Every finding on record at Avir at Johnson City

Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through resident assessments and described in the plan of care for one of two nurse aides (CNA A) reviewed for personnel requirements.CNA A was observed sitting down on her phone during her shift as a caregiver on 7/28/2026.This failure placed residents at risk of decreased monitoring and supervision.Findings included:A record review of TULIP on 7/28/2026 reflected a complaint sent to CII on 7/25/2026 at 2:21 PM. The complaint reflected that female nighttime aides were observed speaking on their personal phones at work.An observation on 7/28/2026 at 5:35 AM revealed that CNA A was sitting down near the front door on her phone.During an observation on 7/28/2026 at 5:40 AM, no call lights were observed to be activated on the 100 or 200 halls.During an interview on 7/28/2026 at 5:56 AM, CNA A stated that she was sitting down using her phone because she saw that it was almost time for her to go, she had finished her resident rounding, and she was waiting on the next shift to arrive.During an interview on 7/28/2026 at 10:40 AM, the DON stated that the Administrator was on PTO that week. The DON said there should be no personal phone usage on duty unless there was an emergency. The DON stated that he was not aware of any emergency that morning (7/28/2026). The DON stated that the shifts were 12 hours, and the overnight shift ended at 6:00 AM. The DON stated that staff were trained on the facility's phone policy upon hire. The DON stated that if staff were on their phones during their shift, it could make residents feel ignored, especially if they were cognitively intact. The DON said that some residents were quiet, so CNA A might not see that a resident needed help.A record review of the facility's employee handbook signed by CNA A on 11/15/2025 reflected the following: All employees are prohibited from using cellular telephones, or any other electronic device while on duty throughout the facility.

Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 4 residents reviewed for pharmacy services. The facility failed to ensure authorized personnel administered a prescription mouthwash [PH1.1](Chlorhexidine Gluconate) to Resident #1 on multiple occasions, by permitting a FM, who was not Resident #1's RP or POA, to administer the mouthwash. This failure could place residents at risk of not receiving medications as prescribed and a decline in health status. Findings included:Review of Resident #1's admission MDS assessment dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 admitted to the facility with the following diagnosis: intentional self-harm by handgun discharge, quadriplegia (paralysis affecting all four limbs and the torso, usually caused by spinal cord injury), aphasia (language disorder with difficulties in speaking, understanding, reading, and writing), dysphasia (neurological disorder that impairs a person's ability to produce and understand spoken language), malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and nutrients), schizophrenia (serious mental health condition that affects how people think, feel, and behave resulting in hallucinations, delusions, and disorganized thinking), dehydration (when the body uses or loses more fluid than it takes in), muscle wasting and atrophy (loss or thinning of skeletal muscle mass, leading to decreased strength and physical function), and gastrostomy complication (complications related to the stomach feeding tube). Resident #1's BIMS score was unable to be conducted due to rarely/never being understood. Review of Resident #1's active doctors' orders as of 5/18/2026 revealed an order for Chlorhexidine Gluconate (a potent, broad-spectrum antiseptic and antimicrobial agent used to kill bacteria and fungi) Mouth[PH2.1]/throat Solution 0.12% to be given every 12 hours related to dry mouth.Review of Resident #1's comprehensive care plan dated 04/30/2026 reflected no indication Resident #1's FM was permitted to administer prescription medication to Resident #1[PH3.1][MY3.2]. Review of Resident #1's MAR for June 2026 reflected Chlorhexidine Gluconate marked as administered from 6/1/2026-6/15/2026 twice a day by a cumulation of the ADON, LVN A, and LVN B.In an interview on 7/7/2026 at 11:40 a.m., Resident #1's FM, stated that the facility allowed them to brush Resident #1's teeth with Resident #1's prescription Chlorhexidine, almost daily, by putting the mouthwash into a medicine cup, with the swabs, and leaving the room. Resident #1's FM would then use the swabs and Chlorhexidine to brush Resident #1's teeth, gums, and inside of the mouth. Resident #1's FM stated that they received training at a previous care facility, but not by this facility prior to administering the mouthwash to Resident #1. The FM stated that she did not become Resident #1's temporary guardian through the county court until 6/29/2026, yet she would have been administering this medication to Resident #1 almost daily after his admission, up until 6/19/2026.[PH4.1][MY4.2]In an interview on 7/7/2026 at 3:15 p.m., the ADON stated that she had been working for the facility since December 2025. She stated that she believed Resident #1's FM was trying to set up one of their nurses, and other staff on multiple occasions because she would complain about the staff to the ADON via text messages and pictures. She stated that early in Resident #1's admission, the facility received information from the military that Resident #1's spouse was his RP, decision maker, POA, and the spouse specified that the FM should not be allowed to have medical information or make medical decisions for Resident #1. The ADON stated that the FM had gotten to the point where she would request certain medications for Resident #1, but the facility had to run it by the MD and the medical POA. The ADON stated that she never handed Chlorhexidine to the FM. She stated that she was aware the FM would ask the staff to leave the cup of Chlorhexidine on the bedside table for the FM to use on Resident #1. She stated that the FM would try to manipulate the staff into letting her do things related to Resident #1's care that only staff would be permitted to do. Such as asking to administer the injection medications. She stated that the licensed personnel would be responsible for passing medications, but for residents with feeding tubes, it would be a nurse. The ADON stated that negative impacts to a resident's health when medications were administered by unauthorized people could have bad consequences depending on what was being administered.In an interview on 7/8/2026 at 10:17 a.m., the DON stated that he had been informed by the ADON that the nurses would allow Resident #1's FM to clean Resident #1's mouth with his prescription Chlorhexidine. He stated that at the time when Resident #1's FM was not authorized to receive medical information by Resident #1's RP, she should not have been administering Chlorhexidine to Resident #1. He stated that typically, the facility would allow a resident to self-administer their medications (including allowing an authorized FM) and the facility would provide family training with the facility RN, and once the family passed proficiency, and the IDT team determined it was okay, the FM would be permitted to administer medications. An interview attempt was made on 7/8/2026 at 11:39 a.m., to Resident #1's RP, but the phone number answering machine relayed a message as if the number was disconnected. In an interview on 7/8/2026 at 12:30 p.m., LVN A who had only been working at the facility for 1 month, stated that family members were not supposed to pass medications, and for residents on a feeding tube, like Resident #1, a licensed nurse passed those medications. She stated that she gave Chlorhexidine once per shift to Resident #1. She stated that the FM would administer the Chlorhexidine because the FM insisted on doing most of Resident #1's care. LVN A stated that Chlorhexidine was a prescription medication usually prescribed by a dentist. She stated the mom tried to do all Resident #1's ADLs. She stated that before she started working at the facility, Resident #1's FM appeared to be in the facility all of the time, and Resident #1's FM started to become more hostile toward staff as the days went on. LVN A stated it was very hard to go into Resident #1's room because the FM was so hostile to the staff, and that none of the staff wanted to be abused when they were at work. LVN B stated it did not matter what she did, or how she did it, Resident #1's FM complained about it. LVN B stated she would try to do everything perfectly, and the FM would still find something wrong, or accuse her of doing things she did not even do. She stated she would give the Chlorhexidine in a cup with the sponges, and set it on the bedside table, which the FM had all of her own supplies set up to use for Resident #1 (distilled water, additional bandages, wash cloths). An interview attempt was made on 7/8/2026 at 1:11 p.m., to Resident #1's RP, but the phone number answering machine relayed a message as if the number was disconnected. The ADON also attempted to call the RP and got the same result. In an interview on 7/8/2026 at 2:01 p.m., LVN B stated that she had been working the night shift at the facility for approximately 3 years. She stated that she recalled early in Resident #1's admission that Resident #1's FM had told LVN B, Oh, I do that for him, you can just leave it here with me. Leave it right here. LVN B stated that Resident #1's FM was very persistent when making requests, more like demands, so LVN B just took the FM's word, because the FM told her the prior facilities had given her training on medication administration. LVN B stated she never gave Resident #1's FM any other medications, just mouthwash, because she did not really think of it as a medication, but stated that Resident #1 did have a prescription for it. She stated she never stood there to watch the FM brush Resident #1's teeth with the mouthwash, but when she entered the room later, she would see the medication cup in the trash. She stated that she never asked the ADON or DON if Resident #1's FM was permitted to administer the mouthwash to Resident #1. LVN B stated she was aware that the FM did not have POA over Resident #1. She stated that if unauthorized people were administering medications to residents, they could be giving the residents the wrong amount, or more specifically, Resident #1 could choke due to his condition. Review of the facility's policy titled 'Medication Administration', dated April 2019 reflected: Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.Review of the facility's policy titled, 'Self-Administration of Medications', dated February 2021 reflected: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re assessed periodically based on changes in the resident's medical and/or decision-making status.6. For self-administering residents, the nursing staff detem1ines who is responsible (the resident or the nursing staff) for documenting that medications are taken.7. If the resident is able and willing to take responsibility for documenting self-administration of medications, the resident is instructed on how to complete a record indicating the administration of the medication.12. Nursing staff reviews the self-administered medication record for each nursing shift, and transfers pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered.Review of the facility's policy titled, 'Mouth Care', dated February 2018 reflected: DocumentationThe following information should be recorded in the resident's electronic medical record (EHR):1.If the resident refused the treatment.2.The signature (initials) and title of the person recording the data.Reporting1.Notify the supervisor if the resident refuses mouth care.2.Complaints of pain or discomfort of mouth, the certified nursing assistant should report to the licensed nurse. 3.Report other information in accordance with facility policy and professional standards of practice.

Based on the interview and record review, the facility failed to properly complete a performance review of every nurse aide at least once every 12 months, for 2 of 4 (CNA A and CNA C) reviewed for nursing services.The facility failed to provide a completed competency checklist for the mechanical lifting device (assists staff with transferring a resident from the bed to a wheelchair and back to the bed) for CNA A and CNA C.This deficient practice resulted in an injury to the Resident #27 and could place other residents at risk of falls and injury.The findings included: Review of Resident #27's face sheet, dated 06/02/2026, revealed she was admitted to the facility on [DATE] with history of Atherosclerotic heart disease of the native coronary artery without angina pectoris (Plaque has built up in the heart's original arteries, restricting blood flow without causing chest pain), Violent behavior, Dementia (Decline in mental ability severe enough to interfere with daily life), Depression (It causes persistent feelings of sadness, emptiness, and a loss of interest in activities), Abnormalities of gait and mobility (Irregular, unsteady, or inefficient walking patterns), A lack of coordination (Inability to control smooth, precise muscle movements), Cognitive communication deficit (Communication challenges caused by underlying disruptions in mental processes), and need for assistance with personal care. Code status: Review of Resident #27's quarterly MDS assessment dated [DATE] reflected that Resident #27 was assessed to have a BIMS score of 00, indicating severe cognitive impairment.Review of Resident #27's Care Plan, dated on 01/30/2026, revealed Resident #27 required assistance by 2 staff with Mechanical lift transfer assistance and dated on 01/31/2026, revealed Resident #27 required assistance by staff with bathing/showering.Review of the competency assessment titled Lifting Machine, Using a Mechanical, showed that the assessment was done by ADON in March 2026. However, there were no employee-associated names, titles, employee signatures, IDs, initials, or completed dates of the employee recorded in the assessment records. The facility did not provide any properly completed documents showing that any of its employees took the competency assessment and in-services on the Lifting Machine, using a Mechanical lift prior to 06/02/2026.Review of video evidence recorded on 06/01/2026 revealed that Resident #27 fell from the mechanical lift due to improper placement of the sling strap.Review of the email statement on 06/04/2026 at 01:14 p.m. revealed that DOC A found Resident #27's injury was serious. DOC A stated that Resident #27's head trauma, requiring stitches to close a wound, was a significant injury. Given her age, there is potential for such trauma to cause intracranial bleeding, which can lead to death or permanent disability, although DOC A did not see evidence of such a more serious injury. DOC A stated Resident #27's head wound was repaired with stitches after being washed out and obtaining CT imaging of her brain and neck to rule out brain bleeding or skull or spine fracture.Interview on 06/02/2026 at 01:31 p.m. with CNA C stated that he had been working at the facility for about four months. CNA C stated he had been trained in abuse, neglect, and exploitation. CNA C stated that around 2 in the afternoon, after lunch, CNA C was helping CNA A with transferring Resident 27 with a mechanical lift from the bed to the shower chair. CNA C stated CNA A was using a sling in the mechanical lift, and CNA C was just behind the shower chair next to the bedside. CNA C stated that two individuals operate a mechanical lift. CNA C stated Resident #27 fell while putting on the shower chair. CNA C stated that the sling was improperly placed, and Resident #27's aggression occurred during the lift. CNA C stated Resident #27 was yelling and moving in the sling. CNA C stated that Resident #27 was yelling in Spanish, and while Resident #27 was in bed, she was trying to hit CNA A. CNA C stated that when Resident #27 was on the sling, she was moving and yelling. CNA C stated that Resident #27 was moving her whole body, and it was very difficult for CNA C to put her on the shower chair in a sitting position. CNA C stated that CNA C did not notice the sling was in the wrong position until Resident #27 fell. CNA C stated that after the fall, CNA C thought the placement of the sling was probably wrong, because the sling came off from the top right corner of the mechanical lift. CNA C stated Resident #27 was on the side of the mechanical lift rather than directly in the middle during transfer from the bed to the mechanical lift. CNA C stated that it is both people's responsibility to ensure the resident is in the proper position during a mechanical lift transfer. CNA C stated he had been trained on the mechanical lift before the incident and had been serviced on a mechanical lift transfer after the incident. CNA C stated that after the fall, CNA C immediately told CNA A to get the nurse and placed a pillow under Resident #27's head. CNA C stated he stayed with the resident until the nurse (ADON) arrived. CNA C stated ADON brought a stronger sling and then put the Resident #27 back to bed so the nurse could properly assess Resident #27. CNA C stated the nurse assessed Resident #27 and sent Resident #27 to the hospital. Interview on 06/02/2026 at 01:42 p.m. with CNA A revealed that she had been working at the facility for almost 5 months. CNA A stated she had been trained in abuse, neglect, and exploitation. CNA A stated she had been trained in the mechanical lift 1-2 months ago. CNA A stated Resident #27 was fighting in the mechanical and moving Resident #27's legs up and down, then Resident #27 came to one side of the mechanical and fell. CNA A stated Resident #27 was in the right position because CNA A helped Resident #27 position on the front by fixing Resident #27's legs, and CNA A's partner, CNA C, helped CNA A to put Resident #27 in the middle from the back. CNA A stated she did not ask for help while Resident #27 was moving too fast in the Hoyer. CNA A stated nothing to Resident #27 this time, and everything happened so fast. CNA A stated she did not ask for help or pause during the transfer because Resident #27 acted the same way throughout. CNA A stated that after the fall, CNA C saw the resident was bleeding, and her partner, CNA C, told CNA A to get the nurse, and CNA A went to get the nurse. CNA A stated that this kind of incident had not happened before. Interview on 06/04/2026 at 01:50 p.m., LVN A stated that a negative outcome of not properly or safely using the mechanical lift could cause a fall, which could cause serious injury. LVN A stated that the prevention measures were: Ensuring loops were properly secured, that two people perform the transfer safely, and double-checking hooks and loops to ensure they were secure and properly in place. Interview on 06/04/2026 at 02:18 p.m. ADON stated that failing to properly evaluate or use an in-service competency checklist can lead to injury, create a paper trail, and leave them without proof. ADON stated that a prevention measure not evaluating the competency checklist was: Every person must be watched while the trainee gives their signature. ADON stated that a proper evaluation of the checklist requires a signature, full name, and date and time; all check boxes need to be filled in and covered for the assessment.Interview on 06/04/2026 at 02:32 p.m. DON stated that failure to properly evaluate or use an in-service competency checklist can lead to incidents involving serious injury. DON stated prevention measures for improper evaluation of the competency checklist, including in-services on videotaping proper procedures during training, watching the video, performing the techniques, and teaching back the process. DON stated he will try to simulate the weight during training. DON stated that the checklist requires a proper signature, full name, and date and time. DON stated that the documents must be completed in full and that there must be no missing data in the boxes. Interview on 06/04/2026 at 03:16 p.m. the ADM stated that failing to properly evaluate or use an in-service competency checklist can result in them not receiving their training. ADM stated it was important for them to receive the training on time and to re-educate them. ADM stated that prevention measures, such as not evaluating in-services and competency checklists, had another set of eyes on them and that they were reviewed after completion. ADM stated that it was typically reviewed by HR. ADM stated that a proper evaluation of the checklist required a proper signature, full name, date, and time. ADM stated CNA A's Hoyer lift competency checklist was completed, but not filled out correctly, because CNA A was upset during the signature. Review of the facility's policy titled Lifting Machine, Using a Mechanical, revision date July 2017, revealed under the Purpose section: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for the manufacturer's training or instructions.

Based on observations, interviews, and record reviews the facility failed to ensure the residents' environment remained free from accidents and hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents, for 4 of 11 residents (Resident #20, Resident #27, Resident #28 and Resident #34,) reviewed for quality of life. The facility failed to ensure Resident #27's mechanical lift sling was securely attached to the sling bar. The facility failed to ensure that the call light was within reach for Resident #34 and Resident #20. The facility failed to serve Resident #28 a mechanically altered diet on 6/1/2026. This deficient practice resulted in an injury to Resident #27 and could have placed Resident #34 and #20 at risk of falls, pain, anxiety, and injuries, and could have placed Resident #28 at risk of choking, reduced intake, and weight loss. Findings included: Resident#27Review of Resident #27's face sheet, dated 06/02/2026, revealed she was admitted to the facility on [DATE] with history of Atherosclerotic heart disease of the native coronary artery without angina pectoris (Plaque has built up in the heart's original arteries, restricting blood flow without causing chest pain), Violent behavior, Dementia (Decline in mental ability severe enough to interfere with daily life), Depression (It causes persistent feelings of sadness, emptiness, and a loss of interest in activities), Abnormalities of gait and mobility (Irregular, unsteady, or inefficient walking patterns), A lack of coordination (Inability to control smooth, precise muscle movements), Cognitive communication deficit (Communication challenges caused by underlying disruptions in mental processes), and need for assistance with personal care. Code status: Full Code (Full code means that if a person's heart stopped beating, all resuscitation procedures will be provided to keep them alive).Review of Resident #27's quarterly MDS assessment dated [DATE] reflected that Resident #27 was assessed to have a BIMS score of 00, indicates severe cognitive impairment. Review of Resident #27's Care Plan, dated on 01/30/2026, revealed Resident #27 required assistance by 2 staff with mechanical lift transfer assistance and dated on 01/31/2026, revealed Resident #27 required assistance by staff with bathing/showering.Review on 06/02/2026 of video evidence recorded on 06/01/2026 revealed that Resident #27 fell from the mechanical lift due to improper placement of the sling strap. Review of the email statement on 06/04/2026 at 01:14 p.m. revealed that DOC A found Resident #27's injury was serious. DOC A stated that Resident #27's head trauma, requiring stitches to close a wound, was a significant injury. Given her age, there is potential for such trauma to cause intracranial bleeding, which can lead to death or permanent disability, although DOC A did not see evidence of such a more serious injury. DOC A stated Resident #27's head wound was repaired with stitches after being washed out and obtaining CT imaging of her brain and neck to rule out brain bleeding or skull or spine fracture. An observation and interview on 06/02/2026 at 11:46 a.m. revealed Resident #27 was in her wheelchair, and Resident #27's FAM A was caring Resident #27. Resident #27 had an above the left eyebrow laceration, and bruises on her left arm. FAM A mentioned, Resident #27 had fallen from the mechanical lift and hit the floor. FAM A stated Resident #27 could not express pain, but if she gets angry, that shows her pain. FAM A stated Resident #27 no longer communicates the way she used to. FAM A stated she had video evidence of one female staff was getting Resident #27 ready without any clothing on, and Resident #27 was on the side lying in the mechanical Lift and Resident #27 fell from it. FAM A stated she was very disappointed about the situation. Interview on 06/02/2026 at 01:31 p.m. with CNA C revealed he had been working at the facility for about four months. CNA C stated he had been trained in abuse, neglect, and exploitation. CNA C stated that around 2 in the afternoon, after lunch on 06/01/2026, CNA C was helping CNA A with transferring Resident #27 with a mechanical lift from the bed to the shower chair. CNA C stated CNA A was using a sling in the mechanical lift, and CNA C was just behind the shower chair next to the bedside. CNA C stated that two individuals operate a mechanical lift. CNA C stated Resident #27 fell from the mechanical lift while putting on the shower chair on 06/01/2026. CNA C stated that the sling was improperly placed, and Resident #27's aggression occurred during the lift. CNA C stated Resident #27 was yelling and moving in the sling. CNA C stated that Resident #27 was yelling in Spanish, and while Resident #27 was in bed, she was trying to hit CNA A. CNA C stated that Resident #27 was moving her whole body, and it was very difficult for CNA C to put her on the shower chair in a sitting position. CNA C stated that CNA C did not notice the sling was in the wrong position until Resident #27 fell. CNA C stated that after the fall, CNA C thought the placement of the sling was probably wrong, because the sling came off from the top right corner of the mechanical lift. CNA C stated Resident #27 was on the side of the mechanical lift rather than directly in the middle during transfer from the bed to the mechanical lift. CNA C stated that it was both people's responsibility to ensure the resident is in the proper position during a mechanical lift transfer. CNA C stated he had been trained on a mechanical lift before the incident and had been in-serviced on a mechanical lift transfer after the incident. CNA C stated that after the fall, CNA C immediately told CNA A to get the nurse and placed a pillow under Resident #27's head. CNA C stated he stayed with the resident until the nurse (ADON) arrived. CNA C stated ADON brought a stronger sling and then put the Resident #27 back to bed so the nurse could properly assess Resident #27. CNA C stated the nurse assessed Resident #27 and sent Resident #27 to the hospital. In an interview on 06/02/2026 at 01:42 p.m. with CNA A revealed that she had been working at the facility for almost 5 months. CNA A stated she had been trained in abuse, neglect, and exploitation. CNA A stated she had been trained on the mechanical lift 1-2 months ago. CNA A stated Resident #27 was fighting in the mechanical and moving Resident #27's legs up and down, then Resident #27 came to one side of the mechanical and fell. CNA A stated Resident #27 was in the right position because CNA A helped Resident #27 position on the front by fixing Resident #27's legs, and CNA A's partner, CNA C, helped CNA A to put Resident #27 in the middle from the back. CNA A stated she did not ask for help while Resident #27 was moving too fast in the Hoyer. CNA A stated nothing to Resident #27 this time because Resident #27 always acted the same during transfer, and everything happened so fast. CNA A stated she did not ask for help or pause during the transfer because Resident #27 acted the same way throughout. CNA A stated that after the fall, CNA C saw the resident was bleeding, and her partner, CNA C, told CNA A to get the nurse, and CNA A went to get the nurse. CNA A stated that this kind of incident had not happened before. In an interview on 06/04/2026 at 01:02 p.m., DOC B stated he saw Resident #27 on 06/04/2026. DOC B stated the laceration of the left eyebrow was superficial with some bruising. He stated the stitches were healing appropriately, and they would be removed in 10 days. DOC B stated Resident #27 denied a headache or pain. DOC B stated Resident #27 was speaking in Spanish. In an interview on 06/04/2026 at 01:50 p.m., LVN A stated that a negative outcome of not properly or safely using the mechanical lift could cause a fall, which could cause serious injury. LVN A stated prevention measures were: Ensuring loops were properly secured, that two people perform the transfer safely, and double-checking hooks and loops to ensure they were secure and properly in place. In an interview on 06/04/2026 at 02:18 p.m. ADON stated that a negative outcome of not properly or safely using the mechanical lift could cause injury. ADON stated prevention measures to stop the injury, such as ensuring slings were properly placed, using proper body mechanics, using a two-person assist, and evaluating the competency checklist. In an interview on 06/04/2026 at 02:32 p.m. DON stated that a negative outcome of improper or unsafe use of the mechanical lift includes injuries and falls. DON stated the prevention measures for improper use of the mechanical lift were stop and check, and that two aides verify every single step of the transfer. In an interview on 06/04/2026 at 03:16 p.m. ADM stated negative outcomes of improper or unsafe use of the mechanical lift could include harm. ADM stated prevention measures of improper use of the mechanical Lift were re-education, consistent education, and training. Resident #28: Record review of Resident #28's face sheet printed on 6/4/2026 reflected an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses including encephalopathy (brain dysfunction which appears as confusion, memory loss, and personality changes), Type 2 Diabetes (metabolic disorder that occurs when the body becomes resistant to insulin), and dysphasia (difficulty swallowing), oropharyngeal phase (earliest and fastest stage of swallowing involving both voluntary and involuntary actions). Record review of Resident #28's quarterly MDS assessment dated [DATE], reflected a BIMS score of 7, indicating severe cognitive impairment. Resident #28's quarterly assessment also indicated the resident was on a mechanically altered diet while a resident at the facility. Record review of Resident #28's care plan initiated on 5/8/2026 and revised on 5/21/2026 reflected a focus stating, The resident has a nutritional problem r/t mechanical soft diet, and intervention/tasks stating, Provide, serve diet as ordered. Monitor intake and record q meal. Record review of Resident #28's order summary printed 6/4/2026, reflected an order started on 12/3/2025 that stated, Regular diet mechanical soft texture, regular consistency. During observation of lunch service on 6/2/2026 at 12:30 PM, Resident #28 was observed to be served spaghetti with mechanically softened meatballs by CNA A. Another resident sitting next to Resident #28, who was not on a mechanically softened diet, was served spaghetti with full-size meatballs by CNA A. When Resident #28 saw the full-size meatballs on her neighbor's tray she complained to CNA A that she had not received any meatballs. The neighboring resident offered Resident #28 her meatballs from her plate and Resident #28 accepted. CNA A stood by watching. CNA B immediately intervened and told CNA A that Resident #27 could not had the meatballs and attempted to replace the resident's tray with new one. Resident #28 refused. CNA B immediately sought out the DON who was in the dining room and informed him of the occurrence. The DON attempted to reason with Resident #28 and offered