of a dime where the tape had come undone from the bandage and a spot of bright red substance on the tape, approximately 1/2 inch in length, that was unattached from the bandage. The bandage was dry. The skin on Resident #1's right arm around the outer edge of the bandage was extremely dry, flaking, and peeling from the mid-forearm, around the elbow, and upper arm. During an interview on 06/04/2024 at 7:46 a.m., Resident #1 said he did not remember who changed his bandage or seeing any type of bugs. Resident #1 said on Sunday (06/01/2024), he did not think he had white bugs on his bandage but Resident #1 said he could not remember. Resident #1 said he had trouble seeing. Record review of Resident #1's nursing progress notes dated 06/01/2024 at 10:05pm by LVN A revealed: (Recorded as Late Entry on 06/03/2024 at 4:11am) Upon assessment, noted dressing to be dry, clean and intact, with small amount of drainage noted on dressing. Date [on dressing] noted to be 5/30. Noted small white debris in dressing, noted to be smaller than grain of rice. Dressing was immediately removed, cleansed and changed. MD was notified and new orders received and placed into the MAR. No other orders received at this time. During an interview on 06/04/2024 at 6:58 a.m., LVN A said she was familiar with Resident #1 and was the nurse who found the bandage on Resident #1's right elbow covered with maggots on Saturday, 06/01/2024, at approximately 9:00 p.m. LVN A said she went into Resident #1's room to do his dressing change and noticed movement under the bandage. LVN A said she observed approximately 100 maggots in and around the bandage and in the gauze wrap. LVN A said the dressing was semi-saturated over the wound. LVN A described the bandage as wet with drainage and said blood had seeped through the gauze. LVN A said Resident #1 did not have doctor orders for wound care on 5/30/2024. LVN A said she cleaned and dressed the wound because she knew the area needed to be cleaned. During a follow-up interview on 06/06/2024 at 9:27 a.m., LVN A said on 05/30/2024, during daily head-to-toe assessments, she changed the bandage on Resident #1's elbow at approximately 7:45pm. LVN A said Resident #1 did not have orders for wound care, but she saw the bandage and did not know when the bandage had been changed. LVN A said she had been off duty for a week and 05/30/2024 was her first shift upon return. LVN A said Resident #1 had fallen prior to her return and she was not aware if Resident #1 had wound care orders or not. During an interview on 06/04/2024 at 9:38 a.m., LVN B said she was on duty the day Resident #1 fell (05/25/2024) but an agency nurse was assigned to Resident #1's hall. LVN B said she had not seen the wound, as it had been covered with a bandage when Resident #1 returned from theER on [DATE]. LVN B said she saw the wound on Resident #1's right elbow for the first time on Monday, 06/03/2024. LVN B said Resident #1 had new orders from the doctor that were started over the weekend on 06/02/2024, when Resident #1 was found with larvae. During an interview on 06/05/2024 at 11:01 a.m., LVN F said Resident #1 had wound care orders to change the dressing on Resident #1's elbow every shift and the orders were initiated on 06/02/2024. LVN F said Resident #1's orders were changed 06/04/2024 from every four hours to once every shift. LVN F said Resident #1 did not have wound care orders prior to 06/01/2024. LVN F said she was not sure how or when Resident #1 obtained the skin tear on his right elbow and had not seen the bandage on Resident #1's right elbow before 06/01/2024. Record review of nursing progress note by LVN H dated 05/28/2024 at 2:30pm revealed Dressing was checked and it was cleand, dry and intact. During an interview on 06/06/2024 at 3:10pm, LVN H said when a resident returned from the hospital or ER, she would get the resident comfortable and ensure interventions were in place. LVN H said she would review the paperwork and place the paperwork in the DON's box. LVN H said she usually did not contact the doctor, family, or the DON. LVN H said if the resident had new orders, she would enter the new orders into the resident's clinical record and text the doctor or call the on-call service During an interview 06/06/2024 at 3:52pm, CNA S stated she was familiar with Resident #1. She said that Resident's #1's family member would give Resident #1 a shower and let CNA S when the shower was completed. CNA S said she would then document the shower in the clinical records. CNA S said she noticed Resident #1's bandage but never looked underneath. CNA S said she never saw a nurse take the bandage off. During an interview on 06/06/2024 at 12:55pm, the ADON said she worked as the nurse on the floor on Saturday, 06/01/2024, 6 a.m. to 6 p.m., and Sunday, 06/02/2024 and did not know Resident #1 had a bandage on his right elbow. The ADON said the night nurse, LVN A, who came in on Saturday night changed the dressing with maggots after she had left at 6pm on 06/01/2024 and she was not notified until the ADON arrived at the facility on 06/02/2024 to work 6 a.m. to 6 p.m. During an interview on 06/05/2024 at 12:35 p.m., the DON said the nurse on duty when Resident #1 returned from theER on [DATE] was an agency nurse, LVN M, and she had not worked in the facility since that date. The DON said the nurse who was on duty when Resident #1 returned from theER on [DATE] was an agency nurse, LVN N. The DON said he was not sure if he would be able to obtain her number from the agency she worked for. During an interview on 06/06/2024 at 12:01 p.m., the DON said he was called by the charge nurse at the facility and informed fly larvae were found on and inside Resident #1's wound dressing located on his right elbow. The DON said he was sent a video by LVN A on 06/01/2024 at approximately 6:30 p.m., by text. The DON said he observed on the video the bandage had drainage on the dressing and he saw larvae moving. The DON said by looking at the dressing, he said the drainage did not look old and the amount of drainage did not concern him because he had seen wounds have copious amounts drainage and still be healthy. The DON said the larvae concerned him. The DON said his expectations when a resident returned the ER or hospital were for the nursing staff to follow the physician's orders. The DON said Resident #1 returned from theER on [DATE] with a bandage on his arm and did not have orders to care for the wound until 06/02/2024. The DON said his expectation was the nurse on duty when Resident #1 returned to the facility on [DATE] would have been to clarify Resident #1's discharge orders with the facility physician. The DON said the progress note in Resident #1's clinical record indicated the doctor was notified upon return from ER but agreed the documentation was not clear what was discussed in the phone conversation with the doctor. The DON said; if the family provided evidence of Resident #1's wound and the bandage appeared in a state that lacked attention by the facility nursing staff, this he would be based the doctor's orders. The DON said he agreed wound care orders were not put into place until 06/02/2024 for Resident #1's wound care until 06/02/2024. The DON said his expectations for was the CNAs to round every 2 hours and if a CNA witnessed drainage, to notify the nurse. During an interview on 06/06/2024 at 3:25pm, the DON said he worked on shift 6 p.m. to 6 a.m., on 05/25/2024 and 6 p.m. to 6 a.m., on 05/26/2024. The DON said he checked on residents during the overnight shift at least twice a shift. The DON said to his knowledge, he did not remember if he saw a bandage on Resident #1's right elbow. During a phone interview on 06/05/2024 at 3:18 p.m., Physician G said he was notified by facility staff when Resident #1 had maggots in his wound on his arm on 06/01/2024. Physician G said he ordered for the area to be flushed once or twice with hydron peroxide and put wound orders in place on 06/02/2024. Physician G said the facility had an in-house order for skin care and should have implemented the orders when Resident #1 returned from the emergency room with a wound or a bandage. Physician G said he was not familiar with Resident #1's fall or skin tear on 05/25/2024 but was aware Resident #1 went to the ER. During an interview on 06/07/2024 at 12:33 p.m., the Administrator said she was familiar with Resident #1 and was aware he fell on [DATE] and 05/25/2024. The Administrator said she, as the facility abuse coordinator, self-reported the incident with the bandage on Resident #1's right elbow that occurred on 6/1/2024. The Administrator said she was told the bandage contained a white debris that was smaller than a grain of rice. The Administrator said she did not see the larvae in Resident #1's bandage and could not confirm the bandage and wound had larvae present. The Administrator said she reported white debris the size of a grain of rice on Resident #1's right forearm near the elbow based on the fact she did not witness the wound at the time of the incident. This was determined to be an Immediate Jeopardy that was called on 06/07/2024. The Administrator was notified on 06/07/2024 at 5:13 p.m. that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on 06/07/2024 at 5:30 p.m. and the plan of removal was requested. The facility's plan of removal was accepted on 06/08/2024 at 1:23 p.m. and included the following: [facility name] Nursing and Rehabilitation Plan of Removal: 684: Professional Standards Date Initiated: 6/7/2024 Today's Date: 6/7/2024 Based on interviews and record reviews, the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 3 residents reviewed for quality care. All residents can be affected by this deficient practice. Action: Identified Resident received a skin assessment, physician notified, follow MD orders, RP notified. Identified Resident not showing any signs of distress or a negative physical outcome as a result of the event. Person(s) Responsible: Charge Nurse and/or Designee Date Action Completed: 06/01/24 Action: All residents received head-to-toe skin assessments. All residents with wounds assessed with no additional adverse findings. Person(s) Responsible: Assistant Director of Nursing, Director of Nursing, and/or Designee Date Action Completed: 06/02/24 Action: Education Wound Care/Treatment Orders/Physician Orders (Nurses) a. Completing head to toe assessments when a Resident returns from the hospital b. Completing wound care treatments as ordered and performing Weekly Skin assessments Change in Condition (Nurses) a. Notification of MD for new or changing wounds and obtaining treatment orders b. Resident Assessment Test will be completed for competency and to ensure understanding. All identified staff will be educated and tested prior to working their next shift. All new and temporary staff will be educated and tested prior to working their first shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Administrator, and/or Designee Date Action Initiated: 06/08//24 Action: All residents that have returned from the hospital in the previous 30 days have been reviewed to ensure that the physician has been notified of any pertinent resident information and ensure we are following physician orders. Person(s) Responsible: Director of Nursing, Assistant Director, and/or designee Date: 6/7/2024 Action: Director of Nursing and/or Designee to observe and/or follow behind and confirm x3 skin assessments a week and verify treatment is in place and dated within the MD's order x2 a week with emphasis on residents, who smoke, go out on pass, and/or spend time outside with wounds for 4 weeks. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date Action Initiated: 06/02/24 Action: Ad hoc QAPI with on call physician reviewing 684 template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 6/7/2024 On 06/08/2024, the investigator confirmed the facility implemented their plan of removal sufficiently to remove Immediate Jeopardy (IJ) by: On 06/08/2024 at 12:55 p.m., completed a record review of a random sample of residents who resided in the facility based on the action that all resident received head-to-toe assessment. Reviewed Resident #4's Clinical Progress Note, dated 06/02/2024 at 6:54 a.m., that indicated Resident #4 received a head-to-toe assessment completed by LVN F. Reviewed Resident #5's Clinical Progress Note, dated 06/04/2024 at 2:04 p.m., which revealed Resident #5 had a head-to-toe assessment completed by LVN B. Reviewed Resident #9's Clinical Progress Note, dated 06/04/2024 at7:27 a.m., which revealed Resident #9 received a head-to-toe assessment completed by LVN F. 06/08/2024 at 1:15 p.m., reviewed progress note dated 06/01/2024, completed by the DON that revealed Resident #1 was assessed immediately after the discovery of the larvae on his right elbow. Review Progress Note dated 06/01/2024 that Physician G was notified on 06/01/2024. Notification was verified by interview with Physician G and review of doctor orders dated 06/02/2024. On 06/08/2024 at 1:25 p.m., completed a record review of Resident #8's clinical record when he returned to the facility on [DATE]. Discharge records, progress notes, doctor orders, and care plan reviewed with no issues noted. During an interview on 06/08/2024 at 1:41 p.m RN O said she worked 6 a.m. to 2:30 p.m. on the weekends and PRN. RN O said she was in-serviced on how to readmit a resident who returned to the facility from the ER prior to her shift that morning. RN O said the process was to receive and review the discharge orders, notify the doctor, family, and put new orders in place after she discussed the orders with the facility doctor. RN O said she would notify the doctor if a resident fell , had new lab orders, showed a change in conditions, or any request by family or resident requesting orders. RN O said if a resident had an open area or wound and no orders for wound care, she would contact the doctor and inform the doctor of the issues and ask if new orders are needed. RN O said she was in-serviced on abuse/neglect and assessments, including head-to-toe, vital signs, and to notify the doctor of results. During an interview on 06/08/2024 at 1:55 p.m., RN, Weekend Supervisor said she worked 8 a.m. to 5 p.m., Saturday and Sunday. RN, Weekend Supervisor said she was recently in-serviced on fall precautions, identifying wounds, abuse/neglect, patient rights, fire safety, and the evacuation plan. RN, Weekend Supervisor said the wound care in-service included notifying the doctor if orders were needed. RN, Weekend Supervisor said wound care orders were need to complete wound care. RN, Weekend Supervisor said if a resident returned from ER, she would notify family, complete an assessment, review the discharge report and orders, contact doctor to obtain any needed orders, and put all orders into the MAR and clinical record. During an interview on 06/08/2024 at 2:06 p, m., LVN C said she worked a 6 a.m. to 6 p.m., rotation that included weekdays and weekends. LVN C said she was in-serviced prior to shift. LVN C said the contents of the in-services were admission protocols, abuse/neglect, following doctor orders, and going over the meds and wound orders with the facility doctor, LVN C said wound care could not be complete without doctor orders. LVN C said when a resident returned from ER, she would ensure the resident was comfortable in bed, complete a head-to-toe assessment to include vital signs and skin assessments. LVN C said she would call the doctor and review the orders to let the doctor know the resident had returned to the facility. LVN C said she would clarify wound care orders to ensure products are available that were included in the ER or facility doctor's order. LVN C said she would notify the family and the administrator. LVN C said she was in-serviced to ensure skin assessment were completed at least weekly, but she would complete more frequently or as needed. During an interview on 06/08/2024 at 3:08 p.m., Housekeeping Q said she had been recently in-serviced on abuse/neglect prior to her shift on this date. Housekeeping Q said if she saw a call light on too long, she would get an aide. Housekeeping Q said examples of abuse included if she saw someone getting to rough or not being physically careful, or residents being mean to each other could be abuse. Housekeeping Q said she identified the categories of abuse as neglect, physical, emotional, or financial. Housekeeping Q said neglect could be a resident that was thirsty and had no water at his bedside. Housekeeping Q said if a resident was wet and had been laying wet for a long time could be neglect. During an interview on 06/08/2024 at 3:15p.m., CNA R said she worked a 6 p.m. to 6 a.m. rotation that included weekdays and weekends. CNA R said she was recently in-serviced on abuse/neglect prior to her shift that morning. CNA R said neglect was not providing resident proper care or not providing care when they needed it. CNA R said an example could be not answering a call light or not providing pain medication. During an interview on 06/08/2024 at 3:27 p.m., LVN A said she worked a 6 p.m. to 6 a.m. rotation that included weekdays and weekends. LVN A said she was in-serviced on 06/07/24 when she came on shift at 6 p.m. LVN A said the in-service covered documentation, abuse/neglect, which including a test, and what action to take when a resident returned from the ER. LVN A said she was to notify the facility doctor and family. LVN A said she was required to scan in the documents and if the discharge orders had new orders, she would enter the new orders into the eMar after she verified with the facility physician. LVN A said if a resident had a wound and no treatment orders, she was in-serviced to notify the facility doctor prior to completing wound care. LVN A said she could not do wound care without doctor orders. LVN A said she would do a head-to-toe assessment when a resident returned from the ER. During an interview on 06/06/2024 at 3:10pm, LVN H said when a resident returned from the hospital or ER, she would get the resident comfortable and ensure interventions were in place. LVN H said she would review the paperwork and place the paperwork in the DON's box. LVN H said she usually did not contact the doctor, family, or the DON. LVN H said if the resident had new orders, she would enter the new orders into the resident's clinical record and text the doctor or call the on-call service On 06/08/2024 at 2:17 p.m., received the Plan of Removal notebook which contained documentation for the action plan of the facility's POR, from the Administrator. Reviewed Resident #1's Doctor's Order History, which revealed wound care orders were initiated 06/02/2024. On 06/08/2024 at 2:34 p.m., reviewed the following in-services and signature sheets: - When do you notify the Attending Physician? Dated 06/02/2024 - Abuse & Neglect Inservice - dated 6/02/2024 for all staff - Wound Treatment Orders, How to input orders into the electronic record - dated 6/08/2024, signed by LVN A - When a resident returns from the ER: steps to take - dated 06/07/2024 - Resident Assessment: reviewed what steps were included - dated 6/02/2024 - Skin assessment and wound orders: when to be completed, who to notify - dated 6/02/2024 - Orders: directions and key points to remember - dated 6/02/2024 - Change in Condition, notifying proper parties - dated 6/03/2024 - Documentation - dated 6/02/2024 - Neglect test - nine (9) random employees included in sample - Resident returning from ER - four (4) nurses included in random sample - Ad Hoc QAPI Meeting Agenda dated [TRUNCATED]

Based on observation, interviews, and record reviews the facility failed to ensure residents were free from neglect for 1 of 3 residents (Resident #1) reviewed for abuse. When Resident #1 obtained a skin tear on 05/17/24 that reopened on 05/25/24, the facility failed to obtain treatment orders and provide wound care treatment. After the wound reopened on 5/25/24, the facility did not provide wound care until 5/30/34 when a family member changed the dressing. On 06/01/24 maggots were found in the wound and dressing. The facility did not obtain treatment orders until 06/02/24. An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 5:13 p.m. While the IJ was removed on 06/08/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, mental anguish, emotional distress, diminished quality of life, and serious physical harm. Findings included: Record review of Resident #1's Face Sheet, dated 06/04/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with of diagnoses Chronic (persisting) obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), unspecified, Unspecified dementia (impaired ability to remember, think, or make decisions that interfere with completing daily activities), Spinal stenosis (occurs when the space inside the backbone was to small and can put pressure on the spinal cord), Essential Hypertension (high blood pressure), and Dysphagia (difficulty swallowing), oropharyngeal phase (affects the oral and pharyngeal [swallowing food or liquid through the pharynx and esophagus] of swallowing). Record review of Resident #1's Doctor Visit Progress Note with Physician D, dated 05/17/2024, revealed Resident #1 had profound hearing impairment and he had an otoplasty (procedure to change the shape, position, or size of the ear using permanent sutures) in the past and had his right ear removed as part of his surgery. Record review revealed diagnoses included a cerebrovascular accident (a stroke) and Degenerative joint disease (another name for osteoarthritis). Record review revealed Physician D noted Resident #1 had no infections or acute issues over the past four to six weeks. Skin and integument was noted as no acute changes. Record review of Resident #1's Admission MDS Assessment, dated 04/14/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which indicated intact cognitive response. Section B - Hearing, Speech, and Vision, under B0200 - Hearing, revealed Resident #1 had moderate hearing difficulty in which the speaker had to increase volume and speak distinctly. Under B1000 - Vision, revealed Resident #1 was highly impaired with object identification in question, but eyes appeared to follow objects. Review of Section J1700 - History of Falls on Admission/Entry or Reentry revealed Resident #1 had no falls in the last two (2) to six (6) months prior to admission. Record review of Resident #1's Care Plan, dated 05/17/2024, revealed the plan was updated to identify Resident #1 had a fall with a laceration to the back of head of 5/17/24 and a fall on 5/25/24 with skin tear to rt elbow. Record review of Resident #1's Event Report, dated 05/17/2024 at 11:45 a.m., and completed by LVN M, revealed Resident #1 fell , sustained a head injury and skin tear to left upper extremity, and was transported to the hospital. Record review of Resident #1's Progress Note, dated 05/17/2024 at 11:50 a.m., revealed Resident #1 was found on the floor in his room by Maintenance Director and had an abrasion on the top of his head and a skin tear to left upper extremity. Resident #1 was sent out by 911. Note documented by LVN M. Record review of Resident #1's Progress Note, dated 05/17/2024 at 6:03 p.m., revealed Resident #1 arrived back from the ER with the presence of a laceration of right forearm, wrapped with ace bandages and a laceration of the scalp. Review revealed there was no documentation LVN M contacted the facility doctor when Resident #1 returned from the emergency room to discuss the discharge orders or confer about orders for Resident #1's laceration on his right forearm. Record review of Resident #1's hospital discharge records, dated 05/17/2025, revealed Resident #1 wound Care to be: care for the wound with soap and water; wound cleanser, saline or germ-free water, gauze, and dressing; use mild soap and water and pat wound dry. Record review of Resident #1's Progress Note, dated 05/25/2024 at 2:15 p.m., revealed Resident #1 returned from the ER and LVN M notified the on-call for Physician G and would continue current care