to get her another tray. Resident #28 again refused. The DON continued to explain to the resident that she could not had whole meatballs, but she refused to listen and put the whole meatball in her mouth. The DON stood by monitoring the resident's consumption to ensure it was properly chewed and swallowed. In an interview on 6/2/2026 at 1230PM, CNA A confirmed Resident #28 was not to have had full meatballs, but she was unsure what to do if the resident insisted. In an interview on 6/4/2026 at 2:50 PM, the DON stated that he and all staff were oriented, trained and regularly in-serviced on topics relevant to their roles and responsibilities, including diets. The DON stated that dietary restrictions were communicated to staff through orders and hand-off reports. The DON stated if a resident refused their served meal, he would educate them on why the meal style was necessary. If they still refused, he would consult with the therapy department, doctor, and care plan team for recommendations. The DON stated that residents were not allowed to share food. He stated that potential negative outcomes from consuming food not prepared for them could be aspiration. The DON stated that CNA A should had immediately intervened and not allowed Resident #28 to accept food from another resident's plate. In an interview on 6/4/2026 at 3:00 PM, CNA D stated that she had been trained and in-serviced on diets and proper diet consumption by residents. She said if she was unsure of a resident's dietary restrictions, she would ask questions. CNA D stated that she was familiar with Resident #28 and her non-compliance with her dietary restrictions. She stated that Resident #27 often questioned why she was not served bacon when everyone else was. CNA D stated that she explained the reasoning to the resident every time. CNA D stated that correct diets were important because if served the wrong item, residents who had swallowing difficulties may choke. She stated it was also important for the resident's best overall health and safety. CNA D stated that Resident #27 was often not accepting of explanations and reasoning regarding her diet, and that she had seen the resident take food or accept food from others, even when instructed not to do so. In an interview on 6/4/2026 at 3:05 PM, CNA B stated that she had been oriented, trained, and regularly in-serviced on resident diets and consumption. She stated the facility's policy regarding diets stated that staff should look at the resident's care record and follow it. CNA B stated that menus and tickets should also be reviewed for accuracy regarding resident dietary restrictions. In regard to the observed incident regarding Resident #28, CNA D stated she would have immediately intervened and not allowed the residents to share food and would had explained the reason to the residents in a way they could understand. In an interview on 6/4/2026 at 3:15 PM, the ADM stated that all staff were properly oriented, trained and regularly in-serviced on topics relevant to their positions and responsibilities. The ADM stated that dietary restrictions for residents were communicated by nursing staff in conjunction with the dietary staff. Crucial information, such as dietary restrictions, were communicated in morning meetings and clinical meetings. The ADM stated if residents were non-compliant with their diet, the nurse was to be immediately notified. The ADM stated that non-compliance with dietary restrictions could lead to choking, allergic reactions, or weight loss. Resident #341. Record review of Resident #34's admission face sheet dated 06/04/26 reflected she was a [AGE] year-old male admitted to the facility on [DATE] with active diagnoses that included: Respiratory Failure, Chronic Obstructive Pulmonary Disease (lung diseases), Sepsis (life-threatening response to an infection), Acute Bronchitis, Enterovirus Infection (inflammation of the breathing tubes), and Depression. Record review of Resident #34's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15, indicating the individual's cognition was intact. Resident #34's MDS Assessment reflected that she was incontinent of bowl and bladder and required assistance with daily care.Record review of Resident #34's Care Plan dated 05/06/2026 indicated that the resident needed assistance with his ADLs. In an observation on 6/2/2026 at 10:24 AM in Resident #34's room, the call light was in the drawer and not within reach. An interview on 6/2/2026 at 10:26 AM with Resident #34 revealed he did not know how the call light ended up in the drawer. Resident #34 stated that he had not had any falls at the facility due to being unable to reach the call light and not receiving help. Resident #34 stated that he did not think about the call light that often. Resident #34 stated that the staff were the ones who helped him with his ADLs. Resident #20 2. Record review of Resident #20's admission face sheet dated 06/04/26 reflected she was an [AGE] year-old male admitted to the facility on [DATE] with active diagnoses that included: Metabolic Encephalopathy (altered mental status), Behavioral Disturbance (sudden changes in personality), Psychotic Disturbance (loses touch with reality), Mood Disturbance (Severe shifts in emotional state), Anxiety, Dysphagia Oropharyngeal (Difficulty swallowing), And Muscle Wasting And Atrophy (deterioration, shrinking, or loss of muscle mass). Record review of Resident #20's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15, indicating the individual's cognition was intact. Resident #20's MDS Assessment reflected that she was incontinent of bowel and bladder and required assistance with ADL care. Record review of Resident #20's Care Plan dated 05/05/2026 indicated that the resident needed assistance with his ADLs. In an observation on 6/2/2026 at 10:30 AM in Resident #20's room, the call light was hanging on the wall behind the bed while Resident #20 was in the recliner and unable to reach the call light. An interview on 6/2/2026 at 10:32 AM with Resident #20, revealed he had put the call light on the wall when he moved to the recliner. Resident #20 stated that he could not reach the call light because it was behind him. Resident #20 stated that he had not had any falls at the facility because he was not able to reach the call lights. An interview on 06/04/2026 at 1:06 PM with CNA D revealed she stated that the residents' call lights should have been next to them or on their outfits, so they were within reach. She stated that they checked on residents regularly to make sure the call light was within reach. She stated that if the call light was not close to the resident, she would move it back close to the resident. She stated that she would remind the residents of the importance of keeping the call light within reach and that they needed to use it in an emergency. She stated she had had in-service training, and the last time was a couple of months ago. She stated that residents could have been injured if the call light was not close. An interview on 06/04/2026 at 1:24 PM with CNA B revealed she stated that the call light should have been placed close to the resident. She stated that she would place the call light on the bed, so it was within reach. She stated that she checked on the residents often to make sure the call light was within reach. She stated that if a resident moved or left the room, when they returned, she would make sure the call light was close to the resident. She stated that if the residents did not like the call light being close to them, she would remind them that it needed to be close for their safety. She stated that she had had in-service training for about a month. An interview on 06/04/2026 at 1:42 PM [SH1] LVN E. He stated that call lights should have been within the resident's reach. He stated there had been a clip on the call light so that it could be kept close to the residents. If the resident moved to a chair, then the call light would have been close to the resident. He stated that residents were checked every couple of hours to ensure the call lights were in place. He stated that he had reinforced to the residents the need to keep the call light within reach for their safety. He stated that his in-service training had been 3 months ago, when he was hired. He stated that the resident could have been injured if the call light was not within reach. An interview on 06/04/2026 at 2:13 PM with the ADON, she stated that call lights should have been within the resident's reach. She stated if a resident moved to a recliner, the call light should have been moved with the resident. She stated that if the resident's call light was not within reach, the resident could have been injured. She stated that she talked to the residents about the importance of the call light being close. She stated that the resident could have fallen and not gotten help. She stated that call lights were talked about daily with the staff. An interview on 06/04/2026 at 3:09 PM with the ADM, she stated the call light should be within reach of the resident when the resident was in the room. She stated the call light should be moved if the resident goes to a recliner. She stated that the call light should always be within the resident's reach while the resident is in the room. She stated that all staff meet every month to remind staff about the call lights. Record Review of the facility's policy titled Lifting Machine, Using a Mechanical revised July 2017 revealed:1.Before using a lifting device, assess the resident's current condition, including:a.Physical:i.Can the resident assist with transfer?ii.Is the resident's weight and medical condition appropriate for the use of a lift?b.Cognitive/Emotional:i.Can the resident understand and follow instructions?ii.Does the resident express fear or appear anxious about the use of a lift?iii.Is the resident agitated, resistant, or combative?2. Measure the resident for proper sling size and purpose, according to the manufacturer's instructions.3. Select a sling bar that is appropriate for the resident's size and the task.12. Attach sling straps to sling bar, according to manufacturer's instructions.a. Make sure the sling is securely attached to the clips and that it is properly balanced.b. Check to make sure the resident's head, neck, and back are supported.c. Before resident is lifted, double check the security of the sling attachment.d. Examine all hooks, clips or fasteners.e. Check the stability of the straps.f. Ensure that the sling bar is securely attached and sound. Record review of the call light policy dated January 2025 reflected the following. Policy:Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. 1.Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor. Record review of the facility's policy and procedures entitled Dining Room Service dated 2023 stated: Dining room staff should check the individual name and diet on the meal identification (ID) card/ticket to verify that the meal was served to the correct person, check items on the plate/tray to ensure accuracy for food preferences, therapeutic or modified consistency diets.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to consistently monitor and discard expired food The facility failed to maintain a sanitary kitchen by keeping the ice scoop in the ice machine. The facility did not label and date food items in the kitchen. The facility failed to keep employee's food items away from residents' food items. These failures can place residents at risk for foodborne illness. Findings included:An observation of Refrigerator #1 on 6-2-2026 at 9:22 AM revealed the following. Individual Butter and jelly were in containers that were not labeled with a date. There was a staff member's cup in the refrigerator. Herbs in a zip top bag that was not labeled with what was in it and had no dates on it. Cut bell pepper in a sealed bag that was not labeled with an open and use-by date. Blueberries in the original container with no date on the package. An Observation of Refrigerator #2 on 6-2-2026 at 9:27 AM revealed the following. Frosting in a sealed bag only the date of 5-27-2026. A tray with Juice that was not labeled with a date. Plastic bag containing lettuce was neither labeled nor dated. Jello in a clear container not labeled with only a date of 6-1-2026 . Bowl of an unknown food item labeled with only the date 5-25-2026. Sandwich bag with a cut red onion that was not labeled, dated, or sealed. Sealed bag with cut tomatoes that had no open date and no use-by date. Lettuce in its original packaging, which had no date on the package. An observation of Freezer #1 on 06/01/2026 9:30 AM revealed the following. Plastic bag containing frozen egg rolls that were not labeled with what was in the bag, or an open or use-by date. Plastic bag containing frozen chicken nuggets that were not labeled with what was in the bag, or an open or use-by date. Plastic bag containing frozen garlic that was not labeled with what was in the bag, or an open or use-by date. An observation of Ice Machine #1 on 06/01/2026 9:34 AM revealed the following. The scope was being stored inside the ice machine on a hook. The ice scope was being stored in an open Ziplock bag on top of the ice machine. An observation of the kitchen on 06/02/2026 9:37 AM revealed the following. The drawer in the kitchen containing serving utensils had food debris at the bottom of the drawer. The tray holding the coffee cups had debris. An interview on 6/02/2026 9:37 AM with the DM revealed the following. DM stated that personal food items should not have been in the kitchen refrigerator. The DM stated that everyone in the kitchen had been responsible for labeling and dating food in the kitchen. The DM stated that dates in the kitchen were checked weekly. The DM stated that if he saw staff not labeling and dating food items, then he would have reminded them to do that. The DM stated that all food items should have been labeled and dated. The DM stated that all staff had been responsible for cleaning the kitchen. The DM stated that the kitchen drawers should have been cleaned 2 times a month. The DM stated that he had not been sure why the drawers were not cleaned. The DM stated that the staff had followed a cleaning schedule. The DM stated that if residents had eaten out-of-date food or food served on dirty utensils, they could have gotten sick.An interview on 6/02/2026 at 11:15 AM with the CK revealed she stated that personal items should not have been left in the fridge. She stated that it had been everybody's responsibility to label and take food items into the kitchen. She said that it had been everybody's responsibility to clean the kitchen. She stated their residents could have gotten sick if they were served out-of-date food or food from dirty utensils.An interview on 06/04/2026 at 2:54 PM with DA revealed she stated that it had been everybody's responsibility in the kitchen to clean. She stated that everyone had been supposed to clean their own area. She stated that everybody in the kitchen had been responsible for labeling and dating food items. She stated that the DM had been the one who checked for dates in the refrigerator. She stated that she had not been aware that no personal food items were to be left on the counter or in the refrigerator. She stated that there had been an ice scoop in the ice machine, but that was not the one that they used. She stated that it had been her drink that was in the refrigerator. She stated that they had had monthly in-service training. She stated that if these things had not been done, then it had been an infection control issue, and residents could have gotten sick.An interview on 06/04/2026 at 3:09 PM with the ADM revealed that she stated that everybody in the kitchen had been responsible for labeling and dating food items. She stated that everybody in the kitchen had been responsible for cleaning. She stated that the ice machine scoop had not belonged in the ice machine. She stated that kitchen staff had not been allowed to have their personal food items in the refrigerator or the kitchen area. She stated that doing these things could have put residents at risk by spreading an infection. She stated that the dietary manager had been responsible for in-service training for all kitchen staff. She stated that she would have reviewed all in-service training with the dietary manager to ensure staff had been updated on policies for labeling, dating, and kitchen cleaning. She stated that if these things had not been done then items could have been contaminated and caused the residents to get sick.Record review of the Labeling and Dating Policy dated November 2022 reflected the following. 2. Foods belonging to residents are labeled with the resident's name, the item, and the use by date.3.Food code was reviewed. Record review of the Sanitation Policy that was not dated reflected the following. Food and nutrition services staff will maintain kitchen sanitation by complying with a comprehensive written cleaning schedule.

Based on the interview and record review, the facility failed to treat Resident #27 with dignity and respect in a manner and environment that promoted the maintenance or enhancement of his or her quality of life for 1 of 11 (Resident #27) residents reviewed for resident rights.The facility failed to ensure Resident #27's private area was covered while staff transferred the resident via a mechanical lift (assists staff with transferring a resident from the bed to a wheelchair and from the wheelchair back to the bed) from the bed to a chair.This deficient practice could place residents at risk for unnecessary exposure, embarrassment, and diminished quality of life. The findings were:Review of Resident #27's face sheet, dated 06/02/2026, revealed she was admitted to the facility on [DATE] with history of Atherosclerotic heart disease of the native coronary artery without angina pectoris (Plaque has built up in the heart's original arteries, restricting blood flow without causing chest pain), Violent behavior, Dementia (Decline in mental ability severe enough to interfere with daily life), Depression (It causes persistent feelings of sadness, emptiness, and a loss of interest in activities), Abnormalities of gait and mobility (Irregular, unsteady, or inefficient walking patterns), A lack of coordination (Inability to control smooth, precise muscle movements), Cognitive communication deficit (Communication challenges caused by underlying disruptions in mental processes), and need for assistance with personal care. Review of Resident #27's quarterly MDS assessment dated [DATE] reflected that Resident #27 was assessed to have a BIMS score of 00, indicating severe cognitive impairment.Review of Resident #27's Care Plan, dated 01/30/2026, revealed a focus that Resident #27 required assistance by 2 staff with mechanical lift transfer assistance, and a focus dated 01/31/2026, revealed Resident #27 required assistance by staff with bathing/showering.Observation and interview on 06/02/2026 at 11:46 a.m. revealed Resident #27 was in her wheelchair, and Resident #27's FAM A was caring for Resident #27. Resident #27 had an above the left eyebrow laceration, and bruises on her left arm. FAM A mentioned, Resident #27 had fallen from the mechanical lift and hit the floor. FAM A stated Resident #27 cannot express pain, but if she gets angry, that shows her pain. FAM A stated Resident #27 no longer communicates the way she used to. FAM A stated she had video evidence that one girl getting Resident #27 ready without any clothing on, and Resident #27 was on the side lying in the mechanical Lift and Resident #27 fell from it. FAM A stated she is very disappointed about the situation. Review of video evidence recorded on 06/01/2026 at 01:15 p.m. revealed that Resident #27's body was fully uncovered on the bed and during transfer from the bed to the mechanical lift. Interview on 06/02/2026 at 01:31 p.m. with CNA C revealed that he had been working in the facility for about four months. CNA C was helping CNA A during transfer of Resident 27 for shower. CNA C was in-serviced on abuse, neglect, and exploitation. CNA C stated that it was both people's responsibility to ensure the resident is in the proper position during a mechanical lift transfer. CNA C had been trained in a mechanical lift. Interview on 06/02/2026 at 01:42 p.m. with CNA A revealed that she had been working at the facility for almost 5 months. CNA A stated she had been trained in abuse, neglect, and exploitation. CNA A stated she had been trained in the mechanical lift 1-2 months ago. CNA A stated Resident #27 was fighting in the mechanical and moving Resident #27's legs up and down, then Resident #27 came to one side of the mechanical and fell. CNA A stated Resident #27 was in the right position because CNA A helped Resident #27 position on the front by fixing Resident #27's legs, and CNA A's partner, CNA C, helped CNA A to put Resident #27 in the middle from the back. CNA A stated she did not ask for help while Resident #27 was moving too fast in the Hoyer. CNA A stated nothing to Resident #27 this time, and everything happened so fast. CNA A stated she did not ask for help or pause during the transfer because Resident #27 acted the same way throughout. CNA A stated that after the fall, CNA C saw the resident was bleeding, and her partner, CNA C, told CNA A to get the nurse, and CNA A went to get the nurse. CNA A stated that this kind of incident had not happened before.In an interview on 06/04/2026 at 01:50 p.m., LVN A stated a negative outcome of transferring a resident without covering private parts from the bed to the mechanical lift can cause skin injury and dignity issues. LVN A stated that some prevention measures include ensuring all pressure points and private areas were covered, preventing skin tears, and maintaining residents' dignity. In an interview on 06/04/2026 at 02:32 p.m., DON stated a negative outcome of transferring a resident totally not covering private parts, from the bed to the mechanical lift, was just dignity. DON stated you didn't want your body to be exposed that's why Resident's body needs to be covered. DON stated some prevention measures to avoid exposing residents include covering the patient, providing privacy, putting them in a gown, and covering them with a loose-fitting garment until they were in the shower. In an interview on 06/04/2026 at 03:16 p.m. ADM stated she did not know the negative outcome of failing to cover a resident's private area during a transfer and would refer to her clinical staff. Review of the facility's policy titled Dignity with a revised date of February 2021 revealed that:1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.12. Demanding practices and standards of care that compromise dignity are prohibited.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #14) reviewed for care plans.1.The facility failed to develop a comprehensive care plan to reflect Resident #14's diagnoses.2.The facility failed to develop a comprehensive care plan to reflect Resident #14's preferences.These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial and medical needs. Record review of Resident #14's face sheet printed on [DATE], reflected a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included Parkinson's Disease with dyskinesia, with fluctuations (progressive neurological disorder with involuntary, abnormal movements due to changes in dopamine levels), unresolved, onset date of [DATE], muscle weakness, unresolved, onset date of [DATE], lack of coordination, unresolved, onset date of [DATE], aphasia (language disorder that affects an individual's ability to communicate effectively), unresolved, onset date [DATE], pneumonia, unresolved, onset [DATE], and urinary tract infection (UTI), unresolved, onset date [DATE]. Record review of Resident #14's Quarterly MDS assessment dated [DATE], reflected Resident #14 had a BIMS score of 3, indicating severe cognitive impairment. The MDS assessment stated Resident #14 needed substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS assessment reflected Resident #14 was dependent on a helper to do all the effort regarding toileting hygiene, shower/bathing, lower body dressing, and putting on and taking off footwear. The MDS assessment reflected Resident #14 needed substantial/maximal assistance rolling left to right, moving from sitting to lying, moving from lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. The MDS assessment reflected that the resident was totally dependent on a helper for tub/shower transfers. The MDS assessment reflected Resident #14 was always incontinent (bowel and bladder). The MDS assessment reflected that Resident #14 had a condition or chronic disease that may had resulted in a life expectancy of less than 6 months. The MDS assessment reflected Resident #14 had been on a mechanically altered diet while a resident and was at risk of developing pressure ulcers/injuries. The MDS assessment reflected Resident #14 was taking an antidepressant, a diuretic, oxygen therapy, and receiving hospice care. Record review of Resident #14's Comprehensive Care Plan initiated on [DATE] and revised on [DATE] reflected 1 Focus as follows: DNR Resident Choice, with a Goal of [Residents] wishes will be honored. The Interventions/Tasks for this focus were: Educate the resident/family of the meaning of the current code status. Ensure the current code status was in the medical record. If arrest occurs CPR will not be given. Notify receiving facility of the current code status. Place DNR in [resident's] record. Residents have right to be a DNR. Review quarterly. No other focus, goal, and/or intervention/tasks listed.In an interview on [DATE] at 2:00 PM, the ADON stated she had been working at the facility since [DATE]. She stated that she had been oriented, trained, and in-serviced on relevant topics to her position. The ADON stated the purpose of care plans was for staff to know how to properly care for the residents and their needs. The ADON confirmed focus were as such as hospice services should be included in a resident's care plan. The ADON stated that a possible negative outcome from an incomplete care plan would be a lack of knowledge of the residents' needs and necessary services. The ADON agreed Resident #14's care plan was incomplete and incorrect. She stated there were several essential focuses were missing that could lead to the resident not getting the services needed.In an interview on [DATE] at 2:50 PM, the DON stated he had been in his position since [DATE]. The DON stated that he left the accuracy and completion of the comprehensive care plans system and monitoring to their MDS nurse which resulted in Resident #14's incomplete care plan. The DON stated care plans should include services and interventions necessary to provide appropriate treatment for identified problems. The DON stated if there was no clear pathway to treat the residents' problem were as, harm may be caused. The DON stated that triggered care were as in the MDS assessment should be carried over to the care plan. The DON agreed that Resident #14's care plan was not complete.In an interview on [DATE] at 2:55 PM, CNA D stated she worked for the facility for almost 4 years. She confirmed she had been appropriately oriented, trained, and in-serviced on relevant topics for her position. CNA D stated the importance of care plans was to determine residents' needs. She stated if she saw an incomplete service plan, she would ask the appropriate staff member or bring it to their attention.In an interview on [DATE] at 3:05 PM, LVN A stated he had worked for the facility for 3 months. He stated that he had been oriented, trained, and in-serviced on relevant topics for his position, including care plans. He stated that care plans needed to be complete to provide the residents with the best therapeutic care possible. He stated that focus were as such as hospice and pneumonia should be included in a resident's care plan. He stated a possible negative outcome of an incomplete care plan would be decreased health.In an interview on [DATE] at 3:15 PM, the ADM stated that she could not speak directly to the contents of a comprehensive care plan and would defer to the facility's MDS nurse. The ADM stated that a possible negative outcome of an incomplete comprehensive care plan was that the resident would not receive adequate care.Record review of the facility's policy entitled, Care Plans, Comprehensive Person-Centered states:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident.Furthermore, the policy interpretation and implementation states:1.The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7.The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. includes the resident's stated goals upon admission and desired outcomes.d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem were and conditions.

Based on observations, interviews, and record review, the facility failed to ensure the safe storage of medications and medical supplies within the medication cart for 1 of 2 medication carts (medication cart on 100 hall) reviewed for pharmacy services. The facility failed to prevent the storage of expired medication and supplies in the medication cart on 100 hall. This deficient practice could place residents at risk of the medications and supplies not being as effective and dealing with the symptoms that the meds were supposed to treat.The findings included: Observation on 06/03/2026 at 02:20 pm showed that the following medication and supplies were expired in the medication cart of the 100 Hall: 1. OCuSoft Lid Scrub Plus, which was used as an Eyelid Cleanser for moderate-severe conditions, expired on 12/2025.2. Nystop. Nystatin Topical Powder, USP 100,000 USP Units Per Gram (Treat fungal infections) expired on 05/31/2026.In an interview on 06/03/2026 at 02:51 p.m., LVN B stated she had been working at the facility for about 3 months. LVN B stated she checked expired medication every couple of weeks. LVN B stated that expired medication can affect its potency, becoming either stronger or weaker in its effects. LVN B stated that she will check more promptly, at least once a week, to prevent expired medication from being in the medication cart. LVN B stated she had been trained to check for expired medication and immediately removed the found expired medications from the medication cart. In an interview on 06/04/2026 at 02:18 p.m., ADON stated that the negative outcome of expired medication was: Expired medication cannot get the full chemicals of the medication and not fully absorbed, which can cause a negative reaction. ADON stated that interventions could be implemented to prevent expired medication from being administered to residents, such as regularly checking stock levels. ADON stated it was the responsibility of the nursing staff to check the expired medication, and anyone assigned to the medication cart. ADON stated she checks the medication cart every month. In an interview on 06/04/2026 at 02:32 p.m., DON stated that a negative outcome of expired medication could be a medication error because one could mistakenly pass that medication and potentially cause patient harm, or the medication may not be therapeutic. DON stated that an intervention can be taken to prevent expired medication from being administered to residents, which includes the following: cart checks being performed in mid-month, not only by the ADON, but also by nurses, who should check the expiration date with each medication administration. In an interview on 06/04/2026 at 03:16 p.m., ADM stated that she would refer to her clinical staff regarding the negative outcomes associated with expired medications. ADM stated that interventions could be taken to prevent expired medication from being administered to residents by checking the medication cart monthly. ADM stated that it is the responsibility of the nursing staff and the ADON to check for expired medication. Review of the facility's policy titled Medication Labeling and Storage, revision date February 2023, revealed under the Medication Storage: 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding resuming or destroying items.