plan. Record review of Resident #1's Progress Note, dated 05/25/2024 at 2:15 p.m., revealed Resident #1 returned from the ER and LVN M notified the on-call for Physician G and would continue current care plan. Record review of Resident #1's clinical Medication Orders, dated 06/04/2024, revealed Resident #1's medication order history from 04/08/2024 - 06/02/2024 did not include an order for wound care until 06/02/2024. Record review of Resident #1 eMar for 05/17/2024 - 05/31/2024, revealed Resident #1 had no wound care orders in place. Record review of Resident #1's nursing progress notes from 05/25/2024 to 06/01/2024 revealed no evidence of nursing care provided wound care. During an interview on 06/05/2024 at 10:15 a.m., Resident #1's family member said she had a video camera in Resident #1's room. Resident #1's family member said she witnessed Resident #1 as he sat on the side of his bed on 05/17/2024 at 11:30 a.m. drop his med cup, bent over, reach toward the floor, and fell forward. Resident #1's family member said Resident #1 fell to the floor and hit his head on the nightstand by his bed. Resident #1's family member said she immediately called the facility to let them know Resident #1 had fell . Resident #1's family member said she went to the ER and met Resident #1 when he arrived and said he had a skin tear on his right elbow. Resident #1's family member said Resident #1 fell again on 05/25/2024 when Resident #1 was found on the floor and sent to the ER for the second time. Resident #1's family member said she went to the ER and met Resident #1 when he arrived and said he had reopened the skin tear on his right elbow. Resident #1's family member said she was at the facility with Resident #1 visiting at approximately 8:15 p.m., on 06/01/2024. Resident #1's family member said she was sitting to the left of Resident #1 and put her arm around his shoulders and Resident #1 said, ouch, that hurts. Resident #1's family member said she asked Resident #1 what hurt, and he told her his right elbow. Resident #1's family member said she looked at the bandage on Resident's elbow and saw movement of approximately 50 maggots on the outside of the bandage. Resident #1's family member said she moved the top layer of the bandage and underneath was approximately 100 to 150 baby maggots. Resident #1's family member said the bandage was saturated in bloody drainage. Resident #1's family member said she immediately called LVN A who came in and changed and cleaned the bandage. Resident #1's family member said she watched as LVN A cleaned the area and she said she saw maggots on the wound. Resident #1's family member said she did not tell Resident #1 about the maggots because she was afraid Resident #1 would freak out. Resident #1's family member said Resident #1 was nearly blind and he could not see the larvae. During a follow-up interview on 06/05/2024 at 11:58 a.m., Resident #1's family member said she was at the facility on 05/30/2024 at 6:00 p.m., and at approximately 6:15pm, noticed Resident #1's bandaged on his elbow had not been removed since he returned from theER on [DATE]. Resident #1's family member said she removed the dressing and saw the area was soaked in dark, black colored drainage and had a bad smell. Resident #1's family member said she reported the wound to the nurse who was in the hall outside Resident #1's door. Review of video evidence submitted by Resident #1's family member, dated 06/01/2024 at 8:36 p.m., revealed an up-close view of the wound. Resident #1's arm laid on unwrapped cotton gauze and was wrapped in woven gauze bandage with small white larvae wiggling on the inside of the top layer of the gauze. The second layer of gauze had an area approximately 4 inches by 4 inches saturated in red blood with dark red colored drainage around the edges. The area was moist, the gauze was stretched, and small white larvae could be seen moving under the second layer. Review of two (2) photos, submitted by Resident #1's family member, dated 05/30/2024 at 6:17 p.m. and 6:23 p.m., revealed Resident #1's wound on his right elbow was uncovered and laid on white bandage that covered the wound. The bandage was saturated in black and thick, dark red drainage and the gauze was stuck to Resident #1 skin. The wound, which was approximately 1 1/2 inches by 1 1/2 inches, was pink, soft, and raw. The skin around the outer edge of the bandage was dry and cracked, with large scales of dry skin present. Based on the photo image, Resident #1's family member was contacted by phone. During an interview on 06/06/2024 at 9:27 a.m., LVN A said on 05/30/2024, during daily head-to-toe assessments, she observed changed the bandage on Resident #1's left elbow at approximately 7:45pm. LVN A said Resident #1 did not have orders for wound care, but she saw the bandage and did not know when the bandage had been changed. LVN A said she had been off duty for a week and 05/30/2024 was her first shift upon return. LVN A said Resident #1 had fallen prior to her return and she was not aware if Resident #1 had wound care orders or not. Review of video evidence submitted by Resident #1's family member, dated 06/01/2024 at 8:39 p.m., revealed an up-close view of the wound. The video showed a bandage that was saturated with a circle of bloody drainage and multiple small white larvae could be seen moving under the gauze. Review of photograph evidence provided by Resident #1's family member, dated 06/01/2024 at 8:40 p.m., revealed an up-close view of the wound of Resident #1's bandage on his right elbow. The area was covered in woven gauze that was stretch and small, white larvae was seen between the fibers of the gauze. The gauze was observed saturated in red drainage with dark edges. During an observation on 06/04/2024 at 7:42 a.m., Resident #1 was observed with a gauze wrapped around his right elbow, with the gauze approximately an inch above and under the elbow. Observed a spot of bright red substance in the middle of the gauze about the size of a dime where the tape had come undone from the bandage and a spot of bright red substance on the tape, approximately 1/2 inch in length, that was unattached from the bandage. The bandage was dry. The skin on Resident #1's right arm around the outer edge of the bandage was extremely dry, flaking, and peeling from the mid-forearm, around the elbow, and upper arm. During an interview on 06/04/2024 at 7:46 a.m., Resident #1 said he did not remember who changed his bandage or seeing any type of bugs. Resident #1 said on Sunday (06/01/2024), he did not think he had white bugs on his bandage but Resident #1 said he could not remember. Resident #1 said he had trouble seeing. Record review of Resident #1's nursing progress notes dated 06/01/2024 at 10:05pm by LVN A revealed: (Recorded as Late Entry on 06/03/2024 at 4:11am) Upon assessment, noted dressing to be dry, clean and intact, with small amount of drainage noted on dressing. Date [on dressing] noted to be 5/30. Noted small white debris in dressing, noted to be smaller than grain of rice. Dressing was immediately removed, cleansed and changed. MD was notified and new orders received and placed into the MAR. No other orders received at this time. During an interview on 06/04/2024 at 6:58 a.m., LVN A said she was familiar with Resident #1 and was the nurse who found the bandage on Resident #1's right elbow covered with maggots on Saturday, 06/01/2024, at approximately 9:00 p.m. LVN A said she went into Resident #1's room to do his dressing change and noticed movement under the bandage. LVN A said she observed approximately 100 maggots in and around the bandage and in the gauze wrap. LVN A said the dressing was semi-saturated over the wound. LVN A described the bandage as wet with drainage and said blood had seeped through the gauze. LVN A said Resident #1 did not have doctor orders for wound care on 5/30/2024. LVN A said she cleaned and dressed the wound because she knew the area needed to be cleaned. During a follow-up interview on 06/06/2024 at 9:27 a.m., LVN A said on 05/30/2024, during daily head-to-toe assessments, she changed the bandage on Resident #1's elbow at approximately 7:45pm. LVN A said Resident #1 did not have orders for wound care, but she saw the bandage and did not know when the bandage had been changed. LVN A said she had been off duty for a week and 05/30/2024 was her first shift upon return. LVN A said Resident #1 had fallen prior to her return and she was not aware if Resident #1 had wound care orders or not. During an interview on 06/04/2024 at 9:38 a.m., LVN B said she was on duty the day Resident #1 fell (05/25/2024) but an agency nurse was assigned to Resident #1's hall. LVN B said she had not seen the wound, as it had been covered with a bandage when Resident #1 returned from theER on [DATE]. LVN B said she saw the wound on Resident #1's right elbow for the first time on Monday, 06/03/2024. LVN B said Resident #1 had new orders from the doctor that were started over the weekend on 06/02/2024, when Resident #1 was found with larvae. During an interview on 06/05/2024 at 11:01 a.m., LVN F said Resident #1 had wound care orders to change the dressing on Resident #1's elbow every shift and the orders were initiated on 06/02/2024. LVN F said Resident #1's orders were changed 06/04/2024 from every four hours to once every shift. LVN F said Resident #1 did not have wound care orders prior to 06/01/2024. LVN F said she was not sure how or when Resident #1 obtained the skin tear on his right elbow and had not seen the bandage on Resident #1's right elbow before 06/01/2024. Record review of nursing progress note by LVN H dated 05/28/2024 at 2:30pm revealed Dressing was checked and it was cleand, dry and intact. During an interview on 06/06/2024 at 3:10pm, LVN H said when a resident returned from the hospital or ER, she would get the resident comfortable and ensure interventions were in place. LVN H said she would review the paperwork and place the paperwork in the DON's box. LVN H said she usually did not contact the doctor, family, or the DON. LVN H said if the resident had new orders, she would enter the new orders into the resident's clinical record and text the doctor or call the on-call service During an interview 06/06/2024 at 3:52pm, CNA S stated she was familiar with Resident #1. She said that Resident's #1's family member would give Resident #1 a shower and let CNA S when the shower was completed. CNA S said she would then document the shower in the clinical records. CNA S said she noticed Resident #1's bandage but never looked underneath. CNA S said she never saw a nurse take the bandage off. During an interview on 06/06/2024 at 12:55pm, the ADON said she worked as the nurse on the floor on Saturday, 06/01/2024, 6 a.m. to 6 p.m., and Sunday, 06/02/2024 and did not know Resident #1 had a bandage on his right elbow. The ADON said the night nurse, LVN A, who came in on Saturday night changed the dressing with maggots after she had left at 6pm on 06/01/2024 and she was not notified until the ADON arrived at the facility on 06/02/2024 to work 6 a.m. to 6 p.m. During an interview on 06/05/2024 at 12:35 p.m., the DON said the nurse on duty when Resident #1 returned from theER on [DATE] was an agency nurse, LVN M, and she had not worked in the facility since that date. The DON said the nurse who was on duty when Resident #1 returned from theER on [DATE] was an agency nurse, LVN N. The DON said he was not sure if he would be able to obtain her number from the agency she worked for. During an interview on 06/06/2024 at 12:01 p.m., the DON said he was called by the charge nurse at the facility and informed fly larvae were found on and inside Resident #1's wound dressing located on his right elbow. The DON said he was sent a video by LVN A on 06/01/2024 at approximately 6:30 p.m., by text. The DON said he observed on the video the bandage had drainage on the dressing and he saw larvae moving. The DON said by looking at the dressing, he said the drainage did not look old and the amount of drainage did not concern him because he had seen wounds have copious amounts drainage and still be healthy. The DON said the larvae concerned him. The DON said his expectations when a resident returned the ER or hospital were for the nursing staff to follow the physician's orders. The DON said Resident #1 returned from theER on [DATE] with a bandage on his arm and did not have orders to care for the wound until 06/02/2024. The DON said his expectation was the nurse on duty when Resident #1 returned to the facility on [DATE] would have been to clarify Resident #1's discharge orders with the facility physician. The DON said the progress note in Resident #1's clinical record indicated the doctor was notified upon return from ER but agreed the documentation was not clear what was discussed in the phone conversation with the doctor. The DON said; if the family provided evidence of Resident #1's wound and the bandage appeared in a state that lacked attention by the facility nursing staff, this he would be based the doctor's orders. The DON said he agreed wound care orders were not put into place until 06/02/2024 for Resident #1's wound care until 06/02/2024. The DON said his expectations for was the CNAs to round every 2 hours and if a CNA witnessed drainage, to notify the nurse. During an interview on 06/06/2024 at 3:25pm, the DON said he worked on shift 6 p.m. to 6 a.m., on 05/25/2024 and 6 p.m. to 6 a.m., on 05/26/2024. The DON said he checked on residents during the overnight shift at least twice a shift. The DON said to his knowledge, he did not remember if he saw a bandage on Resident #1's right elbow. During a phone interview on 06/05/2024 at 3:18 p.m., Physician G said he was notified by facility staff when Resident #1 had maggots in his wound on his arm on 06/01/2024. Physician G said he ordered for the area to be flushed once or twice with hydron peroxide and put wound orders in place on 06/02/2024. Physician G said the facility had an in-house order for skin care and should have implemented the orders when Resident #1 returned from the emergency room with a wound or a bandage. Physician G said he was not familiar with Resident #1's fall or skin tear on 05/25/2024 but was aware Resident #1 went to the ER. During an interview on 06/07/2024 at 12:33 p.m., the Administrator said she was familiar with Resident #1 and was aware he fell on [DATE] and 05/25/2024. The Administrator said she, as the facility abuse coordinator, self-reported the incident with the bandage on Resident #1's right elbow that occurred on 6/1/2024. The Administrator said she was told the bandage contained a white debris that was smaller than a grain of rice. The Administrator said she did not see the larvae in Resident #1's bandage and could not confirm the bandage and wound had larvae present. The Administrator said she reported white debris the size of a grain of rice on Resident #1's right forearm near the elbow based on the fact she did not witness the wound at the time of the incident. Record review of the facility's policy, Abuse, Neglect, and Exploitation, dated 10/2023, revealed possible indicators of abuse include, but are not limited to: failure to provide care needs such as comfort and safety. The facility would prevent abuse by assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors, identification with ongoing assessment, care planning with appropriate interventions, and monitoring of residents with needs which might lead to conflict or neglect. This was determined to be an Immediate Jeopardy that was called on 06/07/2024. The Administrator was notified on 06/07/2024 at 5:13 p.m. that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on 06/07/2024 at 5:30 p.m. and the plan of removal was requested. The facility's plan of removal was accepted on 06/08/2024 at 1:23 p.m. and included the following: [facility name] Nursing and Rehabilitation Plan of Removal: 600: Free from Abuse and Neglect Date Initiated: 6/7/2024 Today's Date: 6/7/2024 Based on interviews, and record reviews, the facility failed to ensure residents were free from neglect for 1 of 3 residents (Resident #1) reviewed for abuse. All residents can be affected by this deficient practice. Action: Resident #1 received a skin assessment, physician notified, follow MD orders, RP notified. Identified Resident not showing any signs of distress or a negative physical outcome as a result of the event. Person(s) Responsible: Charge Nurse and/or Designee Date Action Completed: 06/01/24 Action: All residents received head-to-toe skin assessments. All residents with wounds assessed with no additional adverse findings. Person(s) Responsible: Assistant Director of Nursing, Director of Nursing, and/or Designee Date Action Completed: 06/02/24 Action: Education-- Neglect (All Staff) a. Failing to Obtain treatment orders (Nurses) b. Failing to change wound dressings (Nurses) c. Failing to notify MD of resident status and discharge orders \after a return from hospital (Nurses) Test will be completed for competency and to ensure understanding. All identified staff will be educated and tested prior to working their next shift. All new and temporary staff will be educated and tested prior to working their first shift. Person Responsible: Director of Nursing, Assistant Director of Nursing, Administrator, and/or Designee Date Action Initiated: 06/08/24 Action: All residents that have returned from the hospital in the previous 30 days have been reviewed to ensure that the physician has been notified of any pertinent resident information and ensure we are following physician orders. Person(s) Responsible: Director of Nursing, Assistant Director, and/or designee Date: 6/7/2024 Action: Director of Nursing and/or Designee to observe and/or follow behind and confirm x3 skin assessments a week and verify treatment is in place and dated within the MD's order x2 a week with emphasis on residents, who smoke, go out on pass, and/or spend time outside with wounds for 4 weeks. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date Action Initiated: 06/02/24 Action: Ad hoc QAPI with on call physician reviewing 580 template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 6/7/2024 On 06/08/2024, the investigator confirmed the facility implemented their plan of removal sufficiently to remove Immediate Jeopardy (IJ) by: On 06/08/2024 at 12:55 p.m., completed a record review of a random sample of residents who resided in the facility based on the action that all resident received head-to-toe assessment. Reviewed Resident #4's Clinical Progress Note, dated 06/02/2024 at 6:54 a.m., that indicated Resident #4 received a head-to-toe assessment completed by LVN F. Reviewed Resident #5's Clinical Progress Note, dated 06/04/2024 2:04 p.m., which revealed Resident #5 had a head-to-toe assessment completed by LVN B. Reviewed Resident #9's Clinical Progress Note, dated 06/04/2024 at 7:27 a.m., which revealed Resident #9 received a head-to-toe assessment completed by LVN F. 06/08/2024 at 1:15 p.m., reviewed progress note dated 06/01/2024, completed by the DON that revealed Resident #1 was assessed immediately after the discovery of the larvae on his right elbow. Reviewed Progress Note dated 06/01/2024 that Physician G was notified on 06/01/2024. Notification was verified by interview with Physician G and review of doctor orders dated 06/02/2024. On 06/08/2024 at 1:25 p.m., completed a record review of Resident #8's clinical record when he returned to the facility on [DATE]. Discharge records, progress notes, doctor orders, and care plan reviewed with no issues noted. During an interview on 06/08/2024 at 1:41 p.m RN O said she worked 6 a.m. to 2:30 p.m. on the weekends and PRN. RN O said she was in-serviced on how to readmit a resident who returned to the facility from the ER prior to her shift that morning. RN O said the process was to receive and review the discharge orders, notify the doctor, family, and put new orders in place after she discussed the orders with the facility doctor. RN O said she would notify the doctor if a resident fell , had new lab orders, showed a change in conditions, or any request by family or resident requesting orders. RN O said if a resident had an open area or wound and no orders for wound care, she would contact the doctor and inform the doctor of the issues and ask if new orders are needed. RN O said she was in-serviced on abuse/neglect and assessments, including head-to-toe, vital signs, and to notify the doctor of results. During an interview on 06/08/2024 at 1:55 p.m., RN, Weekend Supervisor said she worked 8 a.m. to 5 p.m., Saturday and Sunday. RN, Weekend Supervisor said she was recently in-serviced on fall precautions, identifying wounds, abuse/neglect, patient rights, fire safety, and the evacuation plan. RN, Weekend Supervisor said the wound care in-service included notifying the doctor if orders were needed. RN, Weekend Supervisor said wound care orders were need to complete wound care. RN, Weekend Supervisor said if a resident returned from ER, she would notify family, complete an assessment, review the discharge report and orders, contact doctor to obtain any needed orders, and put all orders into the MAR and clinical record. During an interview on 06/08/2024 at 2:06 p, m., LVN C said she worked a 6 a.m. to 6 p.m., rotation that included weekdays and weekends. LVN C said she was in-serviced prior to shift. LVN C said the contents of the in-services were admission protocols, following doctor orders, and going over the meds and wound orders with the facility doctor, LVN C said wound care could not be complete without doctor orders. LVN C said when a resident returned from ER, she would ensure the resident was comfortable in bed, complete a head-to-toe assessment to include vital signs and skin assessments. LVN C said she would call the doctor and review the orders to let the doctor know the resident had returned to the facility. LVN C said she would clarify wound care orders to ensure products are available that were included in the ER or facility doctor's order. LVN C said she would notify the family and the administrator. LVN C said she was in-serviced to ensure skin assessment were completed at least weekly, but she would complete more frequently or as needed. During an interview on 06/08/2024 at 3:08 p.m., Housekeeping Q said she had been recently in-serviced on abuse/neglect prior to her shift on this date. Housekeeping Q said if she saw a call light on too long, she would get an aide. Housekeeping Q said examples of abuse included if she saw someone getting to rough or not being physically careful, or residents being mean to each other could be abuse. Housekeeping Q said she identified the categories of abuse as neglect, physical, emotional, or financial. Housekeeping Q said neglect could be a resident that was thirsty and had no water at his bedside. Housekeeping Q said if a resident was wet and had been laying wet for a long time could be neglect. During an interview on 06/08/2024 at 3:15p.m., CNA R said she worked a 6 p.m. to 6 a.m. rotation that included weekdays and weekends. CNA R said she was recently in-serviced on abuse/neglect prior to her shift that morning. CNA R said neglect was not providing resident proper care or not providing care when they needed it. CNA R said an example could be not answering a call light or not providing pain medication. During an interview on 06/08/2024 at 3:27 p.m., LVN A said she worked a 6 p.m. to 6 a.m. rotation that included weekdays and weekends. LVN A said she was in-serviced on 06/07/24 when she came on shift at 6 p.m. LVN A said the in-service covered documentation, abuse/neglect, which including a test, and what action to take when a resident returned from the ER. LVN A said she was to notify the facility doctor and family. LVN A said she was required to scan in the documents and if the discharge orders had new orders, she would enter the new orders into the eMar after she verified with the facility physician. LVN A said if a resident had a wound and no treatment orders, she was in-serviced to notify the facility doctor prior to completing wound care. LVN A said she could not do wound care without doctor orders. LVN A said she would do a head-to-toe assessment when a resident returned from the ER. During an interview on 06/06/2024 at 3:10pm, LVN H said when a resident returned from the hospital or ER, she would get the resident comfortable and ensure interventions were in place. LVN H said she would review the paperwork and place the paperwork in the DON's box. LVN H said she usually did not contact the doctor, family, or the DON. LVN H said if the resident had new orders, she would enter the new orders into the resident's clinical record and text the doctor or call the on-call service On 06/08/2024 at 2:17 p.m., received the Plan of Removal notebook which contained documentation for the action plan of the facility's POR, from the Administrator. Reviewed Resident #1's Doctor's Order History, which revealed wound care orders were initiated 06/02/2024. On 06/08/2024 at 2:34 p.m., reviewed the following in-services and signature sheets: - When do you notify the Attending Physician? Dated 06/02/2024 - Abuse & Neglect Inservice - dated 6/02/2024 for all staff - Wound Treatment Orders, How to input orders into the electronic record - dated 6/08/2024, signed by LVN A - When a resident returns from the ER: steps to take - dated 06/07/2024 - Resident Assessment: reviewed what steps were included - dated 6/02/2024 - Skin assessment and wound orders: when to be completed, who to notify - dated 6/02/2024 - Orders: directions and key points to remember - dated 6/02/2024 - Change in Condition, notifying proper parties - dated 6/03/2024 - Documentation - dated 6/02/2024 - Neglect test - nine (9) random employees included in sample - Resident returning from ER - four (4) nurses included in random sample - Ad Hoc QAPI Meeting Agenda dated 06/07/2024 - [facility name] Tracking Sheet for skin assessments - dated as started 6/02/2024; entries for 6/06/24 & 06/07/24 - List of Last 30 discharge/readmissions ER - dated 6/07/2024 During an interview on 06/08/2024 at 3:37 p.m., the DON said he would use a form similar to a calendar to document that all resident hospital discharge paperwork was reviewed in morning meetings and was documented on the 24-hour report. Overall, the DON said the Plan of Removal was effective and the IJ brought to light the fact that the discharge paperwork needed to be reviewed more carefully to ensure continuity of care. The DON said review of the discharge paperwork with the facility doctor and clear, precise documentation of what the conversation with the facility doctor included would have prevented a lot of issues related to the IJ. On 06/08/2024 at 3:50 p.m., notified Admin [TRUNCATED]

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each of the residents for four (Resident #8, Resident #11, Resident #13, and Resident #14) of 14 residents reviewed for abuse/neglect. The Administrator failed to follow the facility's policy the Abuse-Reportable Events when she verbally/mentally abused Residents #8, #11, #13 and #14. The RDO failed to follow the facility's Abuse policy and throughly investigate and report the incidents of verbal/mental abuse of Residents #8, #11, #13, and #14 by the Administrator. An Immediate Jeopardy was identified on 06/14/17. The Immediate Jeopardy was removed on 06/16/17. The facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 46 residents at risk of being further abused and neglected due to the facility's lack of response and investigation after an allegation of abuse was made. Findings included: 1. Review of Resident #8 undated face sheet received 06/15/17 revealed resident was a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a nurse's note dated 04/25/17 at 8:00 p.m. reflected Resident requesting this nurse to come to her room to read resident rights which she has pulled up on her computer screen related to resident having increased anxiety, because she says she might possibly get roommate and has called staff to her room multiple times to go over scenario related to furniture arrangement and wheelchair placement as if there were another bed in room with her. Review of Resident #8's Mental and Behavioral Health Visit Note dated 04/27/17 reflected the resident to be anxious, tearful, somewhat agitated with potential roommate but used time well to process issues. Review of a nurse's note dated 04/27/17 reflected Resident awake at this time continues to concentrate on computer, reading resident rights, appears very worried and concerned about changes in near future. Resident only sleeping on and off during the night. Record Review of Resident #8 MDS assessment dated [DATE] revealed resident has a BIMS score of 15 indicating no cognitive impairment. Resident required extensive assistance with dressing and toilet use, total dependence with transfers. Review of Resident #8's Mental and Behavioral Health Visit Note dated 05/11/17 revealed the resident to be less anxious than last visit but still concerned/anxious that she'll have to share a room with increasing census. Review of the Monthly Summary dated 05/16/17 reflected resident was obsessed with room change pending and getting roommate. Review of Resident #8's Mental & Behavioral Health Visit Note dated 05/25/17 revealed Description & Purpose of Clinician Interventions: Processed some recent anxiety and irritation with staff wanting her to move to another room while reflecting reducing in anxiety, satisfaction that these plans for now are no longer in place and pt. will be kept in her room. Patient's response to Interventions/Progress toward Goal: Pt acknowledges she needs to revert back to better health behaviors/dietary work to lose weight and that when she feel stressed she gets off her diet. Record Review of Resident #8 Mental & Behavioral Health Visit Note dated 06/08/17 revealed Description & Purpose of Clinician Interventions: Follow up to assess mood. Reflected/reinforce self-perceived reduction in anxiety with closure of staff efforts to move pt. to another room. Interview with Resident #8 on 06/13/17 at 3:30 p.m. revealed she had been at the facility for approximately five years and the Resident Council secretary. She stated she had been in the same room for almost her entire stay at the facility. She stated she was as a big woman; she had to have a specialty bariatric bed and recently received an electric wheelchair which allowed her better freedom and independence. She revealed she was very self-conscious about her weight, but had been trying to lose weight so she could have an eye surgery to improve her sight. She stated a few weeks ago, several residents came to her with a complaint about the brand of chocolate milk being switched. She revealed she went to the dietary manager to discuss the residents' concerns and after she finished her conversation, the Administrator followed her into her room. She stated the Administrator started going off on her about how there were going to be changes and everyone would have to get used to it. Then the Administrator stated some people were gaining too much weight drinking all of that chocolate milk anyways. She stated she felt the Administrator was directing that comment towards her because she loved chocolate milk and drank it at almost every meal. Resident #8 revealed after being yelled at by the Administrator about the chocolate milk, she stopped drinking chocolate milk and stated her feelings were hurt. She revealed the Administrator started coming into her room more often and yelled at her about several other things including telling her to quit spreading rumors about her firing staff. She stated several times, the Administrator would come into her room and start raising her voice and she felt embarrassed and upset because she would yell at her and not even close the door. She stated after the first couple of incidents, she called the corporate office and the RDO came out to investigate. She stated the RDO did interview her about everything, and she stated she told her about the verbal and mental abuse. Resident #8 revealed the RDO told her that she was going to be honest with her and she was not going to fire the Administrator. Resident #8 stated after she reported the Administrator to the corporate office and started learning about her resident rights and letting other residents know, the Administrator started telling her she was going to have to move to a different room or be forced to have a roommate. Resident #8 stated she was emotionally distraught about having to get a roommate because she was unable to use her electric chair if she had another person in the room with her. She stated she was scared she was going to lose her mobility. Resident #8 stated the Administrator came in several times, threatening her with having a roommate and each time she became emotionally distraught. She stated she often broke down in tears and had to be comforted by the DON and LVN J. She stated someone else reported her concern to the RDO, because she came out to investigate again. She stated the RDO interviewed her again, but the RDO did not do anything about her concerns. She stated she was afraid of the Administrator and did not feel safe in her own home. Interview with Resident #8 on 06/15/17 at 11:30 a.m. revealed she was happy with her current room, but the room she was asked to accept would have meant the loss of some of her personal items because of the way it was laid out. And, because she used a large power chair and a large bed, the addition of a roommate would have made it impossible to keep and use these items. She said she feared a complete loss of mobility which she had only just recently secured when she got her power chair. Before that, she said she spent two years in bed and was terrified of losing the mobility the power chair provided. Interview with Resident #8 on 06/16/17 at 1:25 p.m. revealed she had gone to the RDO on 04/27/17 to complain about mistreatment and retaliation from the administrator. She told the RDO that the administrator had told her that she had all the rights and the resident could not do anything about it. She also told the RDO that the administrator had yelled at her on several occasions. The RDO then asked her to give the administrator another chance. During this conversation, which was supposed to be private, she noticed the administrator was standing outside the door listening to the conversation. In a document presented to the surveyor by Resident #8 on 06/13/17 at 1:30 p.m. she wrote: This is a list of concerns we have pertaining to the administrator of our nursing home. She belittles residents. I heard her out in the hallway loudly accuse a resident of stealing money. She asked him where he had gotten the money. He told her his sister had sent it to him. She then told him that she was taking him to her office to call his sister. A few minutes later he passed my door going back down the hall.then she says to him she is still going to keep an eye on him. At another time a resident was going back to his room after a meal and she loudly calls to him down the hallway. He stops in the middle of the hall and she starts yelling at him about taking a sandwich from the plate of his tablemate. The resident tells her he thought the man had finished and had left the table. He had been gone from the table a long time then I hear her say I have seen you take food before so I am going to keep an eye on you. The man gathers leftover scraps after meals to feed the cats out in the backyard. As officers of the resident council we feel that it is our duty to make sure all residents know and understand their rights . we were told we could not do this because it was invading the other residents right to privacy. Not long after the last meeting she came to me to tell me she was going to move me out of the room I have lived in for the last five or so years. When I asked her why she wanted to move me all she would tell me was that she was doing some rearranging. As it turned out I was the only one she was rearranging. I told her I didn't want to move and that I didn't think she could move me without a very good reason. She came back a day or so later and told me she wanted to put fall risk residents close to the nursing station and close to the DON's office. My room is near both. In all the time I have lived in this room this has never been an issue The administrator told me either I moved or she would put another resident in the room with me .Basically this was a threat. But I agreed to move. She has used this threat several times when she thought I might back out on moving. I feel that this whole moving thing is in retaliation for the fact that the council stands up for our rights and the rights of the other residents. When I went to her about this she told me she would be moving someone else, as it turned out, the president of the resident council who has refused to move but agreed to have a roommate if needed. Still the administrator nagged her to move. She is two doors down. We both feel this is a reprisal against us as officers of the resident council Neither room is a good fit for us because we would lose items that would diminish our quality of life She has no respect for the residents or their privacy. My back was to the door when I heard someone in my room. I turned around and the administrator was standing there glaring at me. She did not knock or announce herself. I stated to ask her what she needed but she laid into me. Something about a rumor going around about her. The rumor was that she had fired the dietary manager and hired a friend to be the manager. I am a big woman and she even hit me with a personal knock about it. Interview with the LVN J on 06/13/17 at 5:15 p.m. revealed she had heard the Administrator yelling at Resident #8 several different occasions. She stated she heard the Administrator tell Resident #8 that some residents were gaining too much weight drinking all that chocolate milk. LVN J revealed the Administrator knew Resident #8's weight was a sore spot for her. She stated she did not know how, but the Administrator knew Resident #8 had called corporate on her and after that it seemed like she was out to get Resident #8. She stated she heard the Administrator go into her room several different times and raise her voice and threaten Resident #8 with a roommate if she did not do what she wanted. She stated Resident #8 was terrified of having a roommate because she would be unable to use her electric wheelchair. LVN J revealed Resident #8 was a whole new person after getting the customized wheelchair and had left her bed and started being more involved. She stated the Administrator was torturing Resident #8 by threatening her with a roommate. She stated she had to go over to Resident #8's room several times after the Administrator left the room to comfort her because she was having an emotional breakdown. She stated she had called the corporate compliance line herself with the DON to report the verbal abuse. She stated the RDO had been out twice to investigate and did not do anything about the problem. She stated the Administrator created a very hostile work environment and scared other employees from coming forward with their concerns. Interview with the DON on 06/13/17 at 5:30 p.m. revealed the administrator routinely talked to several residents in a condescending manner. She said the fact that there was no bathroom in Residents #8's and #11's rooms was the official reason for the administrator asking these two residents to move to different rooms. Bedpans from these residents had to be carried down the hall to be cleaned. However, she said the staff had been doing this for years and it was not a problem. She said she believed the real reason was that these residents had overheard things from the administrator's office and had called the corporate office on her. She wanted them moved to the end of the hall so they could not hear. Interview with the DON on 06/14/17 at 8:00 a.m. revealed she had seen several problems between the administrator and residents and was aware of most of the problems. She said she had seen inappropriate verbal interaction between the administrator and Resident #8. Asked if this constituted verbal abuse, she said yes. Asked what her action would have been if this had been a CNA, she said that person would be suspended pending investigation. She said she feared retaliation, but did report the abuse to her superior (the Regional Nurse Consultant). Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had known Resident #8 for several years now and she stated Resident #8 used to always be happy and now she has been so much more tearful and depressed since the Administrator was hired a few months ago. She stated the RDO was good friends with the Administrator and would not do anything about their complaints. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed a few weeks ago they had changed vendors who supplied the chocolate milk. She stated Resident #8 was upset about the change to low fat chocolate milk. She revealed she did talk to Resident #8 about the change and did tell her that some residents were gaining too much weight drinking the chocolate milk. She stated she was just a naturally loud person. She stated she had been suspended by the RDO after a complaint was made about her possibly retaliating against Residents #8 and #11, but she had been reinstated two days later. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed in the beginning of March of 2017, Resident #8 had called corporate and had made a complaint about a chocolate milk incident with the Administrator. She stated she interviewed Resident #8 and investigated the complaint. She stated she told Resident #8 to give the Administrator a chance to be better. She then revealed on 05/17/17, the Administrator called her and told her the ombudsman felt she was retaliating against Resident #8 by making her move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. She stated she interviewed Resident #8 and she stated Resident #8's only concern was not following up on complaints from the Resident Council. She stated she ensured the Administrator was following up on all the complaints and when she was sure all the complaints were followed up on, she let the Administrator come back to work. The RDO stated Resident #8 was out to get the Administrator and she believed the only thing that would make Resident #8 happy would to be to fire the Administrator. The RDO revealed she just thought Resident #8 was having a [MEDICAL CONDITION] episode and was paranoid about the Administrator. She revealed her investigation simply consisted of talking to the DON and Resident #8 and #11 about their concerns, and ensuring the Administrator was following up on the complaints. She stated she believed it was not retaliation because it seemed like Resident #8 was [MEDICAL CONDITION] and just out to get the Administrator. The RDO stated the resident interviews she conducted concerned making sure their grievance had been followed up on by the Administrator. Interview with the RDO on 06/15/17 at 4:40 p.m. revealed the Administrator is the abuse coordinator and the DON is the alternate Abuse Coordinator. She said if the DON received an abuse allegation against the administrator the policy was for the DON to report the allegation to corporate staff. She said if there was an abuse allegation against any other staff the DON would suspend staff pending investigation. Telephone interview with the Regional Nurse Consultant on 06/15/17 at 11:00 a.m. revealed verbal abuse of a resident by the Administrator may have been mentioned to her but she was focused on providing guidance to staff located at another facility. 2. Review of Resident #11's undated face sheet received 06/15/17 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating no cognitive impairment. The resident had no behaviors. She required extensive assistance with toileting, independent and supervision with transfers. Review of Resident #11's Mental and Behavioral Health Visit Note dated 06/08/17 reflected Resident #11 processed reduction in anxiety with staff decision that she could stay in her preferred room and not move. Interview with Resident #11 on 06/13/17 at 3:00 p.m. revealed the Administrator had come to her a few weeks ago asking for her to move rooms down the hall. She stated she told the Administrator she did not wish to move rooms. She stated this seemed to make the Administrator upset and she started being very ugly to her. She revealed she felt like there was a motive behind the Administrator wanting her to move. She stated the Administrator started asking her to move rooms away from the other residents when she had started passing out information to other residents about their rights. She stated the Administrator would come into her room and start demanding she move rooms. She stated the Administrator spoke to her and made her feel like she was the scum of the earth. She stated the Administrator was very cold and mean in her tone of voice to her whenever the Administrator spoke to her about moving rooms. She stated the Administrator wanted to move her to a smaller room away from other residents and she told the Administrator about her concerns about the lack of room and interaction with other people. She stated the Administrator did not care and ignored her concerns. She stated she started to feel threatened and scared of the Administrator because if she moved her to a different room she honestly felt like she would die and would be better off with God. Finally, the ombudsman did confront the Administrator about the room situation and she stated the Administrator backed off. She stated she still felt unsafe with the Administrator in the building and she would probably find another way to torment her. An interview by telephone with Resident #11's family member on 06/14/17 at 9:40 a.m. revealed the administrator was not happy with Residents #8 and #11 because they had passed out a copy of resident's rights to other residents. He/She said she felt Resident #11 was manipulated and mistreated by the administrator for this reason. He/She said this mistreatment caused Resident #11 to be very depressed and made her high blood pressure issue worse because she was very upset. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed she had been asking Resident #11 to move rooms because she wanted to move a resident who was a higher fall risk into her room. She stated Resident #11 did not want to move rooms and she stated she must have told the ombudsman because the ombudsman revealed Resident #11 felt like she was being retaliated against. She stated the RDO had suspended her and investigated the concern. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed 05/17/17, the Administrator called her and told her the ombudsman felt she was retaliating against Resident #11 by making her move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. The RDO stated Resident #11 was out to get the Administrator. 3. Review of Resident #13's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS score of 13 indicated the resident was not cognitively impaired and he did not have behaviors. The resident required extensive assistance with dressing and supervision with transfers. Interview with Resident #13 on 06/15/17 at 9:10 a.m. revealed a while ago he had received ten dollars from his sister. He stated he was going around asking for change for a ten from other residents. He stated another resident around that time had lost ten dollars. He stated the Administrator saw him with a ten dollar bill and came up to him in the hall and accused him of stealing the money. He stated he had tried to explain that the money had come from his sister and at that point, the Administrator made him go down to her office and call his sister. He stated his sister confirmed that she had sent him ten dollars over the phone. He stated the Administrator apologized to him afterwards. He stated it was embarrassing at first, but he was over it. He stated he knows other residents and employees heard her accusing him of stealing money. Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had witnessed the Administrator start yelling and accusing Resident #13 of stealing ten dollars. She stated the Administrator went up to Resident #13 in the hallway and started accusing him of stealing the ten dollars from another resident and demanded he go down to her office and call his sister to confirm he got the ten dollars from her. She stated she was embarrassed for Resident #13 because she yelled at him in the middle of the hallway with other employees and residents around. Interview with LVN D on 06/16/17 at 2:17 p.m. revealed she witnessed the Administrator yell at Resident #13 in the hallway accusing the resident of stealing money. LVN D stated the Administrator had a very accusatory tone. The Administrator then took Resident #13 into her office and had him call his family member to confirm that the family did in fact give the resident the money and he did not steal it. LVN D stated she reported the incident to her direct supervisor, the DON. LVN D stated the DON reported the incident to the RDO because the RDO came and interviewed her. LVN D stated the RDO did not ask her about the incident but only asked her if you need something does the DON get it for you? LVN D stated she was never interviewed regarding what she witnessed. 4. Interview with the MDS Nurse on 06/16/17 at 10:15 a.m. revealed there were specific incidents of verbal abuse by the Administrator towards Residents #8 and #13. She said a meeting was held which consisted of the RDO, the Regional Nurse Consultant, the DON, the ADON, the Administrator, and herself, in which verbal abuse of residents by the Administrator was discussed. She revealed the RDO assured everyone the problem would be investigated and handled. 5. Review of Resident #14's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 11 indicating mild cognitive impairment. Resident #14 required supervision with ADLs. Review of unsigned Progress Notes dated 05/27/17 at 3:25 p.m. revealed Resident #14 received 5 day notice of room relocation due to needing to be moved to a dually certified bed. Resident #14 requested to be moved to another facility stating needs to get out of this environment. Interview with LVN C on 06/16/17 at 9:04 a.m. revealed Resident #14 wanted to move to another facility because of the Administrator. When Resident #14 was moving out of the facility, the Administrator said to the resident in a sarcastic tone do you need help? LVN C stated Resident #14 had plenty of help and did not need additional assistance moving his belongings. LVN C revealed the Administrator was like the mean girl in high school. She stated she heard the Administrator tell Resident #14 to quit breaking things in my building. She stated the administrator was very loud and rude. Interview with LVN C on 06/16/17 at 4:40 p.m. revealed Resident #14 had caused some type of damage in his bathroom and the administrator had told the resident she was going to start charging him for repairs to my building. She said she provided care for Resident #14 and had seen a decline in the resident in recent months which the resident attributed to anxiety related to the Administrator. She said the Administrator had retaliated against Resident #8 because she would not change rooms. She said the Administrator talked to residents inappropriately in front of others. Interview with LVN A on 06/15/17 at 4:00 p.m. revealed the Administrator was afraid of another complaint and wanted Resident #14 out of the building. She stated she did not know why the Administrator felt threatened by Resident #14. 6. A written statement presented by LVN B on 06/15/17 reflected: Concerns: She (administrator) has demonstrated a lack of [MEDICATION NAME] for these people. I have heard her complain about a resident being too loud breathing was driving her crazy and wanted her back on south hall. She forced (Resident #14) to move-he told her he was ready to comply and follow whatever rules she had he just wanted to stay-she stated no way, he is out of here. I tried to explain to her he needed time to adjust and for his meds to be effective and would modify his behavior. She was upset with (Resident #8), then became determined to move her out of her room for a show of power-The resident became very distressed over this crying at times. Then she decided to move (Resident #11) because she stated her BM smelled really bad and wanted her further down the hall. A resident dropped some trash in her trash can in her office and she had it removed immediately. Everyone said speak up when you see an injustice. The truth is everyone is afraid-if we speak the truth, then we set ourselves up for failure. How have we improved the situation if we lose our jobs? She has spied on Resident #8 while she was engaged in a private conversation with another person; she stood outside the door and listened to every word. 7. In a confidential group interview on 06/13/17 at 1:00 p.m. with 12 residents identified by the facility as interviewable, six of 12 said the administrator was rude and said inappropriate things to the residents and staff. 8. Review of the Abuse-Reportable Events policy and procedure dated 12/16 reflected the following: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/even in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal Abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. 9. An immediate jeopardy was identified on 06/14/17 at 3:42 p.m. The RDO and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. 10. The facility's Plan of Removal, accepted on 06/16/17 at 3:33 p.m. reflected: In order to ensure resident safety from abuse, all staff will be educated on the definition of verbal abuse; as well as training, intervention, protection, reporting, and investigating. To further protect residents from abuse, all staff will be educated that any time verbal abuse is suspected the employee must call the Facility Abuse Coordinator (the interim Administrator) immediately. In the event the Facility Abuse Coordinator does not respond then the employee should call the Alternate Abuse Coordinator, the Regional Nurse Consultant. All staff will be educated on how to protect the residents if they suspect abuse has occurred. Specifically, the staff is being trained to protect and report The 3 residents who reported they had been verbally abused were interviewed by the Facility Ambassadors to ensure they feel safe. All alert and oriented residents were interviewed by the Facility Ambassadors to ensure they feel safe. All staff will be educated on where to locate the number to the compliance line in the event they are not comfortable reporting it to the Facility Abuse Coordinator Department heads will conduct random interviews during their daily rounds to ensure the residents feel safe & free from verbal abuse. A QA Meeting was held on 6/15/2017 with members of the QA team and the Medical Director The Administrator was suspended and immediately left the facility upon RDO learning of the alleged verbal abuse. Investigation into the Administrator's alleged unprofessional conduct is ongoing. Director of Nursing and Assistant Director of Nursing have been suspended pending investigation for failure to report suspected verbal abuse following their report to RDO that they were aware of alleged verbal abuse and did not report. Per Company Policy and Code of Conduct, both the DON and ADON will be terminated. An interim DON will start June 22, 2017. Until that time, the facility will have RN coverage 8 hours a day/7days a week. The RN covering for the day will be in charge of clinical systems for the assigned day. The RN will have the support of the Regional Nurse Consultant by telephone. Ambassadors are members of the clinical management and administrative staff. Each are assigned to a block of resident rooms, and acts as an advocate for those residents. Ambassadors visit their assigned residents each day they are assigned to work.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit and prevent abuse of residents for four (Resident #8, Resident #11, Resident #13 and Resident #14) of 14 residents reviewed for abuse and neglect. The Administrator verbally and mentally abused Resident #8 on several occasions resulting in Resident #8 becoming emotionally distraught, anxious and fearful. The Administrator verbally and mentally abused Resident #11 on several occasions resulting in Resident #11 feeling unsafe and threatened in the facility. The Administrator verbally abused Resident #13 on one occasion of accusing him of stealing money in front of other residents and staff in a public hallway. The Administrator verbally abused Resident #14 forcing him to want to move to another facility. The facility failed to thoroughly investigate four complaints of verbal/mental abuse by the Administrator for Residents (#8, #11, #13, and #14). The RDO failed to report allegations of verbal and mental abuse to the Department of Aging and Disabilities. An Immediate Jeopardy was identified on 06/14/17. The Immediate Jeopardy was removed on 06/16/17. The facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 46 residents at risk of being abused or neglected due to the Administrator being in charge of the entire facility and the failure of the RDO to keep the residents safe when an allegation was presented to her. Findings included: 1. Review of the Abuse-Reportable Events policy and procedure dated 12/16 reflected the following: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/even in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal Abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. The home's administration will conduct and investigate allegations of crimes, suspected abuse, neglect, or misappropriation of property, and will provide notification and release of information to the proper authorities in accordance with federal and state regulations. 2. Review of Resident #8 undated face sheet received 06/15/17 revealed resident was a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a nurse's note dated 04/25/17 at 8:00 p.m. reflected Resident requesting this nurse to come to her room to read resident rights which she has pulled up on her computer screen related to resident having increased anxiety, because she says she might possibly get roommate and has called staff to her room multiple times to go over scenario related to furniture arrangement and wheelchair placement as if there were another bed in room with her. Review of Resident #8's Mental and Behavioral Health Visit Note dated 04/27/17 reflected the resident to be anxious, tearful, somewhat agitated with potential roommate but used time well to process issues. Review of a nurse's note dated 04/27/17 reflected Resident awake at this time continues to concentrate on computer, reading resident rights, appears very worried and concerned about changes in near future. Resident only sleeping on and off during the night. Review of Resident #8 MDS assessment dated [DATE] revealed resident has a BIMS score of 15 indicating no cognitive impairment. Resident required extensive assistance with dressing and toilet use, total dependence with transfers. Review of Resident #8's Mental and Behavioral Health Visit Note dated 05/11/17 revealed the resident to be less anxious than last visit but still concerned/anxious that she'll have to share a room with increasing census. Review of the Monthly Summary dated 05/16/17 reflected resident was obsessed with room change pending and getting roommate. Review of Resident #8's Mental & Behavioral Health Visit Note dated 05/25/17 revealed Description & Purpose of Clinician Interventions: Processed some recent anxiety and irritation with staff wanting her to move to another room while reflecting reducing in anxiety, satisfaction that these plans for now are no longer in place and pt. will be kept in her room. Patient's response to Interventions/Progress toward Goal: Pt acknowledges she needs to revert back to better health behaviors/dietary work to lose weight and that when she feel stressed she gets off her diet. Review of Resident #8 Mental & Behavioral Health Visit Note dated 06/08/17 revealed Description & Purpose of Clinician Interventions: Follow up to assess mood. Reflected/reinforce self-perceived reduction in anxiety with closure of staff efforts to move pt. to another room. Interview with Resident #8 on 06/13/17 at 3:30 p.m. revealed she had been at the facility for approximately five years and was the Resident Council secretary. She stated she had been in the same room for almost her entire stay at the facility. She stated she was as a big woman; she had to have a specialty bariatric bed and recently received an electric wheelchair which allowed her better freedom and independence. She revealed she was very self-conscious about her weight, but had been trying to lose weight so she could have an eye surgery to improve her sight. She stated a few weeks ago, several residents came to her with a complaint about the brand of chocolate milk being switched. She revealed she went to the dietary manager to discuss the residents' concerns and after she finished her conversation, the Administrator followed her into her room. She stated the Administrator started going off on her about how there were going to be changes and everyone would have to get used to it. Then the Administrator stated some people were gaining too much weight drinking all of that chocolate milk anyways. She stated she felt the Administrator was directing that comment towards her because she loved chocolate milk and drank it at almost every meal. Resident #8 revealed after being yelled at by the Administrator about the chocolate milk, she stopped drinking chocolate milk and stated her feelings were hurt. She revealed the Administrator started coming into her room more often and yelled at her about several other things including telling her to quit spreading rumors about her firing staff. She stated several times, the Administrator would come into her room and start raising her voice and she felt embarrassed and upset because she would yell at her and not even close the door. She stated after the first couple of incidents, she called the corporate office and the RDO came out to investigate. She stated the RDO did interview her about everything, and she stated she told her about the verbal and mental abuse. Resident #8 revealed the RDO told her that she was going to be honest with her and she was not going to fire the Administrator. Resident #8 stated after she reported the Administrator to the corporate office and started learning about her resident rights and letting other residents know, the Administrator started telling her she was going to have to move to a different room or be forced to have a roommate. Resident #8 stated she was emotionally distraught about having to get a roommate because she was unable to use her electric chair if she had another person in the room with her. She stated she was scared she was going to lose her mobility. Resident #8 stated the Administrator came in several times, threatening her with having a roommate and each time she became emotionally distraught. She stated she often broke down in tears and had to be comforted by the DON and LVN J. She stated someone else reported her concern to the RDO, because she came out to investigate again. She stated the RDO interviewed her again, but the RDO did not do anything about her concerns. She stated she was afraid of the Administrator and did not feel safe in her own home. Interview with Resident #8 on 06/15/17 at 11:30 a.m. revealed she was happy with her current room, but the room she was asked to accept would have meant the loss of some of her personal items because of the way it was laid out. And, because she used a large power chair and a large bed, the addition of a roommate would have made it impossible to keep and use these items. She said she feared a complete loss of mobility which she had only just recently secured when she got her power chair. Before that, she said she spent two years in bed and was terrified of losing the mobility the power chair provided. Interview with Resident #8 on 06/16/17 at 1:25 p.m. revealed she had gone to the RDO on 04/27/17 to complain about mistreatment and retaliation from the administrator. She told the RDO that the administrator had told her that she had all the rights and the resident could not do anything about it. She also told the RDO that the administrator had yelled at her on several occasions. The RDO then asked her to give the administrator another chance. During this conversation, which was supposed to be private, she noticed the administrator was standing outside the door listening to the conversation. In a document presented to the surveyor by Resident #8 on 06/13/17 at 1:30 p.m. she wrote: This is a list of concerns we have pertaining to the administrator of our nursing home. She belittles residents. I heard her out in the hallway loudly accuse a resident of stealing money. She asked him where he had gotten the money. He told her his sister had sent it to him. She then told him that she was taking him to her office to call his sister. A few minutes later he passed my door going back down the hall.then she says to him she is still going to keep an eye on him. At another time a resident was going back to his room after a meal and she loudly calls to him down the hallway. He stops in the middle of the hall and she starts yelling at him about taking a sandwich from the plate of his tablemate. The resident tells her he thought the man had finished and had left the table. He had been gone from the table a long time then I hear her say I have seen you take food before so I am going to keep an eye on you. The man gathers leftover scraps after meals to feed the cats out in the backyard. As officers of the resident council we feel that it is our duty to make sure all residents know and understand their rights . we were told we could not do this because it was invading the other residents right to privacy. Not long after the last meeting she came to me to tell me she was going to move me out of the room I have lived in for the last five or so years. When I asked her why she wanted to move me all she would tell me was that she was doing some rearranging. As it turned out I was the only one she was rearranging. I told her I didn't want to move and that I didn't think she could move me without a very good reason. She came back a day or so later and told me she wanted to put fall risk residents close to the nursing station and close to the DON's office. My room is near both. In all the time I have lived in this room this has never been an issue The administrator told me either I moved or she would put another resident in the room with me .Basically this was a threat. But I agreed to move. She has used this threat several times when she thought I might back out on moving. I feel that this whole moving thing is in retaliation for the fact that the council stands up for our rights and the rights of the other residents. When I went to her about this she told me she would be moving someone else, as it turned out, the president of the resident council who has refused to move but agreed to have a roommate if needed. Still the administrator nagged her to move. She is two doors down. We both feel this is a reprisal against us as officers of the resident council Neither room is a good fit for us because we would lose items that would diminish our quality of life She has no respect for the residents or their privacy. My back was to the door when I heard someone in my room. I turned around and the administrator was standing there glaring at me. She did not knock or announce herself. I stated to ask her what she needed but she laid into me. Something about a rumor going around about her. The rumor was that she had fired the dietary manager and hired a friend to be the manager. I am a big woman and she even hit me with a personal knock about it. Interview with the LVN J on 06/13/17 at 5:15 p.m. revealed she had heard the Administrator yelling at Resident #8 several different occasions. She stated she heard the Administrator tell Resident #8 that some residents were gaining too much weight drinking all that chocolate milk. LVN J revealed the Administrator knew Resident #8's weight was a sore spot for her. She stated she did not know how, but the Administrator knew Resident #8 had called corporate on her and after that it seemed like she was out to get Resident #8. She stated she heard the Administrator go into her room several different times and raise her voice and threaten Resident #8 with a roommate if she did not do what she wanted. She stated Resident #8 was terrified of having a roommate because she would be unable to use her electric wheelchair. LVN J revealed Resident #8 was a whole new person after getting the customized wheelchair and had left her bed and started being more involved. She stated the Administrator was torturing Resident #8 by threatening her with a roommate. She stated she had to go over to Resident #8's room several times after the Administrator left the room to comfort her because she was having an emotional breakdown. She stated she had called the corporate compliance line herself with the DON to report the verbal abuse. She stated the RDO had been out twice to investigate and did not do anything about the problem. She stated the Administrator created a very hostile work environment and scared other employees from coming forward with their concerns. Interview with the DON on 06/13/17 at 5:30 p.m. revealed the administrator routinely talked to several residents in a condescending manner. She said the fact that there was no bathroom in Residents #8's and #11's rooms was the official reason for the administrator asking these two residents to move to different rooms. Bedpans from these residents had to be carried down the hall to be cleaned. However, she said the staff had been doing this for years and it was not a problem. She said she believed the real reason was that these residents had overheard things from the administrator's office and had called the corporate office on her. She wanted them moved to the end of the hall so they could not hear. Interview with the DON on 06/14/17 at 8:00 a.m. revealed she had seen several problems between the administrator and residents and was aware of most of the problems. She said she had seen inappropriate verbal interaction between the administrator and Resident #8. Asked if this constituted verbal abuse, she said yes. Asked what her action would have been if this had been a CNA, she said that person would be suspended pending investigation. She said she feared retaliation, but did report the abuse to her superior (the Regional Nurse Consultant). Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had known Resident #8 for several years now and she stated Resident #8 used to always be happy and now she has been so much more tearful and depressed since the Administrator was hired a few months ago. She stated the RDO was good friends with the Administrator and would not do anything about their complaints. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed a few weeks ago they had changed vendors who supplied the chocolate milk. She stated Resident #8 was upset about the change to low fat chocolate milk. She revealed she did talk to Resident #8 about the change and did tell her that some residents were gaining too much weight drinking the chocolate milk. She stated she was just a naturally loud person. She stated she had been suspended by the RDO after a complaint was made about her possibly retaliating against Residents #8 and #11, but she had been reinstated two days later. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed in the beginning of March of 2017, Resident #8 had called corporate and had made a complaint about a chocolate milk incident with the Administrator. She stated she interviewed Resident #8 and interviewed Resident #8. She stated she told Resident #8 to give the Administrator a chance to be better. She revealed she did not have any evidence of the investigation regarding the chocolate milk incident. She then revealed on 05/17/17, the Administrator called her and told her the ombudsman felt she was retaliating against Resident #8 by making them move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. She stated she interviewed Resident #8 and she stated Resident #8's only concern was not following up on complaints from the Resident Council. She stated she ensured the Administrator was following up on all the complaints and when she was sure all the complaints were followed up on, she let the Administrator come back to work. The RDO stated Resident #8 was out to get the Administrator and she believed the only thing that would make Resident #8 happy would to be to fire the Administrator. The RDO revealed she just thought Resident #8 was having a [MEDICAL CONDITION] episode and was paranoid about the Administrator. She revealed her investigation simply consisted of talking to the DON and Resident #8 and #11 about their concerns, and ensuring the Administrator was following up on the complaints. She stated she believed it was not retaliation because it seemed like Resident #8 was [MEDICAL CONDITION] and just out to get the Administrator. The RDO stated the resident interviews she conducted concerned making sure their grievance had been followed up on by the Administrator. Interview with the RDO on 06/15/17 at 4:40 p.m. revealed the Administrator is the abuse coordinator and the DON is the alternate abuse coordinator. She said if the DON received an abuse allegation against the administrator the policy was for the DON to report the allegation to corporate staff. She said if there was an abuse allegation against any other staff the DON would suspend staff pending investigation. Telephone interview with the Regional Nurse Consultant on 06/15/17 at 11:00 a.m. revealed verbal abuse of a resident by the Administrator may have been mentioned to her from the DON but she was focused on providing guidance to staff located at another facility. 3. Review of Resident #11's undated face sheet received 06/15/17 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating no cognitive impairment. The resident had no behaviors. She required extensive assistance with toileting, independent and supervision with transfers. Review of Resident #11's Mental and Behavioral Health Visit Note dated 06/08/17 reflected Resident #11 processed reduction in anxiety with staff decision that she could stay in her preferred room and not move. Interview with Resident #11 on 06/13/17 at 3:00 p.m. revealed the Administrator had come to her a few weeks ago asking for her to move rooms down the hall. She stated she told the Administrator she did not wish to move rooms. She stated this seemed to make the Administrator upset and she started being very ugly to her. She revealed she felt like there was a motive behind the Administrator wanting her to move. She stated the Administrator started asking her to move rooms away from the other residents when she had started passing out information to other residents about their rights. She stated the Administrator would come into her room and start demanding she move rooms. She stated the Administrator spoke to her and made her feel like she was the scum of the earth. She stated the Administrator was very cold and mean in her tone of voice to her whenever the Administrator spoke to her about moving rooms. She stated the Administrator wanted to move her to a smaller room away from other residents and she told the Administrator about her concerns about the lack of room and interaction with other people. She stated the Administrator did not care and ignored her concerns. She stated she started to feel threatened and scared of the Administrator because if she moved her to a different room she honestly felt like she would die and would be better off with God. Finally, the ombudsman did confront the Administrator about the room situation and she stated the Administrator backed off. She stated she still felt unsafe with the Administrator in the building and she would probably find another way to torment her. An interview by telephone with Resident #11's family member on 06/14/17 at 9:40 a.m. revealed the administrator was not happy with Residents #8 and #11 because they had passed out a copy of resident's rights to other residents. He/She said she felt Resident #11 was manipulated and mistreated by the administrator for this reason. He/She said this mistreatment caused Resident #11 to be very depressed and made her high blood pressure issue worse because she was very upset. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed she had been asking Resident #11 to move rooms because she wanted to move a resident who was a higher fall risk into her room. She stated Resident #11 did not want to move rooms and she stated she must have told the ombudsman because the ombudsman revealed Resident #11 felt like she was being retaliated against. She stated the RDO had suspended her and investigated the concern. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed the Administrator called her and told her the ombudsman felt she was retaliating against Resident #11 by making them move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. The RDO stated Resident #11 was out to get the Administrator . 4. Review of Resident #13's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS score of 13 indicated the resident was not cognitively impaired and he did not have behaviors. The resident required extensive assistance with dressing and supervision with transfers. Interview with Resident #13 on 06/15/17 at 9:10 a.m. revealed a while ago he had received ten dollars from his sister. He stated he was going around asking for change for a ten from other residents. He stated another resident around that time had lost ten dollars. He stated the Administrator saw him with a ten dollar bill and came up to him in the hall and accused him of stealing the money. He stated he had tried to explain that the money had come from his sister and at that point, the Administrator made him go down to her office and call his sister. He stated his sister confirmed that she had sent him ten dollars over the phone. He stated the Administrator apologized to him afterwards. He stated it was embarrassing at first, but he was over it. He stated he knows other residents and employees heard her accusing him of stealing money. Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had witnessed the Administrator start yelling and accusing Resident #13 of stealing ten dollars. She stated the Administrator went up to Resident #13 in the hallway and started accusing him of stealing the ten dollars from another resident and demanded he go down to her office and call his sister to confirm he got the ten dollars from her. She stated she was embarrassed for Resident #13 because she yelled at him in the middle of the hallway with other employees and residents around. Interview with LVN D on 06/16/17 at 2:17 p.m. revealed she witnessed the Administrator yell at Resident #13 in the hallway accusing the resident of stealing money. LVN D stated the Administrator had a very accusatory tone. The Administrator then took Resident #13 into her office and had him call his family member to confirm that the family did in fact give the resident the money and he did not steal it. LVN D stated she reported the incident to her direct supervisor, the DON. LVN D stated the DON reported the incident to the RDO because the RDO came and interviewed her. LVN D stated the RDO did not ask her about the incident but only asked her if you need something does the DON get it for you? LVN D stated she was never interviewed regarding what she witnessed. 5. Interview with the MDS Nurse on 06/16/17 at 10:15 a.m. revealed there were specific incidents of verbal abuse by the Administrator towards Residents #8 and #13. She said a meeting was held which consisted of the RDO, the Regional Nurse Consultant, the DON, the ADON, the Administrator, and herself, in which verbal abuse of residents by the Administrator was discussed. She revealed the RDO assured everyone the problem would be investigated and handled. 6. Review of Resident #14's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 11 indicating mild cognitive impairment. Resident #14 required supervision with ADLs. Review of unsigned Progress Notes dated 05/27/17 at 3:25 p.m. revealed Resident #14 received 5 day notice of room relocation due to needing to be moved to a dually certified bed. Resident #14 requested to be moved to another facility stating needs to get out of this environment. Interview with LVN C on 06/16/17 at 9:04 a.m. revealed Resident #14 wanted to move to another facility because of the Administrator. When Resident #14 was moving out of the facility, the Administrator said to the resident in a sarcastic tone do you need help? LVN C stated Resident #14 had plenty of help and did not need additional assistance moving his belongings. LVN C revealed the Administrator was like the mean girl in high school. She stated she heard the Administrator tell Resident #14 to quit breaking things in my building. She stated the administrator was very loud and rude. Interview with LVN C on 06/16/17 at 4:40 p.m. revealed Resident #14 had caused some type of damage in his bathroom and the administrator told the resident she was going to start charging him for repairs to my building. She said she provided care for Resident #14 and had seen a decline in the resident in recent months which the resident attributed to anxiety related to the Administrator. She said the Administrator had retaliated against Resident #8 because she would not change rooms. She said the Administrator talked to residents inappropriately in front of others. Interview with LVN A on 06/15/17 at 4:00 p.m. revealed the Administrator was afraid of another complaint and wanted Resident #14 out of the building. She stated she did not know why the Administrator felt threatened by Resident #14. 7. A written statement presented by LVN B on 06/15/17 reflected: Concerns: She (administrator) has demonstrated a lack of [MEDICATION NAME] for these people. I have heard her complain about a resident being too loud breathing was driving her crazy and wanted her back on south hall. She forced (Resident #14) to move-he told her he was ready to comply and follow whatever rules she had he just wanted to stay-she stated no way, he is out of here. I tried to explain to her he needed time to adjust and for his meds to be effective and would modify his behavior. She was upset with (Resident #8), then became determined to move her out of her room for a show of power-The resident became very distressed over this crying at times. Then she decided to move (Resident #11) because she stated her BM smelled really bad and wanted her further down the hall. A resident dropped some trash in her trash can in her office and she had it removed immediately. Everyone said speak up when you see an injustice. The truth is everyone is afraid-if we speak the truth, then we set ourselves up for failure. How have we improved the situation if we lose our jobs? She has spied on Resident #8 while she was engaged in a private conversation with another person; she stood outside the door and listened to every word. 8. In a confidential group interview on 06/13/17 at 1:00 p.m. with 12 residents identified by the facility as interviewable, six of 12 said the administrator was rude and said inappropriate things to the residents and staff. 9. An immediate jeopardy was identified on 06/14/17 at 3:42 p.m. The RDO and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. 10. The facility's Plan of Removal, accepted on 06/16/17 at 3:33 p.m. reflected: In order to ensure resident safety from abuse, all staff will be educated on the definition of verbal abuse; as well as training, intervention, protection, reporting, and investigating. To further protect residents from abuse, all staff will be educated that any time verbal abuse is suspected the employee must call the Facility Abuse Coordinator (the interim Administrator) immediately. In the event the Facility Abuse Coordinator does not respond then the employee should call the Alternate Abuse Coordinator, the Regional Nurse Consultant. All staff will be educated on how to protect the residents if they suspect abuse has occurred. Specifically, the staff is being trained to protect and report The 3 residents who reported they had been verbally abused were interviewed by the Facility Ambassadors to ensure they feel safe. All alert and oriented residents were interviewed by the Facility Ambassadors to ensure they feel safe. All staff will be educated on where to locate the number to the compliance line in the event they are not comfortable reporting it to the Facility Abuse Coordinator Department heads will conduct random interviews during their daily rounds to ensure the residents feel safe & free from verbal abuse. A QA Meeting was held on 6/15/2017 with members of the QA team and the Medical Director The Administrator was suspended and immediately left the facility upon RDO learning of the alleged verbal abuse. Investigation into the Administrator's alleged unprofessional conduct is ongoing. Director of Nursing and Assistant Director of Nursing have

Based on interview and record review, the facility failed to have evidence that all alleged abuse violations were investigated thoroughly and reported to the Department of Aging and Disabilities for four (Resident #8, Resident #11, Resident #13, and Resident #14) of 14 residents reviewed for abuse and neglect. The facility failed to thoroughly investigate four complaints of verbal/mental abuse by the Administrator for Residents (#8 and #11). The RDO failed to report allegations of verbal and mental abuse to the Department of Aging and Disabilities. An Immediate Jeopardy was identified on 06/14/17. The Immediate Jeopardy was removed on 06/16/17. The facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 46 residents at risk of being further abused and neglected due to the facility's lack of response and investigation after an allegation of abuse was made. Findings included: 1. Review of Resident #8 undated face sheet received 06/15/17 revealed resident was a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #8 MDS assessment dated [DATE] revealed resident has a BIMS score of 15 indicating no cognitive impairment. Resident required extensive assistance with dressing and toilet use, total dependence with transfers. Interview with Resident #8 on 06/13/17 at 3:30 p.m. revealed she had been at the facility for approximately five years and was the Resident Council secretary. She stated she had been in the same room for almost her entire stay at the facility. She stated she was as a big woman; she had to have a specialty bariatric bed and recently received an electric wheelchair which allowed her better freedom and independence. She revealed she was very self-conscious about her weight, but had been trying to lose weight so she could have an eye surgery to improve her sight. She stated a few weeks ago, several residents came to her with a complaint about the brand of chocolate milk being switched. She revealed she went to the dietary manager to discuss the residents' concerns and after she finished her conversation, the Administrator followed her into her room. She stated the Administrator started going off on her about how there were going to be changes and everyone would have to get used to it. Then the Administrator stated some people were gaining too much weight drinking all of that chocolate milk anyways. She stated she felt the Administrator was directing that comment towards her because she loved chocolate milk and drank it at almost every meal. Resident #8 revealed after being yelled at by the Administrator about the chocolate milk, she stopped drinking chocolate milk and stated her feelings were hurt. She revealed the Administrator started coming into her room more often and yelled at her about several other things including telling her to quit spreading rumors about her firing staff. She stated several times, the Administrator would come into her room and start raising her voice and she felt embarrassed and upset because she would yell at her and not even close the door. She stated after the first couple of incidents, she called the corporate office and the RDO came out to investigate. She stated the RDO did interview her about everything, and she stated she told her about the verbal and mental abuse. Resident #8 revealed the RDO told her that she was going to be honest with her and she was not going to fire the Administrator. Resident #8 stated after she reported the Administrator to the corporate office and started learning about her resident rights and letting other residents know, the Administrator started telling her she was going to have to move to a different room or be forced to have a roommate. Resident #8 stated she was emotionally distraught about having to get a roommate because she was unable to use her electric chair if she had another person in the room with her. She stated she was scared she was going to lose her mobility. Resident #8 stated the Administrator came in several times, threatening her with having a roommate and each time she became emotionally distraught. She stated she often broke down in tears and had to be comforted by the DON and LVN J. She stated someone else reported her concern to the RDO, because she came out to investigate again. She stated the RDO interviewed her again, but the RDO did not do anything about her concerns. She stated she was afraid of the Administrator and did not feel safe in her own home. Interview with Resident #8 on 06/15/17 at 11:30 a.m. revealed she was happy with her current room, but the room she was asked to accept would have meant the loss of some of her personal items because of the way it was laid out. And, because she used a large power chair and a large bed, the addition of a roommate would have made it impossible to keep and use these items. She said she feared a complete loss of mobility which she had only just recently secured when she got her power chair. Before that, she said she spent two years in bed and was terrified of losing the mobility the power chair provided. Interview with Resident #8 on 06/16/17 at 1:25 p.m. revealed she had gone to the RDO on 04/27/17 to complain about mistreatment and retaliation from the administrator. She told the RDO that the administrator had told her that she had all the rights and the resident could not do anything about it. She also told the RDO that the administrator had yelled at her on several occasions. The RDO then asked her to give the administrator another chance. During this conversation, which was supposed to be private, she noticed the administrator was standing outside the door listening to the conversation. The RDO's investigation on 05/18/17 through 05/19/17 included interviewing the DON regarding the Ombudsman report and about the Administrator not following up on complaints, retaliating against residents by making them move, and 'threatening' Resident #8 with a roommate. The RDO reviewed the grievances and followed up to ensure all complaints had been addressed. The RDO stated she 'commended the Administrator and her team on their follow up and monitoring to prevent reoccurrences.' The RDO's investigation did not reveal she had investigated the retaliation issue or the threats made by the Administrator to Resident #8. The investigation was never reported to the state agencies. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed in the beginning of March of 2017, Resident #8 had called corporate and had made a complaint about a chocolate milk incident with the Administrator. She stated she interviewed Resident #8 and interviewed Resident #8. She stated she told Resident #8 to give the Administrator a chance to be better. She revealed she did not have any evidence of the investigation regarding the chocolate milk incident. She then revealed on 05/17/17, the Administrator called her and told her the ombudsman felt she was retaliating against Resident #8 by making them move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. She stated she interviewed Resident #8 and she stated Resident #8's only concern was not following up on complaints from the Resident Council. She stated she ensured the Administrator was following up on all the complaints and when she was sure all the complaints were followed up on, she let the Administrator come back to work. The RDO stated Resident #8 was out to get the Administrator and she believed the only thing that would make Resident #8 happy would to be to fire the Administrator. The RDO revealed she just thought Resident #8 was having a [MEDICAL CONDITION] episode and was paranoid about the Administrator. She revealed her investigation simply consisted of talking to the DON and Resident #8 and #11 about their concerns, and ensuring the Administrator was following up on the complaints. She stated she believed it was not retaliation because it seemed like Resident #8 was [MEDICAL CONDITION] and just out to get the Administrator. The RDO stated the resident interviews she conducted concerned making sure their grievance had been followed up on by the Administrator. Interview with the LVN J on 06/13/17 at 5:15 p.m. revealed she had heard the Administrator yelling at Resident #8 several different occasions. She stated she heard the Administrator tell Resident #8 that some residents were gaining too much weight drinking all that chocolate milk. LVN J revealed the Administrator knew Resident #8's weight was a sore spot for her. She stated she did not know how, but the Administrator knew Resident #8 had called corporate on her and after that it seemed like she was out to get Resident #8. She stated she heard the Administrator go into her room several different times and raise her voice and threaten Resident #8 with a roommate if she did not do what she wanted. She stated Resident #8 was terrified of having a roommate because she would be unable to use her electric wheelchair. LVN J revealed Resident #8 was a whole new person after getting the customized wheelchair and had left her bed and started being more involved. She stated the Administrator was torturing Resident #8 by threatening her with a roommate. She stated she had to go over to Resident #8's room several times after the Administrator left the room to comfort her because she was having an emotional breakdown. She stated she had called the corporate compliance line herself with the DON to report the verbal abuse. She stated the RDO had been out twice to investigate and did not do anything about the problem. She stated the Administrator created a very hostile work environment and scared other employees from coming forward with their concerns. Interview with the DON on 06/13/17 at 5:30 p.m. revealed the administrator routinely talked to several residents in a condescending manner. She said the fact that there was no bathroom in Residents #8's and #11's rooms was the official reason for the administrator asking these two residents to move to different rooms. Bedpans from these residents had to be carried down the hall to be cleaned. However, she said the staff had been doing this for years and it was not a problem. She said she believed the real reason was that these residents had overheard things from the administrator's office and had called the corporate office on her. She wanted them moved to the end of the hall so they could not hear. Interview with the DON on 06/14/17 at 8:00 a.m. revealed she had seen several problems between the administrator and residents and was aware of most of the problems. She said she had seen inappropriate verbal interaction between the administrator and Resident #8. Asked if this constituted verbal abuse, she said yes. Asked what her action would have been if this had been a CNA, she said that person would be suspended pending investigation. She said she feared retaliation, but did report the abuse to her superior (the Regional Nurse Consultant). Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had known Resident #8 for several years now and she stated Resident #8 used to always be happy and now she has been so much more tearful and depressed since the Administrator was hired a few months ago. She stated the RDO was good friends with the Administrator and would not do anything about their complaints. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed a few weeks ago they had changed vendors who supplied the chocolate milk. She stated Resident #8 was upset about the change to low fat chocolate milk. She revealed she did talk to Resident #8 about the change and did tell her that some residents were gaining too much weight drinking the chocolate milk. She stated she was just a naturally loud person. She stated she had been suspended by the RDO after a complaint was made about her possibly retaliating against Residents #8 and #11, but she had been reinstated two days later. Interview with the RDO on 06/15/17 at 4:40 p.m. revealed the Administrator is the abuse coordinator and the DON is the alternate abuse coordinator if the Administrator was unavailable. She said if the DON received an abuse allegation against the administrator the policy was for the DON to report the allegation to corporate staff. She said if there was an abuse allegation against any other staff the DON would suspend staff pending investigation. Telephone interview with the Regional Nurse Consultant on 06/15/17 at 11:00 a.m. revealed verbal abuse of a resident by the Administrator may have been mentioned to her but she was focused on providing guidance to staff located at another facility. 2. Review of Resident #11's undated face sheet received 06/15/17 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating no cognitive impairment. The resident had no behaviors. She required extensive assistance with toileting, independent and supervision with transfers. Review of Resident #11's Mental and Behavioral Health Visit Note dated 06/08/17 reflected Resident #11 processed reduction in anxiety with staff decision that she could stay in her preferred room and not move. Interview with Resident #11 on 06/13/17 at 3:00 p.m. revealed the Administrator had come to her a few weeks ago asking for her to move rooms down the hall. She stated she told the Administrator she did not wish to move rooms. She stated this seemed to make the Administrator upset and she started being very ugly to her. She revealed she felt like there was a motive behind the Administrator wanting her to move. She stated the Administrator started asking her to move rooms away from the other residents when she had started passing out information to other residents about their rights. She stated the Administrator would come into her room and start demanding she move rooms. She stated the Administrator spoke to her and made her feel like she was the scum of the earth. She stated the Administrator was very cold and mean in her tone of voice to her whenever the Administrator spoke to her about moving rooms. She stated the Administrator wanted to move her to a smaller room away from other residents and she told the Administrator about her concerns about the lack of room and interaction with other people. She stated the Administrator did not care and ignored her concerns. She stated she started to feel threatened and scared of the Administrator because if she moved her to a different room she honestly felt like she would die and would be better off with God. Finally, the ombudsman did confront the Administrator about the room situation and she stated the Administrator backed off. She stated she still felt unsafe with the Administrator in the building and she would probably find another way to torment her. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed the Administrator called her and told her the ombudsman felt she was retaliating against Resident #11 by making them move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. The RDO stated Resident #11 was out to get the Administrator . An interview by telephone with Resident #11's family member on 06/14/17 at 9:40 a.m. revealed the administrator was not happy with Residents #8 and #11 because they had passed out a copy of resident's rights to other residents. He/She said she felt Resident #11 was manipulated and mistreated by the administrator for this reason. He/She said this mistreatment caused Resident #11 to be very depressed and made her high blood pressure issue worse because she was very upset. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed she had been asking Resident #11 to move rooms because she wanted to move a resident who was a higher fall risk into her room. She stated Resident #11 did not want to move rooms and she stated she must have told the ombudsman because the ombudsman revealed Resident #11 felt like she was being retaliated against. She stated the RDO had suspended her and investigated the concern. 3. Review of Resident #13's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS score of 13 indicated the resident was not cognitively impaired and he did not have behaviors. The resident required extensive assistance with dressing and supervision with transfers. Interview with Resident #13 on 06/15/17 at 9:10 a.m. revealed a while ago he had received ten dollars from his sister. He stated he was going around asking for change for a ten from other residents. He stated another resident around that time had lost ten dollars. He stated the Administrator saw him with a ten dollar bill and came up to him in the hall and accused him of stealing the money. He stated he had tried to explain that the money had come from his sister and at that point, the Administrator made him go down to her office and call his sister. He stated his sister confirmed that she had sent him ten dollars over the phone. He stated the Administrator apologized to him afterwards. He stated it was embarrassing at first, but he was over it. He stated he knows other residents and employees heard her accusing him of stealing money. Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had witnessed the Administrator start yelling and accusing Resident #13 of stealing ten dollars. She stated the Administrator went up to Resident #13 in the hallway and started accusing him of stealing the ten dollars from another resident and demanded he go down to her office and call his sister to confirm he got the ten dollars from her. She stated she was embarrassed for Resident #13 because she yelled at him in the middle of the hallway with other employees and residents around. Interview with LVN D on 06/16/17 at 2:17 p.m. revealed she witnessed the Administrator yell at Resident #13 in the hallway accusing the resident of stealing money. LVN D stated the Administrator had a very accusatory tone. The Administrator then took Resident #13 into her office and had him call his family member to confirm that the family did in fact give the resident the money and he did not steal it. LVN D stated she reported the incident to her direct supervisor, the DON. LVN D stated the DON reported the incident to the RDO because the RDO came and interviewed her. LVN D stated the RDO did not ask her about the incident but only asked her if you need something does the DON get it for you? LVN D stated she was never interviewed regarding what she witnessed. 4. Interview with the MDS Nurse on 06/16/17 at 10:15 a.m. revealed there were specific incidents of verbal abuse by the Administrator towards Residents #8 and #13. She said a meeting was held which consisted of the RDO, the Regional Nurse Consultant, the DON, the ADON, the Administrator, and herself, in which verbal abuse of residents by the Administrator was discussed. She revealed the RDO assured everyone the problem would be investigated and handled. 5. Review of Resident #14's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 11 indicating mild cognitive impairment. Resident #14 required supervision with ADLs. Review of unsigned Progress Notes dated 05/27/17 at 3:25 p.m. revealed Resident #14 received 5 day notice of room relocation due to needing to be moved to a dually certified bed. Resident #14 requested to be moved to another facility stating needs to get out of this environment. Interview with LVN C on 06/16/17 at 9:04 a.m. revealed Resident #14 wanted to move to another facility because of the Administrator. When Resident #14 was moving out of the facility, the Administrator said to the resident in a sarcastic tone do you need help? LVN C stated Resident #14 had plenty of help and did not need additional assistance moving his belongings. LVN C revealed the Administrator was like the mean girl in high school. She stated she heard the Administrator tell Resident #14 to quit breaking things in my building. She stated the administrator was very loud and rude. Interview with LVN C on 06/16/17 at 4:40 p.m. revealed Resident #14 had caused some type of damage in his bathroom and the administrator told the resident she was going to start charging him for repairs to my building. She said she provided care for Resident #14 and had seen a decline in the resident in recent months which the resident attributed to anxiety related to the Administrator. She said the Administrator had retaliated against Resident #8 because she would not change rooms. She said the Administrator talked to residents inappropriately in front of others. Interview with LVN A on 06/15/17 at 4:00 p.m. revealed the Administrator was afraid of another complaint and wanted Resident #14 out of the building. She stated she did not know why the Administrator felt threatened by Resident #14. 6. A written statement presented by LVN B on 06/15/17 reflected: Concerns: She (administrator) has demonstrated a lack of [MEDICATION NAME] for these people. I have heard her complain about a resident being too loud breathing was driving her crazy and wanted her back on south hall. She forced (Resident #14) to move-he told her he was ready to comply and follow whatever rules she had he just wanted to stay-she stated no way, he is out of here. I tried to explain to her he needed time to adjust and for his meds to be effective and would modify his behavior. She was upset with (Resident #8), then became determined to move her out of her room for a show of power-The resident became very distressed over this crying at times. Then she decided to move (Resident #11) because she stated her BM smelled really bad and wanted her further down the hall. A resident dropped some trash in her trash can in her office and she had it removed immediately. Everyone said speak up when you see an injustice. The truth is everyone is afraid-if we speak the truth, then we set ourselves up for failure. How have we improved the situation if we lose our jobs? She has spied on Resident #8 while she was engaged in a private conversation with another person; she stood outside the door and listened to every word. 7. Review of the Abuse-Reportable Events policy and procedure dated 12/16 reflected the following: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/even in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal Abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. The home's administration will conduct and investigate allegations of crimes, suspected abuse, neglect, or misappropriation of property, and will provide notification and release of information to the proper authorities in accordance with federal and state regulations. An immediate jeopardy in the area of administration, verbal abuse, and failure to report was identified on 06/14/17 at 3:42 p.m. The RDO and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. The facility's Plan of Removal, accepted on 06/16/17 at 3:33 p.m. reflected: In order to ensure resident safety from abuse, all staff will be educated on the definition of verbal abuse; as well as training, intervention, protection, reporting, and investigating. To further protect residents from abuse, all staff will be educated that any time verbal abuse is suspected the employee must call the Facility Abuse Coordinator (the interim Administrator) immediately. In the event the Facility Abuse Coordinator does not respond then the employee should call the Alternate Abuse Coordinator, the Regional Nurse Consultant. All staff will be educated on how to protect the residents if they suspect abuse has occurred. Specifically, the staff is being trained to protect and report The Administrator was suspended and immediately left the facility upon RDO learning of the alleged verbal abuse. Investigation into the Administrator's alleged unprofessional conduct is ongoing. Director of Nursing and Assistant Director of Nursing have been suspended pending investigation for failure to report suspected verbal abuse following their report to RDO that they were aware of alleged verbal abuse and did not report. Per Company Policy and Code of Conduct, both the DON and ADON will be terminated. An interim DON will start June 22, 2017. Until that time, the facility will have RN coverage 8 hours a day/7days a week. The RN covering for the day will be in charge of clinical systems for the assigned day. The RN will have the support of the Regional Nurse Consultant by telephone. Ambassadors are members of the clinical management and administrative staff. Each are assigned to a block of resident rooms, and acts as an advocate for those residents. Ambassadors visit their assigned residents each day they are assigned to work. Calls are being placed to staff members that are not scheduled to work/PRN/on leave, and in servicing is being conducted over the phone for those not able to come to the facility. Post test questions will be asked at the end of their training to ensure their understanding of the materials. The Administrator will not be returning to her position as Administrator at Trinity Nursing and Rehab of Granbury. The RDO stepped out of the investigation. Monitoring: Interview with LVN C, LVN D, CNA E, LVN F, RA G, CNA H, CNA I on 06/16/17 between 2:17 p.m. - 4:00 p.m. revealed all received training regarding identifying and reporting abuse and neglect. All stated were able to identify who the abuse coordinator was. Staff was trained on whom to report allegations of abuse to if the abuse coordinator or management was the alleged perpetrator. Staff interviewed represented various shifts. Review of staff training and competence test completed on 06/16/17 revealed all staff was trained regarding identifying and reporting allegations of abuse and neglect. Interview with the Corporate MDS Consultant on 06/16/17 at 9:50 a.m. revealed the RDO was threatening to discharge Residents #8 and #11 and bring the Administrator back to the facility. The Regional Director of Operations had knowledge of the alleged abuse but was protecting the Administrator for an unknown reason. Corporate MDS Consultant stated she has been in contact with her supervisor and corporate compliance regarding the situation. Interview with LVN A on 06/15/17 at 4:00 p.m. revealed during a meeting earlier today, the RDO told her when state left the building she would reinstate the Administrator and get rid of Resident #8. Review of staff training and competence test completed on 06/16/17 revealed all staff was trained regarding identifying and reporting allegations of abuse and neglect On 06/16/17, the IJ was removed. On 06/16/17, at 4:00 p.m. the Interim Administrator was informed the IJ was removed. While the IJ was removed on 06/16/17, the facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. The facility's Resident and Census and Conditions of Residents, Form CMS-672, signed and dated by the MDS Nurse 06/13/17 reflected a census of 46 residents.

Based on interview and record review, the facility failed to ensure each resident was free from abuse and neglect for four (Resident #8, Resident #11, Resident #14 and Resident #13) of 14 residents reviewed for abuse and neglect. The Administrator verbally and mentally abused Resident #8 on several occasions resulting in Resident #8 becoming emotionally distraught, anxious and fearful. The Administrator verbally and mentally abused Resident #11 on several occasions resulting in Resident #11 feeling unsafe and threatened in the facility. The Administrator verbally abused Resident #13 on one occasion accusing him of stealing money in front of other residents and staff in a public hallway. The Administrator verbally abused Resident #14 forcing him to want to move to another facility. An Immediate Jeopardy was identified on 06/14/17. The Immediate Jeopardy was removed on 06/16/17. The facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 46 residents at risk of being abused or neglected due to the Administrator being in charge of the entire facility and the failure of the RDO to keep the residents safe when an allegation was presented to her. Findings included: 1. Review of Resident #8 undated face sheet received 06/15/17 revealed resident was a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a nurse's note dated 04/25/17 at 8:00 p.m. reflected Resident requesting this nurse to come to her room to read resident rights which she has pulled up on her computer screen related to resident having increased anxiety, because she says she might possibly get roommate and has called staff to her room multiple times to go over scenario related to furniture arrangement and wheelchair placement as if there were another bed in room with her. Review of Resident #8's Mental and Behavioral Health Visit Note dated 04/27/17 reflected the resident to be anxious, tearful, somewhat agitated with potential roommate but used time well to process issues. Review of a nurse's note dated 04/27/17 reflected Resident awake at this time continues to concentrate on computer, reading resident rights, appears very worried and concerned about changes in near future. Resident only sleeping on and off during the night. Review of Resident #8 MDS assessment dated [DATE] revealed resident has a BIMS score of 15 indicating no cognitive impairment. Resident required extensive assistance with dressing and toilet use, total dependence with transfers. Review of Resident #8's Mental and Behavioral Health Visit Note dated 05/11/17 revealed the resident to be less anxious than last visit but still concerned/anxious that she'll have to share a room with increasing census. Review of the Monthly Summary dated 05/16/17 reflected resident was obsessed with room change pending and getting roommate. Review of Resident #8's Mental & Behavioral Health Visit Note dated 05/25/17 revealed Description & Purpose of Clinician Interventions: Processed some recent anxiety and irritation with staff wanting her to move to another room while reflecting reducing in anxiety, satisfaction that these plans for now are no longer in place and pt. will be kept in her room. Patient's response to Interventions/Progress toward Goal: Pt acknowledges she needs to revert back to better health behaviors/dietary work to lose weight and that when she feel stressed she gets off her diet. Review of Resident #8 Mental & Behavioral Health Visit Note dated 06/08/17 revealed Description & Purpose of Clinician Interventions: Follow up to assess mood. Reflected/reinforce self-perceived reduction in anxiety with closure of staff efforts to move pt. to another room. Interview with Resident #8 on 06/13/17 at 3:30 p.m. revealed she had been at the facility for approximately five years and she was the Resident Council secretary. She stated she had been in the same room for almost her entire stay at the facility. She stated she was as a big woman; she had to have a specialty bariatric bed and recently received an electric wheelchair which allowed her better freedom and independence. She revealed she was very self-conscious about her weight, but had been trying to lose weight so she could have an eye surgery to improve her sight. She stated a few weeks ago, several residents came to her with a complaint about the brand of chocolate milk being switched. She revealed she went to the dietary manager to discuss the residents' concerns and after she finished her conversation, the Administrator followed her into her room. She stated the Administrator started going off on her about how there were going to be changes and everyone would have to get used to it. Then the Administrator stated some people were gaining too much weight drinking all of that chocolate milk anyways. She stated she felt the Administrator was directing that comment towards her because she loved chocolate milk and drank it at almost every meal. Resident #8 revealed after being yelled at by the Administrator about the chocolate milk, she stopped drinking chocolate milk and stated her feelings were hurt. She revealed the Administrator started coming into her room more often and yelled at her about several other things including telling her to quit spreading rumors about her firing staff. She stated several times, the Administrator would come into her room and start raising her voice and she felt embarrassed and upset because she would yell at her and not even close the door. She stated after the first couple of incidents, she called the corporate office and the RDO came out to investigate. She stated the RDO did interview her about everything, and she stated she told her about the verbal and mental abuse. Resident #8 revealed the RDO told her that she was going to be honest with her and she was not going to fire the Administrator. Resident #8 stated after she reported the Administrator to the corporate office and started learning about her resident rights and letting other residents know, the Administrator started telling her she was going to have to move to a different room or be forced to have a roommate. Resident #8 stated she was emotionally distraught about having to get a roommate because she was unable to use her electric chair if she had another person in the room with her. She stated she was scared she was going to lose her mobility. Resident #8 stated the Administrator came in several times, threatening her with having a roommate and each time she became emotionally distraught. She stated she often broke down in tears and had to be comforted by the DON and LVN J. She stated someone else reported her concern to the RDO, because she came out to investigate again. She stated the RDO interviewed her again, but the RDO did not do anything about her concerns. She stated she was afraid of the Administrator and did not feel safe in her own home. Interview with Resident #8 on 06/15/17 at 11:30 a.m. revealed she was happy with her current room, but the room she was asked to accept would have meant the loss of some of her personal items because of the way it was laid out. And, because she used a large power chair and a large bed, the addition of a roommate would have made it impossible to keep and use these items. She said she feared a complete loss of mobility which she had only just recently secured when she got her power chair. Before that, she said she spent two years in bed and was terrified of losing the mobility the power chair provided. Interview with Resident #8 on 06/16/17 at 1:25 p.m. revealed she had gone to the RDO on 04/27/17 to complain about mistreatment and retaliation from the administrator. She told the RDO that the administrator had told her that she had all the rights and the resident could not do anything about it. She also told the RDO that the administrator had yelled at her on several occasions. The RDO then asked her to give the administrator another chance. During this conversation, which was supposed to be private, she noticed the administrator was standing outside the door listening to the conversation. In a document presented to the surveyor by Resident #8 on 06/13/17 at 1:30 p.m. she wrote: This is a list of