Based on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 1 of 6 residents (Resident #1) reviewed for advanced directives, in that:The facility failed to ensure Resident #1's OOH-DNR was valid with a physician signature which resulted in Resident #1 receiving life saving measures including CPR when Resident #1 was found unresponsive. This failure places residents at risk of having their end-of-life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident of #1's face sheet, dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of SEPSIS, UNSPECIFIED ORGANISM, (condition that occurs when the body's response to an infection causes injury to its own tissues and organs), PNEUMONIA, (an infection that inflames the air sacs in one or both lungs) and PRESENCE OF PROSTHETIC HEART VALVE (Pacemaker), (a medical device designed to replace a diseased native valve). Record review of an OOH DNR form, dated [DATE], revealed RP and BM/HR's signatures were both on the form. The OOH DNR did not have a doctor's signatures on the form. Record Review on [DATE] of Resident #1 's Orders revealed Code Status: (Advance Directive) *** FULL CODE***. Record review of Resident #1's comprehensive care plan, initiated on [DATE], revealed there was no code status mentioned. During an interview on [DATE] at 3:31 p.m., the BM/HR revealed her responsibilities included performing financial assessments and obtaining paperwork for new admissions. The BM/HR stated, 'I was told by the Regional Trainer that when the family comes in, have them fill out the OOH form. She said the RP signed the new admission forms that included the OOH form. She said she looked it over and signed it. She stated, 'the DON took the OHH off my desk, it was in his office for a while, and I was responsible to upload it to Resident # 1's file.' BM/HR has received training regarding her responsibility to obtain the required signatures on OOH DNR form, and she understands the form is not valid unless a physician's signature has been included on the form. During an interview on [DATE] at 10:37 a.m., LVN A revealed on [DATE] at 6 a.m., CNA B had alerted her that Resident #1 was found unresponsive. LVN A stated she went to Resident # 1s room, he looked pale. She said, she checked his pulse on his neck and his left wrist, she then used the blood pressure cuff and she checked his oxygen; there were no readings on either device. She stated the CNA remained with Resident # 1 in his room while she went to the nurse's station to check the computer to find an Advance Directive for Resident # 1. Resident # 1's Advance Directive was, full code. She contacted the NP. Next, she connected the leads from the Automatic compression machine on Resident # 1 while he was on the bed and she performed CPR. She stated, CNA B called EMS. She stated, Resident # 1 passed away on [DATE] at 6:59 a.m. During an interview on [DATE] at 1:02 p.m., CNA B revealed on [DATE] at 6 a.m. she found Resident # 1, lying in his bed and he was unresponsive. CNA B stated, she notified LVN A of Resident # 1s condition and she checked Residents # 1's file for an Advanced Directive. She stated Resident # 1's file showed the Advance Directive was 'full code'. She said, I accompanied LVN A in Resident # 1's room and I brought the Automatic compression machine over to Resident # 1s bed. During an interview on [DATE] at 1:05 p.m., the DON revealed BM/HR was responsible for obtaining all required signatures on all the admission paperwork. The DON stated, BM/ HR didn't speak with the clinical staff regarding the family's wishes for DNR. The DON stated BM/ HR didn't get the physician's signature on the OOH DNR form. The DON stated, on Monday ([DATE]), the day following Resident # 1's death, DON discovered that Resident # 1's RP had signed and dated a OOH DNR form. The DON stated that the corporate office advised him that the document was not valid if the physician's signature was not on the form. The DON stated he contacted Resident #1's RP regarding Resident # 1's Advanced Directive. The DON said RP told him that he signed the OOH DNR document on [DATE] and he had discussed Resident #1's wishes for a DNR with BM/ HR. The DON said RP told him, he believed that was all he needed to do regarding the Advanced Directive. During an interview on [DATE] at 3:00 p.m., the Administrator stated the staff member who did the admission paperwork for Resident #1 was BM/HR. The ADM stated handling new admission paperwork was in the job description for BM/ HR. The ADM stated it was BM/ HR's responsibility to let the staff know Resident #1's wishes. The ADM stated an Advanced Directive for DNR was valid if a Physicians signature has been obtained on the form. Record review of the facility document titled Advance Directives, dated 09/2022, stated Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. a. Advance care planning - a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. b. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated . Do Not Resuscitate (DNR)- indicates that, in a case of respiratory or cardiac failure, their resident, legal guardian, healthcare proxy, or representative ad directed that no cardiopulmonary resuscitation (CPR) or other life -sustaining treatments or methods are to be used.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure Resident #1 had orders in place to treat his heel abrasion from 11/14/2025 through 12/03/2025. The facility failed to ensure Resident #1 had a weekly skin assessment completed on 11/22/2025 and 11/29/2025. These failures could place residents at risk for unassessed changes in conditions and to not receive adequate care Findings included:Review of Resident #1 face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified fracture of right femur (break in thigh bone), depression (mental health disorder characterized by persistent feelings of sadness), chronic embolism and thrombosis of unspecified deep veins (blood clots in deep veins that cause ongoing circulation problems), and restlessness and agitation. Review of Resident #1 admission MDS dated [DATE] reflected a BIMS of 11 which indicated moderate cognitive impairment. Review reflected Resident #1 had no pressure ulcers/injuries. Review of progress note dated 11/16/2025 by RN B reflected late entry for admission on [DATE] reflected whole body assessment done. bilateral buttock redness . no other skin breakdowns. Review of Resident #1 order summary reflected no orders to treat or monitor Resident #1's heel. Review of physician's orders dated 11/15/2025 reflected an order to for wound consult for skin and wound conditions/prevention. Further review reflected an order dated 11/15/2025 for pressure relieving mattress. Review of Resident #1 admission skin assessment dated [DATE] reflected right foot (heel): superficial abrasion noted. Review of Resident #1 assessment reflected there were no other skin assessments documented for Resident #1. Review of Resident #1 undated care plan reflected Resident #1 had a potential for impaired skin integrity with a goal for his skin to remain intact. Interventions included evaluate skin integrity and provide skin care per facility guidelines and as needed. Review of Resident #1's chart reflected no wound consult notes. Review of Resident #1's November 2025 TAR reflected no wound care was performed on Resident #1's heel. Review of Resident #1's December 2025 TAR reflected no wound care was performed on Resident #1's heel. Observation and attempted interview on 12/02/2025 at 11:24 AM revealed Resident #1 sat in his wheelchair at the nurses station. Resident #1 had socks on and a pillow on the footrest of his wheelchair that his right foot rested on. Resident did not respond to simple questions and did not indicate any nonverbal signs of pain or discomfort. Observation on 12/03/2025 at 9:36 AM revealed Resident #1's right heel had a circular area with flakey skin. Inside the circular area was a smaller circular area with a darker red area with a white center. Above the heel was a smaller circular area that appeared sunken in below the surface and dark black in color. During an interview on 12/02/2025 at 12:07 PM, RN E stated that she worked on 11/30/2025 as the weekend supervisor. She stated that she completed skin assessments for some residents on the weekends and RN F (another weekend supervisor) completed skin assessments for the other residents during her shift. RN E stated she believed there was new breakdown on Resident #1's heels. RN E stated that she was unsure if there were orders in place for Resident #1. RN E stated that she was unable to log into the facility computer on 11/30/2025 and unable to access the resident's charts. RN E stated that she reported the breakdown to RN B, who was the charge nurse this day, and did not report it to the DON/ADON/NP or MD. RN E stated since she did not have access to the computer or charting system she did not finish skin assessments and did not document the assessments she did complete anywhere. RN E stated she only completed a handful of skin assessments and did not complete any other assessments because she was unable to get into the charting system and was busy during her shift. During an interview on 12/02/2025 at 2:01 PM, CNA C stated that he provided care for Resident #1. CNA C stated that he recalled seeing blistering on Resident #1's right heel. CNA C stated sometimes when he arrived for his shift ( 6:00 am to 2:00 PM) he saw brown spots on Resident #1's sock or sheets from his heel. CNA C stated that he reported the change in Resident #1's heel to RN A the second day Resident #1 was at the facility. CNA C stated he was instructed to place a boot on Resident #1's foot, but he was not sure who instructed him to do so. CNA C stated he felt the area on Resident #1's heel was not smaller in size. CNA C stated any changes in skin are reported to the charge nurse and documented on the POC. During an interview on 12/02/2025 at 2:01 PM, CNA D stated that Resident #1 had a sore on his heel, but it looked better. CNA D stated the nurse put a bandage on Resident #1's heel sometimes and that a pillow was kept under his heel. CNA D stated that any changes in skin were reported to the charge nurse. During an interview on 12/02/2025 at 2:05 PM, RN A stated that RN B completed Resident #1's admission and that he was asked by RN B to complete Resident #1's admission skin assessment a few days after Resident #1 admitted . RN A stated that he was not sure if Resident #1 was seen by a wound care doctor. RN B stated when skin issues were found upon admission orders were supposed to be put in to treat the wound and to follow up with wound care. RN A stated that Resident #1 had an abrasion on his heel that was a blister and it was still there. RN A stated that usually blisters were reported to the wound care doctor. He stated that he did not report it because RN A did the admission and he only helped by completing the skin assessment. A telephone interview was attempted with RN B on 12/02/2025 at 3:34 PM a voicemail requesting a return phone call was left. No phone call was returned. During an interview on 12/03/2025 at 9:57 AM, RN A stated that Resident #1's heel was as [RN A] described in my notes. RN A stated that Resident #1 had an abrasion on his heel. RN A described Resident #1's heel as open. RN A stated he did not recall any orders for treatment related to Resident #1's heel. RN A stated that Resident #1 was not admitted during his shift and that Resident #1 had been at the facility for a few days when he completed Resident #1's admission skin assessment. RN A stated that he saw Resident #1'sheel on 12/2/2025 and 12/1/2025 during his shifts and described it as about the same. RN A stated that there should have been an order for treatment of Resident #1's heel. RN A stated that after he completed Resident #1's skin assessment he did not call the NP or doctor. RN A stated that the facility did not have a DON or ADON during the assessment or as of 12/3/2025. RN A viewed a picture of Resident #1's heel dated 12/3/2025 with a time stamp of 9:36 Am. RN A stated that he did not stage Resident #1's heel as it was only an abrasion. RN A stated that it looked like a pressure sore in the picture. RN A stated that if a pressure sore is not addressed it can get worse. RN A stated there was an area above Resident #1's heel that was dark and looked necrotic (relating to or characterized by the death of cells in an organ or tissue due to disease, injury, or failure of the blood supply). RN A stated that he did not recall that dark spot above Resident #1's heel at admission. RN A stated he was not sure what was being done to address Resident #1's heel since there were not orders. RN A stated there was a wound doctor that came to the facility but was not sure who the company was as the facility was recently acquired by a new company. During an interview on 12/03/2025 at 1:18 PM, CNA F stated that if she found a change in skin such as a bruise or anything that was not there before, she would report to the charge nurse immediately. CNA F stated it was important to report to the nurse because it could be a result from a fall or something else. CNA F stated she was not familiar with Resident #1. During an interview on 12/03/2025 at 1:27 PM, RN G stated when skin issues are reported the first thing she would do is assess the resident. RN G stated if it was a known skin issue she would look to see if it has was worse or better and if there was any pain. RN G stated that she viewed Resident #1's heel today (12/03/2025) and stated that it looked like a pressure ulcer was starting on Resident #1's heel. She stated that it did not look like an abrasion. RN G stated an abrasion was surface level scratched and that it looked like a pressure ulcer because of the location. RN G stated Resident #1' had a soft boot to wear but he did not always want to wear it. RN G stated a pillow was put under Resident #1's heel when he was in his wheelchair. RN G stated when she arrived for her shift (6:00 am to 2:00 pm) Resident #1 had pillows under his heels when he was in bed to offload pressure. RN G stated any change in skin was supposed to be reported to the ADM since there was no DON at the facility. RN G stated she could also report changes to the RNC. RN G stated it was important to report changes in the skin because it could increase in size and was important to address before it got worse. RN G stated Resident #1's pressure ulcer on his heel was the size of a nickel and had no depth or odor when she viewed it. RN G stated there was a smaller area above Resident #1's heel that looked as if another pressure ulcer was starting. She stated that it looked black in color and it has not always been like that, but was unsure when it started. She stated that based on the color it looked like eschar (thick, black, scab of dead tissue that forms over deep wound, burn or ulcer). RN G stated there was no drainage and did not think that it was like that when she worked on 11/29/2025 and looked like it was worse. RN G stated Resident #1 should have been seen by the wound doctor. RN G stated skin changes or concerns should also be reported to the NP or doctor. During a subsequent interview on 12/3/2025 at 1:58 PM, RN A stated he did not recall CNA C reported anything to him about Resident #1's heel prior to the skin assessment he did. During an interview on 12/03/2025 at 2:23 PM, RNC stated when there was a change in resident's skin staff should notify the DON or management nurse. RNC stated since there was no DON at the facility staff should notify the ADM who would then call the RNC. RNC stated the NP or doctor should be notified as well. RNC stated it was not acceptable to notify another nurse on duty and leave it at that. RNC stated if staff could not access the charting system they should have contacted the ADM or RNC or anyone in corporate. RNC stated that staff should have still conducted a skin assessment despite not being able to access the resident's chart. RNC viewed a picture of Resident #1's heel dated 12/3/2025 with a time stamp of 9:36 AM. RNC stated that he had not viewed Resident #1's heel in person. He stated that from the look of the picture he would describe the heel as an abrasion and the spot above the heel as a black spot that looked like a scab or looked as if Resident #1 had rubbed his heel on something like the bed. RNC stated an abrasion is from rubbing a sheet and a pressure ulcer was from constant pressure that blocked circulation and caused skin breakdown. RNC stated if there was an order for a wound consult the facility would schedule an appointment at a wound click or the wound physician (that comes into the facility weekly) could have seen the resident. RNC stated the wound care team should have been notified right away. RNC stated no staff reported anything to him about Resident #1's heel and that it should have been reported to the RNC or physician. RNC stated it was important to be reported so it could be addressed and that he expected the physician would have put a treatment order in. RNC stated if Resident #1's heel was compromised and was not treated it could have had a negative impact on Resident #1's health and could have gotten worse. RNC stated that if a resident admitted with skin issues he expected at least weekly monitoring to occur and to be documented. RNC stated that a skin assessment should have been completed at the time of admission not days later. RNC stated that skin assessments were scheduled for Saturday and Sunday and divided between the two weekend supervisors, but that he recently moved the assessments to be completed during the week. RNC stated a skin assessment should have occurred at least every 7 days for all residents. RNC stated an assessment should be completed up on admission to see if a resident admitted with a wound or not. During an interview on 12/3/2024 at 3:06 PM, the ADM stated she has been at the facility since 11/3/2025 and there was not currently a DON. The ADM stated that any change of condition for a resident (including skin) should be reported to the DON or charge nurse and be charted to discuss in the clinical meeting. An interview was attempted with the MD's office on 12/03/2025 at 3:28 PM, a voicemail was left requesting a return phone call with no return phone call received. Review of facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 2001 reflected the nurse should document full assessment of a pressure ulcer including location, stage, length, width, depth and presence of necrotic tissue. The staff will examine the skin of a new admission of ulcerations or altercations in skin. The physician or designee will authorize orders related to wound treatments and interventions related to wound management. The physician or designee will monitor and document the progress of wound healing.

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 3 of 4 (Resident #1, Resident #2, and Resident #3) reviewed for pharmacy services. The facility failed to ensure that all of Resident #1's, Resident #2's, and Resident #3's medications were administered on time as indicated by physician's orders on 11/27/2026. These failures could place residents at risk of exacerbation and/or deterioration of their health conditions, and delayed relief or treatment of symptoms which could result in decreased quality of life, discomfort or hospitalization. Findings included: Review of Resident #1 face sheet dated 12/02/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified fracture of right femur (break in thigh bone), depression (mental health disorder characterized by persistent feelings of sadness), chronic embolism and thrombosis of unspecified deep veins (blood clots in deep veins that cause ongoing circulation problems), and restlessness and agitation. Review of Resident #1 physician orders reflected an order dated 11/15/2025 for Divalproex Sodium Oral Capsule Delayed Release 125 MG with instructions to give 2 capsules by mouth every morning and at bedtime. Review also reflected an order dated 11/15/2025 for Sacubitril-Valsartan Oral tablet 24-26 MG with instructions to give 1 tablet by mouth every morning and at bedtime. Review of Resident #1's MAR reflected Divalproex was scheduled for 7:00 am and 7:00 PM. Review reflected LVN H administered Resident #1's first dose of Divalproex on 11/27/2025. Review also reflected Sacubitril-valsartan was scheduled for 7:00 AM and 7:00 PM. Review reflected LVN H administered Resident #1's first dose of Sacubitril-valsartan on 11/27/2025. Review of Resident #1's medication admin audit report reflected on 11/27/2025 LVN H administered Resident #1's Divalproex at 9:25 AM, two hours and twenty five minutes after scheduled administration time of 7:00 AM. Further review of the medication admin audit report reflected on 11/27/2025, LVN H administered Resident #1's Sacubitril-valsartan at 9:35 AM, two hours and thirty-five minutes after the scheduled administration time of 7:00 AM. Review of Resident #1 admission MDS dated [DATE] reflected a BIMS of 11, which indicated moderate cognitive impairment. Review of Resident #2's face sheet dated 12/02/2025 reflected a [AGE] year old woman admitted on [DATE] with diagnoses of immobility syndrome (paraplegic), hypokalemia (condition where blood potassium levels are too low and impact muscles, nerves, heart and kidneys), major depressive disorder (serious mood disorder causing persistent sadness and loss of interest that impacts daily life), and other chronic pain (persistent pain not tied to specific injuries). Review of Resident #2's physician orders reflected an order dated 11/19/2025 for Aspirin Oral tablet Chewable 81 MG with instructions to give by mouth every morning and bedtime. Review reflected an order with a start date of 11/19/2025 for baclofen Oral tablet 10 MG with instructions to give by mouth three times a day. Review reflected an order with a start date of 11/19/2025 for buspirone HCL Oral Tablet 5 MG with instructions to give 2 tablets by mouth every morning and at bedtime. Further review reflected an order dated 11/19/2025 for Potassium Chloride ER Oral tablet Extended Release 10 MEQ with instructions to give 2 tablets by mouth two times a day. Review of Resident #2's MAR reflected Aspirin was scheduled for 7:00 AM and 7:00 PM. Review reflected LVN H administered Resident #2's first dose of Aspirin on 11/27/2025. Review reflected Resident #2's buspirone was scheduled for 7:00 am and 7:00 pm and the first dose was administered by LVN H on 11/27/2025. Review reflected Resident #2's Baclofen was scheduled for 6:00 am, 11:00 am and 7:00 pm. Review reflected LVN H administered Resident #2's first and second dose of Baclofen on 11/27/2025. Review reflected Resident #2's Potassium was scheduled to be administered at 7:00 am and 7:00 pm. Review reflected LVN H administered Resident #2's first dose on 11/27/2025.Review of Resident #2's medication audit report reflected on 11/27/2025 LVN H administered Resident #2's 6:00 Am dose of Baclofen at 10:43 AM, four hours and forty-three minutes after scheduled administration time. Review reflected LVN H administered Resident #2's 7:00 am dose of aspirin at 10:42 AM, three hours and forty-two minutes after the scheduled administration time on 11/27/2025. Review reflected on 11/27/2025 LVN H administered Resident #2's 7:00 AM dose of buspirone at 10:43 AM, three hours and forty-three minutes after scheduled administration time. Review reflected on 11/27/2025, LVN H administered Resident #2's 7:00 AM dose of Potassium at 10:43 AM, three hours and forty-three minutes after scheduled administration time. Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS of 15, which indicated cognitively intact. Review of Resident #2's care plan dated 05/29/2025 reflected Resident #2 was on anticoagulants with goal to take anticoagulant as ordered and interventions to administer medication per MD order. Review of Resident #3's face sheet dated 12/3/2025 reflected a [AGE] year old male admitted on [DATE] with diagnosis of Alzheimer's disease (progressive brain disorder leading to gradual memory loss and difficulty thinking), and gastro-esophageal reflux disease without esophagitis (chronic digestive condition where stomach acid frequently flows back into the esophagus). Review of Resident #3's physician orders reflected an order dated 11/25/2025 for Donepezil HCL Oral Tablet 10 MG with instructions to give 1 tablet by mouth every morning and at bedtime. Review reflected an order dated 11/25/2025 for Pantoprazole Sodium Oral Tabley Delayed release 40 MG with instructions to give 1 tablet by mouth every morning and at bedtime. Review of resident #3's MAR reflected Donepezil was scheduled for 7:00 Am and 7:00 PM, review reflected LVN H administered Resident #3's first dose of Donepezil on 11/27/2025. Review reflected Resident #3's Pantoprazole was scheduled for 7:00 am and 7:00 PM. Review reflected LVN H administer Resident #3's first dose of Pantoprazole on 11/27/2025. Review of Resident #3's medication audit report reflected on 11/27/2025, LVN H administered Resident #3's 7:00 am dose of Pantoprazole at 10:12 AM, three hours and twelve minutes after scheduled administration. Review reflected on 11/27/2025, LVN H administered Resident #3's 7:00 AM dose of Donepezil at 10:12 AM, three hours and twelve minutes after scheduled administration time. Review of Resident #3's unspecified MDS dated [DATE] reflected BIMS was not completed and Resident #3 had short term memory problems. During an interview on 12/02/2025 at 11:42 AM, LVN H stated that she worked 25 hours straight from 11/26/2025 through 11/27/2025. She stated that she worked from 6:00 pm on 11/26/2026 until almost 7:00 pm on 11/27/2025. LVN H stated that the oncoming nurse called in on 11/27/2025 due to family emergency. LVN H stated that the ADM and staffing coordinator attempted to find coverage. LVN H stated that she had to step out twice and that she was in tears because she was overwhelmed. LVN H stated she texted the ADM that she did not feel competent taking care of the residents and safe passing out medications due to lack of sleep. LVH H stated after working 16 hours she did not feel comfortable passing out medications. She stated that she did not believe there were any missed medications, but she was also not sure if medications were on time because she was so tired on 11/27/2025. During an interview on 12/03/2023 at 1:27 PM, RN G stated that medication had to be passed on her shift (6:00 am to 6:00 PM) between 7:00 am and 10:00 Am. RN G stated if medication was scheduled at 7:00 am, it could be administered an hour prior or an hour after 7:00 AM. RN G stated after the hour mark, it was considered late. During an interview on 12/03/2025 at 1:58 PM, RN A stated medication could be passed 30 minutes to an hour prior to scheduled time. RN A stated if a medication was scheduled for 7:00 am after 8:00 am it was considered late. RN A stated it was important to administer medications on time to ensure noon medications or other subsequent medications did not overlap. During an interview on 12/03/2025 at 2:23 PM, RNC stated the facility was on a liberalized medication administration timeframe (staff could administer between 7:00 AM through 11:00 AM for medications unless order says otherwise), but some medications had specific time to be administered. RNC stated if specified, there was an hour before and hour after that the medication could be administered. During an interview on 12/03/2025 at 3:06 PM, the ADM stated that she was not aware of the time frames for medication administration. An interview was attempted with the MD's office on 12/03/2025 at 3:28 PM, a voicemail was left requesting a return phone call with no return phone call received. Review of facility policy titled Administering Medications with revision date of April 2019, reflected medications are administered in a safe and timely manners, and as prescribed and staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Review also reflected medication administration times are determined by resident need and benefits which includes optimal therapeutic benefit, prevention medication or food interaction and resident preference. Medications are administered within one (1) hour of their prescribed time.