concerns we have pertaining to the administrator of our nursing home. She belittles residents. I heard her out in the hallway loudly accuse a resident of stealing money. She asked him where he had gotten the money. He told her his sister had sent it to him. She then told him that she was taking him to her office to call his sister. A few minutes later he passed my door going back down the hall.then she says to him she is still going to keep an eye on him. At another time a resident was going back to his room after a meal and she loudly calls to him down the hallway. He stops in the middle of the hall and she starts yelling at him about taking a sandwich from the plate of his tablemate. The resident tells her he thought the man had finished and had left the table. He had been gone from the table a long time then I hear her say I have seen you take food before so I am going to keep an eye on you. The man gathers leftover scraps after meals to feed the cats out in the backyard. As officers of the resident council we feel that it is our duty to make sure all residents know and understand their rights . we were told we could not do this because it was invading the other residents right to privacy. Not long after the last meeting she came to me to tell me she was going to move me out of the room I have lived in for the last five or so years. When I asked her why she wanted to move me all she would tell me was that she was doing some rearranging. As it turned out I was the only one she was rearranging. I told her I didn't want to move and that I didn't think she could move me without a very good reason. She came back a day or so later and told me she wanted to put fall risk residents close to the nursing station and close to the DON's office. My room is near both. In all the time I have lived in this room this has never been an issue The administrator told me either I moved or she would put another resident in the room with me .Basically this was a threat. But I agreed to move. She has used this threat several times when she thought I might back out on moving. I feel that this whole moving thing is in retaliation for the fact that the council stands up for our rights and the rights of the other residents. When I went to her about this she told me she would be moving someone else, as it turned out, the president of the resident council who has refused to move but agreed to have a roommate if needed. Still the administrator nagged her to move. She is two doors down. We both feel this is a reprisal against us as officers of the resident council Neither room is a good fit for us because we would lose items that would diminish our quality of life She has no respect for the residents or their privacy. My back was to the door when I heard someone in my room. I turned around and the administrator was standing there glaring at me. She did not knock or announce herself. I stated to ask her what she needed but she laid into me. Something about a rumor going around about her. The rumor was that she had fired the dietary manager and hired a friend to be the manager. I am a big woman and she even hit me with a personal knock about it. Interview with the LVN J on 06/13/17 at 5:15 p.m. revealed she had heard the Administrator yelling at Resident #8 several different occasions. She stated she heard the Administrator tell Resident #8 that some residents were gaining too much weight drinking all that chocolate milk. LVN J revealed the Administrator knew Resident #8's weight was a sore spot for her. She stated she did not know how, but the Administrator knew Resident #8 had called corporate on her and after that it seemed like she was out to get Resident #8. She stated she heard the Administrator go into her room several different times and raise her voice and threaten Resident #8 with a roommate if she did not do what she wanted. She stated Resident #8 was terrified of having a roommate because she would be unable to use her electric wheelchair. LVN J revealed Resident #8 was a whole new person after getting the customized wheelchair and had left her bed and started being more involved. She stated the Administrator was torturing Resident #8 by threatening her with a roommate. She stated she had to go over to Resident #8's room several times after the Administrator left the room to comfort her because she was having an emotional breakdown. She stated she had called the corporate compliance line herself with the DON to report the verbal abuse. She stated the RDO had been out twice to investigate and did not do anything about the problem. She stated the Administrator created a very hostile work environment and scared other employees from coming forward with their concerns. Interview with the DON on 06/13/17 at 5:30 p.m. revealed the administrator routinely talked to several residents in a condescending manner. She said the fact that there was no bathroom in Residents #8's and #11's rooms was the official reason for the administrator asking these two residents to move to different rooms. Bedpans from these residents had to be carried down the hall to be cleaned. However, she said the staff had been doing this for years and it was not a problem. She said she believed the real reason was that these residents had overheard things from the administrator's office and had called the corporate office on her. She wanted them moved to the end of the hall so they could not hear. Interview with the DON on 06/14/17 at 8:00 a.m. revealed she had seen several problems between the administrator and residents and was aware of most of the problems. She said she had seen inappropriate verbal interaction between the administrator and Resident #8. Asked if this constituted verbal abuse, she said yes. Asked what her action would have been if this had been a CNA, she said that person would be suspended pending investigation. She said she feared retaliation, but did report the abuse to her superior (the Regional Nurse Consultant). Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had known Resident #8 for several years now and she stated Resident #8 used to always be happy and now she has been so much more tearful and depressed since the Administrator was hired a few months ago. She stated the RDO was good friends with the Administrator and would not do anything about their complaints. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed a few weeks ago they had changed vendors who supplied the chocolate milk. She stated Resident #8 was upset about the change to low fat chocolate milk. She revealed she did talk to Resident #8 about the change and did tell her that some residents were gaining too much weight drinking the chocolate milk. She stated she was just a naturally loud person. She stated she had been suspended by the RDO after a complaint was made about her possibly retaliating against Residents #8 and #11, but she had been reinstated two days later. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed in the beginning of March of 2017, Resident #8 had called corporate and had made a complaint about a chocolate milk incident with the Administrator. She stated she interviewed Resident #8 and investigated the complaint. She stated she told Resident #8 to give the Administrator a chance to be better. She then revealed on 05/17/17, the Administrator called her and told her the ombudsman felt she was retaliating against Resident #8 by making her move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. She stated she interviewed Resident #8 and she stated Resident #8's only concern was not following up on complaints from the Resident Council. She stated she ensured the Administrator was following up on all the complaints and when she was sure all the complaints were followed up on, she let the Administrator come back to work. The RDO stated Resident #8 was out to get the Administrator and she believed the only thing that would make Resident #8 happy would to be to fire the Administrator. The RDO revealed she just thought Resident #8 was having a [MEDICAL CONDITION] episode and was paranoid about the Administrator. Interview with the RDO on 06/15/17 at 4:40 p.m. revealed the Administrator is the abuse coordinator and the DON is the alternate abuse coordinator if the Administrator was unavailable. She said if the DON received an abuse allegation against the administrator the policy was for the DON to report the allegation to corporate staff. She said if there was an abuse allegation against any other staff the DON would suspend staff pending investigation. Telephone interview with the Regional Nurse Consultant on 06/15/17 at 11:00 a.m. revealed verbal abuse of a resident by the Administrator may have been mentioned to her by the DON but she was focused on providing guidance to staff located at another facility. 2. Review of Resident #11's undated face sheet received 06/15/17 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating no cognitive impairment. The resident had no behaviors. She required extensive assistance with toileting, independent and supervision with transfers. Review of Resident #11's Mental and Behavioral Health Visit Note dated 06/08/17 reflected Resident #11 processed reduction in anxiety with staff decision that she could stay in her preferred room and not move. Interview with Resident #11 on 06/13/17 at 3:00 p.m. revealed the Administrator had come to her a few weeks ago asking for her to move rooms down the hall. She stated she told the Administrator she did not wish to move rooms. She stated this seemed to make the Administrator upset and she started being very ugly to her. She revealed she felt like there was a motive behind the Administrator wanting her to move. She stated the Administrator started asking her to move rooms away from the other residents when she had started passing out information to other residents about their rights. She stated the Administrator would come into her room and start demanding she move rooms. She stated the Administrator spoke to her and made her feel like she was the scum of the earth. She stated the Administrator was very cold and mean in her tone of voice to her whenever the Administrator spoke to her about moving rooms. She stated the Administrator wanted to move her to a smaller room away from other residents and she told the Administrator about her concerns about the lack of room and interaction with other people. She stated the Administrator did not care and ignored her concerns. She stated she started to feel threatened and scared of the Administrator because if she moved her to a different room she honestly felt like she would die and would be better off with God. Finally, the ombudsman did confront the Administrator about the room situation and she stated the Administrator backed off. She stated she still felt unsafe with the Administrator in the building and she would probably find another way to torment her. An interview by telephone with Resident #11's family member on 06/14/17 at 9:40 a.m. revealed the administrator was not happy with Residents #8 and #11 because they had passed out a copy of resident's rights to other residents. He/She said she felt Resident #11 was manipulated and mistreated by the administrator for this reason. He/She said this mistreatment caused Resident #11 to be very depressed and made her high blood pressure issue worse because she was very upset. Interview with the Administrator on 06/14/17 at 2:00 p.m. revealed she had been asking Resident #11 to move rooms because she wanted to move a resident who was a higher fall risk into her room. She stated Resident #11 did not want to move rooms and she stated she must have told the ombudsman because the ombudsman revealed Resident #11 felt like she was being retaliated against. She stated the RDO had suspended her and investigated the concern. Interview with the RDO on 06/14/17 at 1:25 p.m. revealed on 05/17/17, the Administrator called her and told her the ombudsman felt she was retaliating against Resident #11 by making her move rooms. She stated she immediately suspended the Administrator and came up the next two days to investigate the concern. The RDO stated Resident #11 was out to get the Administrator. 3. Review of Resident #13's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS score of 13 indicated the resident was not cognitively impaired and he did not have behaviors. The resident required extensive assistance with dressing and supervision with transfers. Interview with Resident #13 on 06/15/17 at 9:10 a.m. revealed a while ago he had received ten dollars from his sister. He stated he was going around asking for change for a ten from other residents. He stated another resident around that time had lost ten dollars. He stated the Administrator saw him with a ten dollar bill and came up to him in the hall and accused him of stealing the money. He stated he had tried to explain that the money had come from his sister and at that point, the Administrator made him go down to her office and call his sister. He stated his sister confirmed that she had sent him ten dollars over the phone. He stated the Administrator apologized to him afterwards. He stated it was embarrassing at first, but he was over it. He stated he knows other residents and employees heard her accusing him of stealing money. Interview with LVN A on 06/14/17 at 9:54 a.m. revealed she had witnessed the Administrator start yelling and accusing Resident #13 of stealing ten dollars. She stated the Administrator went up to Resident #13 in the hallway and started accusing him of stealing the ten dollars from another resident and demanded he go down to her office and call his sister to confirm he got the ten dollars from her. She stated she was embarrassed for Resident #13 because she yelled at him in the middle of the hallway with other employees and residents around. Interview with LVN D on 06/16/17 at 2:17 p.m. revealed she witnessed the Administrator yell at Resident #13 in the hallway accusing the resident of stealing money. LVN D stated the Administrator had a very accusatory tone. The Administrator then took Resident #13 into her office and had him call his family member to confirm that the family did in fact give the resident the money and he did not steal it. LVN D stated she reported the incident to her direct supervisor, the DON. LVN D stated the DON reported the incident to the RDO because the RDO came and interviewed her. LVN D stated the RDO did not ask her about the incident but only asked her if you need something does the DON get it for you? LVN D stated she was never interviewed regarding what she witnessed. 4. Interview with the MDS Nurse on 06/16/17 at 10:15 a.m. revealed there were specific incidents of verbal abuse by the Administrator towards Residents #8 and #13. She said a meeting was held which consisted of the RDO, the Regional Nurse Consultant, the DON, the ADON, the Administrator, and herself, in which verbal abuse of residents by the Administrator was discussed. She revealed the RDO assured everyone the problem would be investigated and handled. 5. Review of Resident #14's MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 11 indicating mild cognitive impairment. Resident #14 required supervision with ADLs. Review of unsigned Progress Notes dated 05/27/17 at 3:25 p.m. revealed Resident #14 received 5 day notice of room relocation due to needing to be moved to a dually certified bed. Resident #14 requested to be moved to another facility stating needs to get out of this environment. Interview with LVN C on 06/16/17 at 9:04 a.m. revealed Resident #14 wanted to move to another facility because of the Administrator. When Resident #14 was moving out of the facility, the Administrator said to the resident in a sarcastic tone do you need help? LVN C stated Resident #14 had plenty of help and did not need additional assistance moving his belongings. LVN C revealed the Administrator was like the mean girl in high school. She stated she heard the Administrator tell Resident #14 to quit breaking things in my building. She stated the administrator was very loud and rude. Interview with LVN C on 06/16/17 at 4:40 p.m. revealed Resident #14 had caused some type of damage in his bathroom and the administrator told the resident she was going to start charging him for repairs to my building. She said she provided care for Resident #14 and had seen a decline in the resident in recent months which the resident attributed to anxiety related to the Administrator. She said the Administrator had retaliated against Resident #8 because she would not change rooms. She said the Administrator talked to residents inappropriately in front of others. Interview with LVN A on 06/15/17 at 4:00 p.m. revealed the Administrator was afraid of another complaint and wanted Resident #14 out of the building. She stated she did not know why the Administrator felt threatened by Resident #14. 6. A written statement presented by LVN B on 06/15/17 reflected: Concerns: She (administrator) has demonstrated a lack of [MEDICATION NAME] for these people. I have heard her complain about a resident being too loud breathing was driving her crazy and wanted her back on south hall. She forced (Resident #14) to move-he told her he was ready to comply and follow whatever rules she had he just wanted to stay-she stated no way, he is out of here. I tried to explain to her he needed time to adjust and for his meds to be effective and would modify his behavior. She was upset with (Resident #8), then became determined to move her out of her room for a show of power-The resident became very distressed over this crying at times. Then she decided to move (Resident #11) because she stated her BM smelled really bad and wanted her further down the hall. A resident dropped some trash in her trash can in her office and she had it removed immediately. Everyone said speak up when you see an injustice. The truth is everyone is afraid-if we speak the truth, then we set ourselves up for failure. How have we improved the situation if we lose our jobs? She has spied on Resident #8 while she was engaged in a private conversation with another person; she stood outside the door and listened to every word. 7. In a confidential group interview on 06/13/17 at 1:00 p.m. with 12 residents identified by the facility as interviewable, six of 12 said the administrator was rude and said inappropriate things to the residents and staff. 8. Review of the Abuse-Reportable Events policy and procedure dated 12/16 reflected the following: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/even in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Mental/psychological abuse: Mistreatment within the definition of abuse means to inappropriately treat or exploit a resident not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation. Verbal Abuse: The use of oral, written, or gestured language that includes disparaging derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. 9. An immediate jeopardy was identified on 06/14/17 at 3:42 p.m. The RDO and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. 10. The facility's Plan of Removal, accepted on 06/16/17 at 3:33 p.m. reflected: In order to ensure resident safety from abuse, all staff will be educated on the definition of verbal abuse; as well as training, intervention, protection, reporting, and investigating. To further protect residents from abuse, all staff will be educated that any time verbal abuse is suspected the employee must call the Facility Abuse Coordinator (the Interim Administrator) immediately. In the event the Facility Abuse Coordinator does not respond then the employee should call the Alternate Abuse Coordinator, the Regional Nurse Consultant. All staff will be educated on how to protect the residents if they suspect abuse has occurred. Specifically, the staff is being trained to protect and report The 3 residents who reported they had been verbally abused were interviewed by the Facility Ambassadors to ensure they feel safe. All alert and oriented residents were interviewed by the Facility Ambassadors to ensure they feel safe. All staff will be educated on where to locate the number to the compliance line in the event they are not comfortable reporting it to the Facility Abuse Coordinator Department heads will conduct random interviews during their daily rounds to ensure the residents feel safe & free from verbal abuse. A QA Meeting was held on 6/15/2017 with members of the QA team and the Medical Director The Administrator was suspended and immediately left the facility upon RDO learning of the alleged verbal abuse. Investigation into the Administrator's alleged unprofessional conduct is ongoing. Director of Nursing and Assistant Director of Nursing have been suspended pending investigation for failure to report suspected verbal abuse following their report to RDO that they were aware of alleged verbal abuse and did not report. Per Company Policy and Code of Conduct, both the DON and ADON will be terminated. An interim DON will start June 22, 2017. Until that time, the facility will have RN coverage 8 hours a day/7days a week. The RN covering for the day will be in charge of clinical systems for the assigned day. The RN will have the support of the Regional Nurse Consultant by telephone. Ambassadors are members of the clinical management and administrative staff. Each are assigned to a block of resident rooms, and acts as an advocate for those residents. Ambassadors visit their assigned residents each day they are assigned to work. Safe Surveys were conducted with all residents. The ambassadors asked the same questions to all residents and documented results on the questionnaire. All residents voiced that they feel safe in the facility. Calls are being placed to staff members that

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #1) of 31 residents reviewed for the use of side rails on the bed. Resident #1, who had a recent history of falling out of bed and entrapment between the mattress and side rail and who was high risk of entrapment, had ,[DATE] side rails on her bed. She was found by staff on her knees facing the bed with her chin caught on the ,[DATE] side rail on the bed, with her head turned sideways and wedged between the pressure-relieving air mattress and the side rail, which obstructed her air flow. The resident's pulse was found to be low and no B/P was able to be obtained. The resident had a Do Not Resuscitate Order, so no life-saving measures were taken. Oxygen was applied, 911 was called and the Paramedics pronounced the resident deceased upon their arrival. This failure could affect the 31 residents, with side rails on their bed, by placing them at risk for serious injury, harm or death. Findings included: Review of Resident #1's Face Sheet (illegible date) revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted after a hospitalization on [DATE]. Resident #1's Side Rail Assessment Review, dated [DATE], had spaces for the resident's weight, height, length of bed, last MDS assessment date, Fall Risk Assessment Score, B/P sitting, B/P standing, and Medications with side effects of drowsiness, which were all blank. The Assessment reflected she was moderately cognitively impaired, severely cognitively impaired, alert and oriented to self, rarely/never understood others, sometimes made herself understood, needed extensive assistance with bed mobility and transfers, incontinent of bowel and bladder, and unable to attempt a standing or sitting balance test without physical help. The box next to "Resident/Family have been educated on risks of side rail (strangling, suffocation, bodily injury or death when patients or part of their body are caught between rails or between bed rails and mattress; more serious injuries from falls when patient climbs over rails; skin bruising, cuts, and scrapes; inducing agitated behavior when bed rails are used as a restraint; preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet" was not marked, which indicated the resident nor her family was informed of the dangers of the side rails. The Recommendations were for side rails on the left and right sides of the bed. The boxes next to RAP Review Complete and Side Rails have been Care Planned were not marked, which indicated the review was not completed and the side rails were not care planned. The boxes next to each of the following sentences: "No gaps between bed surface and frame allowing for resident to get wedged in equipment. Side rails/equipment is appropriate for bed, attached correctly and in functioning condition. Bed and equipment are appropriate for resident's height and weight, ensuring reduction of potential injury," were blank, which indicated no assessment of the equipment was conducted. This same assessment reflected, "The above assessment remains accurate and current." This statement was dated [DATE]. Resident #1's Care Plan, dated [DATE], reflected the problem/need as: Requires side rails when in bed related to (blank). The Goal was to be safe and free from injury related to the use of side rails times 90 days and will have increased mobility and independence for turning and repositioning times 90 days. Approaches included: "Assess need for adaptive equipment and provide as necessary-,[DATE] (the rails extended to the middle of the bed on each side like ,[DATE] rails) side rails for repositioning/turning...Instruct use of side rails and how to use them to promote independent repositioning of self. Respond to call light promptly and call bell within reach...Side rails up when in bed at all times for safety and support. Side rails up x 2 at bedtime...Monitor q 2 hours & prn when in bed. Siderail assessment quarterly." Resident #1's MDS assessment, dated [DATE], reflected she was severely cognitively impaired, she was dependent on two persons' assistance with bed mobility, transfers, and dressing, and dependent on one person's assistance with bathing. Resident #1 did not walk, and she was frequently incontinent of bowel and bladder. Her range of motion was limited in one leg. Resident #1's Entrapment Risk Assessment, dated [DATE], reflected a score of 38, which indicated the resident was at high risk for entrapment. The facility's Incident Report, dated [DATE], revealed Resident #1 was found at 7:00 AM on her knees, "hanging onto ? rail on floor mat." The resident was confused and stated, "I'm not sure" when asked how it happened. At that time, the resident had an air mattress, ? rail, floor mat and bed alarm. The resident suffered a 6.0 inch by 4.0 inch skin tear and bruising on her right elbow from the side rail. The description of the incident reflected the resident rolled off the side of the bed onto her knees on the floor mat. The resident's right arm was between the mattress and the ? side rail. The blankets were on the floor. Her call light was on and her bed alarm was on. The Investigation portion of the form reflected the cause of the incident was the resident got out of bed without assistance. The Incident Report reflected the injury was not preventable as it was unforeseen that the resident would get out of bed without assistance. The action taken was wound care was provided, the resident was assisted back to bed and the bed alarm was re-activated. The Incident Report also reflected this was the first incident of this type. The facility's Fall Team Falls Assessment, dated [DATE], reflected to increase Resident #1's involvement in activities when she was out of bed, and she was recently discharged from therapy. The Assessment also reflected her falls were reported in the early morning hours, staff should attend to her needs, be aware when she wants out of bed, Hoyer lift was in her room, and the fall mat was poorly placed. The Action Plan was to educate the staff. The Assessment also reflected the current fall interventions were the following: fall mat, pressure alarm, clip alarm, rails, and highback wheelchair. Resident #1's Fall Risk Assessment, dated [DATE], reflected a score of 20, which indicated the resident was at high risk for falls. Resident #1's History and Physical, dated [DATE], reflected Resident #1's [DIAGNOSES REDACTED]. Resident #1's Side Rail Assessment Review, dated [DATE], had spaces for the resident's weight, height, length of bed, Fall Risk Assessment Score, B/P sitting, B/P standing, and Medications with side effects of drowsiness, which were all blank. The Assessment reflected she was moderately cognitively impaired, understood others, made herself understood, was totally dependent on two or more persons for bed mobility and transfers, was frequently incontinent of bowel and bladder, was unable to attempt a standing balance test without physical help and was unsteady, but able to rebalance herself without physical support during a a sitting balance test. The Assessment reflected, "Resident Preference for side rail: ,[DATE] as enabler." The box next to resident/family education was marked. The recommendations were side rails for the left and right side of her bed. Further review of the Assessment revealed the RAP review was conducted and the side rails were care planned. The Assessment also reflected the equipment was assessed and the results were "No gaps between bed surface and frame allowing for resident to get wedged in equipment. Side rails/equipment is appropriate for bed, attached correctly and in functioning condition. Bed and equipment are appropriate for resident's height and weight, ensuring reduction of potential injury." Resident #1's [DATE] physician's orders [REDACTED]. The physician's orders [REDACTED].? side rail on bed to prevent resident from injury and promote independent mobility (dated [DATE]). Review of the facility's Incident Report, dated [DATE], completed by LVN A, revealed Resident #1 was found by CNA B on [DATE] (time not documented) on her knees, facing the bed. Her mental status was unresponsive. Medical devices involved were ? side rail and safety device involved was a bed alarm. Vital signs were Pulse 23, Respirations 0, and Blood Pressure 0. The Investigation portion of the form, completed by the DON, reflected no abuse or neglect was alleged and the injury/incident could not have been prevented due to "all safety measures were in place and followed." At the time of the incident, the CNA called for help, assisted the resident to the floor, the LVN checked for a pulse and breath sounds and a faint pulse was noted. 911 was called and oxygen was applied. The LVN stayed with the resident until the ambulance arrived. An audit was completed on all side rails. The staff was re-inserviced on checking side rails, alarms, and call lights. All orders were audited for side rails/alarms. Administrative staff provided support to staff. Witness statements were obtained by staff. Review of the Certificate of Death, dated and signed by the State Registrar on [DATE], revealed the Immediate Cause of Death for Resident #1 was " fell off of bed, head wedged betwwen (sic) matress (sic) and safety rail, rail cut off air flow." The Certificate of Death also reflected an autopsy was not performed. Observations on [DATE] at 9:00 AM revealed there were quarter side rails in use on 34 beds. On [DATE] at 4:00 PM, it was observed three residents had side rails and pressure-relieving mattresses on their beds. The pressure-relieving mattresses were soft around the edges and with manual pressure, were easily compressed towards the middle of the mattress, leaving at least a 4 inch gap between the side rail and the mattress. An interview with CNA B on [DATE] at 2:00 PM revealed she was working the 2:00 PM to 10:00 PM shift on [DATE] and was the first staff member to find Resident #1 after her fall. She stated it was about 7:00 PM and she was walking down the South hall, where Resident #1 resided, to answer a call light in Room 25. She stated at the same time she heard a bed or chair alarm sounding. She revealed she continued down the hall, stopping at each door and listening to where the alarm was coming from. CNA B approached Resident #1's Room and realized the alarm was coming from her bed. She stated as she entered the room she saw Resident #1 with her knees on the floor, facing the bed. The resident's arms were hanging down by her sides. The bed was in the lowest position and the mat was on the floor next to the bed. The resident's head was wedged between the mattress and the side rail, with her head turned sideways, resting on the bed. CNA B stated the Resident was making "gurgling" sounds. CNA B revealed she tried to lift the resident off the rail, but could not, so she stepped in the hall and called out for CNA C and SNA E , who were in the hall. Within a few seconds, LVN A also entered the room and they were all able to lift the resident off the side rail and to the floor on her back. CNA B stated Resident #1's eyes were opened, but were staring blankly ahead. CNA B revealed the resident had an air mattress on the bed and the sides were soft, so there was room for the resident's neck/head to be lodged. CNA B stated she last saw Resident #1 about 6:30 PM, when she picked up the resident's dinner tray. She revealed Resident #1 did not eat any of her meal as she often had a poor appetite. CNA B stated she had seen Resident #1 try to get out of bed before. At that time, she slid to the bottom of the bed. The resident was not very mobile and she required a Hoyer lift for transfers. Resident #1 used the side rail as an enabler to hold onto when she was turned by the staff. CNA B revealed the resident was confused and oriented to self only. CNA B stated she had never seen anyone caught in side rails before. An observation on [DATE] at 2:15 PM of CNA B's re-enactment of Resident #1's position after the fall, at the surveyor's request, revealed her facing the right side of the bed on her knees. Her arms dangled by her sides. The quarter side rails were in the up position. The resident's head was turned sideways towards the left facing the head of the bed. The right side of her face was resting against the bed. Resident #1's neck was wedged between the end of the quarter rail and the mattress. An interview with CNA C on [DATE] at 3:00 PM revealed she worked the 2:00 PM to 10:00 PM shift and was on duty on [DATE]. She stated she and SNA E left Resident #1 in bed for dinner because she was very groggy. She had not eaten her dinner meal, but was "okay." After dinner, she and SNA E laid another resident down in bed. When they emerged from the room, they saw CNA B at the doorway of Resident #1's room calling to get a nurse and " hurry." CNA C estimated the time as 10 to 15 minutes from the time they had last checked on Resident #1 until CNA B called for help. CNA C stated when she entered the room, she saw Resident #1 had her head caught between the mattress and the quarter rail. She stated it appeared the air mattress "gave" a little when she fell . The bottom of her chin was resting on the rail and her body weight was pulling her down. She was sitting somewhat on her knees and hip. CNA C stated she could tell the resident was "stuck." They called for the first nurse they could find, which was LVN A. The three nurse aides and the LVN then moved the resident to the floor. She revealed she saw a red mark on the resident's neck and a bleeding skin tear on her right arm. CNA C stated she always positioned Resident #1 the same way when she laid her down in bed, on her left side facing the wall. She revealed she must have rolled this time out of bed, but she had never known her to do that before. She also stated Resident #1 was confused, but could talk to staff and answer questions. The resident was able to move her arms and would grab the rail when during peri-care or repositioning, but was unable to ambulate or move herself in her bed very well. An interview with LVN A on [DATE] at 5:00 PM revealed she was working on the East Hall giving medications on [DATE] when SNA E told her Resident #1 was on the floor. She stated she immediately locked her medication cart and went to the resident's room. She revealed when she entered the room, she saw CNA B standing next to Resident #1. The resident was in the "prayer position," on her knees and facing the bed. The pressure alarm on the bed was sounding. She saw the resident's neck/chin overlapping the side rail bar, which was in the "up" position. The resident was white around her lips. LVN A stated she could tell immediately Resident #1's air supply was cut off. She stated CNAs B, C and SNA E and herself lifted the resident off the rail and onto the mat on the floor. LVN A stated she believed the resident was a DNR status, but she sent the ADON, who had entered the room, to ensure that and to call 911 and the resident's family member to ensure he did not want life-saving measures taken. She also sent a CNA to obtain oxygen as Resident #1's respirations were very shallow, if any. The resident's pulse was thready and slow. LVN A could not obtain a blood pressure for the resident. She revealed she tilted Resident #1's head back to open the airway and applied the oxygen per mask. She stated the EMTs arrived and took over the scene. Resident #1 was pronounced deceased while at the facility and was not taken to the hospital. LVN A stated she noticed Resident #1 had an abrasion on the left side of her face and a red mark on her neck. She added she did not feel anybody did anything wrong, that it was a tragic accident. LVN A stated Resident #1 had a previous fall about two months ago in which she slid off the mattress in the same way onto the floor. Her head was not close to the side rail at that time, but she was holding onto the side rail. She stated in that fall and the current fall, it looked as if the resident did a "360 degree turn" and fell out of bed. At the request of the surveyor, LVN A re-enacted the position she stated she first saw Resident #1 in. She was her on her knees, resting on one hip with her body facing the bed on the right side of the bed. Her arms were dangling by her sides. The resident's neck was turned with the right side of her face/head on the bed. The chin was on the quarter side rail with her neck wedged between the side rail and the bed. She stated there was about a three to four inch gap between the side rail and the air mattress. LVN A stated the air mattress was "slicker " than regular, firm mattresses, so there was a tendency for the resident to slide on the mattress. (NOTE: The bed used for re-enactment was a regular mattress. At the time, there were no air mattresses available that were not in use by a resident.) An interview with the facility's only ADON on [DATE] at 9:20 AM revealed at about 7:00 PM on [DATE] she was in her office on the South hall. She stated she heard an alarm sounding. She stated soon (within two minutes) she saw CNA B walk by her office, down the South hall. She then heard CNA B tell SNA E to get the nurse. The SNA and the LVN hurried to the room. She heard LVN A yell to call 911. She stated she checked Resident #1's clinical record to check if she was DNR or Full Code status. She revealed the resident was DNR status. The ADON called the resident's family member to inform him/her of Resident #1's condition. She stated she saw Resident #1 on her back on the floor in her room. LVN A was with the resident and had applied oxygen to her. LVN A told her the resident had a faint pulse. By the time the paramedics arrived, the resident had expired. Further interview with the ADON and DON on [DATE] at 10:00 AM revealed the mattress Resident #1 was on was an alternating pressure mattress with horizontal cells across the mattress, with a pump to inflate the cells. Every other cell would inflate and then the opposite cells would inflate, in an alternating pattern, to provide constant movement of the mattress for skin protection. The mattress was used for treating and preventing pressure ulcers. An interview with Central Supply/CNA D on [DATE] at 11:10 AM revealed Resident #1's air mattress was rented from an equipment company as the facility did not have enough in stock. She stated it was ordered for Resident #1 when she returned from the hospital in [DATE]. She stated the mattress was picked up by the equipment company on [DATE], after the resident's death. CNA D stated there were no other mattresses currently in the building like the one Resident #1 was using. An interview with the ADM and DON on [DATE] at 8:55 AM revealed Resident #1 was found on [DATE] on the floor next to her bed with her chin resting on the side rail, and her air supply had been cut off. At that time, they had been unable to view the death certificate. The side rail was quarter length and was pulled up. The resident's alarm was on and sounding. The resident was in the middle of the bed. CNA B found the resident and immediately called for the nurse. Resident #1 had a DNR order, but 911 was called due to the accidental nature of the injury. The nurse tilted Resident #1's head back and applied oxygen. The resident had a faint, low pulse at that time. The paramedics arrived and pronounced the resident deceased . The ADM stated the police were called, and a detective came and interviewed staff. He concluded the facility was not at fault. The ADM stated Resident #1 used the side rail for positioning and to assist with peri-care. She was using a pressure-relieving mattress, air mattress, due to pressure ulcers on her body. The facility began their investigation by having the staff who found the resident perform a re-enactment of the resident's position. They began an audit of all side rails for safety in the facility, checking for size of rail, condition of side rail, and proximity to the bed frame. They have also, after evaluation, eliminated side rails on some residents and plan to continue the evaluations and remove as needed. An interview with the Corporate Consultant on [DATE] at 11:10 AM revealed she had literature regarding side rails and an assessment tool, which was provided by an equipment company. She stated she provided the information to the facility to begin using the assessment tool for all side rails in use. The Consultant revealed she provided the information after the incident with Resident #1. The undated Audit Tool Bed Systems, Support Surfaces & Bed Rails Guideline: Equipment Checklist reflected, "Record Review: Recommend completing the checklist below on each bed system between patient use, when a mattress, bed rail or other equipment is changed or added and upon admission and every 6 months thereafter per Bed Safety Management Program...Bed frame, rail and mattress are compatible based upon manufacturer's guidelines. Bed frame and deck in good working order. Bed rails move as the head or foot sections of the bed are raised or lowered. Zone 1 - Open space within the perimeter of the rail... Bed rail is checked to make sure it is not loose, which can change the size of the space and increase the risk for entrapment. Zone 2 - Under the Rail, Between the Rail Supports or Next to a Single Rail Support...Mattress has been checked for any change over time in mattress compressibility due to wear and any lateral shift of the mattress or rail, and any degree of place from loosened rails or rail supports. Zone 3 - Between the Rail and the Mattress...Air-filled speciality mattresses with compressible edges are not in use with side rails, related to the potential for entrapment and/or risk of serious injury in F323. Zone 4 - Under the Rail at the Ends of the Rail...Zone 5 - Between Split Bed Rail...Zone 6 -Between the End of the Rail and Side Edge of the Head or Foot Board...Zone 7 - Between the Head or Foot Board of the Mattress End...." An interview with CNA F on [DATE] at 1:45 PM revealed she worked the 6:00 AM to 2:00 PM shift on the South Hall. She was familiar with Resident #1 since her admission. She stated the resident was confused. She would talk to you, but not always appropriately. She was in a high-backed wheelchair and was unable to propel herself. A Hoyer lift was used to transfer her from the bed to chair due to the resident not being strong enough in her legs to hold herself up. Once she was in bed, she usually stayed in the same position. She was up in the chair for meals, but was usually in bed otherwise. CNA F stated she never saw Resident #1 fall or try to get out of bed on her shift, but was aware she had at times. She had the pressure alarms on when she was in bed or in the chair and she rarely heard the alarm sound. CNA F stated the resident seemed to be fearful of falling and clung tightly to the rail when they turned her for changing or repositioning and did assist with the process. An interview with the Staff Development Coordinator on [DATE] at 3:00 PM revealed in-services regarding side rail safety monitoring had not been conducted prior to the incident on [DATE] with Resident #1. Inservice training dated [DATE], reflected subject as 1) checking alarms in place and that they are functioning. 2) Also, if side rails are used, make sure side rails are in place. 3) If you notice something on care card that needs to be updated, let your charge nurse know. Twenty-five staff members signed as attending (CNAs, LVNs , RNs). Inservice training, dated [DATE], reflected subject as Bed safety, prevention of incidents and accidents, safety precautions and timely response to alarms and call lights. Fifty-two staff members signed as attending (CNAs, LVNs, RNs, Therapists, Housekeeping and Administrative staff). The facility's current policy "Side rails," revised [DATE], reflected, "...All side rails (half or full) will be ordered by the physician on the physician order [REDACTED]. Purpose: To prevent resident from injury and to promote independent mobility...Procedure: 1. Assess siderail fit on the bed prior to use to determine any potential risks associated with gaps between the rails and the mattress of the bed. Also assess size of resident in proportion to siderail openings...3. Check residents at frequent intervals for safety and security of bedrails. 3. A physician's orders [REDACTED]. 4. Document siderail use in the medical record." The "Clinical Guidance for the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings," developed by the Hospital Bed Safety Workgroup under the Food and Drug Administration (FDA), [DATE], reflected the following: 1) National surveys of patient deaths occurring in the bed environment demonstrate the risk of entrapment when a patient slips between the mattress and bed rail or when the patient becomes entrapped in the bedrail itself. 2) The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, and uncontrolled body movement that cause them to move about the bed or try to exit the bed. 3) A patient is assessed to be unsafe in bed, or at high risk for injury due to: inability to transfer safely to and from the wheelchair, previous entrapment or near-entrapment episodes, episodes of falling out of bed and inconsistent in notifying staff of needs or unable to access the call system. 4) If it is determined that bed rails are required, then close attention must be given to the design of the rails. Check for compression of the mattress' outside perimeter. Easily compressed perimeters can increase the gaps between the mattress and the bed rail. The "Guidance for Industry and FDA Staff/Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," published by the US Department of Health and Human Services, Food and Drug Administration and Center for Devices and Radiological Health, [DATE] reflected: "Framed flotation therapy beds, powered air mattress replacements, and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose an additional risk of entrapment when used with the conventional bed systems. When these type of mattresses compress, the space between the mattress and the bed rail may increase and pose an additional risk of entrapment. When these products are used, we recommend that steps are taken to ensure that the therapeutic benefit outweighs the risk of entrapment. " The facility reported on [DATE] that 31 residents had been identified as using side rails attached to their bed to prevent residents from injury and to promote independent mobility.