Based on interview and record review, the facility failed to use the services of a registered nurse of at least 8 consecutive hours a day, 7 days a week for 2 of 14 days reviewed (11/27/2025 and 11/28/2025) reviewed for RN coverage. The facility failed to ensure they had an RN charge nurse on duty on 11/27/2025 and 11/28/2025. This failure could place residents at risk of missed nursing assessments, interventions, care and treatment. Findings included: Review of November 2025 nurses schedule reflected zero hours worked by an RN on 11/27/2025 and 11/28/2025. Review of time sheets and scheduled reflected LVN H worked 11/26/2025 from 5:50 PM until 11/27/2027 at 6:54 PM (25 hours). Review of time sheet reflected LVN J relieved LVN H at 6:52 PM on 11/27/2025 and left the shift at 12:38 PM on 11/28/25. Further review of scheduled reflected LVN I worked on 11/28/2025 from 6:00 am to 6:00 pm and was relieved by LVN K who worked from 6:05 pm on 11/28/2025 to 6:47 AM on 11/29/2025. During an interview on 12/02/2025 at 11:42 AM, LVN H stated that she worked 25 hours straight from 11/27/2025 to 11/28/2025. LVN H stated that she was scheduled to work 11/26/2025 to 11/27/2026 from 6:00 pm to 6:00 am. She stated the morning of 11/27/2026 at 4:00 AM (two hours before her shift was scheduled to end) LVN I called in with a family emergency. LVN H stated that the staffing coordinator (CNA D) was on the shift with her and she called other staff to come in to relive LVN H. LVN H stated she was told at 10:37 AM on 11/27/2025 that RNC was going to relieve her but that she was then told at 1:00 pm on 11/27/2025 that RNC was not in the area to relieve her. RNC stated that no one showed up to relieve her until 11/27/2025 at 6:15 PM which was LVN J. LVN H stated that she had to step out twice because she was in tears and felt she did not feel comfortable to pass medication after 16 hours due to being tired and stated she was not sure medications were on time. During an interview on 12/02/2025 at 12:57 PM, CNA D stated she was the staffing coordinator and scheduled staff. She stated that call-ins go through her and the former DON used to handle nursing call-ins. She stated that for any call-ins she sends out a message in the group chat and asks if any nurses are available to pick up a shift. CNA D stated that LVN L never called in but she had a family emergency and called in early morning on 11/27/2025. CNA D stated that RN M was scheduled to work on 11/27/2025 with LVN L, but she called in after she found out LVN L would not be working. CNA D stated that RN M stated she would not come in if there was not going to be a nurse working the floor. CNA D stated when she received word from RN M that she was not going to come in she reached out to the ADM and RNC. CNA D stated she worked from 11/26/2025 at 10:00 pm to 11/27/2025 at 6:00 AM as a CNA. CNA D stated the facility tried to hire more nurses and they just hired RN G. CNA D stated that the LVN J relieved LVN H on 11/27/2025 and LVN I received LVN J on 11/28/2025 both of whom are agency staff. During an interview on 12/03/2025 at 12:30 PM, RN M stated that she was scheduled to work on 11/27/2025 and did not come to the facility because she did not feel safe. RN M stated that on 11/27/2025 at 2:00 AM LVN L called in due to a family emergency. RN M stated that she did not feel comfortable passing medications and had never passed medications to the residents at the facility and did not feel comfortable taking responsibility for 31 residents with 2 CNAs working. RN M stated she was a registered nurse and retired nurse practitioner and she has given medication before. RN M stated she normally worked as a weekend RN supervisor on Saturdays. During an interview on 12/03/2025 at 2:23 PM, RNC stated that he was not aware of an ongoing issue with no RNs being at the facility. RNC stated that the facility was supposed to have at least one RN working 8 consecutive hours and the facility should schedule an RN even if they have to get agency staff or ask the weekend RN supervisor to come in. RNC stated that he has interviewed DON candidates on 12/2/2025 and 12/3/2025. RNC stated DON position is posted on job sites. RNC stated that residents were not admitted to the facility that required treatment only an RN could provide. RNC stated that he was made aware that LVN L called in at 4:30 AM on 11/27/2025 and that the other scheduled nurse (RN M) decided she was not going to come into work. RNC stated that there were originally two nurses (LVN L and RN M) scheduled to work on 11/27/2025. RNC stated that CNA D handled staffing. RNC stated he was not sure why RN M did not come to work. RNC stated he expected RN supervisors to help with whatever was needed during their shifts and to pass medications if needed. RNC stated efforts were made to relieve LVN H. RNC stated that the maximum amount of hours a nurse could work the floor was 20 hours. RNC stated that a potential risk to working longer than 20 hours was that the nurse may not be as alert working so long. During an interview on 12/03/2025 at 3:06 PM, the ADM stated that LVN H worked the night of 11/26/2025 and started at 6:00 PM and was scheduled to work until 6:00 am on 11/27/2025. The ADM stated on 11/27/2025 LVN L and RN M were scheduled to work. The ADM stated when RN M discovered LVN L was not going to work, RN M decided not to how up because she did not want to be the only nurse. The ADM stated when she found out there were no nurses to relieve LVN H she contacted corporate. The ADM stated that prior to 11/27/2025 staffing had been in place as it was a directive for the facility not to utilize agency staff. The ADM stated the maximum amount of hours staff were supposed to work was 16 hours. The ADM stated the risk for working longer is exhaustion, increased error rates and late medications. The ADM stated that a registered nurse was required to work 8 hours a day. Review of facility policy titled Staffing, Sufficient and Competent Nursing with revision date of August 2022 reflected a registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen and 1 of 1 nourishment room reviewed for kitchen and food sanitation. 1. The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. 2. The facility failed to ensure food in the dry storage area was properly sealed from air-borne contamination. 3. The facility failed to maintain a sanitary open front refrigerator/freezer in the nourishment room. 4. The facility failed to label, date, and discard expired food items in the side-by-side refrigerator in the kitchen. 5. The facility failed to label, date, and discard expired food items in the nourishment room refrigerator and freezer. These failures could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 04/01/2025 at 09:52 AM of the side-by-side refrigerator revealed an open a box of thawed bacon labeled with a date of 03/13/2025, that was not properly sealed, and the bacon was exposed to the elements. The box was located on the bottom shelf. There were 23 containers of individual yogurt labeled with a date of 02/27/2025 that had a manufacture's date of 03/26/2025. There was a label on the side of the shelf that listed bread, dated 03-13-2025 that contained four loaves of white bread that were dated 03/20/2025. There was one open container of thickened sweetened tea dated 02-13-2025. The manufacturing instructions revealed, Directions: Refrigerator prior to serving .After opening, may be kept up to 7 days under refrigeration. Observation on 04/01/2025 at 09:57 AM of the walk-in pantry revealed an open bag of potato chips that was not properly sealed. The bag was open at one end and exposed to the elements. Observation on 04/01/2025 at 10:52 AM in the kitchen revealed four loaves of bread were sitting in their packaging out on a cart and had not been disposed of. Observation on 04/01/2025 at 11:53 AM in the kitchen revealed three loaves of bread in their original packaging sitting out on a cart. The trash can had the container of tea, the yogurts, and the open bag of chips. The open box of bacon was in the refrigerator. Observation on 04/01/2025 at 12:03 PM revealed one open bag of bread on the counter dated 03/20/2025. Half of the bread had been served and the CK opened the bag to get out more bread. Observation on 04/01/2025 at 01:15 PM of the nourishment room revealed a sign on the outside of the refrigerator that reflected, As always, please remember to check all expirations of items in this refrigerator and discard if items are not properly labeled and/or expired. A sign on the freezer door reflected, Residents Refrigerator Only. Date and Name Required. Items will be eliminated for expiration day. Every Friday Housekeeping will clean out frig. The refrigerator contained a bowl of dry cereal covered in plastic wrap, an open soda bottle, a bottle of Gatorade, and a bottle of juice all of which were not labeled with a resident's name nor dated. The inside bottom shelf was dirty with brown stains and the pull-out drawer was dirty with hair, food crumbs, and light sticky residue. Observation of the inside freezer shelf was dirty with red residue stains. Five frozen food items in freezer were not labeled with resident's names and four of the items were not dated. There was one container of expired yogurt with a manufacture date of 03/07/2025 and a box of popsicles with a best buy date of January 2025. Observation on 04/02/2025 at 11:31 AM of the nourishment room revealed the refrigerator contained a bowl of dry cereal covered in plastic wrap, a bottle of Gatorade, and a bottle of juice all of which were not labeled with a resident's name nor dated. The inside bottom shelf was dirty with brown stains and the pull-out drawer was dirty with hair, food crumbs, and light sticky residue. Observation of the inside freezer shelf was dirty with red residue stains. Five frozen food items in freezer were not labeled with resident's names and four of the items were not dated. There was one container of expired yogurt with a manufacture date of 03/07/2025 and a box of popsicles with a best buy date of January 2025. In an interview on 04/01/2025 at 10:00 AM, the DA stated she had worked at the facility for 3 years. She had received training on labeling, dating, and storing food and handling expired food from the dietitian that came once a month. The DA stated all food must be covered or properly sealed in a plastic bag and labeled with an open date. All open food must be used or thrown away within 7 days or within the manufacture's used by date. All expired food must be thrown away, otherwise it would be bad for a resident to consume expired food. She stated the bread in the side-by-side refrigerator had been previously frozen and was dated with the date it was pulled out of the freezer and should be used or thrown away within 7 days. She stated all kitchen staff were responsible for checking food for proper labeling, storage, and dating and checking for expired food. In an interview on 04/01/2025 at 10:04 AM, the CK stated she had worked at the facility since 1992. She had received training on labeling, dating, and storing food and handling expired food from the dietitian that came once a month. The CK stated that all food must be covered or properly sealed in a bag, labeled with an opened date, and expired date. She stated all opened or cooked food must be used or thrown away within 7 days. If the food was not sealed properly, the CK stated that it could cause cross contamination from chemicals and could make residents sick. She stated all expired food must be thrown away, otherwise it could make residents sick. She stated the bread in the side-by-side refrigerator had been previously frozen, was dated with the date it was pulled out of the freezer, and it should be used or thrown away within 7 days. She stated all kitchen staff were responsible for checking food for proper labeling, storage, and dating and checking for expired food, which she did each morning. In an interview and observation on 04/01/2025 at 10:07 AM, the DM stated he had worked at the facility for about 1 ½ years and did not really have any experience. The DM stated he had received training on labeling, dating, and storing food. He had not received any training on handling expired food. The DM stated all food must be sealed in a bag, labeled with a received date, and an opened date. He stated all opened or cooked food must be used or thrown away within 7 days. If the food was not sealed properly, the DM stated that would be cross contamination and food not properly sealed should be thrown out. He stated all expired food must be thrown away, otherwise it could be dangerous and make the residents sick. He stated he was responsible for checking food for proper labeling, storage, and dating and checking for expired food. The DM stated the bread in the side-by-side refrigerator had been previously frozen and was dated with the date it was pulled out of the freezer and should be used or thrown away within 7 days. The state surveyor showed the DM the concerns in the kitchen. The DM stated he had no concerns about the box of bacon being left open. He stated the date of 03/13/2025 was when the bacon was received, not when it was opened. He thought it had been opened about 5 days ago and had no concern it was not labeled. He stated he planned to serve the bacon tomorrow morning for breakfast. The DM stated the bread was expired, and he planned to throw them out. The DM was observed placing two of the loaves of bread on the counter but did not throw them away. The DM stated the yogurt was expired and he planned to throw it away. He left the yogurt in the refrigerator. The DM stated he did not think the container of thickened sweetened tea had been opened and was not concerned. The state surveyor showed him the container had been opened. The DM was not sure what he would do. After reading the directions, he stated he would throw it away and took it out of the refrigerator and sat the container on the kitchen counter. He stated the bag of chips should have been sealed in a plastic bag and should be thrown away. The DM stated the food not being properly sealed, labeled, and dated, and the expired food did not meet his expectations. In an interview and observation on 04/01/2025 at 12:14 PM, the ADM stated her expectation was that kitchen staff follow their policy for food labeling and storage. She stated all food must be dated with an opened date, received date, labeled, and tightly sealed in plastic bag and used by the manufacture's guideline or within 7 days. The ADM stated there was a sign in the kitchen that listed when food needed to be used or thrown away for safety and they follow the recommended guidelines. She stated expired food needed to be thrown away to avoid residents getting salmonella, sick, and foodborne illnesses. The ADM stated the open box of bacon in the refrigerator would not meet her expectations and was observed throwing it away. The ADM stated she had no way of knowing how long it had been in the refrigerator. She stated if her kitchen staff stated the bread was expired, then it should be thrown out and serving it would not meet her expectation. She was observed telling the DM to throw out the bread. The DM stated he thought the bread was good and denied telling the state surveyor tit was expired, or he would throw it away. In an interview on 04/02/2025 at 04:00 PM, the RDN stated she visited the facility about once a month. She stated during that time she toured the kitchen and went over the Quality Assurance Checklist. She stated all her concerns were listed on the monthly checklist. The RDN stated her expectations for food storage were based off the facility policies. She stated all opened food was to be used within 7 days or it should have been disposed of. She stated manufacturers guidelines should have been followed and any items should have been thrown out by the manufacturers date. She stated any opened item in the refrigerator should have been sealed to prevent exposure. She stated the bacon and yogurt should have been discarded. The RDN stated consumption of expired or opened unsealed food items could lead to food that was subpar in quality or food-borne illness. In an interview on 04/02/2025 at 12:24 PM, HSK stated she had worked at the facility for two months. She received orientation training on cleaning duties. She stated she cleaned the nourishment room and cleaned the outside and inside of the refrigerator and freezer once every two weeks. She stated the refrigerator and freezer were last cleaned on 03/31/2025. She stated she also cleaned out and threw away food once a week by the use by date or expired date. She stated all food must be labeled with the resident's names and dated. In an interview on 04/02/2025 at 12:31 PM, CNA C stated all food in the resident's refrigerator in the nourishment room must be labeled with resident's name, room number, and dated. She stated everyone was responsible for doing that. She stated she had not used the nourishment refrigerator since it was moved recently and was not responsible for cleaning it. She stated not labeling it could lead to a resident not getting their prescribed diet and make them sick. In an interview on 04/02/2025 at 12:35 PM, RN E stated all food in the resident's refrigerator in the nourishment room must be labeled with the resident's name and dated so staff could identify whose food it was to avoid potential reactions due to residents with food restrictions, allergies, or textured diets. RN E stated nurses were supposed to check daily for expired food and dates. She stated food without a resident's name or date would be discarded to avoid residents getting sick from spoiled food. RN E stated the residents do not have access to that room. She stated she did not know who was responsible for cleaning the inside of the refrigerator or freezer. In an interview on 04/02/2025 at 12:45 PM the DON stated she did not know the facility's policy on resident's personal food or food in the nourishment room, but stated all food should be labeled with the resident's name and dated. The DON stated all staff were responsible for labeling and dating the room and could access the nourishment room for the residents. She stated the residents did not have access to the nourishment room. The DON stated she did not know who was responsible for checking and throwing out expired food or food that was not labeled and dated, but it was an administrative task. She stated it was important to label and date all food items to avoid residents getting an illness or being harmed due to expired food. She stated it would not meet her expectations to have expired food or food without labels and dates. The DON stated that housekeeping was responsible for cleaning the refrigerator and freezer, but she did not know how often that occurred. Review of the facility's Kitchen/Food Service observations dated 10/15/2024, 11/20/2024, and 12/18/2025 completed by the RDN reflected: Section: 5: Food storage Refrigerators/Freezers All leftovers and open food covered, labeled, and dated with a use by date. All other food items covered, labeled, and dated. Received dates present on all items. Food not expired or soiled. Section 6: Meal Service Observation Nourishment room: clean, no out of date foods, temps logs in use. RDN's comments dated 10/15/2024 regarding the nourishment room reflected, encouraged staff to label and date pt (residents) items discarding s/p 3 days; spill/dirty fridge needing addressing. RDN's comments dated 11/20/2024 regarding the nourishment room reflected, encouraged staff to label and date pt (residents) items discarding s/p 3 days . RDN's comments dated 12/18/2024 reflected, To work on - hazardous food storage, labeling/dating . and nourishment room Missing labels/date on food, spill in fridge needs cleaning. Review of the QA/Monitor Report dated 03/19/2025 completed by the registered dietitian reflected, No for nourishment room being clean, and no out of date foods. Review of the DM's certificate reflected the DM had completed the Food Manager Certification Program on 01/18/2023. Review of the facility's undated policy titled Food Storage reflected: Policy: 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 and HACCP guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old .

Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 7 residents (Resident #18 and #22) reviewed for resident rights. The facility failed to ensure Resident's #18's and Resident #22's call light was within reach on 03/31/25. This failure could place residents at risk of needs not being met. Findings included: Record Review of Resident #22's undated face sheet reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (a serious condition where the lungs fail to adequately oxygenate the blood, leading to low blood oxygen levels), diabetes (a group of diseases that result in too much sugar in the blood), atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), and chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation). Record Review of Resident #22's Quarterly MDS dated [DATE] reflected Resident #22 was independent for eating, required partial or moderate assistance for toileting, required supervision or touching assistance for bathing, and was dependent on staff for personal hygiene. The MDS reflected Resident #22' had a BIMS score of 08 which indicated Resident #22 was moderately cognitively impaired. Record review of Resident #22's care plan dated 03/18/25 reflected: Resident was at risk for falling R/T Chronic pain syndrome. Goal: Resident #22 would remain free from injury. Interventions included: Keep call light in reach at all times. Record review of Resident #22's care plan dated 03/18/25 reflected: Resident had moderately impaired, vision R/T Nonexudative age-related macular degeneration, bilateral. Goal: Resident #22 would not experience negative consequences of vision loss as evidenced by remaining physically safe and participating in social and self-care activities. Interventions included: Keep call light in reach at all times. In an interview and observation on 03/31/25 at 11:03 AM, Resident #22 stated things were fine and staff treated him well. Observed Resident #22's call light on the floor on the right side of the residents bed and on the other side of the residents bedside table, and out of the residents reach. He stated he has used his call light to call for staff and they responded immediately. He stated he usually had his call light close to him or attached to his bed, but where it was at that time, he would have had to roll off of the bed to get it. He stated he guessed it fell off when the last person was in there. Record Review of Resident #18's undated face sheet reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), aphasia (inability to use spoken language), and cerebral aneurysm (a weakness in the blood vessels in the brain that balloons and fills with blood). Record Review of Resident #18's Quarterly MDS dated [DATE] reflected Resident #18 required substantial or maximal assistance for eating and was dependent on staff for toileting, bathing, and personal hygiene. The MDS reflected Resident #18's BIMS score was left blank due to Resident #18 was rarely/never understood and was not able to answer questions. Record review of Resident #18's care plan dated 03/18/25 reflected: Resident was at risk for falling R/T hemiplegia. Unsafe self-transfers. Resident does not call for assistance. Staff anticipates resident's needs. Goal: Resident #18 would remain free from injury. Interventions included: Give resident verbal reminders to call for assistance with ADLs. In an observation on 03/31/25 at 11:27 AM, Resident #18 was lying in bed with his call light out of reach and wrapped around his overhead light fixture. Resident #18 had garbled speech and was not able to communicate with the state surveyor. The resident appeared clean and groomed and showed no signs of pain or distress. The resident was not able to demonstrate if he could or could not reach his call light. In an interview on 03/31/25 at 11:13 AM, CNA B stated all residents call lights should be within their reach at all times. She stated Resident #22 regularly put himself to bed and she thought he had just gotten into bed. She stated she usually clipped it to the side of his bed, where his call light was in reach. She stated Resident #22 could not have reached the call light where it was laying when the state surveyor saw it. She stated she had been in-serviced on call light placement and if a call light was out of reach it could cause a fall or the resident would not have been able to call for help. In an interview on 03/31/25 at 11:34 AM, LVN A stated Resident #18's call light should be in reach and all residents call lights should be in reach at all times. She stated she was trained on call light placement. She stated if a residents call light was out of their reach, they could have been injured or been in distress, could not get to staff if they needed something, and their needs may not have been met. She stated Resident #18 understood when he was spoken to but could not always answer back correctly due to having a diagnosis of aphasia. In an interview on 04/02/25 at 10:19 AM, the DON stated it was her expectation that all residents call lights should be within reach at all times. She stated staff have been trained on call light placement. She stated if a residents call light was out of reach, it could have inhibited them from getting the care or requests they may have needed. In an interview on 04/02/25 at 10:32 AM, the ADM stated it was her expectation that all residents had their call lights within reach at all times. She stated staff had been trained on call light placement. She stated if a resident could not reach their call light they could not notify the team if they needed assistance. Record review of the facility policy titled Answering the Call Light and dated 2001 (revised March 2021) reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Level 1 Screening for 1 of 2 residents (Resident #14) reviewed for PASRR. The facility failed to ensure Resident #14 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 03/03/2025. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #14's face-sheet, dated 04/01/2025, revealed a [AGE] year-old female, admitted on [DATE]. Her diagnoses included metabolic encephalopathy (confusion, memory loss, and loss of consciousness due to an underlying condition affecting metabolism), bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (a condition that affects how the body uses sugar as a fuel), dependent personality disorder (a personality disorder characterized by a person's need to be taken care of and a fear of having to take care of themselves), avoidant personality disorder (a personality disorder characterized by poor self-esteem, an intense fear of rejections, and extreme shyness), anxiety disorder (a mental health condition characterized by excessive fear), and muscle weakness. Record review of Resident #14's admission MDS, dated [DATE], Section C (Cognitive Patterns) revealed a BIMS score of 14 indicating intact cognition. Section I (Active Diagnoses) revealed anxiety disorder, depression, and bipolar disorder. Record review of Resident #14's care plan, dated 05/23/2023 and revised on 03/18/2025, revealed Resident is at risk for changes in mood R/T anxiety disorder, bipolar disorder, depression, and dependent personality disorder. Record review of Resident #14's history and physical, dated 03/15/2025, revealed active medical problems that included: bipolar disorder, major depressive disorder, dependent personality disorder, and avoidant personality disorder. Record review of Resident #14's PASRR Level 1 Screening, dated 03/03/2025, section C0100, revealed no evidence or indicators Resident #14 was an individual that has a mental illness. During an interview on 04/02/2025 at 11:33 AM with the MDS, she stated she was responsible for PASRR documentation. She stated she received the PASRR from acute care facilities prior to the resident's admission. She stated if a PASRR assessment was incorrect then she was responsible for contacting the previous facility for a correct PASRR. She stated she didn't have any PASRR's under review for correction at that time. She stated a resident with diagnoses that included anxiety disorder, bipolar disorder, depression, and dependent personality disorder should have a positive PASRR Level 1 Screening. The MDS stated if a PASRR Level 1 screening was incorrectly indicated as negative then the resident wouldn't receive care and services available from the state. During an interview on 04/02/2025 at 11:43 AM with the DON, she stated the MDS was responsible for receiving and ensuring the accuracy of PASRR Level 1 Screenings. She stated she wasn't aware of any PASRR Level 1 screenings that were incorrect. The DON stated a resident with anxiety disorder, bipolar disorder, depression, and dependent personality disorder should be positive. She stated if PASRR screenings were incorrect the resident wouldn't have access to needed resources. During an interview on 04/02/2025 at 12:35 PM, the ADM stated the MDS and case management were responsible for the accuracy of PASRR Level 1 Screenings. She stated if the resident was admitted with a PASRR Level 1 screening that was incorrect then the acute care facility should have been contacted for a correction. She stated a resident wouldn't have access to available resources if the PASRR Level 1 Screening was completed incorrectly. Requested the facility policy related to PASRR Level 1 Screenings on 04/01/2025 at 1:10 PM from the ADM. No policy received prior to exit.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 7 residents (Resident's #30 and #14) reviewed for care plans. The facility failed to include the resident was a smoker and the resident had a diagnosis of acute gastritis with bleeding in Resident #30's comprehensive care plan. The facility failed to ensure Resident #14's care plan was updated to reflect their current ADL functional status. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included : Record review of Resident #30's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included acute gastritis with bleeding (a condition where the stomach lining becomes inflamed and bleeds), Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), dysphagia (difficulty in swallowing), and fibromyalgia (a functional somatic medical syndrome with symptoms of chronic widespread pain, accompanied by fatigue, sleep disturbance including awakening unfreshed, and cognitive symptoms). Record review of Resident #30's admission MDS assessment dated [DATE], reflected that Resident #30 was using tobacco. Record review of Resident #30's Quarterly MDS assessment dated [DATE], reflected that Resident #30 had a BIMS score of 06 which reflected the resident was severely cognitively impaired. Resident #30's Quarterly MDS assessment reflected the resident required supervision or touching assistance with eating, toileting, and personal hygiene, and partial to moderate assistance with bathing. Resident #30's Quarterly MDS reflected resident had a diagnosis of acute gastritis with bleeding. Record review of Resident #30's care plan reflected Resident #30 was not care planned for being a smoker or having a diagnosis of acute gastritis with bleeding. Record review of Resident #30's safe smoking evaluation, dated 01/21/25, reflected the resident had demonstrated ability to safely smoke. In an interview on 03/31/25 at 11:47 AM Resident #30 stated everything was good and the staff treated her good. She stated she did not usually need to use her call light because she mostly did thing's for herself. She stated she had been living in the facility for about a year and she wanted to go home. She stated she was going to talk to the staff about it and she had no concerns. Record review of Resident #14's face-sheet, dated 04/01/2025, revealed a [AGE] year-old female, admitted on [DATE]. Her diagnoses included metabolic encephalopathy (confusion, memory loss, and loss of consciousness due to an underlying condition affecting metabolism), bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (a condition that affects how the body uses sugar as a fuel), dependent personality disorder (a personality disorder characterized by a person's need to be taken care of and a fear of having to take care of themselves), avoidant personality disorder (a personality disorder characterized by poor self-esteem, an intense fear of rejections, and extreme shyness), anxiety disorder (a mental health condition characterized by excessive fear), and muscle weakness. Record review of Resident #14's admission MDS, dated [DATE], Section C (Cognitive Patterns) revealed a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) revealed resident required Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene: the ability to maintain perineal (genital) hygiene, adjust clothes before and after voiding or having a bowel movement. Section H- Bladder and Bowel revealed resident was frequently incontinent of bowel and bladder. Review of Resident # 14's care plan, dated 05/23/2023 and revised 03/18/2025, revealed Resident experiences occasional bowel and bladder incontinence R/T impaired mobility with approaches that included Resident toilets self independently. During an interview on 04/02/2025 at 10:32 AM, Resident #14 stated she was unable to sit up independently and required assistance to go to the bathroom because of her weakness. In an interview on 04/02/25 at 10:19 AM, the DON stated it was a collaborative effort as far as who completed the care plans. She stated the baseline care plan was done by nursing administration within 48 hours and then the MDS nurse and herself updated the care plans for acute changes. She stated the MDS nurse mostly did the comprehensive care plans and then as a team, they updated them as needed. She stated they had all been trained on completing the care plans accurately. She stated if a resident was a smoker, and all of their diagnoses should be care planned, including acute gastritis with bleeding. She stated she was not aware Resident #30 was not care planned for being a smoker or having the diagnosis of acute gastritis with bleeding. She stated Resident #30 was not smoking when she first admitted to the facility, but had smoked prior to admitting, and she started back smoking after about a month or so. She stated she was going to correct Resident 30's MDS. She stated if a resident was not care planned for being a smoker or having a diagnosis of acute gastritis with bleeding, it would not be a whole reflection of the resident and that was how staff were made aware of residents continuity of care. In an interview on 04/02/25 at 10:26 AM, the MDS nurse stated the ADON was responsible for baseline care plans. She stated when she completed the MDS assessments it triggered the CAA's and then as a collaborative team, they care planned things as they came along. She stated she had been trained on completing the care plans accurately. She stated if a resident was a smoker, it should be care planned and all diagnoses should be care planned, including acute gastritis with bleeding. She stated she was not aware that Resident #30 was not care planned for being a smoker or for having a diagnosis of acute gastritis with bleeding. She stated if a resident was not care planned for smoking she was not sure what it could cause but if they were not care planned for having acute gastritis with bleeding, it could have possibly interrupted the resident's nursing care. In an interview on 04/02/25 at 10:32 AM, the ADM stated it was a combination of the MDS nurse and nursing administration that completed the care plans and they had all been trained on completing care plans accurately. She stated she was aware Resident #30 was a smoker. She stated she was not aware that Resident #30 was not care planned for being a smoker or for having a diagnosis of acute gastritis with bleeding. She stated if a resident was not care planned for being a smoker or for having all of their diagnoses, including acute gastritis with bleeding, the residents needs may not have been met. During an interview on 04/02/2025 at 10:51 AM, CNA C stated she utilized the care plans to determine the needs of the residents. She stated the DON, and the charge nurse were responsible for updating the care plans. CNA C stated if the care plans were current and correct then the resident might not receive the care they need. She stated Resident #14 required assistance to get up to the bathroom. During an interview on 04/02/2025 at 11:11 AM, RN D stated the nurses, and the case manager were responsible for starting and revising care plans. She stated if the care plan was not correct then the resident might not get the care they required. She stated Resident #14 required assistance to get out of bed and to the toilet. During an interview on 04/02/2025 at 11:33 AM, the MDS stated the DON was responsible for updating care plans related to ADL's. She stated the care plans were used by the staff providing care and if not updated they might not get the care they required. During an interview on 04/02/2025 at 11:43 AM, the DON stated the CNA's used the care plan for determining resident needs. She stated she was responsible for baseline care plans. She stated the resident might not get the help they need if the care plan wasn't correct. During an interview on 04/02/2025 at 12:35 PM, the ADM stated the MDS, and nursing administration were responsible for ensuring care plans were correct. She stated the care plans were utilized by staff providing care. She stated the resident might not get the care they needed if the care plan wasn't correct. Review of the facility policy revised on 01/26/2024 titled Comprehensive Care Plans revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment and by Day 21 of the patient's stay. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the care plan. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 9. The services provided or arranged by the facility, as outlined in the comprehensive care plan, will meet professional standards of quality, and will be provided by qualified persons in accordance with each resident's written plan of care .

Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. NA A failed to have another staff assist while providing care for Resident #1 in the bed on 12/29/2024. Resident #1 rolled out of the bed, fell to the floor face down, was transferred to the ER and was diagnosed with laceration on left forehead, a subdural hematoma (collection of blood outside the brain that can be life threatening), a subarachnoid hemorrhage(bleeding in the space below the arachnoid layer of the brain) and possible C6/T1 fractures (C6 is the 6th cervical vertebrae that is in your neck, supports the head, protect the spinal cord and allow head motion; T1 is the 1st Thoracic vertebrae, connect the neck to the upper back) . Resident #1 was hospitalized . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/30/24 at 4:18 pm and an IJ template was given. While the IJ was removed on 12/31/24 at 1:47 pm, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for falls, injuries, hospitalization , and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Vascular dementia, Cognitive communication deficit, Unspecified sequelae of cerebral infarction (a condition that may occur at any time after causal condition. Cerebral infraction is process that result in an area of necrotic tissue in the brain) . Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS( is a mandatory tool used to screen and identify the cognitive condition of residents) could not be conducted , and staff interview indicated Resident #1 had both short and long-term memory problems. Section GG (Functional abilities) reflected impairment on one side of both upper and lower extremities. It was also reflected in section GG Resident #1 was dependent to roll left and right - the ability to roll from lying on back to left and right side and return to lying on the back on the bed (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.). Review of Resident #1's care plan dated 10/29/2024 reflected Resident #1 had ADL Functional Status/Rehabilitation Potential and Bed Mobility amount of assist: x 2. The resident was at risk for falling related to Hemiplegia (characterized by total or complete paralysis on one side of the body), Impaired mobility, Poor sitting trunk control, and was NWB. The care plan reflected the resident was dependent transfers with a mechanical lift (often referred to as Hoyer lifts, are devices designed to help caregivers move a person from a sitting to standing position and from one place to another within a room or house). The resident was limited in the ability to dress/undress self, related to hemiplegia with contractures. Review of Resident #1's POC (carefully prepared outline of nursing care showing all of the patient's needs and the ways of meeting them) or CNAs reflected Resident #1 requires x2 assist with bed mobility. Review of Resident #1's progress note from 12/29/24 reflected written by LVN C CNA reported resident rolled off bed when she was changing brief. Supervisor RN here and advised. Resident face down on floor. Called EMS. EMS transporting resident to [city name]. Gash noted on forehead. Called (family) No answer. Unable to leave vm Left VM (DON) notified by nurse supervisor. family returned call. Advised resident will be transported to .ER. Review of Resident #1's hospital records from 12/29/24 reflected: Patient had a left forehead laceration that was repaired. She was also found to have subdural hematoma, subarachnoid hemorrhage and possible C6/T1 fractures. placed in C-collar. Will admit to Trauma Service for further care. During an interview on 12/30/2024 at 10:21 am NA B stated he knew not work alone with any Resident. NA B stated if the other CNAs were busy, he would call the nurse for assistance to provide care for a Resident. NA B stated he was in-serviced by the Weekend Supervisor on fall risk, bed safety and safe lifting. NA B stated he was trained on where and how to find the residents care plan in matrix. Later at about 1:30 pm, NA B demonstrated to the state surveyor on how to locate residents POC in matrix to provide care for resident. NA B stated is was important to know how to locate the residents POC to know how much assistance was needed. During a phone interview on 12/30/2024 at 11:17 am the Weekend supervisor stated on the morning of 12/29/2024 a little before 5:00 am, she heard the NA called out for help and she went to the room and found Resident #1 on the floor between the bed and the wall, by the window, face down with blood coming from her face. The Weekend Supervisor stated the NA was in the room by herself, and no other staff was in the room assisting the NA to provide care for Resident #1. The Weekend Supervisor stated she protected Resident #1's head because she was bleeding from the left eyebrow area, and moaning, while LVN C called EMS. She stated Resident #1 was immediately transferred to the ER due to concerns for injuries. The Weekend Supervisor said she notified the DON of the incident and initiated in-services on 12/29/2024 regarding fall preventions, safe lifting and bed safety. The Weekend Supervisor stated Resident #1 required 2-persons physical assist to roll over in bed due to her contractures from a stroke. She stated the CNAs/NAs were trained on how to check the residents POC for ADL assistance. During a phone interview on 12/29/2024 at 12:31 pm LVN C stated she was the nurse on duty when Resident #1 fell out of bed. LVN C stated she heard NA A called for help and stated Resident #1 had fallen from the bed. LVN C stated when she and the Weekend Supervisor got to the room, NA A was in the room without another staff, Resident#1 was face down on the floor between the wall and the bed with blood. LVN C stated they were not sure where the blood was coming from, so the Weekend Supervisor tried to protect Resident#1's head while went to call EMS. LVN C stated they did not want to move Resident #1 due to a possible head injury, so the Weekend Supervisor was on the floor with the Resident #1 until EMS got to the facility. LVN C stated EMS got to the facility, repositioned Resident #1 and they noted a big gash on her forehead and Resident #1 was transported to the local hospital ER. LVN C stated she completed an incident report, the Weekend Supervisor started in-services on safe transfers, bed safety and fall prevention. LVN C stated Resident #1 required 2-persons for bed mobility due to history stroke. During a phone interview on 12/30/2024 at 12:54 pm NA A stated on the morning of 12/29/2024 while she was getting Resident #1 ready for a Hoyer transfer , she rolled Resident #1 to the right side, and she fell out of bed, and landed between the bed and the window. NA A stated she notified LNV C and the Weekend Supervisor, and the resident was transferred to the ER. NA A stated she was going to call for help after prepping Resident #1 for the transfer. NA A stated she knew Resident #1 was 2-person assist with Hoyer transfers and she now found out that Resident #1 was 2-persons with bed mobility. NA A stated she was trained on how to check the matrix (the system used by the facility for electronic documentation) to access the residents POC to provide care and on how to position and transfer a resident. NA A said she was called by the Administrator and told she was suspended pending the investigation of the incident. During an interview on 12/30/2024 at 2:26 pm the Sr. VP of Clinical Operation stated NA A was not a CNA, she was an NA, and she knew not to provide care for residents unless there was a licensed nurse or another CNA present. She also stated the NA A knew Resident #1 was a 2-person assist with bed mobility and NA A knew how to check the POC for residents to know how to provide care. During an interview on 12/31/2024 at 10:51 am, the HR/BOM staff stated she was responsible to ensure all new hires knew their job descriptions. She stated NA A went over her job description. She Stated NA A was not yet certified so she could not do any direct care for a resident except if a CNA or a licensed nurse was present. Multiple telephone calls were attempted on 12/30/2024 at 11:16 am, 11:17 am,3:25 pm through 12/31/2024 at 10:16 am to reach NA A regarding her job description and not providing direct care for a r resident unless there was another CNA or a licensed nurse present but was unsuccessful. A returned call was not received prior to exit. Review of NA A's competency check-off dated 10/30/2024 reflected she was check-off on turns, repositioning residents timely/correctly, and transfers (1-person assist, 2-person assist and Hoyer lift). Review of the facility's in-services reflected the facility-initiated in-services on 12/29/2024 on safe lifting, bed safety and fall preventions for nursing staff (Nurses, CNAs and NAs). Review of NAs job description for the facility reflected: Position Title: NURSE AIDE Reports To Position: DIRECTOR OF NURSING JOB SUMMARY-- Under the supervision of the Charge Nurse, the Helping Hands Aide performs non-professional, non-direct resident care duties and assists in maintaining a positive physical and psychosocial environment for the resident. Review of facility's policy titled Accidents and incidents-Investigating and Reporting dated November 2021 reflected: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of facility's policy titled Required Training, Certification and Continuing Education of Nurse Aides, undated, reflected: It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. 2. This facility will employ nurse aides in the following circumstances: a. Those who have successfully completed a State approved nurse aide training or competency evaluation program (NATCEP) and are awaiting certification results. They may be employed as full-time and permanent but must provide documentation of certification within 4 months of their hire date. Facility will verify certification through the appropriate state's nurse aide registry. The Sr. VP for Clinical and ADON were notified on 12/30/24 at 4:18 pm that an IJ had been identified and an IJ template was provided. The following Plan of Removal submitted by the facility was accepted on 12/31/2024 @ 10:57 AM. Plan of Removal: F689 - The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. NA failed to have another staff assist while providing care with Resident #1 in the bed. [Resident #1] rolled out of the bed, fell to the floor face down, was transferred to the ER and was diagnosed with laceration on left forehead and fracture of C6 and T1 vertebrae. 1. Immediate Actions Taken for Those Residents Identified: Action: [Resident #1] was assessed following fall, transferred to the ER, and subsequently admitted to the hospital for further evaluation and treatment. Person(s) Responsible: Charge Nurse/Weekend Supervisor Date: 12-29-2024, 5:30 a.m. 2. How the Facility Identified Other Possibly Affected Residents: Action: All residents' orders, care plans, resident profile and MDSs reviewed to ensure the methods of transfer match. Any discrepancies will be discussed with the IDT , to include clinical leadership, therapy, and certified nurse aides and licensed nursing staff, as needed, to verify the proper method of transfer is occurring. After any discrepancies have been identified and corrected, resident orders, care plans, resident profile and MDS will be compared no less than quarterly when MDS assessments are completed to ensure everything matches. When changes are made related to change of condition, all noted changes will be verified in the order, care plan, resident profile, and any significant change MDS assessment, if applicable. Person(s) Responsible: Director of Nursing, MDS Nurse, Regional MDS, and/or Designee Date: 12-30-2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Educate Director of Nursing and Assistant Director of Nursing on required new hire orientation with Certified Nurse Aides/Nurse Aides and licensed nurses to include return demonstration for where to find resident profile information in MatrixCare POC (transfer ability, bed mobility, self-care, toileting, eating, and the number of staff required to complete these activities of daily living to ensure resident safety). Person(s) Responsible: Sr. VP of Clinical Operations or designee Date: 12-30-2024 Action: Licensed Nurses and Certified Nursing Aides/Nurse Aides educated on Safe Lifting and Movement of Residents and checking resident profile to ensure appropriate number of staff used for all activities of daily living (i.e., transfers, bed mobility, toileting, eating, and self-care). Staff to be educated includes facility staff and temporary staff- agency and/or PRN staff (licensed nurses and nurse aides) that may transfer a resident or assist with activities of daily living. Unlicensed Nurse Aides will be educated that they are not authorized to transfer any resident without a Certified Nurse Aide or licensed nurse present. Licensed Nurses and Certified Nursing Aides/Nurse Aides will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 12-30-2024 Action: Despite having documented education on Matrix POC and resident profiles as well as her own admission that she knew where to find transfer ability and mobility assistance requirements for each resident, by her own admission, the NA stated that she made the decision not to follow established policies and procedure which resulted in injury to [Resident #1]. The NA was suspended immediately pending outcome of the investigation. The NA's employment will be terminated effective immediately. Person(s) Responsible: Director of Nursing and/or Designee Date: 12-31-2024 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Director of Nursing and/or Designee will observe 3 transfers/resident ADL activities per week x4 weeks to ensure staff (licensed nurses/CNAs/NAs) check the resident profile and perform the appropriate transfer or ADL care based on the resident plan of care which designates the number of staff required. Monitoring will continue for 4 weeks or until compliance is achieved. At no time will NAs be allowed to transfer residents without direct supervision. Person(s) Responsible: Director of Nursing and/or Designee Date: 12-30-2024 Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 12-30-2024, 5:30 PM The Surveyor monitored the POR on 12/31/24 as followed: Review of facility's in-services reflected the following: 12/29/2024 the following in-services were initiated by the weekend supervisor for all direct care staff after the incident: Safe Lifting, fall prevention and bed safety. 12/30/2024 the DON and ADON were educated by the Sr. VP of Clinical Operation on new hire orientation. LVN/RN/CNA/NA must do return demonstration on how to find Resident's profile info in matrix. 12/30/2024 All direct care staff were in-serviced on POC training and abuse and neglect, initiated by the ADON. During interviews on 12/31/2024 from 11:10 am - 1:20 pm, two CNAs, one RN, and one LVN stated there were trained on abuse and neglect, safe lifting, fall prevention and bed safety, POC training prior to starting their shifts. They all stated they knew how to find the residents mobility status in the POC in matrix. They stated they had to do return demonstration on how to access a resident's POC. They all stated 2-person bed mobility meant 2-persons assist while working with a resident in the bed. Staff stated it was important to follow the resident's POC to prevent injuries. They all stated an NA was not to provide direct care for a resident independently except there is a licensed nurse or another CNA. Review of facility's POR document dated 12 /30/2024 @ 5:30 pm,reflected QAPI was held with the Medical Director, the ADON and the Administrator via phone to discuss the Immediate Jeopardy template. Review of NA A's personnel file reflected the staff was terminated as of 12/31/2024. The ADM, ADON and Sr, VP of clinical Operation were notified on 12/31/24 at 1:47 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for pain. The facility failed to provide effective pain management or investigate the reason for the increased pain for Resident #1 when he complained of pain to his lower abdomen/groin area from 09/01/24 - 09/03/24. He was sent to theER on [DATE] and diagnosed with a UTI, sepsis, and a blood clot in his bladder. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/29/24 at 3:56 PM and an IJ template was given. While the IJ was removed on 10/30/24 at 3:00 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute kidney failure, disorder of urinary system, diabetes , and a history of UTIs and sepsis (a serious condition in which the body responds improperly to an infection). Review of Resident #1's quarterly MDS assessment, dated 08/20/24, reflected a BIMS score of 15, indicating he had no cognitive impairment. Section H (Bladder and Bowel) reflected he had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 08/01/24, reflected he required a suprapubic catheter related to obstructive uropathy (a blockage in the urinary tract that makes it hard to urinate) with an intervention of frequent and as needed incontinence checks to ensure catheter was not leaking. It further reflected he was at risk for increased pain related to DM, PVD , and generalized weakness with an intervention of monitoring pain every shift. Review of Resident #1's progress note, dated 08/31/24 at 11:31 AM and documented by LVN F, reflected the following: [Resident #1] C/O lower abdominal pain. Distention noted. Has blood coming out around meatus/catheter and bloody urine. Denies any trauma. Cath appears intact . Called EMS for transport . Review of Resident #1's progress note, dated 08/31/24 at 7:41 PM and documented by LVN E, reflected the following: [Resident #1] returned by ambulance from (hospital) . [Resident #1] had suprapubic catheter reinserted 16F. Spoke with (nurse) from hospital who stated [Resident #1]'s urine is wine in color . Review of Resident #1's ER documentation, dated 08/31/24, reflected the following: . [Resident #1] is more altered than normal and pulled out his suprapubic cath and is now having blood and blood clots out of his cath. Final diagnosis: Suprapubic catheter dysfunction Review of Resident #1's progress note, dated 09/01/24 at 9:28 PM and documented by RN A, reflected the following: [Resident #1] c/o penile pain. PRN Tylenol given as ordered and [Resident #1] stated that it is not effective and requesting for a more effective pain pill . Nurse to notify PCP. Review of Resident #1's progress note, dated 09/01/24 at 10:50 PM and documented by RN A, reflected the following: (Physician) called and gave the ff T.O: Tramadol 50mg Q6hrs PRN x 10 days for pain - placed to MAR Review of Resident #1's progress note, dated 09/02/24 at 8:40 AM and documented by LVN B, reflected the following: [Resident #1] complaints of pain at penis . Tylenol given per PRN order on file . Review of Resident #1's progress note, dated 09/03/24 at 7:31 AM and documented by LVN B, reflected the following: Tramadol given for pain per PRN order on file. Review of Resident #1's progress note, dated 09/03/24 at 11:40 AM and documented by LVN B, reflected the following: [Resident #1]'s suprapubic catheter drainage tube not draining properly; repositioned tubing to gravity, currently flowing. [Resident #1] complains of pain; Tylenol given per PRN order on file. Review of Resident #1's progress note, dated 09/03/24 at 8:38 PM and documented by RN A, reflected the following: [Resident #1] complaining of penile pain. Tramadol still not due until 10:46PM. Tylenol PRN given as ordered. [Resident #1] stated that he wants to go to the ER and having a pain scale of 10 . Called 911 . Review of Resident #1's September 2024 MAR reflected the following documented for pain: 09/01/24: Day 8/10; Night 6/10 09/02/24: Day 2/10; Night 2/10 09/03/24: Day 2/10; Night 4/10 Review of Resident #1's physician order, dated 09/20/23, reflected acetaminophen capsule; 500 mg; 2 tabs ; every 6 hours - PRN. Review of Resident #1's September 2024 MAR reflected acetaminophen was administered the following times: 09/01/24: 7:33 AM (Somewhat effective) 09/01/24: 8:15 PM (Not effective) 09/02/24 8:37 AM (Somewhat effective) 09/02/24 2:39 PM (Effective) 09/02/24 8:39 PM (Effective) 09/03/24 11:37 AM (Not effective) 09/03/24 8:32 PM (Not effective) Review of Resident #1's physician order, dated 09/01/24, reflected tramadol; 50 mg; 1 tab; every 6 hours - PRN. Review of Resident #1's September 2024 MAR reflected tramadol was administered the following times: 09/01/24 11:09 PM - (Somewhat effective) 09/03/24 7:31 AM (Effective) 09/03/24 4:46 PM (Not effective) Review of Resident #1's hospital discharge paperwork, dated 09/17/24, reflected the following: admitted : 09/03/24 Service Date: 09/04/24 HPI: [Resident #1] . who presents with sepsis 2/2 SP tube infection . [Resident #1] presents from (facility) c/o severe pain to penis and lower abdomen. [Resident #1] has suprapubic catheter and noticed blood in catheter x4days . Brief Hospital Course: [Resident #1] transferred to our emergency room with complaining of severe lower abdominal pain and blood around the suprapubic catheter. [Resident #1] found to have hypoglycemia , acute renal failure and UTI and admitted to IMCU . underwent cystoscopy and evacuation of large clot . His urine culture grew multiple bacteria and treated with IV Zosyn more than 10-day course. [Resident #1] presented with an elevated creatinine and went up to 7.4 and subsequently down to 3.3. His acute kidney injury most likely related to large blood clot in the bladder neck obstructing the ureter. During a telephone interview on 10/21/24 at 11:15 AM, Resident #1's FM C stated before he (Resident #1) was sent to the hospital on 09/03/24, he had been complaining of pain to his penis for several days. She stated when she visited him before he was sent out, he was doubled over crying in pain and crying out, I just wish they would get this fixed! She stated it was heart-breaking and he should have been sent to the hospital sooner . During a telephone interview on 10/21/24 at 12:38 PM, Resident #1's NP stated when a resident was in pain, she would want to try all interventions first before sending them to the ER. She stated if the tramadol had not been effective for Resident #1 (from (09/01/24 - 09/03/24) she would have thought the staff would have reached out to her for other possible interventions such as a medication or dosage change. During a telephone interview on 10/21/24 at 12:54 PM, RN A stated the PRN medication (tramadol and Tylenol) had not helped to alleviate Resident #1's pain (from 09/01/24 - 09/03/24). She stated she could not remember how much pain he was in on 09/01/24, but believed it was a lot. She stated on 09/03/24, he was yelling/moaning/groaning in pain and the CNA told her he had been like that and he was getting worse. She stated whenever she thought he needed hospitalization in the past he would always refuse, but that day (09/03/24), he was in so much pain he kept telling her to send him. During an interview on 10/21/24 at 1:14 PM, LVN B stated she could not remember if the tramadol was effective for Resident #1 (at the beginning of September 2024). She stated he had always been very vocal about his pain levels. During an interview on 10/21/24 at 1:30 PM, CNA D stated she remembered Resident #1 being in a lot of pain, way much more than normal from 09/01/24 - 09/03/24. She stated there was something really, really wrong. She stated urine and blood was coming out of his penis. She stated he kept saying, it hurts, it hurts. She stated he believed he should have been sent to the hospital sooner but Resident #1 had a history of saying, Why? They do not do anything for me anyways. She stated on 09/03/24 he could not take the pain anymore and requested to go to the hospital. During an interview on 10/21/24 at 3:14 PM, the DON stated she remembered Resident #1 complaining of pain (at the beginning of September 2024) but could not remember if it was an increase in pain any more than normal. She stated she was not made aware that his pain medications were not effective. She stated her expectations would be for the nursing staff to notify the NP if they were not effective to ensure they could alleviate his pain in a timely manner . During a telephone interview on 10/29/24 at 11:40 AM, LVN B stated if she knew blood and urine was coming out of Resident 1's penis, it would be in her progress notes. She stated he had bouts where that would happen when there was over-flow and because of his end-stage kidney disease. She stated when it would happen, they would send him to the ER and they would send him back same day with no new orders. During a telephone interview on 10/29/24 at 12:38 PM, LVN E stated she remembered Resident #1 having pain at the beginning of September (2024) to his groin/stomach area. She stated she could not remember if the pain medications were effective. She stated she did not know about urine or blood coming out of his penis. She stated if she had, she would have notified the NP . During a telephone interview on 10/29/24 at 1:12 PM, Resident #1's NP stated if a resident was in pain and the current pain regiment was not effective and all interventions had been tried and the pain was still uncontrolled and unmanaged, she would expect for the nurses to use their nursing judgement regarding when to send a resident out to the ER. She stated she could not answer if Resident #1 had been sent out sooner (than 09/03/24) if it would have prevented the blood clot. Review of the facility's Pain Assessment and Management Policy, revised July of 2022, reflected the following: General Guidelines: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. . 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassess as indicated until relief is obtained. . Reporting: Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain ; . 3. Prolonged, unrelieved pain despite care plan interventions. The ADM and DON were notified on 10/29/24 at 3:56 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 10/30/24 at 12:44 PM: Plan of Removal: F697 - The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to provide effective pain interventions for Resident #1 when he was complaining of pain to his lower abdomen/groin area. The facility failed to investigate the reason for Resident #1`s pain. 1. Immediate Actions Taken for Those Residents Identified: Resident #1 no longer resides at [the facility]. 2. How the Facility Identified Other Possibly Effected Residents: Action: All residents' pain monitoring on the residents' Medication Administration Record MAR was reviewed by DCO for the month of October. Director of Nursing and/or Designee will communicate with Medical Director all residents that triggered for pain and any new orders will be implemented by the Director of Nurses Person(s) Responsible: Director of Clinical Operations, Director of Nursing, and/or Designee Date: 10/30/2024 by 10AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Director of Nurses educated Assessing pain, treating pain (as ordered), monitoring for effectiveness, and notifying physician for any residents whose pain medication is not effective or new onset or increase/change in pain. Person(s) Responsible: Clinical Resource Nurse Date: 10/29/2024 by 10PM Action: Licensed Nurses and Certified Nursing Aides educated over pain & reporting pain. Licensed Nurses: Assessing pain, treating pain (as ordered), monitoring for effectiveness, and notifying physician for any residents whose pain medication is not effective or new onset or increase/change in pain. Licensed Nurses and Certified Nursing Aides will be educated prior to working their next shift The Facility is not currently using agency personal, but PRN and new hires will be educated before working their first shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Review pain assessments for prior day(s) during clinical meeting for 4 weeks and will be ongoing for any residents that have expressed or demonstrated pain to ensure effective intervention/investigation/notification for residents complaining of pain. Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 continue ongoing QAPI: Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 10/29/2024 by 10PM The Surveyor monitored the POR on 10/30/24 as followed: During interviews on 10/30/24 from 1:42 PM - 2:50 PM, two RNs and three CNAs from both shifts stated they were in-serviced on pain management before working their shift. The CNAs stated any time a resident was in pain a nurse should be notified immediately. All stated some non-verbal signs of pain would be grimacing, moaning, crying, or increased blood pressure. The nurses stated after administering pain medication, the effectiveness needed to be checked within the hour, and if it was not effective, the NP needed to be notified . All staff stated the importance of pain management was to ensure residents were comfortable, vital signs were controlled, and to ensure a good quality of life. During interviews on 10/30/24 from 12:38 PM - 12:59 PM with three residents , all reported they were not currently in pain and when they were, they told their nurse and would receive pain medication. Review of QAPI documentation, dated 10/29/24, reflected the DON and ADM met with the MD via telephone to discuss the Immediate Jeopardy template. Review of an in-serviced, dated 10/29/24 - 10/30/24 and conducted by the Administration staff, reflected all direct care staff were educated on pain management and reporting pain. Review of an in-service, dated 10/29/24 and conducted by the CRN, reflected the DON was in-serviced on assessing pain, treating pain (as ordered), monitoring the effectiveness, and notifying the MD. Review of a Daily Pain Audit, dated 10/30/24 and completed by the CRN, reflected all residents were audited for pain and only one had a pain score over 4 (from 1-10). He was administered his pain medication and it was effective. The ADM and DON were notified on 10/30/24 at 3:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of three residents reviewed for accidents and hazards. The facility failed to have consistent documentation for Resident #2's transfer status and failed to ensure she was properly transferred on 10/27/24. Her left leg foot caught on the wheelchair while being transferred by one person assistance to her bed which resulted in multiple fractures to her tibia and fibula (spiral fractures). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/29/24 at 3:56 PM and an IJ template was given. While the IJ was removed on 10/30/24 at 3:00 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a potential for more than minimal harm, that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for falls, injuries, and hospitalization . Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes memory loss, thinking problems, and behavior changes), repeated history of falls, lack of coordination, and muscle wasting and atrophy (wasting away). Review of Resident #2's quarterly MDS assessment, dated 10/08/24, reflected a BIMS could not be conducted due to rarely/never being understood. Section G (Functional Status) reflected she required extensive assistance with 2+ assistance for transferring and bed mobility. Review of Resident #2's quarterly care plan, revised 10/29/24, reflected she had impaired balance during transfers R/T OA and limited ROM to bilateral shoulders. She was a 1-2 person transfer but can use mechanical lift depending on her capabilities with an intervention of providing 1 person assistance for transferring. Review of a Physical Therapy order, dated 05/01/24, reflected Resident #2 may be transferred using the mechanical lift for safe transfers. Review of a progress note in Resident #2's EMR, dated 10/27/24 at 11:03 PM and documented by LVN E, reflected the following: [CNA F] informed this nurse as he was pickins [sic] [Resident #2] from wheelchair to lay her in bed when he heard [Resident #1]'s left ankle pop. [CNA F] believes her foot got caught on wheelchair. Fibula is swollen and bruised. [Resident #2] is stating it hurts . Call made for STAT x-ray . Review of a progress note in Resident #2's EMR, dated 10/28/24 at 5:41 AM and documented by LVN E, reflected the following: 911 called for pickup . [Resident #2] complaining of pain. Left lower leg has gotten more swollen and bruised. Reapplied ice . (x-ray company) has not made it here yet. Review of a progress note in Resident #2's EMR, dated 10/28/24 at 8:45 AM and documented by LVN B, reflected the following: Recvd [sic] verbal report from (hospital ER) for [Resident #2] return . Verbal Report: Multiple fractures to tibia and fibula (spiral fractures) . Left leg placed in long splint from hip to mid-thigh. To be bedbound upon return to facility. Review of Resident #2's ER discharge paperwork, dated 10/28/24, reflected the following: Visit Diagnoses: Closed fracture of proximal end of left fibula (primary), closed nondisplaced spiral fracture of shaft of left tibia. Medical Decision Making: [Resident #2] was found to have left fibula and spiral tibia fracture . I did ask the charge nurse to file an APS report given reportedly low mechanism injury and injury pattern. Observation on 10/29/24 at 10:22 AM revealed Resident #2 asleep in her room. Her bed was in a low position, fall mat in place, and call light was within reach. During an interview on 10/29/24 at 10:33 AM, the PTA stated Resident #2 had not been on therapy's caseload since 2023. She stated it was up the staff member's preference on how to transfer Resident #2. She stated there were some aides who did not have the correct stand-and-pivot technique or did not feel comfortable transferring her alone. She stated Resident #2's physical abilities could fluctuate often. She stated in her opinion, to transfer her safely, there should be two staff members assisting. During a telephone interview on 10/29/24 at 12:38 PM, LVN E stated she was working the night shift when the incident with Resident #2 happened (10/27/24). She stated CNA F informed her he believed her foot got stuck in the wheelchair when he heard a popping sound. She stated the fractures she acquired were consistent with the twisting motion of her leg getting stuck in the wheelchair. She stated Resident #2 was a 1-2 person assist and it normally depended on the aide. She stated CNA F transferred her on his own before with no issues. She stated he was a big guy and used a gait belt and did not have any problems. During an interview on 10/29/24 at 1:03 PM, the DON stated staff knew residents' transfer status by their care plans, in the POC (EMR), and it was communicated to them. She stated the POC, MDS, and care plans should typically match. She stated Resident #2 could be a 1-2 person transfer or a mechanical lift could be utilized when needed. She stated Resident #2's physical ability fluctuated during the day - sometimes she was more tired at different times of the day. She stated the mechanical lift could be used for safety but it was not very typical that it was used for her. She stated CNA F told her when he was transferring Resident #2 from her wheelchair to her bed (on 10/27/24) he heard a pop and believed her leg was caught by the wheelchair. She stated upon hire, they conducted trainings and competencies regarding transferring but no in-servicing or trainings were conducted since the incident with Resident #2. Attempted interviews with CNA F On 10/29/24 were unsuccessful. Multiple telephone calls were attempted to reach CNA F. A returned call was not received prior to exit. Review of CNA F's competency check-off, dated 08/29/24, reflected he had been observed and checked off for transfers. review of the facility's Safe Lifting and Movement of Residents Policy, revised 03/31/23, reflected the following: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. . 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. The ADM and DON were notified on 10/29/24 at 3:56 PM that an IJ had been identified and an IJ template was provided. The following Plan of Removal submitted by the facility was accepted on 10/30/24 at 12:44 PM: Plan of Removal: F689 - The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident #2 was properly transferred. Her foot got caught in the wheelchair when being transferred to the bed. She was diagnosed with multiple fractures to her tibia and fibula (spiral fracture). The facility failed to have consistent documentation for Resident #2's transfer status. 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #2 was assessed by the LVN on duty post-accident, MD notified, MD ordered x-rays, Resident was sent to the hospital. Resident returned to facility. Resident discharge orders included remain non weight bearing and follow up with the orthopedic surgeon. This appointment was scheduled for 10/31/24. The Licensed Nurses and the CNAs were educated on the these orders, Person(s) Responsible: Charge Nurse Date: 10/30/2024 continue to monitor 2. How the Facility Identified Other Possibly Affected Residents: Action: All residents' orders, care plans, resident profile and MDSs reviewed by the Regional MDS Nurse to ensure the methods of transfer match. Any discrepancies were reviewed with the IDT on 10/30/24, to include clinical leadership, therapy, and certified nurse aides and licensed nursing staff. The method of transfer determined by IDT such as gait belt, one/two person or mechanical lift will be updated in the Orders, care plan, resident profile and the MDS. Resident #2 was reviewed upon return, and it was determined by the IDT that she was now a mechanical lift 2 person transfer. The orders, care plan and resident profile were updated. Person(s) Responsible: Director of Nursing, MDS Nurse, Regional MDS, and/or Designee Date: 10/30/2024 by 9AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Educate Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator on residents' orders (if resident requires a mechanical lift), care plans, resident profile and MDSs accurately reflect residents' transfer status. Person(s) Responsible: Clinical Resource Nurse Date: 10/30/2024 by 1PM Action: The CNA that transferred Resident #2 when they received the fracture was educated on Safe Lifting and Movement of Residents on 10/28/24 and return demonstration was completed at this time. Licensed Nurses and Certified Nursing Aides educated on Safe Lifting and Movement of Residents and checking resident profile to ensure that they are aware of the correct transfer method for that resident. Lift and Transfer competencies will be performed on licensed Nurse and Certified Nurse Aides. Licensed Nurses and Certified Nursing Aides will be educated prior to working their next shift. There will be safe transfer training and how to access resident profile to ensure proper transfer is being used. The facility is not using agency personal, but all PRN and New hires will be trained prior to working their first shift Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: MDS Coordinator to complete MDSs to include the transfer status in the look back period, prior to the RN signature, Director of Nursing will review the transfer coding on the MDS and will ensure orders (if mechanical lift), care plans, and resident profile match to have consistent documentation in place for all residents for next 4 weeks . Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM Action: Director of Nursing and/or Designee will observe 3 transfer a week, including any current, PRN or newly hired staff for x4 weeks and then monthly thereafter to ensue staff check resident profile and perform the appropriate transfer per the resident profile and procedure. The facility does not currently use agency staff. Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM QAPI: Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 10/29/2024 by 10PM The Surveyor monitored the POR on 10/30/24 as followed: During an observation and interview on 10/30/24 at 1:10 PM revealed CNA D finding a resident's transfer status on their profile in their POC. Before the transfer, she locked the resident's wheelchair, ensured his feet were flat on the ground in front of him, explained to him what they were about to do, and appropriately utilized the gait belt to transfer him from his wheelchair to his bed. She stated she was in-serviced before her shift on safe transfers and locating residents' transfer status. During interviews on 10/30/24 from 1:42 PM - 2:50 PM, two RNs and three CNAs from both shifts stated they were in-serviced on safe transfers before working their shift. All stated they were able to find resident transfer statuses on their face sheet in the POC or in their care plans. They all stated gate belts should always be used for safety. The staff stated if it was a transfer from the wheelchair to the bed, you would ensure the wheelchair was locked, the resident's feet were flat on the floor and facing the bed, they were stable, and at a safe distance to the bed. They all stated limited assistance meant close supervision and residents should never transfer alone unless they were independent. The staff stated safe transfers were important to avoid injuries. Review of QAPI documentation, dated 10/29/24, reflected the DON and ADM met with the MD via telephone to discuss the Immediate Jeopardy template. Review of the audit conducted by the RMDSN to ensure all residents' care plans, orders, MDS, and profiles matched for transfers, dated 10/29/24, reflected 19 residents requiring 1 person assistance, five residents requiring 2-person assistance, two residents that were independent, and seven residents who required a hoyer (mechanical) lift. Review of an in-service, dated 10/29/24 and conducted by the CRN, reflected the DON, ADON, and MDSC were educated on the following: Ensure that all care plans, each residents' profiles, and the MDS match and line up per resident and that the proper transfer status is listed adequately in each place. Please ensure that if the resident is a mechanical lift that the orders are in place aligning with the care plan and MDS. Review of three residents' EMRs, on 10/30/24, reflected their transfer status consistent throughout their charts. Review of an in-serviced, dated 10/29/24 - 10/30/24 and conducted by the Administration staff, reflected all direct care staff were educated on safe transferring and finding resident transfer status in their POC profiles. Review of a document, dated 10/29/24 and documented by the DON, reflected the following: CNA F was re-educated on safe transfers and mobility post-incident and demo/re-demo skills were verified by nurse and DON. The ADM and DON were notified on 10/30/24 at 3:00 PM that the IJ had been removed. While the IJ was removed, The facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record review, it was determined that the facility failed to ensure residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 2 of 4 Residents (Resident #1 and Resident #2) reviewed for resident rights. The facility did not allow Resident #1 and Resident #2 to visit with a family member of a former resident. This failure placed residents at risk of isolation, decreased emotional wellbeing, and diminished quality of life. Findings included: Review of Resident #1's face sheet dated 09/06/2024 reflected that Resident #1 was a [AGE] year old female readmitted on [DATE] with diagnoses of heart failure (condition that occurs when heart is unable to pump enough blood and oxygen to the body's organs), muscle wasting and atrophy (a condition that causes muscle tissue to decrease in size and thin out), major depressive disorder (serious mental illness that affects how people feel, think and function in their daily lives), and anxiety disorder (mental health condition that cause people to experience excessive and uncontrollable feeling of fear and anxiety). Review of Resident #1's quarterly MDS dated [DATE] reflected the resident had a BIMs score of 14 which indicated no cognitive impairment. Review of Resident #1's care plan dated 04/12/2020 reflected that under activities the resident liked family visits often. Approach for this care plan included to provide setting in which activities were preferred including family visits. Review of the annual activities assessment dated [DATE] included that the resident was alert and oriented, talkative, and enjoyed family visits. Review of the quarterly activities assessment dated [DATE] included that the resident enjoyed small groups and enjoyed family and friends. Review of Resident #1's progress notes did not include any information regarding visitation limitations or concerns from the facility or Resident #1. Review of Resident #1's progress notes reflected no conversations or requests regarding visitors/visitation. Review of Resident #2's face sheet dated 09/06/2024 revealed a [AGE] year old female readmitted on [DATE] with diagnoses of lumbar spina bifida (birth defect when the spine does not fully develop), major depressive disorder recurrent (serious mental illness that affects how people feel, think, and function in their daily lives), and mild intellectual disabilities (a condition that affects a person's ability to learn and adapt to their environment). Review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #2's care plan dated 07/02/2024 reflected Resident #2 was identified as being PASRR positive status due to mild intellectual disabilities. Goal for this care plan included to maintain the highest level of practicable well-being. Review of Resident #2's progress notes reflected no conversations or requests regarding visitors/visitation. During an interview on 09/06/2024 at 12:21 PM with Resident #1, she stated that she has had one issue of not being able to have some visitors. She stated that she was friendly with another resident for a long time, which has since passed, and that resident's family would visit often. She stated that after the other resident passed, Resident #1 was told by the ADM and the DON that the family was not allowed to visit her. She stated that she was asked to sign a document about visitation but did not understand it. She stated that she signed the document initially, but then told the ADM that she did not want to sign another that did not allow her friends to visit her. Resident #1 stated that she believed the facility staff told her they would only be able to visit outside. Resident #1 stated that she was told if those visitors wanted to visit her, they would have to let the facility know in advance and set an appointment. Resident #1 stated that was strange and she had not heard of that, and it was unusual to make someone schedule an appointment to visit with her. Resident #1 stated that she missed her friends and would like to see them. During an interview on 09/06/2024 at 1:40 PM, Resident #2 stated that the facility limited her visitors and that she was unable to visit with the family of her former roommate. She stated that she had to sign a form saying she did not want the visitors to come, but she had since notified the facility that she would like them to come and visit. She stated that she was not sure why they were unable to come and see her. She stated that it made her sad that they could not come to see her. Resident #2 stated that she had their phone number, but it was not the same as it was to visit in person. Resident #2 stated that she believed she was told she would have to visit outside if she wanted the visitors to come. During an interview on 09/06/2024 at 1:57 PM, the SW stated that Resident #1 did not want a specific family to visit her and then later decided that she did. The SW stated that Resident #2 also wanted a specific family to come and visit her. She stated that as of right now there were no residents that have requested not to have a visit with anyone specific. The SW stated that she believed residents were asked if they wanted visits from family members of former residents and that she believed there were not any residents who wanted visits. The SW stated that from her understanding the visitor would have to call the facility and let them know when they would visit the facility to ensure that management was here during the visit. The SW stated that this was not considered home-like. The SW stated that no residents have stated that they were scared of these visitors nor had the family had issues directly with any residents at the facility. During an interview on 09/06/2024 at 2:06 PM with the ADM, she stated that when specific visitors would come into the facility they would go around and visit every resident not just their relative. She stated that they could restrict visits to only when residents requested. She stated that during a resident council meeting the residents were asked about visits with this family and that some residents stated that they did not want a visit. The ADM stated that this was not documented on the resident council minutes. She stated that initially Resident #1 stated she did not want a visit and requested her statement be torn up. She stated that she told Resident #1 if she wanted to visit it was no problem but the family would have to notify the facility and that they could go visit in the resident's room. The ADM stated that there were residents at the facility that did not want visits from this family, and she needed to protect their rights. The ADM stated that during the resident council meeting Resident #2 did not want a visit and then also changed her mind. The ADM stated that they told the resident council if they did want to visit with this family it would have to be in an area to protect the rights of resident who did not want those visitors here. During an interview on 09/06/2024 at 2:51 PM, the AD stated that Resident #1 was spunky and was the of the resident council. She stated that she was social, and she could be very loving and caring. The AD stated that Resident #2 was very kindhearted and very talkative. She stated that she was a social butterfly and used to have visitors but not as many lately. She stated that she would benefit from family visits and would benefit from having family closeness and family encounters. Review of facility grievance dated 08/05/2024 revealed that Resident #1 was playing bingo and appeared anxious and was fidgeting. When asked what was wrong, Resident #1 responded all this going on the (visitors) just makes me upset. Review of resident council minutes dated 07/24/2024, no information regarding visitors included as discussed during meeting. Review of facility policy titled Resident Rights Guidelines for All Nursing Procedures with revision date of October 2010 reflected resident rights included visitation. Review of facility all staff in-service dated 08/16/2024 reflected that resident rights were reviewed and included resident rights should always be upheld. Review of facility policy titled Visitation: Right to Access and Visitation dated June 13, 2024 reflected It is the policy of the facility to support and facilitate the resident's right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's rights to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Further review reflected visitation would be person-centered, consider the psychosocial well-being of the resident, and support his or her quality of life. Policy included The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 4 of 16 residents (Residents #2, 12, 18, and 28 ) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #18 physically assaulted Resident #2 on 04/27/22, verbally assaulted Resident #28 on 08/10/22, or after Resident #18 physically assaulted Resident #12 on 12/28/22. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/10/23 at 11:25 AM. While the IJ was removed on 01/13/23, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure placed residents at risk of bodily, emotional, and psychosocial harm and neglect, including hospitalization or death. Findings included: Review of facility's policy Abuse Prevention Program dated June 2021 reflected the following: Policy Statement 1. The administrator is responsible for the overall coordination and implementation of our centers abuse, prevention, program, policies, and procedures. 2. All residents have the right to be free from abuse, collect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary, seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents symptoms. 6. Our center will protect residents from harm, reprisal, discrimination, or coercion, during investigations of abuse allegations. 7. Our center will provide protections for the health, welfare, and rights of each resident residing in the center to ensure the reporting of crimes. 9. All occurrences of abuse, neglect, miss treatment, injuries of unknown source and theft or misappropriation of resident. Property will be analyzed by the quality assurance and performance improvement committee to determine if system changes need to be made. Policy Interpretation and Implementation As part of the resident abuse prevention program, the administration will: 8. Involve the resident council in monitoring and evaluating the centers abuse, prevention program, and 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. Identification 4. The physician and staff will help identify risk factors for peace within the center; for example, significant numbers of residence/patience, with unmanaged, problematic behavior; significant injuries and physically dependent individuals; problematic family relationships; issues related to staff, knowledge, and skill; or performance that might affect resident care. Investigation 1. The administrator has the overall responsibility for the coordination and implementation of our centers. Abuse, prevention, program, policies, and procedures. The administrator is the abuse prevention coordinator. In the absence of the administrator, the Director of nursing will serve in this capacity. 2. Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the center. 7. The administrator will ensure that any further potential abuse, neglect, exploitation, or miss treatment is prevented. 8. The administrator will inform the resident and his/her representative of the status of the investigation, and measures taken to protect the safety and privacy of the resident. Response Treatment/Management 1. The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood, and function. Monitoring/Follow-Up 2. The Medical Director will advise center management and staff about ways to ensure the basic medical, functional, and psychosocial needs are being met, and that potentially preventable or treatable conditions affecting function and quality of life or dressed appropriately. 3. Physician will advise the center and help review and address abuse and neglect issues as part of the quality assurance process. Protection of residents during abuse investigations 1. During abuse, investigations, residence will be protected from harm by the following measures: see. c. If the alleged abuse involves another resident, the accused resident's representative and attending physician will be informed of the alleged abuse incident, and that there may be restrictions on the accused resident's ability to visit other resident rooms on attended. If necessary, the accused resident's family members may be required to help meet this requirement. d. Within five working days of the alleged incident, the center will give the resident, the resident's representative, state survey and certification agencies, accused individuals, the ombudsman as needed, etc. a written report of the findings of the investigation, and a summary of corrective action taken to prevent such an incident from recurring. Analysis 1. The quality assurance and performance improvement committee will review all reports of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property during their regularly scheduled meetings. 2. Reviews of each occurrence will be made to determine if policies, procedures, or center systems need to be modified to prevent further incidents of abuse or theft. 3. The quality assurance and performance improvement committee will provide the administrator with a written report of its findings and recommendations. The administrator will review such recommendations and act accordingly. 4. Copies of any changes to our abuse prevention program policies and procedures will be provided to Residents and Center stuff as established by center policy and training programs. Resident #2 Review of the undated face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of half the body), dementia with behavioral disturbance, and cognitive communication deficit (difficulty speaking and understanding language). Review of the quarterly MDS for Resident #2 dated 11/03/22 reflected a BIMS score of 11, indicating a mild cognitive impairment. It reflected a mood severity score of 00, indicating little or no depressive mood. It reflected Resident #2 required the extensive assistance of one person for transfer and the limited assistance of one person for locomotion. Review of the care plan for Resident #2 dated 10/11/22 reflected the following: Resident is limited in range of motion to RT side R/T CVA. Resident has delusions R/T Psychotic Disorder with Delusions. Impaired memory/recall problem R/T Hx of CVA AEB short term memory problem. Maintain body in functional alignment when at rest Review of a progress note dated 04/27/22 documented by LVN B reflected: During shift change, CNA yelled down the hall for nurses to come to resident's room due to an altercation. This nurse and oncoming nurse went to resident's room and oncoming nurse separated residents who were in the middle of room. This nurse interviewed both residents to attempt to determine factors contributing to altercation and actions of both residents during the event. This nurse obtained this resident's statement which was difficult due to constant interruption from (Resident #18) even with attempted redirection. resident's statement of altercation was obtained without difficulty or interruption from resident. This resident's statement he reported he was cold in his room and drew the curtain in attempt to prevent the cold air from blowing directly on him like he always does when he feels cool. However (Resident #18) stated that he didn't care that his roommatewas cold that he felt claustrophobic and therefore drew the curtain back. (Resident #2) reported that after (Resident #18) did not care he was cold that he swung at (Resident #18) in an attempt to get him to leave the curtain alone swung at (Resident #18) but did not make contact with (Resident #18) during the swing. This nurse specifically asked (Resident #18) if this resident actually touched or made contact with him during the swing with (Resident #18) reported He tried to hit me but did not. Then resident stated that (Resident #18) hit this resident in the head with his crutch and knocked his cowboy hat off his head. CNA indicated when she came in the room before contacting nurses (Resident #18) was picking up hat from ground and throwing it back at this resident. (Resident #18) reported that, Yes he hit (Resident #2) and was aware of situation and circumstance during this event. This nurse did clarify with both residents that the only one that made contact hitting this resident was (Resident #18), both agreed that this was the case. Oncoming nurse asked (Resident #18) to calm down in the day room. While (Resident #18) was walking past this resident, he was being verbally aggressive and very hostile toward this resident. (Resident #2) did make an attempt to grab at (Resident #18) at this time but was unable to; CNA intervened and no contact made. (Resident #18) continued to yell and be very hostile toward this resident in a very loud tone. This nurse called DON to inform her of altercation and that this resident received a blow to the head with crutch by (Resident #18). No LOC. She informed this nurse to separate residents so they could calm down/cool off and then she would call back, check in and address event tomorrow being she was at home. This nurse informed oncoming nurse of conversation. (Resident #18) in day room. This resident stayed in room, sitting in his wheelchair. Resident #12 Review of the undated face sheet for Resident #12 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia with behavioral disturbance, impulse disorder, major depressive disorder, and anxiety disorder. Review of the quarterly MDS for Resident #12 dated 12/19/22 reflected a BIMS score of 01, indicating a severe cognitive impairment. It reflected a mood severity score of 05, indicating a moderately depressive mood. It reflected Resident #12 required the extensive assistance of one person for transfer and the limited assistance of one person for locomotion. Review of the care plan for Resident #12 dated 10/11/22 reflected the following: Resident has impaired decision making R/T dementia. Was struck by another resident on 08/14/20. Resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed. Determine if decisions made by the resident endanger the resident or others. Intervene if necessary. Encourage to verbalize feelings, concerns and fears. Clarify misconceptions. Respect resident's rights to make decision(s). Use non-verbal communication techniques to encourage response. Review of progress notes for Resident #12 reflected the following: *12/28/2022 by LVN B: This nurse heard yelling coming from another resident's (Resident #18's) room, when approaching the room, PT was in the hallway and looking in (Resident #18's) room as this nurse was approaching room-stating Don't hit resident! PT informed this nurse that (Resident #18) just struck (Resident #12) in the face. When this nurse arrived to room it was crowded in the doorway, because it was on the opposite side of (Resident #18) who struck (Resident #12). (Resident #12) had a banana that was taken from (Resident #18) roommate's side of the room. This nurse and med aide removed (Resident #12) from room to evaluate to, (Resident #12) crying and did say I'm ok. Some redness on left cheek and neck areas. (Resident #12) offered ice pack or pain reliever-resident declined at this time. This nurse contacted ADM, DON and RP. Witness statement faxed to admin. *01/02/2023 by PsyPA: A patient visit with (Resident #12) was conducted at (facility) on 01/02/23. She appeared at ease with no emotional or physical discomfort. Her EMR was reviewed, and staff input was sought. It was reported that (Resident #12) was struck by another resident on 12/28/22, during an incident involving her presence in another resident's room and a banana. No serious injuries were reported. Cognitive function was unchanged. No adverse side effect from prescribed psychiatric medication were reported by staff. The current plan of care appears to be reasonable. Psychiatric medication, require no changes. SPC will continue to visit with the resident, review progress notes and make recommendations regularly. Resident #28 Review of the undated face sheet for Resident #28 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of heart failure, hypertension (high blood pressure), kidney failure, and asthma. Review of the quarterly MDS for Resident #28 dated 12/20/22 reflected a BIMS score of 7, indicating a moderate cognitive impairment. It reflected a mood severity score of 00, indicating little or no depressive mood. It reflected Resident #28 required supervision of one person for transfer and the limited assistance of one person for locomotion. Resident #18 Review of the undated face sheet for Resident #18 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral palsy, muscle wasting and atrophy, lack of coordination, muscle weakness, psychophysiological insomnia (disorder in which sleep-preventing associations have become internalized and persist even though the initial cause of insomnia has been removed), major depressive disorder, disruptive mood dysregulation disorder (mood disorder diagnosed in children who present with recurrent irritable or angry mood and severe temper outbursts that interfere with their ability to function at home, in school, or with their friends), spinal muscular atrophy (a genetic neuromuscular disorder that affects motor neurons in the spinal cord causing progressive muscle degeneration and weakness), borderline intellectual functioning, and irritability and anger. Review of the quarterly MDS for Resident #18 dated 12/20/22 reflected a BIMS score of 15, indicating no cognitive impairment. It reflected a mood severity score of 00, indicating little or no depressive mood. It reflected Resident #18 exhibited verbal behavioral symptoms toward others 1-3 days of the lookback period. It reflected Resident #18 required the extensive assistance of two people for transfer and the limited assistance of one person for locomotion. Review of the care plan for Resident #18 dated 10/11/22 reflected no care planning for aggressive behaviors. It reflected no care planning related to Resident #18's cognition. Review of progress notes for Resident #18 reflected the following: *04 /27/22 written by LVN B During shift change, CNA yelled down the hall for nurses to come to (Resident #18)'s room due to an altercation. This nurse and oncoming nurse went to (Resident #18)'s room and oncoming nurse separated residents who were in the middle of room. This nurse interviewed both residents to attempt to determine factors contributing to altercation and actions of both residents during the event. This nurse obtained (Resident #2)'s statement which was difficult due to constant interruption from (Resident #18) even with attempted redirection. (Resident #18)'s statement of altercation was obtained without difficulty or interruption from (Resident #2). In (Resident #2)'s statement he reported he was cold in his room and drew the curtain in attempt to prevent the cold air from blowing directly on him like he always does when he feels cool. However this (Resident #18) stated that he didn't care that his (Resident #2) was cold that he felt claustrophobic and therefore drew the curtain back. (Resident #2) reported that after this (Resident #18) did not care he was cold that he swung at this (Resident #18) in an attempt to get him to leave the curtain alone but did not make contact with this (Resident #18) during the swing. This nurse specifically asked (Resident #18) if the (Resident #2) actually touched or made contact with him during the swing with this (Resident #18) reporting He tried to hit me but did not. Then (Resident #2) stated that (Resident #18) hit (Resident #2) in the head with his crutch and knocked his cowboy hat off his head. CNA indicated when she came in the room before contacting nurses the (Resident #18) was picking up hat from ground and throwing it back at (Resident #2). This (Resident #18) reported that, Yes he hit (Resident #2) and was aware of situation and circumstance during this event. This nurse did clarify with both (Resident #18)s that the only one that made contact hitting (Resident #2) was this (Resident #18), both agreed that this was the case. Oncoming nurse asked (Resident #18) to calm down in the day room. While (Resident #18) was walking past (Resident #2), he was being verbally aggressive and very hostile toward (Resident #2). (Resident #2) did make an attempt to grab at this (Resident #18) at this time but was unable to; CNA intervened, and no contact made. This (Resident #18) continued to yell and be very hostile toward (Resident #2) in a very loud tone. This nurse called DON to inform her of altercation and that (Resident #2) received a blow to the head with crutch by this (Resident #18). No LOC. She informed this nurse to separate residents so they could calm down/cool off and then she would call back, check in and address event tomorrow being she was at home. This nurse informed oncoming nurse of conversation. (Resident #18) in day room. As this nurse was leaving the facility and holding the door open for another (Resident #18) to come in, this (Resident #18) started walking out the building, this nurse tried to stop (Resident #18) from coming out by informing him he needed to sign out. This (Resident #18) ignored this nurse and pushed by to continue outside without notifying the staff/signing out as care plan. This nurse informed charge nurse that (Resident #18) was outside. *04/28/22 by former DON: (Resident #18) reports he is in a foul mood today. Seen by (PsyPA) this morning for discussion. No changes noted to orders. Patient's (family member) came in to speak with DON regarding yesterday's incident - writer not part of conversation. After discussion, resident and (family member) left the facility for the day. (family member) given labeled/individually packaged medications for the day. - no questions for RN. 04/28/22 by former DON: Talked with (Resident #18's) (family member) today in a long meeting of approx. an hour. (Resident #18's) (family member) was concerned about the altercation between (Resident #18) and the roommate. I have discussed this at length and the plan is to have the roommate moved and the Mental health PA to once again talk to (Resident #18). *05/04/22 by LVN B: This nurse heard this resident down the hall yelling SHUT UP at another resident in the hallway. This nurse redirected this resident and informed him not to speak to residents in this manner. Resident stated that the resident yelled at him first, no indication this happened. *7/20/22 by LVN B: This nurse heard this resident yell, Shut up! from the nurse's station and this nurse went to the day where this nurse confronted resident to ask what/who he was yelling at and he said that he was yelling at another resident, because she yelled at him first. This nurse spoke to resident and informed him not to yell at anyone and to respect other residents. Resident told the nurse, he will not and that he didn't not want this nurse to look at him and if he was to go anywhere it was outside. This nurse did not engage in behavior and informed DON. *07/20/22 by LVN B: This nurse went back to check on resident in day room, when resident had another female resident in a wheelchair in very close contact. This nurse removed female resident and then this resident huffed and puffed and proceeded to the outside patio. This nurse informed DON and DON notified (therapist) and now since resident is interfering with the care and health of our residents the DON stated to keep resident on an every 30 minutes monitoring at this time. This nurse informed oncoming shift and informed CNAs. *08/10/22 by LVN D: CNA witnessed pt. shoving cane into other resident's face in front on the nurses station. They were standing about 5 feet apart and cane did not touch (Resident #28). It was obvious that pt. did not want to hurt (Resident #28) but was informed that his actions were unacceptable. Pt. has been upset since he dropped his phone on the floor earlier today and the phone stopped working correctly. (Resident #28) stated that he was Okay and that he would let (Resident #18) cool down. (Resident #28) went down to his room and got ready for bed. (Resident #18) stayed at the nurse's station and talked to (former staff member), he calmed down after their conversation and then headed to his room. Pt. has history of agitation and aggressive behavior. Will continue to monitor. *10/17/22 by the SW: Completed Safe Survey with resident today. Stated he was not afraid of any abuse or neglect. In fact he said if anyone tried to hurt him he would hurt them first. He was upset and stated he felt he was being wrongfully accused of inappropriately touching someone. Resident went on to say he is misunderstood and his (family member) feels as if he is being discriminated against because he is misunderstood. He stated that the way to treat the other residents is like you would a child, slap their hands and tell them no when they misbehave. Resident stated that the pillow in his chair is the blue wedge pillow that his (family member) previously referred to be missing. He stated he keeps it in his chair at all times. *10/28/22 by unnamed agency LVN: Observed resi throwing items out of his room. This nurse was down the hall checking blood sugars and went to go see what was going on. This nurse observed resi slowly slid self down to his knees then lay his crutches out beside him. Resident did let himself slid down the last 6 inches to a foot slightly harder but did not appear to be in any pain. Resi then looked up and saw this nurse standing there and got himself up without saying anything. Shortly after this resi came screaming down the hall scaring other residents that he did not want fish. This nurse advised him that screaming down the hall was not appropriate behavior, and it was disrespectful to the other residents. Resi then stated well I am angry because I just fell . Resi again told that was not appropriate behavior. Resi was walking around ad lib with use of his crutches. No redness noted to knees and no pain or limitations to movement beyond normal deformity noted or expressed. Resi then was approached by another resident asking if he was ok and he yelled at that resident as well. *11/15/22 by MD: Staff reports more aggressive behavior lately. Chart and meds reviewed. Request psych visit with pt. and daytime staff to review and evaluate. *12/28/22 by LVN B: This nurse heard yelling coming from resident's room, when approaching the room, PT was in the hallway and looking in resident's room as this nurse was approaching room-stating Don't hit resident! PT informed this nurse that this resident just struck another resident in the face. When this nurse arrived to room it was crowded in the doorway, because it was on the opposite side of the resident's room. Resident upset that resident was taking roommate's banana. This nurse and med aide removed other resident from this resident's room. This resident kept yelling with PT about other resident She shouldn't be in my room! Resident then seen going to his side of the room and sitting in recliner and getting on his phone. This nurse then receives a phone call from DON stating that resident contacted mom and DON received an email from mom regarding incident. This nurse informed admin and DON of incident. Regional DON informed this nurse that she overheard the conversation resident was having on the phone admitting to hitting resident. *12/30/22 by the DON: This nurse addressed the altercation with resident that happened on 12/28/2022 between him and another resident. I spoke with him on how to control his anger and other ways he could have handled the situation. He agreed that he should have left the room and came to find a staff member to help. He stated that he gets angry really fast and it's hard for him to control his temper. He did ask to speak to his therapist. I emailed his therapist who replied that he would be by to see resident as soon as he could. Resident seems to be calm during this conversation but very defensive. Will continue to monitor. *01/02/23 by PsyPA: A patient visit with (Resident #18) was conducted at (facility) on 01/02/23. He demonstrated agitation and anger and repeatedly complained about the facility staff and his family. He said that he is never happy and that when death comes, he will welcome it, because he will be at peace. It was reported in the resident's progress notes that he had struck an elderly resident with dementia resident in the face on 12/28/22, because the other resident had taken a banana that belonged to his roommate. (Resident #18) says that the other resident struck in first. When questioned about the incident, he attempted to justify his actions as a manifestation of the anger which he holds inside of himself because, as he says, no one understands his personal pain, nor do they attempt to understand his needs. He has demonstrated problems with personal interaction with other residents, some of whom are elderly and suffering from dementia. He believes that the facility will try to discharge him, and he is fearful of where he will end up. Changes to his psychiatric medication will likely not resolve any of these issues, and (Resident #18) has been resistant any increases or additions to his medication. (Psychiatric clinic) will continue to visit with the resident, review progress notes and make recommendations regularly. *01/04/23 by the DON: Contract for Safety signed by resident. Witnessed by DON and BOM. Resident's (family member) informed and verbalized understanding. Resident has no threats for harming himself or others. Review of the facility investigation report (HHSC 3613) dated 01/04/23 reflected the following: Description of the allegation: PT heard Resident #18 yelling at someone, he walked to Resident #18's door and saw Resident #12 on Resident #18's roommate's side of the room holding a banana. Resident #18 was yelling at her to 'give it back.' When she didn't. Resident #18 struck Resident #12 in the face and neck. Description of Injury: Resident #12 was very shaken and upset. Description of Assessment: Head to toe assessment, resident crying. Some redness on left cheek and neck areas. Resident offered ice pack or pain reliever - resident declined at this time. Provider response: Residents separated, Resident #12 assessed. 911 call to report incident, PD report #2219528. Families/RPs notified. Medical Director notified. Resident #18 cautioned about striking other residents. Body audits on all of the residents, safe surveys conducted, no findings of abuse or neglect to other residents. Referral concerning this incident made to Resident #18 psych NP and LCSW therapist. Investigation Summary: PT witnessed Resident #18 strike Resident #12 in the face and neck. In an interview on 1/2/2023 conducted by psych NP, Resident #18 admitted striking Resident #12, because she had taken a banana belonging to his roommate, and that Resident #12 struck him first. Monitored Resident #12 for any signs of injury or dress. Nursing continues to monitor Resident #18 behaviors. Observation on 01/09/23 at 07:03 AM revealed Resident #18, a younger male with contractions in his arms and legs, walking with aluminum crutches in hall 100. Resident #12, a frail, elderly female self-ambulated in her wheelchair up and down hall 100 and did not reply when addressed. No staff was immediately visible on hall 100 until 7:10 AM. During an interview on 01/09/23 at 07:15 AM Resident #18 stated there was an incident three weeks ago in the sanctuary of his room regarding himself and Resident #12. Resident #18 stated he was not what they would call an impulsive person and then amended his statement to say that he was actually impulsive. Resident #18 stated he would be lying if he said he did not do this on impulse. Resident #18 began speaking about some family history and the psychological and anger management problems it had caused him. Resident #18, with that understood, he was not saying what he did was a good idea, and he took responsibility for everything that happened. Resident #18 stated at the time of the incident, he was already a little bit frustrated, and Resident #12 happened to be in the wrong place at the wrong time. Resident #18 stated he was sitting on his end of the room by the computer, window, and bathroom when Resident #12 came in as a wanderer. Resident #18 stated staff would often overlook these wandering residents going into rooms. Resident #18 stated Resident #12 came into their room and began going through his roommate's refrigerator and got out and began eating a banana. Resident #18 stated without yelling and screaming but making his voice heard, he told Resident #12 she could not be in there. Resident #18 stated there was staff at the time was walking up and down the halls, and no one came in and intervened. Resident #18 stated he understood they could not always stop what they were doing, and what he was told afterward was, It's not your responsibility to protect your roommate's stuff. Resident #18 stated if it was not his responsibility, it had to be somebody else's. Resident #18 stated he was not saying the staff did not act accordingly, as they may have been waiting for the right moment to intervene, but no one came in. Resident #18 stated he went toward Resident #12 and told her again to leave. Resident #18 stated he grabbed Resident #12 and pulled her back out of the refrigerator and his roommate's side of the room, took the banana out of her hand, and told her a third time he needed her to leave. Resident #18 stated Resident #12 said, go to hell and hit him with an open palm on the right side of his face. Resident #18 stated as a knee jerk reaction, he slapped Resident #12 in the face. Resident #18 stated at this point the PT and LVN B came into his room. Resident #18 stated they did not bother to react if a wandering resident was in there, but they would react if Resident #18 got loud enough and hit her. Resident #18 stated he did not injure her, she was not broken, and there were no marks. Resident #18 stated he was making the point that he may have been outraged and pissed off, but that was not an excuse for what he did. Resident #18 stated Resident #12 could not defend herself. Resident #18 stated Resident #12 had not been in his room since then. Resident #18 stated the ADM had not talked to him about this incident. Resident #18 stated he had anger management problems and unresolved anger, but he would not lash out at anyone unless it was an emotional reaction. During an interview on 01/09/23 at 11:17 AM, LVN B stated she was a witness to part of the incident of resident-to-resident abuse of Resident #12 by Resident #18. LVN B stated she was also aware that Resident #18 had made aggressive physical contact with one other resident in the past, and that was Resident #2. LVN B stated at that time, Resident #2 wanted his curtain closed, and Resident #18 hit Resident #12 with his crutch. LVN B stated Resident #2 was not injured, and there were no obvious long term effects. LVN B stated they had moved Resident #2 out of that room. moved them out of rooming together and there has been no conflict between the two residents since . LVN B stated on 12/28/22, she was passing medication on hall 100, and she and the PT heard yelling come from Resident #18's room. LVN B stated the PT got to the room first, and she heard the PT yell, don't hit her in the face! L [TRUNCATED]

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with professional standards of practice consistent with the resident's comprehensive assessment and plan of care for 2 of 4 (Residents #3 and #4) residents reviewed for quality of life. The facility failed to ensure visitation of friends for Resident #4 and Resident #3 which resulted in a decline in Resident #4's physical and mental/emotional well-being as well as sadness and disappointment on the part of Resident #3. The facility failed to ensure that the ADM refrained from demeaning remarks to, about, and in the presence of residents in the facility. This failure placed residents at risk for developing a decreased sense of well-being/self-worth, self-esteem, and a feeling of helplessness. Findings include: 1. Review of Resident #4's face sheet reflected a [AGE] year-old male admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's latest annual MDS dated [DATE], reflected a BIMS of 15 indicating no cognitive impairment, and reflected he required: extensive assistance of two staff for bed mobility, supervision and set up for walking, extensive assistance of two staff for dressing, and supervision and set up for toileting. Review of Resident #4's quarterly MDS dated [DATE], reflected he required: supervision and no assistance for bed mobility, supervision and set up for walking, supervision and setup assistance for dressing, and supervision and set up for toileting. Review of Resident #4's undated Care Plan reflected a problem with psychosocial well-being updated 9/20/21, related to ineffective coping, frustration due to room change, social distancing/restricted visitation secondary to COVID-19 pandemic with goals of: Resident will establish coping mechanisms as evidenced by verbal expression of frustration With approaches of: Encourage resident to verbalize feelings and fears and clarify misconceptions Weekly telephone conversations with PASRR Crisis Intervention Specialist. Review of Resident #4's weight record dated 8/1/21 indicated a weight loss of 5 pounds which was a 2.8% loss from his previous weight of 180 on 7/2/21. No other weight loss was noted. Review of Incident and Accident Report dated 3/23/21 - 10/24/21 reflected Resident #4 had not fallen since 7/16/21 and had three falls in October on 10/15/21, 10/26/21, and 10/31/21. Review of psychological services clinician note for Resident #4 dated 6/7/21 reflected resident had an angry and anxious mood over socialization issues. Clinician note dated 9/25/21 reflected resident had an anxious and dysthymic mood and was experiencing distress due to conflicts within the facility. Clinician note dated 10/9/21 reflected the LCSW was addressing current distress including medical decline and facility management related distress. The facility SW sent a referral for psychiatrist on 11/17/21. Review of Resident #4's H&P dated 4/26/21 reflected Resident #4 was doing well, no complaints, and not depressed or anxious. 2. Review of Resident #3's face sheet reflected a [AGE] year-old female admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's latest quarterly MDS dated [DATE], reflected her BIMS score was 14 indicating no cognitive impairment. Review of Resident #3's care plan edited 9/16/21, indicated the resident had a Potential for complaints of acute pain R/T poor positioning/gait and internalized responses to stress/anxiety. Resident has repetitive anxious complaints/concerns (non-health related) (e.g., persistently seeks attention/reassurance regarding schedules, medications, meals, laundry, clothing, relationship issues) which sometimes she gets so anxious it causes her to have a [CONDITION(S)]. She takes [MEDICATION(S)] and [MEDICATION(S)]. Resident will respond to others without expressing repetitive anxious complaints/concerns. She will be redirected to something else when she starts obsessing on certain things. Distract resident with physical activities and social interactions. Review of CMS [NAME] Report dated 6/1/21 - 9/30/21, provided by the facility when surveyor requested an 802, indicated R #4 triggered for falls, behavior symptoms affect others, increase in ADL help and moving independently had worsened. Interview on 11/18/21 at 10:22 AM, FM K said this whole situation with restricting visitors was affecting R #3's quality of life and was not fair. He stated his wife was an LCSW, LNFA and said during one visit not long ago the ADM's demeanor was so bad, swearing so loud everyone could hear him and appeared as if he did not care about the lives of these residents. He stated that he and his wife were both professionals and were not making this up. He stated it was sad, because this was Resident #3's home and she felt terrified. He stated the ADM was detrimental to the elderly in the building when he prevented them from visiting with friends and when he told staff to put them in their rooms and shut the door on them, instructing staff not to allow them out to see visitors (FR A & FR B) who had come to see someone across the hall. Observation on 11/18/21 at 11:37 AM of Resident #4, reflected he was in his room in a chair neatly dressed and groomed, having a frown on his forehead, staring at a screen while a video game played without him holding controller or involved in game. During an interview on 11/18/21 at 11:39 AM, Resident #4 stated he played video games to calm down. When asked why he felt a need to calm down he said because the ADM would not allow him to see his friends (FR A and FR B). Resident #4 stated since the ADM had started working at the facility, Resident #4 had an increase in shaking and trembling, frustration and anger, a tightness in his chest with SOB on occasion, loss of appetite off and on, an increase in depression, anxiety, and panic attacks and feels emotionally drained. He stated the ADM does not respect the residents and would not listen to their issues or feelings. He stated the new SW listened to him and he had a new referral for psych services due to her. He stated activities did not appeal to him any longer and that he preferred to stay in his room. He stated when the ADM was gone for the day or on weekends when he was not present in the facility, staff approaches towards all residents improved, visitation improved including allowing FR A to visit his mother. He stated he overheard the ADM telling FR B I will toss you out when she arrived to visit a Hospice nurse who had asked her to come into the facility to talk about her loved one. Resident #4 stated that he tried to intervene, saying the State guidelines say that FR B could visit, and that the ADM told him I run the facility not the State. He stated the ADM once told him if you keep that up, I will make you a Troubled Resident in your file. He said he did not recall what he was doing to prompt that response and he did not know exactly what that meant for his future. He stated he feared the ADM and feared every day he would be evicted. He stated he had a panic attack one night on the phone with FM C while discussing the facility situation of not being allowed to visit his friends. Resident #4 had tears in his eyes. During an interview on 11/18/21 at 12:02 PM, Resident #3 stated she wanted to move back to her old room, pointing to her former room and saying her roommate got to stay in there, but there was a leak in the floor on her side. She stated they moved her a bunch a times but they still have not moved her back in my room. She stated it was because the ADM knew she could see FR B across the hallway when that person has family visits. She stated she liked to go over and see them because they were her only friends. She stated staff told her the ADM did not want her to go to that room and see those family members visiting. She stated there was an incident in which FR B was visiting, and Resident #3 was taken to her room and the door was shut. She stated she was not sure but thought it was CNA X that took her to her room and shut the door on her. She stated CNA X does not work here any longer. She stated she saw FR B in her neighbor's room and wanted to go see them but was afraid of what the ADM would do and feared he might throw her out of the facility. She said it made her mad and hurt her so bad because those were the only friends she had outside the facility. She stated being told she could not see them was not right. She stated if her friend's family members tried to visit with her or other residents in the hall, the staff would tell them to go to their rooms and shut their doors. She had tears in her eyes and stated she did not know what to do and that it made her afraid of being kicked out and helpless. She stated she is afraid of the ADM because he is loud and scary and carries a cane and sometimes shakes it at the residents. She stated she is afraid he might keep her family from visiting her like he did with another resident. She said about a month ago some friends of hers were coming to visit their loved one and she heard the ADM tell a staff member to take Resident #3 to her room and shut the door. She stated that upset her so much she called FM J crying. During an interview via phone on 11/18/21 at 12:47 PM, Resident #3's family member, FM J, stated the restriction of not being able to visit with FR A and FR B who come to see their loved one had changed Resident #3 in that she was showing signs of reclusion and depression, as she was staying in her room more often. FM J stated Resident #3 was often tearful and expressed feelings of loneliness and fear. She stated due to these emotional changes in Resident #3, she had attempted to transfer her to another facility, but was denied because the other facility said they could not meet her needs. She stated it was hard to see Resident #3 sad, desperate sounding, and crying so much. During an interview on 11/18/21 at 1:12 PM, RN D stated the ADM instructed staff not to allow FR A and FR B to visit with any other resident than their loved one. She stated the ADM told staff when FR A and FR B visit to make sure everyone is in their room with their door shut so that those family members can only visit their own relative. She stated she disobeys the ADM, because if other residents want a visit from FR A and FR B, that is their right. She stated facility leadership should guide the staff to do what is right, not instruct them to violate resident's rights. During an interview on 11/18/21 at 1:48 PM, a staff member who wished to remain anonymous stated the ADM had been heard referring to a group of residents on their way out the door for an activity as herding a group of cats and had been heard referring to a staff member as a truffle [NAME] as in digging in the dirt for things referring to a staff member asking a lot of detailed questions. The anonymous staff said no staff or resident that the anonymous staff was aware of, was truly fearful of FR A or FR B or felt they should not be banned. The anonymous staff stated it was unfair, unjust, and not good for most all the residents who knew them and enjoyed their company before the ADM banned them. The anonymous staff said they saw a video of the family/friend to many residents and the video did not reflect he was out of control. During an interview on 11/18/21 at 2:12 PM, the IDON stated she held an in-service training on abuse, neglect, and resident rights herself last week. When asked if staff were trained routinely on abuse and resident rights she stated there are online training courses from SLP Corporation that staff are required to take. She stated she felt that residents should be allowed to have visitors of their choice, that it is their right and she did not agree with the ADM about restricting visitation regarding FR A and FR B. She said the residents react to those restrictions by acting out or getting upset. During an interview on 11/18/21 at 2:20 PM with FR B stated she came to the facility on [DATE], because a Hospice nurse called and wanted to talk with her at the facility about her loved one. FR B said she went to the patio entrance to avoid confrontation with the ADM but he saw her and told her he would toss her out of the facility for good making an issue of the fact she entered by the patio and not the front door. During an interview on 11/18/21 at 2:43 PM, FR A stated that Resident #4 calls him on the phone frequently very upset that he and FR B cannot come in and visit him in person. He stated Resident #4 talked about how the ADM is disrespectful towards residents telling them to go to their rooms. He stated that another resident, who is a family friend, called him and said the ADM made the resident go to her room by instructing a staff member to take her to her room and shut the door on her. During a second interview on 11/18/21 at 3:44 PM, RN D stated she had been working at the facility since June. She stated she had seen a physical decline in Resident #4 physically evidenced by his complaint of increased pain and an emotional decline evidenced by his increased frustration and anger. She stated Resident #4 came to her and confided in her that the ADM was causing him distress due to the ADM's actions towards his friends, FR A and FR B. RN D stated that Resident #4 has told her that he fears being evicted, because FR A and B are his friends. She stated Resident #3 was also affected by the ADM's behavior in that she would hold her head down and go to her room whenever the ADM was near the nurse's station to avoid him. She stated Resident #3 once told her she was afraid of the ADM because he told staff to take her to her room and shut the door when FR A and FR B visited their loved one. During an interview on 11/19/21 at 9:57 PM, Resident #6 stated FR A and FR B are very nice and friends of hers, too. She stated she loved seeing them and it was a shame the ADM won't just let them visit anyone and everyone like it used to be. She stated the ADM had not told her personally she could not visit with FR A and FR B. During an interview on 11/19/21 at 10:10 AM, DA G stated she had worked at the facility [AGE] years and had known Resident #4 since he admitted . She said she had noticed a decline over the last several months in Resident #4's demeanor where he used to be happy but now appeared worried and sad. She stated she felt it was the new ADM that was causing Resident #4 distress. During an interview on 11/19/21 at 10:15 AM, CNA B stated she had worked at the facility [AGE] years and knew Resident #4 since he admitted and said she has noted a decline in Resident #4 by his complaint of increased pain and his anger over the last two or three months. During an interview on 11/19/21 at 11:22 AM, the AD stated she had worked at the facility [AGE] years and had known Resident #4 since he admitted . She said Resident #4 was so different than he used to be. She said he wasn't smiling and happy; he was worried looking and always in a bad mood and wasn't participating in activities like he used to earlier in the year. During an interview on 11/19/21 at 2:40 PM, Resident #5, stated he knew FR A and FR B very well, and they were good friends of his. He said he was not afraid of them but he sure was afraid of the ADM because he was a big man with a big voice and carried a big stick and he would swear sometimes. Resident #5 stated the ADM is just a big bully getting these kids (Resident #3 and Resident #4) crying. During an interview via phone on 11/19/21 at 2:56 PM, FM C stated she had seen a decline in Resident#4's mental health over the last several months in that he seemed more depressed, angry, desperate sounding and told her he was afraid of retaliation from the ADM. She stated the issue that occurred on 11/9/21 with FR B being told she would be tossed out was just devastating for Resident #4. She stated Resident #4 became terrified of being evicted and feels powerless and helpless. She stated it is an abuse of power by the ADM. She stated because she is complaining, Resident #4 is afraid the ADM will prevent her from visiting Resident #4, who is her son. She stated the last time she had spoken to the ADM which she thought was 11/9/21, she told the ADM that Resident #4 had the right to see his friends and the ADM responded saying no, R #4 cannot see those particular friends. FM C stated when she asked the ADM why not, the ADM responded saying it was none of her business and if she wanted to call State then call the State. During an interview on 11/19/21 at 3:17 PM, the ADM stated his comment about tossing FM B out was because she had come inside through the patio door and was not screened. He said he did not recall making that statement, but it was something similar in that if FM B breaks the rules I can eject her. He stated he had no recollection of making any resident's visits monitored. He stated he did not recall telling any staff to take Resident #3 to her room and shut the door. He stated he did not recall restricting FR A and FR B visitation to Resident #3. He stated he did not recall saying to Resident #4 that he ran the facility, not the State. He stated he did not recall saying to Resident #4 he would label him as a Trouble Resident in his file. When asked what harm could any of those statements have towards a resident, he stated he guessed they would be upset. During a second interview on 11/19/21 at 3:30 PM the ADM presented a notice dated 11/19/21 addressed to staff that effective immediately, there will be no restrictions on Fr A and Fr B visitation and to please extend all courtesies, and screen as is required. It contained the name of the ADM, MHA, LNFA Administrator at the end. Surveyor asked the ADM if he wrote the notice to please sign it which he promptly did. During an interview on 11/19/21 at 3:40 PM, the IDON was asked why the ADM changed his visitation restriction on Fr A and Fr B and she stated the Corporation made him change it. During an interview via phone on 11/19/21 at 4:30 PM, the Psychological Services LCSW said he started therapy with R #4 in April 2021, and he had seen an overall decline in R #4 since the current ADM started working at the facility in June. He stated R #4 had an emotional decline with increased anxiety, depression, anger, and frustration and a physical decline with increased pain. He stated the stress of not seeing his friends (FM A and FM B) exacerbated those emotions and decline. He said he was working with R #4 to apply principles of life to his behaviors. Review of online course list reflected the ADM had taken the online course for Resident/Client Rights Guidelines on 7/30/21 with a score of 100 and Abuse Awareness and Prevention on 7/30/21 and with score of 94. The ADM took the online course of Customer Service on 10/13/21 and had a score of 100 and conflict Resolution/Effective Communication on 10/13/21 with a score of 90. Review of the facility policy on Resident Rights, revised December 2016, reflected: Section 1 f. that residents have the right to communication with and access to people and services both inside and outside the facility; h. that residents have the right to be supported by the facility in exercising his or her rights; u. voice grievances without fear of discrimination or reprisal v. have the facility respond to his or her grievances aa. visit and be visited by others from outside the facility Section 2 Copies of our resident rights are posted throughout the facility and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents Review of the facility undated policy on Grievance/Complaint Resolution under the section of Policy the third paragraph reflects: It is the policy of Senior Living Properties that when a resident or family has a complaint during their stay at the facility, the facility shall, whenever possible, be responded to by the department manager closest to the problem causing the complaint. The fourth paragraph reflects in part: it should be noted that if the resident or resident's family continue to complain and in their view , the problem is not resolved, the Administrator must keep the Regional Vice President of Operations informed. The sixth paragraph reflects: it is critical that all efforts are made to resolve the complaint, never label the one filing the complaint as 'chronic complainer' or a 'problem'. The facility must demonstrate aggressive actions to resolve any and all complaints. The Section of Procedure item 7 reflects in part: This complaint should be looked at in terms of how resident care is affected. If there are any opportunities to improve quality of care, and whether an evaluation of the action or any related issue is needed. The NCBI, a part of NLM, which is a branch of the NIH, published the following article dated 1986: The principles of Quality of Life included a sense of well-being, satisfaction with life, and feeling of self-worth and self-esteem; and a sense of satisfaction with oneself, the environment, the care received, the accomplishments of desired goals, and control over one's life. Facilities must create and sustain an environment that humanizes and promotes each resident's well-being and feeling of self-worth and self-esteem. This requires nursing home leadership to establish a culture that treats each resident with respect and dignity as an individual, and addresses, supports and/or enhances his/her feelings of self-worth including personal control over choices, such as mealtimes, activities, clothing, and bedtime; privacy during visits, and treatments; and opportunities to engage in religious, political, civic, recreational or other social activities. Facility leadership must be aware of the culture that exists in its facility and may use various methods to assess the attitudes and values prevalent amongst staff. These methods include, reviewing complaints or grievances, which could reasonably impact a resident's quality of life, or allegations of abuse, neglect or mistreatment. In order to identify whether staff supports each resident's quality of life, leadership should observe and evaluate verbal and nonverbal interactions between staff and residents. Negative observations could include staff actions such as the following: o Verbalizing negative or condescending remarks . o Dehumanizing an individual through verbal and nonverbal actions such as talking to others over a resident without acknowledging his/her presence, treating the resident as if he/she were an object rather than a human being, mistreating . https://www.ncbi.nlm.nih.gov/books/NBK 8/#ddd

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for nine of thirty-three residents (Residents #4, #11, #20, #26, #27, #28, #32, #33, and #34) reviewed for respiratory care, in that: The facility failed to: - have a system in place for residents who utilize oxygen concentrators ,d+[DATE] and PRN (Resident #4, Resident #11, Resident #20, Resident #26, Resident #27, Resident #28, Resident #32, Resident #33, and Resident #34) should the facility lose power. - educate staff to be aware of where the crash cart was at all times and ensuring all necessary supplies and a full oxygen tank were available on the crash cart. - have a contract with an oxygen company or have a designee that inventoried their oxygen tanks and ordered as needed. - ensure all staff were educated on where oxygen tanks were stored. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 2:47 PM. While the IJ was removed on [DATE] at 4:35 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices placed residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health due to not having oxygen or the crash cart immediately available if a resident was in distress or severe need of oxygen. Findings included: During an observation and interview on [DATE] at 5:45 AM with RN M AND LVN N, they were asked where the crash cart was located. They both pointed to a small room to the left of the nurse's station. There was no crash cart in the room. They both stated they did not know where it was. When asked where the facility stored their oxygen tanks, they stated the facility didn't have oxygen tanks. When asked what they would do if they were to find a resident unresponsive, RN M stated she would begin CPR and have the aides call 911. When asked how a resident would receive oxygen should the power go out and there were no tanks, they stated they were not sure. RN M stated she had been asking the DON (who was no longer working there) for months to purchase oxygen tanks because she felt as though it was a safety issue not having any in the facility. During an observation and interview on [DATE] at 5:55 AM with CNA C and CNA G, CNA C stated if she were to find a resident unresponsive, she would tell the nurse and then go get one of the big tanks for oxygen. The Surveyor requested to see what she was talking about. CNA C and CNA G retrieved keys from the nurses' station and took the Surveyor to the end of the hall to the medical supply closet. CNA C pointed to an oxygen concentrator and stated that was what she was referring to. They both stated there were no oxygen tanks at the facility because the residents that needed oxygen used concentrators, not tanks. There was a closet in the medical supply room that had a sign that read Oxygen on it. During an observation and interview on [DATE] at 6:10 AM, RN M stated she did not know what was in the closet inside of the med supply room, and doubted she had a key for it. She attempted to unlock the closet with the keys on the nursing lanyard, but none of the keys opened it. During an interview on [DATE] at 8:00 AM with the ADM, he stated he didn't know why the DON (who was no longer employed at the facility) had not ordered any oxygen tanks. He stated it was a serious matter because it could cause serious harm to a resident, however, the fire department was approximately a mile away and got to the facility quickly when called. During an interview on [DATE] at 11:00 AM with RN M, she stated she noticed there were red outlets in the resident rooms in which would be powered by the generator. They were located by door of the resident rooms. She stated due to her experience and background, she knew what the red outlet was for, but there was no way that every other staff member that worked there would know that. She stated they had not been in-serviced on the red outlets. She stated they did not receive in-services or any kind of in-person education. She stated when she started working at the facility a few months ago, she was not even trained on how to use the EMR system. During an interview on [DATE] at 11:15 AM with the CCM, she stated the crash cart had been found in Resident #33's room. She stated she worked as a CNA on the night of [DATE] and she needed the cart to suction Resident #33. She was in disbelief that the crash cart was never returned. When asked what would have happened if a resident had been in respiratory distress from [DATE] - [DATE], she stated she did not know, because no one knew where it was, and nobody realized it wasn't where it was usually stored. She stated the night nurses were responsible for ensuring the cart was properly stocked. During an observation and interview on [DATE] at 11:28 AM with RN M, she uncovered the crash cart which revealed an empty oxygen tank. When asked how if a resident was in respiratory distress would receive oxygen if there were no oxygen tanks in the facility that contained oxygen, she stated she did not know. The REGN overheard the conversation and stated in disbelief, There aren't any oxygen tanks in the facility?! During an observation on [DATE] at 12:05 PM revealed the concentrators of residents that were in the B bed (furthest from the door) would not reach the red outlet. Upon further investigation, there were no red outlets in the dining room, activity room, or therapy gym. During an observation and interview on [DATE] at 1:45 PM with the CCM, she stated she was notified by the ADON that there were three spare oxygen tanks locked in an oxygen closet inside of the medical supply room. Upon observation, these tanks had been prescribed to hospice residents who had passed away. There was one full and two partial tanks. None of the staff interviewed from 5:45 AM - 1:45 PM, including the ADM, knew that there were tanks in the facility or knew that there was a key for the oxygen closet. During an interview on [DATE] at 3:15 PM with ADM, he provided a name of an oxygen company an oxygen company that the facility is supposedly contracted with. During an interview on [DATE] at 8:30 AM with the oxygen company the ADM provided the name of indicated their customer service stated they do have the facility on their list, but they were not currently active, meaning they have not been delivering oxygen to the facility. Surveyor was unable to reach the local location to find out when the last time they had ordered from the company. During an interview on [DATE] at 9:32 AM with the IDON, she stated everyone should know where the crash cart was located, even agency staff. She stated in her [AGE] years of nursing, there has always been an oxygen tank available (back-up tank) for anyone with a concentrator. She stated, What if the resident needed to go to a doctor's appointment? You could not take the concentrator; they would have to have a tank. She stated the red outlets are for emergency and they would use heavy-duty power cords the concentrator didn't reach the outlet. During an interview on [DATE] at 9:50 AM with MA K, she stated if the power were to go out, they would not use a power cord, but would move the concentrator (and resident) to the A bed so it would be able to reach the red outlet. During an interview on [DATE] at 9:52 with the CCM, she stated power cords are not allowed in the facility. She stated they would have to move the bed to other side of the room to reach the red outlet. She stated no education or in-services had been provided to staff on this matter. She stated there was no designee to check or re-order oxygen currently working and that there is no distinct process to ensure oxygen tanks are available and full, and that no one in the facility has been trained on that process. During an observation and interview on [DATE] at 10:06 AM with RN M and the CCM, both stated there is no education or training being conducted regularly or for new hires related to where medical supplies are located, how to use their charting system, that there was a key to the oxygen closet, or anything else related to this failure. She provided a document that indicated which residents had orders for PRN oxygen: Residents #4, #11, #20, #26, #27, #28, #32, #33, and #34. Review of Resident #4's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's most recent MDS, dated [DATE], reflected a BIMS of 3, indicating a severe cognitive impairment. Review of Resident #4's care plan, revised [DATE], reflected nothing regarding the use of oxygen PRN. Review of Resident #4's physician orders, date [DATE], reflected no orders for PRN oxygen. Observation on [DATE] at 9:02 AM revealed an oxygen concentrator next to Resident #4's bedside. (A bed) Review of Resident #11's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's most recent MDS, dated [DATE], reflected a BIMS of 12, indicating a moderate cognitive impairment. Review of Resident #11's care plan, revised [DATE], reflected nothing regarding the use of oxygen PRN. Review of Resident #11's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2L O2 per nasal cannula continuous in her room for shortness of breath and drop in O2 saturation. Observation on [DATE] at 9:54 AM revealed an oxygen concentrator by Resident #11's bed (B bed). Review of Resident #20's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's most recent MDS, dated [DATE], reflected a BIMS was not performed. Review of Resident #20's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] O2 via nasal cannula @2L >92% - Every shift - PRN Observation on [DATE] at 10:02 AM revealed an oxygen concentrator by Resident #20's bed (B bed). Review of Resident #26's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's most recent MDS, dated [DATE], reflected a BIMS of 12, indicating a moderate cognitive impairment. Review of Resident #26's care plan, revised [DATE], reflected he was to utilize oxygen therapy/O2 sats as ordered. Review of Resident #26's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Monitor oxygen humidification bottle every shift. Replace or refill as required. Observation on [DATE] at 10:06 AM revealed an oxygen concentrator by Resident #26's bed (A bed). Review of Resident #27's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's most recent MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. Review of Resident #27's care plan, revised [DATE], reflected she had the potential for desaturation related [CONDITION(S)] and had shortness of breath related to heart failure. She was to utilize oxygen 2 L at bedtime and PRN. Review of Resident #27's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Nasal Cannula (PRN): O2 @ 2L/Min During an observation and interview on [DATE] at 11:40 AM, Resident #27 was getting a nubelizer treatment. She had an oxygen concentrator by her bed (B bed). She stated she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's most recent MDS, dated [DATE], reflected a BIMS of 4, indicating a severe cognitive impairment. Review of Resident #28's care plan, revised [DATE], reflected nothing regarding PRN oxygen use. Review of Resident #28's physician orders, reflected an order, dated [DATE], reflecting the following: Nasal cannula O2 @ 2 L/min for O2 sats <92%) Obseration on [DATE] at 10:09 AM revealed an oxygen concentrator by Resident #28's bed (B bed). Review of Resident #32's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's most recent MDS, dated [DATE], reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #32's care plan, revised [DATE], reflected she had a [CONDITION(S)] due to having an irregular sleep cycle. Review of Resident #32's physician notes reflected a note, dated [DATE], reflecting the following: Oxygen PRN for saturation <90% During an observation and interivew on [DATE] at 7:05 AM with Resident #32, she was in bed (A bed) utilizing continuous oxygen. She stated the order was for PRN, but she preferred to wear it continuously during the night. Review of Resident #33's undated face sheet reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's most recent MDS, dated [DATE], reflected a BIMS of 2, indicating severe cognitive impairment. Review of Resident #33's care plan, revised [DATE], reflected nothing regarding the use of oxygen PRN. Review of Resident #33's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Nasal cannula (PRN): O2 @ 2 L/min Observation on [DATE] at 7:30 AM revealed Resident #33 asleep in his bed (A bed) utilizing oxygen via oxygen concentrator. Review of Resident #34's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #34's most recent MDS, dated [DATE], reflected a BIMS of 12, indicating a moderate cognitive impairment. Review of Resident #34's care plan, revised [DATE], reflected he was at respiratory distress and adverse effects related to [CONDITION(S)] and he may use O2 per order. Review of Resident #34's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Nasal cannula: O2 @ 2L/Min while sleeping During an observation and interview on [DATE] at 11:08 AM with Resident #34, he was laying in his room (B bed) utilizing continuous oxygen. He stated he had an order to only wear the oxygen during the night, but he preferred to utilize the continuous oxygen ,d+[DATE]. The ADM was notified on [DATE] at 2:47 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on [DATE] at 3:05 PM. A Plan of Removal was first submitted by the VPO on [DATE] at 4:05 PM and the following POR was accepted on [DATE] at 5:54 AM: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on [DATE] for failing to assure staff were provided essential supplies to provide emergency care. 1. Action: Center to secure oxygen cylinders for emergency use from 1) Affiliate center; and 2) Contracted respiratory supplies vendor. To ensure an adequate supply is available to accommodate the needs of residents with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Beginning [DATE], Administrator and Administrative Nursing team educated regarding the adequate supply of oxygen cylinders for emergency and supplemental use. Completion Timeline: [DATE] Responsible: Administrator, Director of Nursing, LRVP, RNM 2. To ensure normal operating power of resident care equipment upon emergency power failure, with resident consent center staff relocated residents with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Completion Timeline: [DATE] Responsible: Administrator, Director of Nursing 3. Action: Administration conducted education with licensed nursing staff regarding: 1) Supplier to order oxygen cylinders from to include contact information; 2) Location of oxygen cylinder storage; 3) Location of key to access oxygen storage; and 4) Emergency Crash Cart: Location, Daily Inventory, and Restock Following Use. Beginning [DATE], licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning [DATE], and on a go-forward. Responsible: Administrator, Director of Nurses, Assistant Director of Nurses, Clinical Case Manager 4. Action: Conducted education with Administrator, Director of Nursing, Assistant Director of Nursing, and Clinical Case Manager regarding direct care new hire orientation process to include emergency procedures, charting system, and location/access of resident medical supplies. Beginning [DATE], agency, PRN, newly hired staff who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning [DATE], and on a go-forward Responsible: Administrator, Director of Nurses, Assistant Director of Nurses, Clinical Case Manager 5. Action: Beginning on [DATE], and twice a week for the next 30 days, Administration will utilize the staff interview section of the disaster/emergency response QAPI audit tool to verify staff knowledge of emergency response during a power outage. Six staff members will be interviewed per week. The QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion Timeline: Beginning [DATE] and ending [DATE]. Responsible: Administrator, Director of Nursing The survey team monitored the plan of removal on [DATE] as follows: During an observation and interview on [DATE] at 11:16 AM with the IDON, she stated 20 oxygen tanks were delivered by an oxygen company on [DATE]. She stated all nurses had been in-serviced on the oxygen key on the nurse's lanyard, that would be kept in the drawer of the nurse's station. She retrieved they keys and headed to the medical supply room, which also now had Oxygen Supply posted on the door. She opened the oxygen closet to reveal 20 full oxygen tanks. Observation on [DATE] at 11:18 AM revealed the crash cart to be in the room to the left of the nurse's station. The oxygen tank on the cart was full, and there was a check-off for the night nurses to complete each night ensuring all supplies were in the crash cart and that the tank had oxygen. During an observation and interview on [DATE] at 11:23 AM with the IDON, she revealed the in-services (which the Surveyor reveiwed) she had been conducting on all staff beginning on [DATE]: crash cart location and check-off sheet (to be completed by the night nurses), oxygen cylinders - when to order more and who to tell when they were getting low, that they more tanks needed to be ordered when they were down to 5 tanks, location of oxygen storage closet key, and if the power were to go out they would move the residents (that were in the B bed) over to the A bed so the concentrator would reach the red outlet. She stated she would be responsible for ensuring the crash cart check-off was completed each night. She stated all staff will be in-serviced before they were allowed to work. She stated she would be orientating the ADON and CCM on how to conduct training upon employment of a new hire. She stated they were not moving residents with concentrators that were in the B bed at this moment, but were contacting their representatives to get their permission to do so in the future, should it be necessary. During an interview on [DATE] at 12:10 PM with LVN L, she stated the key to the oxygen room was located on the nurse's lanyard in the drawer at the nurse's station. She stated the night nurses are to conduct a check-off of the crash cart each night. She stated she had been in-serviced on these issues. During an interview on [DATE] at 12:20 PM with the CCM, she stated the DON had been in-servicing all staff regarding the crash cart, oxygen supply key, and oxygen tanks. She stated the key to the oxygen supply closet was to remain in the drawer of the nurse's station. Observation on [DATE] at 1:42 PM revealed the key to the oxygen supply closet on the lanyard in the drawer of the nurse's station. During an interview on [DATE] at 1:55 PM with the ADM, he stated they key to the oxygen supply closet would be kept in the drawer of the nurse's station at all times. He stated he was responsible for ensuring all staff were in-serviced before they worked their next shift. Review of the facility's contract agreement with the oxygen company, dated [DATE], reflected the facility had been added to the agreement. Review of the oxygen company invoice, dated [DATE], reflected ten E tanks and 10 regulators had been delivered to the facility on [DATE]. The IJ was lifted on [DATE] at 4:35 PM. While the IJ was removed on [DATE] at 4:35 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness.