Every finding on record at Avir at Lancaster

Based on observations, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 7 residents reviewed for care plans. The facility failed to follow Resident #1's care plan to have staff near him during meals to ensure he did not take other residents' food when resident #1 choked and vomited on 05/07/26 resulting in staff performing the Heimlich.This failure could place residents at risk of not receiving individualized care and services to meet their needs.Findings included:Record review of Resident #1's Care Plan, dated 5/11/26, reflected he was a [AGE] year-old male, admitted to the facility 11/03/25. Focus: he had a nutritional problem or potential for aspiration related to dysphagia and pureed diet. Interventions: stay during meals so that you[staff] were able to assist as needed or redirect when he attempted to consume other residents' food. Record review of Resident #1's Quarterly MDS assessment, dated 03/26/26, reflected his BIMS score was 03 (Severe cognitive impairment). He had diagnoses of diabetes (a chronic health condition where the body cannot properly process food into energy, leading to high blood sugar levels), bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity levels, and focus), and non-Alzheimer's dementia (encompass several distinct brain disorders causing cognitive decline).Record review of Resident #1's Order Summary Report, dated 04/01/26, reflected his diet was reduced concentrated sweets, pureed texture, nectar consistency. Observation of noon meal on 07/28/26 at 11:53 a.m. revealed an LVN-C and the Activity Director present in the dining room. LVN-C was observed assisting residents and the Activity Director was observing the residents while they were eating. During an interview on 07/28/26 at 1:15 p.m. with the DON, she stated she had only been the DON a few months. She stated she was not aware there was a problem with Resident #1's care plan. She stated all care plans were being re-evaluated at the time of investigation, and they had a targeted date of 08/16/2026 to have all reevaluations completed. She stated they had developed a process to forward speech therapy recommendations to the doctor, nursing, and dietary. She stated the nursing staff would receive an in-service on all changes to care plans when changes were updated. She stated if a recommendation was made the care plan should be consistent through the care plan, speech therapy and doctor orders. She said when a care plan was not carried out properly the resident would be at risk of not receiving the interventions of what the care plan had put in place. She said the resident could also be at risk of injury. She stated the DON was responsible for ensuring the care plans were followed and implemented by the nursing staff.During an interview on 07/28/26 at 1:38 p.m. with CNA-A, he stated on 05/07/26 during feeding time Resident #1 wanted his pudding opened, he opened the pudding and continued to pick up the other trays in the dining area and on the hall. He stated he was not aware that Resident #1's care plan noted staff needed to stay with him during his meals. He stated the CNAs decided among themselves who stayed in the dining area during meals. He stated they would be notified of care plan changes by the nurses after they attended the change of shift report meeting. He stated when he was not informed of a change in the care plan it could put the resident at risk of not receiving proper care. During an interview on 07/28/26 at 1:48 p.m. with CNA-B, she stated there was a schedule for who was assigned to assist in the dining area. She stated the staff in the dining area on 07/28/26 were the nurse and the activity director. She stated it was important that nursing and CNAs stayed in the dining area to monitor choking. She stated it was important to know the residents' care plans to ensure they received the proper diet and the staff could provide adaptive equipment if needed.During an interview on 07/28/26 at 2:16 p.m. with LVN-C, she stated she monitored the dining room during the breakfast meal and noon meal on 07/28/26. She stated the CNAs were on the hall with the residents who needed to be fed. She stated she checked the meals prior to them being given to the residents. She stated if a resident received the wrong diet she would notify the kitchen and not give the resident the meal. She stated if a care plan was not followed the resident would be at risk of receiving the wrong food which could be harmful. During an interview on 07/28/26 at 3:23 p.m. with CNA-D, he stated on 05/07/26 he did not see LVN-E when he was passing through the dining room, but he did see her when he returned to the dining room from passing trays on the hall. He stated he did not know that someone needed to stay with Resident #1 when he was eating. He stated he was only told that someone needed to stay in the dining room during meals. He stated when it was not written on the schedule which staff would stay in the dining room the CNAs decided among themselves. He stated a resident's care plan could be found in the POC. He stated he checked the POC at the beginning of his shift, after meals, and prior to the end of his shift. He stated he had not seen Resident 1's care plan that someone needed to stay with him. During an interview on 07/28/26 at 3:36 p.m. with LVN-E, she stated on 05/07/26 she was monitoring the dining area during the dinner meal. She stated CNA-A was assigned to help in the dining room. She stated she was standing in the area near the nursing station where she could see the residents. She stated she checked all of the trays prior to them being passed out on 05/07/26. She stated Resident #1 received the correct diet. She stated she did not get a change in Resident #1's care plan and it would have been communicated during shift report. She stated she knew she needed to keep an eye on him because he liked to take other residents' food but she was not aware the words stay near him was in the care plan. She stated when the care plan was not followed the resident would be at risk of getting something they are not supposed to get. Record review of Resident #1's hospital record dated 5/7/26 reflected, patient with past medical condition of multiple medical problems presented to the emergency room with cardiac arrest after vomiting and becoming unresponsive at facility. Resident #1 passed away of cardiac arrest on 05/07/26.Record review of the facility's in-service, dated 5/9/26, reflected, Staff should follow physician orders for diet and checking trays for diet type, signed by staff, LVN-E, CNAs A and D along with all staff employedRecord review of the facility's in-service, dated 5/10/26, reflected, Care Plans acknowledgement and instructions following care plans and adding changes to nursing staff, signed by LVN-E and other nursing staff responsible for updating care plans.Record review of the facility's policy titled, Policy & Procedure Manual, The Dining Experience, dated 2023, reflected, Policy: The dining experience will be person centered., Individuals will be provided restorative dining services as needed to maintain or improve eating skills.7. f. Staff will offer assistance as needed in order to maintain, improve and/or prevent a decline in eating ability.10. Individuals will be provided cues, prompting or assistance as needed in order to maintain, improve and prevent decline in eating ability.Record review of the facility's care plan policy titled Care Plans, Comprehensive Person-Centered March 2022, reflected, 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: g. receive the services and/or items included in the plan of care

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 drugs and biologicals) to meet the needs of each resident for 1 of 3 Residents (Resident #1) reviewed for medication and pharmacy services.The facility failed to administer Resident #1's blood pressure medications in accordance with physician's orders, by not obtaining his blood pressure prior to medication administration.This failure could place residents at risk of not receiving therapeutic dosages of their medications.Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), stroke, and Non-Alzheimer's Dementia (brain disease that alters brain function and causes a cognitive decline). Resident #1's BIMS score was a 3, indicating severe cognitive impairment.Record review of Resident #1's care plan, dated 07/08/2026 reflected The resident has hypertension (HTN) r/t lifestyle choices, Stroke with an intervention that included Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness.Record review of Resident #1's physician's order summary reflected the following: - Amlodipine Besylate Tablet 5 MG Give 7.5 tablet by mouth one time a day Hold if SBP (top number in a reading) BELOW 100 OR DBP (bottom number in a reading) BELOW 60 - start date 07/13/2026.- Lisinopril Oral Tablet 40 MG Give 1 tablet by mouth one time a day for Hold if SBP BELOW 100 OR DBP BELOW 60 - start date 07/13/2026.Record review of Resident #1's July 2026 MAR did not reflect any blood pressure readings prior to the administration of Amlodipine Besylate or Lisinopril.Record review of Resident #1's blood pressure summary reflected no blood pressure documented by the nurse for 07/07/26, 07/18/26, 07/19/26, 07/20/26, 07/21/26, and 07/22/26.Interview on 07/25/26 at 12:05 PM, MA A stated she had worked at the facility for about a month. She stated she was not able to give Resident #1's medications last weekend or take his blood pressure, and informed the nurse who said to hold them. She said she knew when to take a resident's blood pressure when the MAR told her to. She said it would prompt her to enter the blood pressure before charting on it. She stated if the blood pressure was below parameters, she was not to give the medication and was supposed to report it to the nurse. She stated if it was high she would still administer the medication and report to the nurse it was high. She said the nurse administered prn (as needed) medications and contacted the doctor. She said the risk of not taking blood pressure before administering blood pressure meds was the resident could bottom out (when the blood pressure drops) and end up on the floor. Interview and record review on 07/25/26 at 12:36 PM, RN B stated if a MA was passing out blood pressure medicine, they were responsible for taking the resident's blood pressure before and documenting it. She said the risk if not done would be the resident could be hypotensive and it could bottom out the blood pressure. She stated the ADON and DON were responsible for auditing physician's orders. RN B showed Resident #1's orders which revealed the ADON had entered the orders and the parameters were not added. RN B stated MAs should report to the nurse that the MAR was not prompting for blood pressure because that was basic knowledge when giving blood pressure medication. Interview on 07/25/26 at 1:45 PM, MA D stated she took Resident #1's blood pressure before passing out his meds, but did not document it. She said it may have been one where the tasks were not added when the order was put in. She said she was not able to chart on it if the parameters were not added. She stated the risk to residents would be if the blood pressure was low, it could drop lower.Interview on 07/25/26 at 2:43 PM, the ADON stated for blood pressure medication, there was a range and if it was too low, the medication was not given. She said whoever passed out the medication was responsible for taking the blood pressure. She said if it was a MA and there was no place to document the blood pressure, the MA should let the nurse know. She said the risk to residents was blood pressure could go lower, they could pass out and the heart rate could go lower. She stated it was important to ensure physician's orders were entered correctly so there would be no medication errors. She stated that she and the DON were responsible for auditing orders.Interview on 07/25/26 at 3:41 PM, the DON stated the admitting nurse was responsible for entering orders and making sure the parameters were selected. She stated Resident #1's blood pressure should have been documented, and the MA should have notified the nurse they were not able to. The DON stated she and the ADON were responsible for auditing the orders. She stated they would assume the blood pressure was taken and the medication given in parameters because everyone knows not to give it outside those parameters.Record review of the facility's Administering Medications policy, revised April 2019, reflected: .23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:.e. any complaints or symptoms for which the drug was administered;f. any results achieved and when those results were observed;.

Based on observation and interview the facility failed to store all drugs and biologicals in locked compartment and permit only authorized personnel to have access to the keys for 1 (medication cart #1) and 1 (crash cart #2) of 3 medication carts observed for medication and biological storage. On 06/30/26, LVN A failed to ensure medications were secured or attended to by authorized staff when LVN A did not lock medication cart #1. On 06/30/26, the facility failed to ensure crash cart #2 (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was secured. These failures place residents at risk of unauthorized access to medications and biologicals. Findings Included: During an observation on 06/30/26 at 6:42 A.M., one medication cart #1 and one crash cart #2 were unlocked with drawers facing outward towards the hallway at the North nursing station. The red dot was visible on the lock mechanism of both carts.During an observation on 6/30/26 at 6:43 A.M., nursing staff left the North nursing station with the medication cart #1 and crash cart#2 unlocked with no staff in view of the carts.During an interview on 06/30/26 at 6:50 A.M., LVN A stated the medication cart #1 was her cart and she did not realize it was unlocked. LVN A stated the medication cart should be kept locked for safety of the medications and the residents. LVN A stated residents could take medications that did not belong to them. During an observation on 6/30/26 at 6:57 A.M., crash cart #2 revealed:Alcohol prep padsSaline solutions tubeslancetsScissors(AA) batteriessuction catheterLarge adult reservoir mask not in bagSilicone fix tapeGauze sponge (2x2) boxAdult electrode padSuction tubingLubrication jelly Normal saline I.V flush syringes - 12ml Adult nasal oxygen canula tubingDuring an interview on 06/30/26 at 7:42 A.M., RN A stated the medication cart must stay locked when not in use. RN B stated the crash cart should be left unlocked for easy access. During an interview on 06/30/26 at 12:05 P.M., LVN C stated the medication cart and crashed cart must be locked when not at use to prevent unauthorized use of medications and to keep residents safe.During an observation on 06/30/26 at 3:00 P.M., crash cart #2 was unlocked at the North Nursing station.During an interview on 06/30/26 at 3:30 P.M., the DON stated medication cart and crash cart must be locked when not in use to protect the residents and staff from taking medications. The DON stated the nurse on the cart was responsible for the cart security and she was responsible for in-services with staff. Record review of facility policy, titled, Administering medications reflected, 19. During administration, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident room, with open drawers facing inward and all other sides closed.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1(Resident #1) of 6 residents reviewed for baseline care plan. The facility failed to include on baseline care plan that Resident #1 was placed in the secure unit.The facility failed to include on baseline care plan that Resident # 1was an elopement risk.The facility failed to include Resident #1 Behaviors on baseline care plan. These failures place residents at risk of not receiving the care needed. Findings included: Record review of Resident #1's face sheet dated 06/30/26 reflected, Resident #1 was a [AGE] year-old male, initially admitted on [DATE] and readmitted on [DATE]. Resident#1 was diagnosed with Schizophrenia unspecified, (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, and disorganized thinking), depression unspecified (common and serious mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional and physical problems), and cognitive communication deficit (A condition where communication is impaired due to underlying cognitive difficulties rather than a primary language or speech problem). Record review of Resident#1's MDS entry assessment, dated 05/23/26 reflected a BIMS of 03 which indicated, severe cognitive impairment. Resident#1 entered from nursing home (long-term care facility). MDS reflected, Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Documented at a 1 for behavior occurred 1 to 3 days. Record review of Resident#1's previous long term care facility orders dated 04/15/26 to 05/15/26 reflected, Resident#1 requires secured unit d/t wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Record review of Resident#1's elopement evaluation dated 05/15/26 reflected elopement score of 0.0 (low risk for elopement) written by RN D. Record review of Resident#1's progress note dated 05/16/26 reflected, Upon arrival, [RN E] observed the [Resident #1] actively breaking a dining room window using a chair. Record review of progress note dated 05/22/26 reflected, Resident #1 grabbed his plastic tray and slammed it on the floor several times until it broke. Resident then began waving a broken piece of the tray at staff. Resident became upset in room and tore blinds off the wall. Resident threw a cup, causing the window to break again, and kicked a hole in the wall. Written by DON. Record review of Resident#1's MDS entry, dated 06/13/26 reflected, a BIMS of 99 which indicated, resident was rarely/never understood. Resident#1 entered from psychiatric Hospital. Record review of Resident#1's elopement evaluation dated 06/12/26 reflected elopement score of 7.0 (high risk), written by RN B. Record review of Resident#1's baseline care plan undated reflected, no notation of Resident#1's need for secure unit, elopement risk and behaviors. During an over the phone interview on 06/30/26 at 1:15 P.M., NP and MD stated they did not write an order for Resident#1 to be in the secure unit. The resident was transferred in from another facility secure unit. NP stated at this time Resident#1 needed to be on the secure unit. During an interview on 06/30/26 at 1:50 P.M., the MDS Nurse stated Resident#1 was transferred from another facility secure unit. MDS Nurse stated the 48-hour care plan was in the EHR. The MDS Nurse stated she had 21 days to update the care plan. During an interview on 06/30/26 at 2:00 P.M., the Admin stated the facility had clinical meetings weekly and went over concerns for residents. The Admin stated Resident#1 came in on 05/11/26 and was discharged to the Psychiatric hospital on [DATE] and returned back to the facility on [DATE]. The Admin stated he did not have a specific policy about baseline care plan but did have the policy on the comprehensive care plan. During an over-the-phone interview on 06/30/26 at 4:15 P.M., the Marketer stated she received a referral from a local nursing facility secure unit. The marketer stated Resident #1 was on the secure unit for behavior and elopement risk. During an interview on 06/30/26 at 4:50 P.M., DON stated Resident#1's care plan had to be completed in 21 the days. The DON stated Resident#1's baseline care plan should include falls, code status, diet, ADL, immediate concerns/goals. The DON stated the MDS Nurse was responsible for care plans.

Based on observations, interviews and record reviews, the facility failed to ensure the residents had a right to a safe, clean, comfortable and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for four (Residents #1, # 2, #3 and anonymous) of eight residents reviewed for resident rights. The facility failed to ensure Residents #1, #2, #3's and anonymous' rooms and bathrooms were free from accumulated dirt, uneven/mix matched and missing floor tiles, rust stained bathroom fixtures and broken ceiling panel. These failures could place residents at risk of preventing residents from having a homelike experience which could cause illnesses, infections and hazards and could result in deteriorating health and decreased psycho-social well-being. Findings included:During an interview and observation on an undisclosed date and time, Anonymous stated they had issues with the flooring, but had not fallen or tripped over them. They stated the Maintenance Director said he would fix the flooring two or three months ago. There were several tiles that looked missing because they were a darker color (approximately 26 dark grey floor tiles, three tan floor tiles, 14 light grey tiles that did not match the original beige flooring tiles. The floor tiles were uneven, mix matched with gaps and blackish built-up grime between some of the floor tiles. Observed by the bathroom entrance, there was a dry white ceiling tile that was broken with 1/2 inch protrusion, by the A/C vent. Observed at the lower end of the light brown wall located behind the A bed was a 3-foot x 4-inch area of missing paint which left a blackish color on the wall. The floor underneath the sink had blackish areas of dirt around the baseboards with a medium size brown box underneath the sink. There were two black base boards by the bathroom door separated from the wall with crumbled sheetrock exposed. Observed along the baseboard was blackish dirt and grime accumulated along both walls. 1) Record review of Resident #1's Quarterly MDS Assessment, dated 04/24/26, revealed a [AGE] year-old male admitted [DATE]. He had a BIMS score of 99 (Resident unable to complete) and staff assessment for mental status was 03 (severe cognitive impairment). He had no upper or lower extremity limitations with no use of mobility devices. He was independent with most ADLs but needed supervision or touching assistance with bathing. He was always incontinent with bladder and occasionally incontinent with bowels and had medically complex conditions. He was diagnosed with heart failure (heart not pumping blood effectively), hyperlipidemia (high amounts of fats), Cerebral Vascular Accident (stroke), malnutrition (not getting enough nutrients), anxiety (tension, worried, racing heart), asthma (chronic respiratory disease), and need for assistance with personal care. During an attempted interview and observation on 06/11/26 at 11:43 a.m., Resident #1 was sitting in a chair watching TV, but he was not interviewable because of his cognitive deficit. His room had several areas of brownish stains underneath the sink and brownish rust discoloration was inside of the sink. There were blackish colored dirt and grime along the base boards by the closet. Observation reflected a dark greyish 4-inch x 2-inch sticker on the floor by the B Bed.2) Record review of Resident #2's Face Sheet, printed 06/11/26, revealed a [AGE] year-old female admitted [DATE] with diagnoses of schizoaffective disorder (hallucinations, delusions and mood disorder), COPD (progressive lung disease), bilateral cataracts (cloudy eye lenses in both eyes), age related choroidal atrophy (thinning of eye vessel), muscle weakness (reduced muscle capacity), difficulty walking, unsteadiness on feet, muscle wasting atrophy (loss of thinning muscle tissue) of right and left thigh and lower legs. During an interview and observation on 06/11/26 at 11:51 a.m., Resident #2 stated her room floors had been like this for over a year and said she had not said anything about it because the staff did not care. There were blackish and rust colored stains observed on the floor under the sink with a white box that had brownish splash stains around it. The tiles at the entrance of the room door had blackish dirt and grime along the base boards and the sink. There was a brownish rust stain line and blackish discoloration around the drain hole in the sink. The wall was bumpy and uneven that was painted over and located above the left side of her window. 3) Record review of Resident #3's Quarterly MDS Assessment, dated 05/06/26, revealed a [AGE] year-old female admitted [DATE], a BIMS score 10 indicating moderate cognitive impairment. She had no upper or lower impairment with no use of mobility devices and was independent with most ADLs but needed supervision or touching assistance with showers. She was always continent with bladder and occasionally incontinent with bowels. She had medically complex conditions. She had diagnoses of coronary artery disease (narrowing or blockage of arteries to heart), hypertension (high blood pressure), hyperlipidemia, other fractures (broken bones), non-Alzheimer's dementia (progressive brain disorder causing cognitive and behavioral decline), anxiety (tension, worried, racing heart), depression (sadness), psychotic disorder (severe mental health condition on what was real thoughts), pain in left knee and unsteadiness on feet.During an interview and observation on 06/11/26 at 4:29 pm, Resident #3 stated her toilet was stopped up last month and Maintenance Director A fixed it. She stated the toilet was stopped up again and he fixed it again a few days ago. She stated the toilet was still not flushing all the way at times and sometimes the water would rise up, in the toilet bowl. She stated the toilet might need to be replaced. She stated the last time the toilet did not flush right was today, she stated she saw Maintenance Director A walking up and down the hallway, but he looked so busy all the time. She stated the housekeepers did not clean or mop her floors but did empty the trash daily. She stated she could not remember the last time the flooring was swept and mopped. She stated her room and bathroom had not been swept and mopped since being at this facility. She stated if this facility was taken care of properly, it would be a better place. She stated she did not like the toilet not working and wished they would clean the room better. The bathroom floor was missing 21 tiles and had a very dark brownish color; the floor had several layers of blackish dirt with more blackish dirt accumulated along the baseboards. Two areas of the floor had white paint stains on them and the whole bottom of the toilet bowl was rusty brown. Observation of the back of the toilet seat revealed a large brown stain on it and the sink had blackish colored stains around the sink drain. The base board along the front entrance and bathroom had blackish dirt and grime. Observed was a 2-inch x 1 inch crack in one tile that caused the floor to be uneven. During an interview on 06/12/26 at 1:45 pm, Housekeeper B stated she worked the north hall and that the residents' rooms were swept, mopped and furniture wiped down daily. She stated they used a scraper to get the black stuff that was hard to get off the floor. She stated she asked the Administrator about the need for more floor tiles in some of the residents' rooms and he said he would work on it. She stated some of the room floors were dirty and it did not do any good to sweep and mop them because the missing tiles on the floor looked dirty. She stated the missing tiles in Anonymous and Resident 3's rooms had been like that since she started working here three years ago. She stated at times while she cleaned a room, management would want her to stop cleaning a room to do something else. She stated she needed to completely clean a room before going to another room but sometimes could not. She stated the morning shift CNAs did not wipe up anything, like feces on the toilet and would wait for housekeepers to clean it. She stated the toilet bowl in Resident #3's bathroom had a brownish stain and blackish areas on her floor. She stated Resident #3's toilet and flooring had been like that since she worked here. She stated this facility did not have enough housekeepers because when they hired them, they did not stay. She stated they had three housekeepers and no floor tech, and she said they did their best to clean the floors with the scraper but could not get all the dirt up. She stated she worked the 7:00 am to 3:00 pm shift and was not aware of any housekeepers who worked after 3:00 pm. During an interview on 06/12/26 at 2:00 pm, Housekeeper C stated she cleaned the south hall rooms and memory care unit. She stated she swept and mopped the floors and wiped down the light fixtures, counter tops, sinks, removed trash, cleaned the bathroom, and wiped the bedside tables. She stated they needed at least one more housekeeper so that it would not be so stressful for them to get the room cleaned. She stated the housekeepers had to clean the common areas first like the front offices, bathrooms, and shower rooms. She stated after that they cleaned the resident's rooms, which she said usually took 15 to 20 minutes cleaning each resident's room and bathroom. She stated she stayed longer for any spills or food on the resident's floor. She stated when urine was on the floor, the CNAs did not clean it up and just left it there for the housekeepers to clean. She stated her hours worked was from 8:00 am - 4:00 pm and she worked weekends. She stated the facility had two laundry aides and she worked in the laundry department every other weekend. She stated the facility needed to change the flooring in some of the residents' rooms and that some of the residents' rooms had new flooring which was easier to clean. She stated she tried to clean the toilets, and they used bleach and a toilet bowl scrubber, but the brownish and black stains did not go away in some of the residents' bathrooms. She stated she wished they were paid more for the work they did because the nursing staff dropped gloves and medication cups on the floor and did not pick them up. She stated she was not the maid for the nurses. She stated they were only paid $12.00 per hour and added they did not have a floor tech. She stated they offered her the floor tech position, but she said management was not going to increase her pay so she said no to the floor tech position. She stated she knew how to professionally strip and buff floors, because she used to work with a professional floor cleaning company. She stated the Maintenance Director has had enough time to look and see what needed to be fixed, like the floors. She stated the floors had not been stripped and buffed since she started working here. She stated the housekeepers dusted the A/C vents and it was still dusty. She stated she noticed the rust stains in the toilets and sinks and had asked the Housekeeping Director if they could paint them and she said no. She stated no one cleaned up spills on the floors when the housekeepers were not there. She stated none of the nursing staff helped with cleaning spills and picking up trash on the floors. She stated she would talk to the Administrator about her concerns, but he was too busy to talk to. During an interview on 06/12/26 at 3:30 pm, Housekeeping Director D stated the facility had three main Housekeepers and there were two part time and two PRN housekeepers. She stated all the residents' rooms were cleaned daily which included the common areas, nurses' station, bathroom, conference room, dining room, therapy gym and four shower rooms. She stated the housekeepers cleaned the nightstands, wiped the overhead lights, blinds, emptied the trash, wiped the windowsills and call lights. She stated they also wiped the beds, TV remotes, doorknobs, swept and mopped and deep cleaned one room per hall, per day. She stated the housekeepers deep cleaned the common areas per day and added the facility did not have a floor tech who stripped and waxed the floors. She stated they had a floor tech, but he left or quit a few months in January 2026. She stated the [NAME] or Van driver stripped and buffed the dining room floor three weeks ago but not the common areas and resident's room. She stated the facility interviewed someone for the Floor tech position, but he was not qualified for it, but they did have a Floor tech position job notice on an employment website. She stated the floors needed to be replaced because the residents' spilled drinks on them and even though they started using the floor scrapers last week, they could not clean the floors effectively. She stated the facility needed a carpet cleaner because some spots did not go away. She stated the housekeeper cleaned the floors, but it often did not look like they did because of the missing tiles in some of the residents' rooms. She stated Resident #3's bathroom and flooring had been like that since she worked here. She stated she had tried to order different cleaners to clean the brown stains but could not get the stains to go away. She stated the facility was supposed to be better than this and the facility needed teamwork. She stated sometimes she felt like the housekeepers cleaning was not enough because there was no teamwork with cleaning the facility. She stated she went far and beyond by putting up the residents' hangers and clothes and threw away the nursing department's gloves that were on the floor. She stated the nursing staff did not pick their gloves off the floor. She stated when this facility did not have a maintenance director she changed light bulbs, unclogged sinks, moved and made beds. She stated these all fell under nursing and maintenance department duties, but this was the resident's home. She stated Resident #3's toilet was hard to flush and thought it might be the water pressure was low. She stated Resident 3's toilet did not completely flush and was still that way. She stated she trained her staff on how to clean as thoroughly as possible, and she did spot checks to ensure they were cleaning thoroughly. She stated Resident 3's flooring needed new tile because some were missing and uneven. She stated Resident #1 and #2's floors also needed to be replaced, and Resident #1 urinated on the floor when they left for the day. She stated they were not supposed to clean up bodily fluids or clean spills after they left at 5:00 pm, but the nursing staff waited for them to return to work the next day. She stated the new Maintenance Director A had been here for a little over a month, but the staff still called her to fix things. She stated she did not mind doing it if it was for the residents. She stated she wished they had enough of a budget to manage her department and added ADON F ordered supplies for the housekeeping department. She stated she wished she could order for her own department, so she did not have to look for supplies to clean the facility. She stated they had enough carts but could use more brooms and mops. During a telephone interview on 06/12/26 at 4:48 pm, Maintenance Director A stated he started working at this facility a month ago. He stated he absolutely did a good job with the facility's maintenance needs. He stated he fixed Resident #3's toilet last week because it was clogged and had to snake (tool used to clear stubborn clogs) the clog out. He stated he checked Resident #3's toilet today (06/12/26) and it was flushing perfectly fine, but would go back to check it. He stated the toilet was scratched off from the snake device he used and with having to twist and pull up the waste the poop could have caused those stains. He stated a housekeeper needed to clean Resident #3's toilet after he unclogged it, but he had not talked to housekeeping about cleaning it. He stated the housekeeper regularly cleaned the residents' rooms, but stated he had to talk to the housekeepers about making sure they cleaned the toilets after she unclogged them. He stated if sitting water accumulated it could stain the toilet and stated he had not noticed the missing tiles in Resident #3's bathroom. He stated he had just hired a floor tech last week and told the new floor tech he had a big plan to get this facility running the way it was supposed to run. He stated he did have tiles on order and would add Resident #3 to his list to repair the floor. He stated the hallway floors were replaced with new flooring, but the residents' rooms were old. He stated the glue on the residents' floors came up and when they stepped on them, the floors started getting black spots. He stated the facility stripped and buffed the floors a month ago and needed to start stripping and buffing the floors more often. He stated he noticed the uneven wall over Resident #2's window and said the shifting of the facility may have attributed to that and would check it. He stated he noticed the ceiling tiles in one room were broken and protruding, but not noticed the tiles were uneven in that room. He stated many of the repair requests had to go through approval, from corporate first to fix things. He stated he had not noticed the flooring issues in Resident #1's room. He stated he planned to on Monday 06/15/26 to look at each room needing repairs. He stated he was notified of maintenance requests electronically and the staff were good at letting him know when repairs were needed. He stated these residents meant everything to him and if it were his house he would expect someone to come out as soon as possible to repair them. He stated not having repairs completed could affect the residents drastically and they would not be able to live their day-to-day lives like they should. He stated timely repairs in a fashionable manner was his goal because this was the resident's home. During an interview on 06/12/26 at 5:15 pm, the DON stated when housekeepers were not at the facility, the nursing staff were supposed to help keep this place clean. She stated the nursing staff were supposed to take out the trash and gloves and said this facility was very old. She stated she was not aware the nursing staff was not cleaning up spills after 5:00 pm when no housekeepers were on duty. She stated this building needed a makeover and management was trying to get the building in good condition. She stated the new owners have been making changes since November 2025. She stated it was a safety hazard having missing and uneven tiles on the floors. During an interview on 06/12/26 at 5:52 pm, the Administrator stated he was not aware of any housekeeping issues and not aware of the broken ceiling tile that was protruding from the ceiling. He stated the staff was supposed to notify management about the main issues. He stated the facility just hired a floor tech to address the missing and uneven floor tiles issues and hopefully he would start next week. He stated they planned to get the floors stripped and buffed next week and said the new ownership had 140 facilities in Texas. He stated this was an old facility that would eventually look new and was not aware of the safety issues in some of the residents' rooms. He stated having a broken ceiling tile and missing floor tiles could be a safety issue to the residents. He stated he was not aware of any missing floor tiles or broken ceiling tiles, but would get with the Maintenance Director Monday 06/15/26 to fix them. He stated he would do training with the with staff to be more detailed on things they needed to observe and report to Maintenance Director A. He stated he expected the housekeeping and maintenance departments to clean and fix things correctly. He stated as the facility's administrator he looked at the rooms each day to make sure the O2 signs were up and that the residents' rooms were homelike. He stated the former Maintenance Director was terminated March 2026 and Maintenance Director A started two or three weeks ago. He stated during that time, the facility had no Maintenance Director onsite, the Corporate Maintenance Director E visited once or twice a week for repairs when needed. He stated Housekeeping Director A was responsible for cleaning the facility and the Maintenance Director was responsible for repairs. He stated he was going to count how many floor tiles were needing to be replaced in the rooms and fix the ceiling tile and get with Housekeeping Director on addressing the cleaning concerns. He stated floor and ceiling tile issues could cause issues for the residents and would get with Maintenance Director A this Monday 06/15/26. (After several attempts, the Administrator would not answer how these issues could affect the residents.)Record review of the facility's Resident rights policy undated revealed, (RESIDENT'S RIGHTS A resident has a right to a dignified existence, self determination and communication with and access to persons and services inside and outside the facility. As an employee of this facility you must protect and promote the rights of each resident. Violations of any of the resident rights are against the law.b. A safe, decent and clean living environment and condition .Record review of the Facility's Maintenance Service Policy dated 2001 revealed, Maintenance Service Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation1.The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2.Functions of maintenance personnel include, but are not limited to:a.maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b.maintaining the building in good repair and free from hazards.f.establishing priorities in providing repair service.3.The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.4.A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents.10.Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.Record review of the Facility's Homelike Environment policy dated 2001 revealed, Policy StatementResidents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Policy Interpretation and Implementation1.Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a.clean, sanitary and orderly environment.

Based on interview and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality or 3 (Resident #1, #2, and #3) of 3 reviewed for personal privacy. The facility failed to ensure CNA-A did not use her personal phone to record Residents #1, #2, and #3 and posted the images to her public social media platform without permission from the residents or representatives. This failure could place residents at risk of psychological harm.Photo observed on public social media of CNA-A revealed Resident #1 smiling and looking toward the camera with the caption, Memory care everyone daddy [Resident #1's nick name] says he remembers some words. CNA-A's photo was in the middle right side of the photo with 16.5 hearts, 471 comments, 487 saves, and 3,752 shares.Photo observed on public social media of CNA-A revealed Resident #2 standing in the hallway with her hands in a half raised position with the caption, When you live in memory care and a song come on and bring back old memories. CNA-A's photo was in the middle right side of the photo with 16.5 hearts, 471 comments, 487 saves, and 3,752 shares. Photo observed on public social media of CNA-A revealed Resident #3 in the hallway standing on a walker (walking assistance device that provides support with walking)with the caption, Everyone in memory care has a song that brings it all out. CNA-A's login identification was located under the social media logo. 1.Record review of Resident #1's comprehensive MDS dated [DATE], reflected he was a [AGE] year-old male admitted to the facility 04/05/25 with diagnoses of paranoid schizophrenia (a chronic brain disorder characterized by intense, irrational paranoia, auditory hallucinations), and major depressive disorder (a common severe mental health condition characterized by persistent sadness, loss of interest, low energy). He had a BIMS of 14 indicating he was cognitively intact (sufficient mental capacity to manage normal daily demands, including adequate judgment, planning, organization, and self-control).During an interview with Resident #1 on 05/04/26 at 11:48 a.m. he stated he had not given anyone permission to record him and put the video on the internet. He stated if someone had taken pictures of him and put them on the internet it was an invasion of his privacy and he would not be happy with it. He denied he had seen anyone take a picture of him while he was in the facility. 2.Record review of Resident #2's Quarterly MDS dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility 11/12/25 with diagnoses of intermittent explosive disorder (a mental health condition characterized by recurrent, sudden episodes of impulsive, aggressive, or violent behavior, where reactions are grossly out of proportion to the situation), dementia (umbrella term for a progressive decline in memory, thinking, and behavior), and major depressive disorder (a common severe mental health condition characterized by persistent sadness) She had a BIMS score of 06 indicating severe impairment (a physical or mental condition that significantly limits an individual's ability to perform basic work activities, such as walking, sitting, lifting, or understanding instructions).During an attempted interview with Resident #2 on 05/04/26 at 10:58 a.m., she did not respond to any questions posed to her regarding a video taken of her and posted on a staff member's social media, all of her responses were that she wanted to go and smoke her cigarette. 3.Record review of Resident #3's Quarterly MDS dated [DATE] reflected she was a [AGE] year-old female originally admitted to the facility 11/12/12 with diagnoses of schizophrenia (chronic, severe brain disorder), schizoaffective disorder( a chronic mental health condition characterized by a combination of schizophrenia symptoms -such as hallucinations or delusions-and mood disorder symptoms, such as mania (state of abnormally elevated arousal, energy, and mood) or depression (a serious, common medical illness causing persistent sadness, loss or interest, and physical symptoms that interfere with daily life for two weeks or more)). She had a BIMS score of 03 indicating severe impairment (a physical or mental condition that significantly limits an individual's ability to perform basic work activities, such as walking, sitting, lifting, or understanding instructions). During an attempted interview with Resident #3 on 05/04/26 at 1:50 p.m., she did not respond to any questions posed to her including questions regarding a video taken of her and posted on a staff member's social media. During a telephone interview with CNA-A on 05/04/26 at 1:44 p.m., she stated she took pictures of some residents and employees while they were dancing during a pizza party they were having on 05/04/26. She denied she put the pictures of residents on her social media page. When she was informed there were video/pictures of residents with her face from her social media page provided for the investigation, she still denied she had posted the video/pictures. She stated she changed the handle on social media depending on what she was posting. She stated she had recently changed her profile because she had posted pictures of her family. She stated a risk to posting pictures/videos of residents on social media could be exploitation or psychological harm. During an interview and observation with Administrator on 05/04/26 at 2:00 p.m., he stated he had been notified by the ADON on the evening of 05/01/26 that CNA-A had posted photos of some residents on her social media. He stated he had reached out to CNA-A to let her know she should not come to work until after the investigation was completed. He stated CNA-A denied she had posted a video/picture of the residents. He reviewed the pictures used for the investigation; he confirmed CNA-A's picture was on the right side of the residents' photos. He stated they completed educational training with the staff on 05/04/26 regarding using cell phones while on the floor working. He stated he had informed all staff that they should protect the residents' rights and always keep all of their information confidential. He stated during his investigation he determined CNA had posted the video/pictures on her social media account when he saw the photos with her face and name on the account. He stated the residents had been at risk of psychological harm and privacy when their pictures/video were posted on public social media.During interview with ADON on 05/04/26 at 2:29 p.m., she stated a CNA had sent her the picture on 04/30/26, she stated she did not see anything on the video that was harmful to the residents. She stated she waited to notify the administrator the next day. She stated the residents had been at risk of psychological harm and embarrassment. In a confidential witness interview on an undisclosed date at an undisclosed time, the witness stated at the time of interview they had not been notified by the facility of the privacy violation. They stated their family member had not shown any changes in condition because of having the photo/video posted to social media. Record review of CNA-A signed and dated 02/13/26, facility handbook indicating she was informed, employees must maintain resident/patient privacy, also known as protected health information (PHI) and comply with all HIPAA regulations. Therefore, employees may not communicate or upload on any social media site any PHI, pictures or images of residents/patients or resident/patient property.Record review of facility Phones on Floor in-service dated 05/04/26 reflected, there should be no phone usage while on duty, absolutely No Recording of Residents at any time. Record review of facility undated Resident's Rights policy reflected, CNA-A signed and dated 02/13/26 A resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. As an employee of this facility, you must protect and promote the rights of each resident. Violations of any of the resident rights are against the law. A resident may not be threatened, coerced, intimidated, or retaliated against because he or she chooses to exercisehis/her rights. Violation of a resident's rights by any employee of the facility will result in disciplinary action up totermination and possibly criminal and/or civil prosecution.A resident has right to:d. Be treated with courtesy, consideration, and respectf. Privacy, including privacy during visits and telephone calls

Based on interview and record review, the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 (Resident #1) of 3 residents reviewed for radiology services.The facility failed to obtain the x-ray and results for Resident #1's leg and knee in a timely manner, resulting in a delay to diagnoses of Resident #1's right femur and right knee. The STAT x-ray should be completed as soon as possible. On 04/11/26 at 2:14 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/11/26, the facility remained out of compliance at a severity level of Immediate Jeopardy to resident health or safety and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.On 04/11/26 at 2:14 PM an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. This failure could place the residents at risk of further injury, pain, and a delay in treatment. Findings included :Record review of Resident #1's electronic admission record, 04/11/2026 revealed an [AGE] year-old female, admitted [DATE], with diagnoses that included traumatic hemorrhage of cerebrum (a life threatening, often fatal emergency caused by bleeding within the brain tissue), fracture of left femur (a severe injury causing intense, immediate thigh pain, inability to bear weight), anxiety disorder (mental health condition characterized by excessive persistent fear or worry), hypothyroidism (the thyroid gland fails to produce sufficient hormones, slowing the body's metabolism), dementia (a progressive, umbrella term for cognitive decline), and epilepsy (a chronic neurological disorder, unprovoked seizures).Record review of Resident #1's Part A (Medicare Part A, hospital insurance) PPS Discharge MDS assessment, dated 03/28/26, reflected the resident was unable to verbally respond. Resident #1 had a BIMS score of 00, indicating severe cognitive impairment. Resident #1 needed supervision or touching assistance to roll left and right. Resident #1 needed partial/moderate assistance sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #1's care plan , dated 12/10/25, reflected focus she had an actual fall in room beside the bed, no injuries noted (12/10/25). The care plan was updated 12/12/25the goal was to resume usual activities without further incident. Interventions/task were after a fall and before moving Resident #1, elevate for changes in range of motion and notify the nurse, check on resident at frequent intervals at least q 2 hours to see if any assistance was needed and to offer reassurance. Increase supervision by positioning Resident #1 in staff-visible area, pharmacy consult for drug regimen review as needed, provide first aid if indicated and obtain emergency assistance from EMS (911) if appropriate. Remind her to use assistive devices w/c. Evaluate the environment at the time and location of the fall and attempt to identify any factors that may have contributed to the fall, such as uneven surfaces, bed not in lowest position, poor lighting or glare present, not wearing foot ware with non-skid soles. Focus was Resident had altered neurological status (clinical evaluation of the nervous system's function), goal was that Resident would maintain baseline neurological status, intervention/tasks were to monitor behavioral changes, monitor for complaints of headache, monitor for signs/symptoms of dysphagia.During a confidential interview on an undisclosed date at an undisclosed time, the interviewee stated Resident #1 was currently in the hospital heavily sedated due to pain after surgery and would not be able to participate in an interview. The interviewee stated they preferred an interview not to be attempted. The interviewee stated he had not been given an explanation of how the injury could have happened. The interviewee stated they were notified by hospice of the injury and had told hospice staff it was preferred that Resident #1 not be sent to the hospital until x-ray results had been received. Record review of progress notes reflected Resident #1 was assessed by LVN-A nurse at 10:56 a.m. on 04/06/26, reflected Resident #1 had swelling to her right knee and bruising to the underside of right knee, LVN-A notified Hospice Nurse. Resident #1 was later assessed by Hospice Nurse on 04/06/26 at 12:00 p.m., who ordered the x-ray STAT. Hospice Nurse contacted the facility on 04/06/26 at 2100 (9:00 p.m.) to check on Resident #1 and was told by the facility nurse Resident #1 had not had the x-ray completed. The Hospice Nurse sent the x-ray order to the facility at that time (8:00 p.m.) to order a second x-ray request from the facility vender. On 04/07/26 at 9:17 a.m., the x-ray was done on Resident #1.The results, a fractured tibia, were received on 04/07/26 at 12:00 p.m., which was twenty-four hours from the initial x-ray request (12:00 p.m.). The physician then requested an additional x-ray. Resident #1 received repeat x-ray 04/07/26 at 16:00 (4:00 p.m.). The results of the repeat x-ray were received 04/07/26 at 20:01 (8:01 p.m.) indicated Resident #1 had a fractured right knee. MD notified of result and order given to send Resident #1 to the ER on [DATE] at 9:24 p.m. Thirty-three hours lapsed from time of original x-ray request before the resident was sent to the hospital.During an interview with the DON on 04/11/26 at 10:19 a.m., she stated that on 04/06/26 during incontinent care, the staff noticed bruising and swelling on the right leg of Resident #1. She stated she did an assessment of Resident #1 and there was swelling to the right leg and knee and some discoloration on the inner thigh and right knee. She stated the resident was given Tramadol for pain. She stated Resident #1's hospice agency was notified, and x-rays were ordered by the hospice nurse on 04/06/26 after the hospice nurse had assessed the resident. She stated usually when a resident was on hospice, all invasive interventions would be stopped, and the facility would defer to hospice for all treatment. She stated that it was the facility's responsibility to carry out orders from the hospice agency. She stated the facility staff followed up with hospice regarding the x-ray. She denied she knew which staff followed up with hospice regarding the x-ray or what times the staff had followed up. She stated when Resident #1 had not received the x-ray timely she was at risk of more pain and not knowing if Resident #1 had a significant injury. During an interview with CNA-B on 04/11/26 at 1:30 p.m., he said he went to Resident #1's room at about 7:30 a.m. and when he pulled the cover back, he saw that her right leg was bigger than her left leg. He stated that when he began to touch Resident #1's leg to change her, Resident #1 started screaming. He stated he asked Resident #1 how her leg became swollen and she was unable to give an explanation. He stated he notified LVN-A and he did not attempt to move Resident #1 again. CNA B said he changed her and left her in bed. He stated he worked with Resident #1 before and had not seen her leg swollen. During an interview with LVN-A on 04/11/26 at 2:22 p.m., she stated she was notified by CNA-B that Resident #1's knee looked swollen. She stated when she went into the room to assess Resident #1 her knee looked swollen, bruised, and twisted. She stated she notified hospice, who stated they would order the x-ray STAT.LVN A stated hospice said their nurse was on her way to the facility to assess Resident #1. She stated Resident #1 was previously able to get on and off of the bed without assistance . She stated that they would always encourage her to ask for help. She stated sometimes she would go into the room and Resident #1would be on the fall mat that was placed beside her bed or in her [NAME] r. She stated per the care plan Resident #1's bed was placed in the lowest position, she had a fall mat next to her bed and her bedroom was across from the nurse station. When she was out of bed she was in the common area or in the hallway next to the nursing station. She stated the DON told her if no one from hospice showed up by 7:00 p.m. that she should get an order from the facility NP for the STAT x-ray. She said she was in contact with the hospice nurse several times during the wait, but she did not document that she contacted the hospice nurse. She stated the hospice nurse kept stating she had sent the order to the hospice x-ray contractor, for the x-rays to be done. She stated that while they were waiting for the x-ray technician they monitored Resident #1's pain and provided pain medication. She stated that hospice provided an order for morphine. She stated the resident was at risk of having to wait until the next day to get x-ray was pain management and the fracture could have been affecting any other vital parts of the body.During an interview on 04/11/26 at 2:53 p.m. with Hospice RN, she stated she received a phone call from the hospice aide that Resident #1's leg was swollen. She stated she asked to speak to LVN-A, who informed her Resident #1's leg was swollen and she was grimacing in pain. She stated she informed LVN-A she was heading to the facility to do an assessment. She stated after she completed her assessment she contacted the hospice doctor and received an order for STAT x-rays. She stated after calling in the order for the x-ray, she left the facility. She stated while she was charting later in the night she called the facility at about 9:00 PM on 04/06/26, to check the status of Resident #1. She stated that when she asked about the status of Resident #1, she learned the x-ray technician had not arrived to do the x-ray. She stated this was the first time hospice had an issue with the x-ray company not showing up for an x-ray. She stated when she found out the x-ray company had not shown up, she instructed the facility to request x-rays from their x-ray provider. She stated at that time she sent the STAT x-ray order to the facility. She stated that she did not remember the name of the nurse she spoke with for that order. She stated the family stated they did not want Resident #1 sent to the hospital until x-ray results were received. She stated risk would have been minimal because Resident #1 was sent to the hospital the night of 04/07/26 and did not have surgery until Friday (04/10/26). Record review of physician's telephone orders, dated 04/06/26, no time indicated, for STAT x-ray of Resident #1's right foot, bilateral hip (pelvis-both hip joints ) 2 views, right femur (right thigh, extending from the hip to the knee).Record review of Resident #1's physician's telephone orders, dated 04/07/26, no time indicated, for x-ray of Resident #1's right knee, 3 views.Record review of Provider Investigation Report dated 04/07/26, reflected Resident #1 was seen on the floor by her roommate on the morning of 04/06/26, who was not certain how Resident #1 ended up on the floor. Resident #1 go herself up off the floor and back into her wheelchair. [Resident #1] was assessed by DON on 04/06/26 around 10:50 AM. [Resident #1] had swelling and pain noted to her right leg. X-rays were conducted in-house. On 04/07/26 at around 10:30 a.m., the [provider] was provided x-ray results, which indicated [Resident #1] suffered an acute distal femoral fracture (a serious break in the thighbone just above the knee joint on her right leg, often caused by simple falls in the elderly). [Resident #1] was on [hospice], so pain management will be provided. [Resident #1's family elected to not send her to the hospital x-rays of the right knee will be repeated on 04/07/26.Record review of facility policy titled, Lab and Diagnostic Test Results, dated 04/2007, reviewed by QAPI 3/24/26, reflected Assessment and Recognition: 2. The staff will process test requisitions and arrange for tests. Procedure: 5. Critical Values: Must be immediately communicated to the provider (within 1 hour). Document provider notification, instructions, and interventions.This was determined to be an Immediate Jeopardy (IJ) on 04/11/26 at 2:14 p.m. The Administrator and DON were notified. The Administrator was provided with the IJ template on 04/11/26 at 2:14 p.m.The following Plan of Removal submitted by the facility was accepted on 04/11/26 at 5:27 p.m.: PLAN OF REMOVAL:Radiology Services F776Name of Facility: [Facility]Date: 04/11/2026F776 Radiology Services: The facility failed to ensure STAT x-ray results were done and reviewed timely. Resident #1 was found with fracture to her right leg and further x-rays showed Resident #1 was found with a fracture to her right knee.Immediate Action:Action: The facility immediately notified the attending physician when the final x-ray results were obtained and orders received to send the resident to the ER for evaluation. The new orders were promptly carried out, and the resident was sent to the ER on [DATE] at 9:24 p.m.Person(s) Responsible: Director of NursingDate/Time: 04/07/26Identification of Residents Affected or Likely to be Affected::Action: A retrospective audit of all STAT diagnostic orders from the last 30 days was conducted to identify any delays in completion or review. Any identified delays were immediately addressed with physician notification and follow up care as neededPerson(s) Responsible: Regional Nurse Consultant, Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 04/11/26Actions to Prevent Occurrence/Recurrence:Action: The facility implemented a revised STAT order protocol that includes:1. Clear definition of STAT to be completed within 4 hours.2. Follow up with Principle Labs to determine if x-ray technician is en route after 2 hours and if not assigned and in route the MD will be notified and alternate care will be arranged at the emergency room3. The DON and ADON will track/monitor all ordered labs/diagnostics and ensure they're received, resulted and communicated with MD in a timely manner. The facility will ensure proper communication between the hospice and the facility by providing education to hospice and facility staff on co-managing the residents carePerson(s) Responsible: Regional Nurse Consultant, Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 04/11/26Action: A tracking system will be implemented for all STAT x-rays to ensure timely follow up that includes logging of time order place, time procedure performed, time results received and time of physician notificationPerson(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 04/11/26Action: Licensed Nurses have been educated by the Director of Nursing on: 1. STAT orders procedures and urgency expectations2. Documentation requirementsEducation will be completed by 04/11/2026 with the attendance documented. Newly hired licensed nurses will be educated prior to working their next scheduled shift. Person(s) Responsible: Director of NursingDate/Time: 04/11/2026Action: DON/ADON will audit 100% of all STAT diagnostic orders for 4 weeks then; Weekly audits for 2 months and Monthly audits thereafterPerson(s) Responsible: Director of NursingDate/Time: 04/11/26Action: QAPI meeting held with Medical Director to discuss the Immediate Jeopardy template, F776, and the facility's plan of action to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date/Time:04/11/26 Monitoring for the Plan of Removal from 04/11/26 included the following: During interviews with Regional Nurse Consultant, Director of Nursing, Assistant Director of Nursing, LVN-A, RN-C, LVN-D, RN-E, and RN-F on 04/11/29 from 6:50 p.m. - 7:45 p.m., reflected they were in-serviced that STAT orders must be completed within 4 hours, staff must follow up with radiology if STAT x-ray has not been completed within 2 hours, if the x-ray technician was not assigned and enroute after 2 hours staff must notify the physician and arrange an alternate, significant x-ray findings must be immediately reported to the physician, after receiving physician orders related to x-ray results staff should carry the orders out promptly. The Administrator was informed the Immediate Jeopardy was removed on 04/11/26 at 7:50 p.m. The facility remained out of compliance at a severity level of Immediate Jeopardy to resident health or safety and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.Record review of Diagnostic Tracking audit dated 4/11/26 reflected STAT x-rays ordered on 03/14/26 and 3/16/26 were completed on their perspective days, results received and MD notified.Record review of x-ray/pain management/hospice services in-services dated 04/11/26, reflected Director of Nursing, Assistant Director of Nursing, LVN-A, RN-C, LVN-D, RN-E, and RN-F had been in-serviced in person or verbally over the phone.

Based on interview, observation and record review, the facility failed to provide a safe environment and adequate supervision for 1 (Resident #1) of 5 residents reviewed for falls. The facility failed to ensure Resident #1 received adequate supervision when she had a fall that resulted in a fractur to her right thigh and right knee. This failure could place residents at risk for injuries and a decline in health. Findings included:Record review of Resident #1's electronic admission record, 04/11/2026 revealed an [AGE] year-old female, admitted [DATE], with diagnoses that included traumatic hemorrhage of cerebrum (a life threatening, often fatal emergency caused by bleeding within the brain tissue), fracture of left femur (a severe injury causing intense, immediate thigh pain, inability to bear weight), anxiety disorder (mental health condition characterized by excessive persistent fear or worry), hypothyroidism (the thyroid gland fails to produce sufficient hormones, slowing the body's metabolism), dementia (a progressive, umbrella term for cognitive decline), and epilepsy (a chronic neurological disorder, unprovoked seizures).Record review of Resident #1's Part A (Medicare Part A, hospital insurance) PPS Discharge MDS assessment, dated 03/28/26, reflected the resident was unable to verbally respond. Resident #1 had a BIMS score of 00, indicating severe cognitive impairment. Resident #1 needed supervision or touching assistance to roll left and right. Resident #1 needed partial/moderate assistance sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #1's care plan , dated 12/10/25, reflected focus she had an actual fall in room beside the bed, no injuries noted (12/10/25). The care plan was updated 12/12/25 the goal was to resume usual activities without further incident. Interventions/task were after a fall and before moving Resident #1, evaluate for changes in range of motion and notify the nurse, check on resident at frequent intervals at least q 2 hours to see if any assistance was needed and to offer reassurance. Increase supervision by positioning Resident #1 in staff-visible area, pharmacy consult for drug regimen review as needed, provide first aid if indicated and obtain emergency assistance from EMS (911) if appropriate. Remind her to use assistive devices w/c. Evaluate the environment at the time and location of the fall and attempt to identify any factors that may have contributed to the fall, such as uneven surfaces, bed not in lowest position, poor lighting or glare present, not wearing foot ware with non-skid soles. Focus was Resident had altered neurological status (clinical evaluation of the nervous system's function), goal was that Resident would maintain baseline neurological status, intervention/tasks were to monitor behavioral changes, monitor for complaints of headache, monitor for signs/symptoms of dysphagia.During a confidential interview on an undisclosed date at an undisclosed time, the interviewee stated Resident #1 was currently in the hospital heavily sedated due to pain after surgery and would not be able to participate in an interview. The interviewee stated they preferred an interview not to be attempted. The interviewee stated he had not been given an explanation of how the injury could have happened. The interviewee stated they were notified by hospice of the injury and had told hospice staff it was preferred that Resident #1 not be sent to the hospital until x-ray results had been received.Record review of progress notes reflected Resident #1 was assessed by LVN-A nurse at 10:56 a.m. on 04/06/26, reflected Resident #1 had swelling to her right knee and bruising to the underside of right knee, LVN-A notified Hospice Nurse. Resident #1 was later assessed by Hospice Nurse on 04/06/26 at 12:00 p.m., who ordered the x-ray STAT. Hospice Nurse contacted the facility on 04/06/26 at 2100 (9:00 p.m .) to check on Resident #1 and was told by the facility nurse Resident #1 had not had the x-ray completed. The Hospice Nurse sent the x-ray order to the facility at that time (8:00 p.m .) to order a second x-ray request from the facility vender. On 04/07/26 at 9:17 a.m., the x-ray was done on Resident #1.The results, a fractured tibia, were received on 04/07/26 at 12:00 p.m., which was twenty-four hours from the initial x-ray request (12:00 p.m.). The physician then requested an additional x-ray. Resident #1 received repeat x-ray 04/07/26 at 16:00 (4:00 p.m.). The results of the repeat x-ray were received 04/07/26 at 20:01 (8:01 p.m.) indicated Resident #1 had a fractured right knee. MD notified of result and order given to send Resident #1 to the ER on [DATE] at 9:24 p.m. Thirty-three hours lapsed from time of original x-ray request before the resident was sent to the hospital.During an observation of the room assigned to Resident #1 on 04/11/26 at 9:56 a.m., revealed a w/c next to the head of the bed, a low bed with a fall mat under the side of the bed. No other obstacles were observed around the bed.During an interview with the Administrator on 04/11/26 at 10:00 a.m., he stated he was notified of Resident #1's swollen leg on 04/06/26 during the morning after the DON had completed her assessment of the leg/knee of Resident #1, he stated on 04/07/26 after they received the x-ray results, he began his investigation to determine how the injuries could have happened. He stated he interviewed the roommate and the staff who worked with Resident #1 on 04/05/26 and the morning of 04/06/26 and none of them knew when or how Resident #1 could have sustained the injuries. He stated he checked the area around Resident #1's living space and did not observe any tripping hazards. During an interview with the DON on 04/11/26 at 10:19 a.m., she stated that on 04/06/26 during incontinent care, the staff noticed bruising and swelling on the right leg of Resident #1. She stated she did an assessment of Resident #1 and there was swelling to the right leg and knee and some discoloration on the inner thigh and right knee. She stated the resident was given Tramadol for pain. She stated Resident #1's hospice agency was notified. She stated Resident #1 did not provide an explanation of how the injury could have happened. She stated she observed the area around the bed and did not observe any tripping hazards. She stated Resident #1 was at risk of falls and the care plan had been updated in January after she had a fall with the fall mat and having her in an area where staff could keep an eye on her during waking hours. During an interview with CNA-B on 04/11/26 at 1:30 p.m ., he said he went to Resident #1's room at about 7:30 a.m. and when he pulled the cover back, he saw that her right leg was bigger than her left leg. He stated that when he began to touch Resident #1's leg to change her, Resident #1 started screaming. He stated he asked Resident #1 how her leg became swollen and she was unable to give an explanation. He stated he notified LVN-A and he did not attempt to move Resident #1 again. CNA B said he changed her and left her in bed. He stated he worked with Resident #1 before and had not seen her leg swollen. He stated when he entered the room Resident #1's fall mat was on the floor beside her bed, and her w/c was parked by the door near the head of the bed. He stated he did not observe any other objects near the area. During an interview with LVN-A on 04/11/26 at 2:22 p.m ., she stated she was notified by CNA-B at about 7:30 a.m. that Resident #1's knee looked swollen. She stated when she went into the room to assess Resident #1 her knee looked swollen, bruised, and twisted. She stated she notified hospice. She stated Resident #1 had been on hospice, so she notified hospice of her assessment. She stated Resident #1 was previously able to get on and off of the bed without assistance. She stated that they would always encourage her to ask for help. She stated sometimes she would go into the room and Resident #1would be on the fall mat that was placed beside her bed or in her chair. She stated per the care plan Resident #1's bed was placed in the lowest position; she had a fall mat next to her bed and her bedroom was across from the nurse station. When she was out of bed she was in the common area or in the hallway next to the nursing station. She stated while they were waiting for the x-ray technician they monitored Resident #1's pain and provided pain medication. She stated that hospice provided an order for morphine. She stated she observed the area around the bed and saw the fall mat next to the bed and the wheelchair next to the head of the bed. She stated the resident was a fall risk and getting up without assistance had placed her at risk of harm.Record review of progress note dated 4/6/2026 17:11(5:11 p.m.) Order Note: Morphine given, Note Text: This order is outside of the recommended dose or frequency. Morphine Sulfate Oral Solution 20 mg/5ml *Controlled Drug* **DAW** given 0.5 ml by mouth every 2 hours as needed for Pain: Shortness of Breath.Record review of progress note dated 4/7/2026 05:00 a.m. reflected Note Text: Morphine Sulfate Oral Solution 20 mg/5ml, given 0.5 ml by mouth every 2 hours as needed for Pain; Shortness of Breath.Record review of progress note dated 4/7/2026 at 9:30 a.m. reflected, Note Text: Morphine Sulfate Oral Solution 20 mg/5ml; was given 1 ml by mouth every 2 hours as needed for Pain; Shortness of Breath.Record review of progress note dated 4/7/2026 at 13:17(1:17 p.m.) reflected Morphine Sulfate Oral Solution 20 mg/5ml was given for Pain; Shortness of Breath PRN Administration was: Effective, Follow-up Pain Scale was: 4Record review of Provider Investigation Report dated 04/07/26, reflected Resident #1 was seen on the floor by her roommate on the morning of 04/06/26, who was not certain how Resident #1 ended up on the floor. Resident #1 got herself up off the floor and back into her wheelchair. [Resident #1] was assessed by DON on 04/06/26 around 10:50 AM. [Resident #1] had swelling and pain noted to her right leg. X-rays were conducted in-house. On 04/07/26 at around 10:30 a.m., the [provider] was provided x-ray results, which indicated [Resident #1] suffered an acute distal femoral fracture (a serious break in the thighbone just above the knee joint on her right leg, often caused by simple falls in the elderly). [Resident #1] was on [hospice], so pain management will be provided. [Resident #1's] family elected to not send her to the hospital x-rays of the right knee will be repeated on 04/07/26. [sic]Record review of the facility policy titled, Falls and Fall Risk, managing dated March 2018, reflected risk factors could be poor lighting, lower extremity weakness, delirium and other cognitive impairment, incontinence, and neurological disorders. Staff will monitor and document each resident's response to interventions intended to reduce fall or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.

Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 3 residents (Resident #44) reviewed for contracture management.The facility failed to provide equipment/services for Resident #44's left hand contracture (a permanent tightening of the muscles). This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures, and a decline in physical capabilities.Findings included:Record review of Resident #44's quarterly MDS dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included diabetes, non-Alzheimer's dementia, and seizure disorder. Resident #44 had a BIMS of 3 which indicated his cognition was severely impaired. The MDS further reflected the resident used a manual wheelchair and had impairment on one side to the upper extremity and impaired on both sides to the lower extremities.Record review of Resident #44's care plan edited on 09/01/25 reflected the resident had self-care deficits and required assistance with ADLs. The resident required assistance from two staff for bathing/hygiene. The Care plan further reflected to consult PT, OT, and ST as needed. Record review of Resident #44's OT Evaluation and Plan of Treatment dated 06/18/25 completed by the previous therapist reflected the following: .New GoalPt will maintain L hand ROM via us of hand roll splint for contracture management. Review of Resident #44's monthly physician orders for January 2026 reflected there was no order for a left hand contracture or management in place. Observation and interview on 01/13/26 at 11:02 AM revealed Resident #44 was in his wheelchair in the day room playing with a puzzle. The resident was noted to have a left-hand contracture and there was no device in place. Resident #44 was asked if he could open his left hand and he said some and he was able to slowly open his fingers enough to show there were no skin issues or odors in his contracted hand. The resident was asked if he had ever had a device in place for his contracture and he said no and he went on to play with his puzzle. Interview on 01/14/26 at 3:36 PM with CNA A revealed he had worked at the facility for 3 weeks and he had never seen Resident #44 wear a device in his contracture. CNA A said the resident was able to open his hand a little and the resident would allow the staff to clean inside his hand. Interview on 01/14/26 at 3:38 PM with the Director of Rehab revealed Resident #44 had a splint to his left-hand contracture and he was supposed to wear for 2 to 3 hours a day or however long he could tolerate it if there was no pain or skin issues. The Director of Rehab said she was not sure if it was the DON or nursing staff that would apply the splint to the resident. The Director of Rehab further stated Resident #44's contracture could worsen if he did not wear the splint. Interview on 01/14/26 at 3:49 PM with LVN B revealed she had never seen any kind of device on Resident #44's left hand contracture nor had anyone told her the resident needed one. LVN B said Resident #44 was able to open his contracted hand a little bit, enough to clean the palm and see the skin integrity. Interview on 01/15/26 at 10:31 AM with LVN C revealed she had never seen a splint on Resident #44's left hand contracture. LVN C said if residents required some kind of device for a contracture, they would get an order from therapy and get instructions on how to apply the device and told how long the resident needed to wear it. LVN C further stated she had never seen an order for Resident #44 to wear a splint for the contracture. Interview on 01/15/26 at 12:24 PM with the Director of Rehab revealed Resident #44 had a splint evaluation in June 2025, prior to her working at the facility by a therapist that no longer worked at the facility. The Director of Rehab said normally if a resident required a device for contracture management, they would give the order to the nurse and educate them about the use of the device. She further stated she could not recall the last time she saw Resident #44 wearing the hand splint and could not locate it when she looked for it in the room. The Director of Rehab also said Resident #44 was currently on therapy caseload for his hand contracture and they were working on range of motion and said the resident's contracture had not worsened. Interview on 01/15/26 at 2:08 PM with the ADON revealed she had been at the facility for over a year, and she had never seen a splint in Resident #44's left hand contracture. The ADON said that if Resident #44 required a splint it would help keep his hand open and keep his fingernails from embedding in his palm. Interview on 01/15/26 at 3:13 PM with the DON revealed she had been at the facility since September 2025, and she had never seen a splint on Resident #44's left hand contracture and nothing had been discussed with her that he needed one. The DON said usually therapy would order the contracture device and write the order and then inform the nurse to educate them on it. The DON said it was important for Resident #44 to have a splint in his hand contracture to prevent the contracture from worsening and to prevent skin breakdown and infection. Record review of the facility's undated policy titled Therapy Policy and Procedures Contracture Management reflected the following: Purpose and ScopePurpose:To ensure effective, evidence-based, and interdisciplinary management of contractures in residents, promoting optimal functional outcomes, comfort, and quality of life.Policy StatementContracture management in this facility will be approached through proactive assessment, early intervention, and interdisciplinary collaboration. The use of splints, braces, therapeutic modalities, and nursing/therapy coordination is critical in both prevention and treatment.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen food processor equipment was clean and free from build-up. [NAME] F placed food containers of the lunch meal in the steamtable that contained contaminated tinted water and burnt food particles floating in it on 01/14/26.These failures could place residents at risk for food contamination and foodborne illness.Findings included:Continuous observations on 01/14/26 from 10:56 AM to 12:15 PM revealed the following:- [NAME] F preparing the pureed lunch meal. [NAME] F pureed sweet potatoes, greens, and ham. The food processor/blender that [NAME] F used to puree the food had a see-through handle, which had a white build-up inside the handle. [NAME] F washed the food processor after every use, but the handle continued to have the white build-up inside the handle. - The kitchen steam table had five compartments, and the last two compartments from the right side had a few inches of brown tinged water. There was also build-up of food particles at the bottom of the compartment and floating in the water [NAME] F placed the pureed trays in the dirty steam table compartments. Interview on 01/14/26 at 12:20 PM, [NAME] F revealed she noticed the steamtable compartments in the kitchen had dirty water in them while she was placing the cooked food for the lunch service. [NAME] F stated it was the Cooks responsibility for cleaning the steamtables after every meal. [NAME] F stated she could not recall the exact date of when the last time the steamtables water was emptied out but could have been a month ago. She stated she does not know why it had not been done. [NAME] F stated the food processor had built-up inside the handle. She stated when cleaning the food processor/blender the handle could be removed so they could clean inside. She stated she had been busy and had not had the time to clean it. Interview on 01/14/26 at 12:26 PM, the Dietary Manager revealed it was the kitchen staff responsibility to clean kitchen equipment. She stated the steamtables were wiped down after every meal and deep cleaned monthly. She stated the steamtables water was emptied out daily. She stated the steamtables were emptied out the other day but could not recall the exact date. The Dietary Manager stated she was aware of how the food processor handled looked like and stated she had ordered a new food processor about 2 weeks ago. She stated the steamtable was not up to her expectations on how it should be. The Dietary Manager stated she had a cleaning schedule that helped monitor what items needed to be cleaned in the kitchen. She stated the potential risk would cross contamination with the steamtable and food processor handle. The Dietary Manager stated that it could make a resident sick. Record review of facility Daily Cleaning Schedule dated January 2026, week 11-19 revealed the steamtable was last cleaned Tues. Record review of facility Monthly Cleaning Schedule dated Year 2026, revealed Steamtable (Degrease & Polish) was completed December 2025. Record review of facility Sanitization policy, dated November 2022, reflected the following: The food service area is maintained in a clean and sanitary manager.2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning seals, hinges and fasteners are kept in good repair. 8. When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are: a. washed and sanitized, and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution (at the effective concertation); and b. the equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized (according to the manufacturer's instruction).

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #8) reviewed for tube feedings. LVN E attempted to feed Resident #8 who was on a g-tube (a tube inserted through the abdomen directly into the stomach for feeding, fluids, or medicine when someone can't eat enough by mouth) a regular texture meal and had an order of NPO (nothing by mouth). This failure could place residents at risk for choking and aspiration.Findings included:Record review of Resident #8's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The residents' diagnoses included heart failure, diabetes, non-Alzheimer's dementia, and schizophrenia. The resident had long and short-term memory impairment and therefore a BIMS was not completed. The MDS further reflected Resident #8 was on a feeding tube. Record review of Resident #8's care plan edited on 09/01/25 reflected the resident was NPO due to oropharyngeal dysphagia (difficulty with the initial stage of swallowing). Approaches included administer bolus/continuous feeding per schedule and diet order of NPO (with trial feeding by speech therapy ONLY. Record review of Resident #8's January monthly order summary report reflected Resident #8 had an NPO diet, NPO texture, and NPO consistency. The order summary report further reflected continuous feeding started at bedtime and stopped in the morning (7PM to 7AM). Observation and interview on 01/14/26 at 12:05 PM revealed CNA E had a meal tray with regular texture food sitting on Resident #8's nightstand and she was trying to feed Resident #8, but the resident was observed pushing the CNA's hand away. There was a feeding pump next to the resident's bed and it was turned off at the time of the observation. CNA E then exited the room and stated she tried to feed Resident #8 food yesterday as well, 01/13/26, and the resident had pushed her hand away then too. CNA E further stated she had been told by other staff, but did not say who, that if the resident refused, they would leave the tray in the room and try again later. Surveyor attempted to speak with Resident #8 but the resident told the surveyor to get out of her room. Further interview on 01/14/26 with CNA E at 1:45 PM revealed she had just started working two days prior, 01/12/26 and it appeared she had gotten Resident #8 mixed up with her roommate. CNA E further stated she took responsibility and should have checked with another staff member to make sure the resident could or could not eat because she had noticed a feeding pump at the resident's bedside. CNA E also said there was another resident on that same hall that was on a g-tube and he also ate pureed foods. Interview on 01/14/26 at 3:48 PM with LVN B revealed Resident #8 was NPO and was not supposed to have anything by mouth. LVN B said because she worked the second shift, she was not aware CNA E, who worked first shift, had tried to feed Resident #8. Interview on 01/15/26 at 10:26 AM with LVN C revealed Resident #8 was NPO and CNA E was a new aide to the facility and yesterday, 01/14/26, had only been her second day working on the floor. LVN C said CNA E was safe to be on her own while she was training because she had been a aide for many years and she just had to learn the names of the residents. LVN C said if an aide was unsure of a resident's care needs, the new staff needed to ask another aide or her for further guidance. LVN C also said she was not aware CNA E had tried to feed Resident #8 and there could have been a risk of the resident aspirating if she tried to eat food. Interview on 01/15/26 at 2:02 PM with the ADON revealed Resident #8 had a feeding tube and was NPO. The ADON said she was not aware CNA E tried to feed Resident #8 regular food and there was a possibility of aspiration if the resident would have eaten it. Interview on 01/15/26 at 3:10 PM with the DON revealed Resident #8 was NPO and had been for a long time. The DON said she was not aware CNA E had tried to feed the resident regular food. The DON said new aides trained with another CNA and if they had questions, they should refer to the tenured aide for assistance or guidance. The DON further stated there was a risk of aspiration if the resident ate solid food.Record review of the facility's policy titled Enteral Nutrition updated on 12/17/24 reflected the following: Policy StatementAdequate nutrition support through enteral feeding will be provided to residents as ordered.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 15 residents (Resident #44) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #44's left hand contracture.This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included:Record review of Resident #44's quarterly MDS assessment, dated 11/03/25, reflected the resident was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included diabetes, non-Alzheimer's dementia, and seizure disorder. The MDS reflected Resident #44 had severe cognitive impairment with a BIMS score of 3. The MDS also reflected that the resident used a manual wheelchair for mobility, and he had impairment to both of his lower extremities (leges) and one of his upper extremities (arm). Record review of Resident #44's care plan edited on 09/01/25 reflected the resident had self-care deficits and required assistance with ADLs. The resident required assistance from two staff for bathing/hygiene. The care plan further reflected to consult PT, OT, and ST as needed. The care plan did not address Resident #44 had a left hand contracture or interventions to care for it. Record review of Resident #44's OT Evaluation and Plan of Treatment dated 06/18/25 completed by the previous therapist reflected the following: .New GoalPt will maintain [left] hand ROM via us of hand roll splint for contracture management. Review of Resident #44's monthly physician orders for January 2026 did not address a left hand contracture or contracture management devices. Observation and interview on 01/13/26 at 11:02 AM revealed Resident #44 was in his wheelchair in the day room working on a puzzle. The resident's left-hand was contracted, but he did not have a contracture management device in his left hand. Resident #44 was asked if he could open his left hand, and he said some. He was able to slowly open his fingers enough to show there were no skin issues or odors in his contracted hand. The resident was asked if he had ever had a device in place for his contracture, and he said no. He did not provide any further information. Interview on 01/14/26 at 3:36 PM with CNA A revealed he had worked at the facility for three weeks, and he had never seen Resident #44 wear a device in his contracture. CNA A said the resident was able to open his hand a little and the resident would allow the staff to clean inside his hand. Interview on 01/14/26 at 3:38 PM with the Director of Rehab revealed Resident #44 had a splint to his left-hand contracture and he was supposed to wear for 2 to 3 hours a day or however long he could tolerate it if there was no pain or skin issues. The Director of Rehab said she was not sure if it was the DON or nursing staff that would apply the splint to the resident. The Director of Rehab further stated Resident #44's contracture could worsen if he did not wear the splint. Interview on 01/14/26 at 3:49 PM with LVN B revealed she had never seen any kind of device on Resident #44's left hand contracture nor had anyone told her the resident needed one. LVN B said Resident #44 was able to open his contracted hand a little bit, enough to clean the palm and see the skin integrity. Interview on 01/15/26 at 10:31 AM with LVN C revealed she had never seen Resident #44 with a splint in his left contracted hand. LVN C said if residents required some kind of device for a contracture, they would get an order from therapy. The order would provide instructions on how to apply the device along with how long the resident needed to wear the device. LVN C stated she had never seen an order for Resident #44 to wear a splint for his contracted hand. Interview on 01/15/26 at 12:24 PM with the Director of Rehabilitation revealed Resident #44 had a splint evaluation in June 2025 completed by a therapist, who no longer worked at the facility. She stated this was done prior to her employment at the facility. She stated normally if a resident required a device for contracture management, they would give the order to the nurse and educate them about the use of the device. She further stated she could not recall the last time she saw Resident #44 wearing the hand splint and could not locate it when she looked for it in the room. She stated Resident #44 was currently on their therapy caseload for his contracted hand. She stated they were working on his range of motion, and his contracture had not worsened. Interview on 01/15/26 at 2:08 PM with the ADON revealed the MDS Nurse usually created resident care plans, but there were some care plans the nursing staff could do. The ADON said she did not know if Resident #44's left hand contracture should have a care plan, but the staff knew about the resident's contracture because it was something the nursing staff talked about. The ADON did not have any further information related to Resident #44's care plan. Interview on 01/15/26 at 3:13 PM with the DON revealed care plans could be completed by the MDS nurse and/or the nursing staff. The DON said she was not aware the resident did not have a care plan for his left-hand contracture. The DON further stated care plans were important to ensure the residents got the care they needed so they could function to the best of their ability. Interview on 01/15/26 at 4:25 PM with the MDS Nurse revealed if Resident #44 had a contracture, then there should have been a care plan. She stated she was not aware of the issue and had she been aware she would have developed a care plan herself. The MDS Nurse further stated accurate resident care plans were important, so staff knew the care the residents required. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised on March 2022, reflected the following: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely and had acceptable labeling for 1 of 3 medication carts (North Hall nurse medication cart) reviewed for drug storage and labeling.The facility failed to ensure expired medications, Ondansetron and Naproxen, were removed from North Hall nurse medication cart.This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included:Observation on 01/14/2026 at 8:26 AM of the North Hall nurse medication cart with LVN C revealed 30 tablets of ondansetron 4 mg (used to prevent nausea and vomiting) with an expiry date of December 2025 and 29 tablets of Naproxen 250 mg (used to reduce pain, fever, and inflammation from conditions like arthritis, gout, menstrual cramps) with an expiry date of December 2025.Interview on 01/14/2026 at 8:40 AM, LVN C revealed she was responsible for checking the cart for expired medications. She stated she checked the cart daily for expired medications. She stated she forgot to check her cart that morning. She stated failing to remove the expired medication could result in the medications being administered which could cause reactions, and the residents would not get the required therapy. She stated she had done training on checking the carts for expired medications, but she could not recall when she had completed the training. Interview on 01/15/2026 at 3:37 PM, the DON revealed she expected the nursing staff to check their carts for expired medications often. She stated it was all nurses' responsibility to check the carts and remove expired medications. She stated it was her responsibility and nursing management to monitor and ensure the nurses were discarding the expired medications, monthly. She stated the last time the carts were checked was on 01/12/26, and she thought they missed those medications. She stated if the staff were not checking carts for expired medications, it would place residents at risk of having reactions like the medication being ineffective since they could not tell of the potency. She stated she had done training on medications storage. The training titled auditing cart dated 10/27/25 revealed and LVN C was in attendance. Record review of the facility's training record, dated 10/27/25, reflected that: Expired medications should be removed from nurses' carts to ensure patient safety, maintain medication effectiveness, prevent errors and comply with healthcare. The training titled auditing cart dated 10/27/25 revealed LVN C was in attendance.Record review of facility's Medication Storage policy, dated February 2023, reflected:3.If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items

Based on interview, and record review, the facility failed to hold, safeguard, manage personal funds for 1 of 4 residents (Resident #5) reviewed for management of resident funds. The facility failed to ensure the BOM had a witness when distributing cash from the trust fund for Resident #5. The Facilities policy requires the signatures of 2 staff members when cash is dispersed to residents. The failure could place residents at risk for not having funds available when needed. Findings included:Record review of Resident #5's face sheet dated 09/30/2025 reflected the resident was a [AGE] year-old female admitted on [DATE] with active diagnoses that included Schizoaffective disorder, bipolar, Posterior subcapsular polar age-related cataract, right eye, Posterior subcapsular polar age-related cataract, bilateral, Age-related choroidal atrophy, bilateral, Transient visual loss, right eye, Major depressive disorder.An interview with Resident #5 on 09/30/2025 at 10:20 am. The resident stated that she had been at the facility for a long time. She stated the office gave her money when she asked for it. An interview Resident #5 on 10/01/2025 at 10:30 am revealed the resident asked for money on a regular basis, almost daily. She stated she got different amounts $50, $75 up to $90. She reported having $65 in her possession at the time of the interview. She was able to present this money as it was kept in her shoe. She reported she liked having her money in her hand. She stated that she buys food and cigarettes. She stated she gets all of her money. She stated she could see her money and counted her money. Record review of Resident #5's MDS assessment dated [DATE] list the resident's vision as impaired, reflecting she is able to read large print. The resident had a BIMS of 9 (moderate impairment). Record review of undated policy titled 'Resident Trust Fund & Representative Payee Regulation' reflected the following: (Page 3) .Witness Signature Requirement When a resident cannot sign to approve a withdrawal, the facility must obtain the signature of a witness.The witness cannot be: The person responsible for accounting for the resident's trust funds. That person's supervisor. The individual who accepts the withdrawn funds or sells the item being purchased. The facility must be able to identify the witness's name, address, and relationship to the resident or facility.Record review of the Resident Trust fund Petty Cash Logs revealed the following: The 09/03/2025 log revealed Resident#5 withdrew $75 and signed for the cash. There were no witness signature. The 09/05/2025 log Revealed Resident #5 withdrew $200 and signed for the cash. There were no witness signature.The 09/15/2025 log revealed Resident #5 withdrew $125 signed for the cash. There were no witness signature.and The 09/17/2025 log revealed Resident #5 withdrew $85 signed for the cash. There were no witness signature.Review of Resident #5's clothing store receipt, dated 09/09/25 reflected clothing purchased for $167.29. The receipt corresponded with the $200 withdrawal on 09/09/2025. The receipt was signed by Resident #5.The interview with the facility administrator on 09/30/2025 at 2:15 pm, revealed the BOM was still on leave. She stated that policy required two staff to issue cash. She stated that when she issued cash, she had another person with her and she counted the money out to them and signed the log and the other person counted the money out and signed the log. It was then passed to the person receiving the cash and the log was signed by that person. She stated the BOM did not have a witness or that second person observe the transaction. She stated during a corporate audit the issue with the BOM not having a witness when she dispensed cash was found. She stated corporate called and asked for the Resident Trust Fund Petty Cash Log report that she was not aware she needed to submit, at that point they conducted an audit. She stated that corporate was conducting the investigation, so she was not fully aware of all details at this time. She stated she did not believe there were any funds missing, it was a process that was not being followed. A telephone interview was attempted with the facility BOM on 09/30/2025 at 3:01 pm and 3:45pm. without success. A message was left on the telephone and requested a call back. (No call was received prior to exit.)An interview with corporate BOM on 09/30/2025 at 3:07 pm, revealed during an audit it was found that the business office manager was not following proper procedures. She stated her manager(regional BOM) would be able to give greater detail about the situation and provided a number for her.An interview with Regional Business Office Manager on 09/30/2025 03:26 pm she stated they found an issue where the BOM was not having a witness and witness signature when the BOM passed out funds. Corporate audited several resident's records and Resident #5 was the only one they had questions about. She stated some transactions had witnesses and other's only had the business office manager's signature. When corporate staff talked to Resident #5 she reported she never got more than $50 At that point the corporate office was not sure if Resident #5 was being sincere or deceitful. The corporate office decided for every transaction over $50 they would reimburse the resident the difference and came up with $310. During the corporate investigation they were provided receipt from a clothing purchase for almost $200 (provided by Resident #5 for the same time period.). Regional BOM stated they still covered the $150. Corporate staff confirmed they do not believe that BOM took any money, she was just not following the proper policy for disbursement of funds and the police were notified. The corporate office reconciled the funds and found no discrepancies other than the procedure was not followed. The Regional BOM stated they understood that the resident does have cognitive issues and may not remember the exact amounts, but the corporation did not want to appear like they were hiding anything, So the $310 was the amount we thought was most accurate. There was a corporate training class at the end of August 2025, for all of the business office managers and the facility BOM was present. Effective September 1, 2025, the facility BOM should have been followed the policy from that point on. (No evidence of training was provided.)An interview with the administrator on 10/17/2025 at 12:05 pm revealed the BOM had not returned to the building since 09/22/2025 when she was suspended and was terminated effective 10/10/2025. She stated that after the initial findings she decided to terminate the BOM. She stated the BOM was scheduled to come in on 10/08/2025 for a meeting but never showed up. The termination papers were signed on 10/10/2025. Review of punch detail for BOM dated September 2025 reflected BOM's last day worked was on 09/22/2025.

Based on interviews and facility policy review, the facility failed to ensure the individual financial record must be available to the resident through quarterly statements and upon request for 1 (Resident #1) of 5 residents reviewed for personal funds. The facility failed to provide statements of personal funds upon request. This failure could place the residents at risk of not having knowledge of the balance of their funds. Findings included:Record Review of Resident #1 face sheet, dated 11/0525, revealed a [AGE] year-old man originally admitted on [DATE] with a diagnosis of end stage renal disease (kidneys have severely damaged and can no longer function properly), anxiety disorder due to known physiological condition (mental health conditions characterized by excessive worry, fear, and nervousness that can interfere with daily life). Record review of Resident #1's discharge MDS assessment, dated 09/26/2025, revealed Resident #1 BIMS score of 14 which indicated intact cognitive function. Record review of an undated list of residents provided by the ADM revealed that 26 residents received healthcare insurance funds. The list included Resident #1. An interview on 11/05/25 at 11:16 a.m., the BOM revealed she was hired on 10/27/25 and on 10/29/25 Resident #1 asked for her to provide a printout of his account statements. The BOM stated Resident #1 revealed to her that he had not received a statement since July 2025. The BOM could not provide evidence that Resident 1's received monthly statements from July to September that he had requested. The BOM stated residents who had a trust fund must be provided with a monthly statement and a quarterly trust fund statement. The BOM stated that the importance of the statement was to inform the residents where he or she money went and how much remained. An interview on 11/05/25 at 12:47 p.m., Resident #1 revealed that he had not been provided with an account statement since July until the current BOM gave him one on 10/29/25. Resident #1 stated that he would like to see how much remained on his account to ensure he didn't overdraw his account. Resident #1 stated that the BOM provided his balance, but he wanted preferred the statement. An interview on 11/05/25 at 4:17 p.m., with the ADM revealed he was hired on 10/27/25 and upon hire he ensured the new BOM provided all residents with their most recent October statement. The ADM stated that his expectation was for the facility to provide them with the monthly schedule and as requested by the residents, it is their right to know how their funds are being used.Requested resident rights policy from BOM on 11/05/25 did not receive prior to exit.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically and allegedly sexually assaulted her on 06/18/25. An IJ was identified on 06/19/25. The IJ began on 06/18/25 and removed on 06/19/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 06/19/25, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm because all staff had not been trained on resident-to-resident abuse prevention. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's face sheet, dated 06/19/25, reflected Resident #1 was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 05/16/25, reflected a BIMs score was not calculated. Her active diagnoses included non-alzheimer's dementia (refers to any form of dementia other than Alzheimer's disease), anxiety disorder (characterized by excessive, persistent, and uncontrollable worry and fear about everyday situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a serious mental health condition that affects how people think, feel, and behave). Record review of Resident #1's Progress Notes reflected the following: - 06/18/25 at 7:35 PM, LVN A wrote: This nurse was summoned by assigned aide, upon walking towards resident this nurse noted redness to residents neck area '[NAME]/Love Bite' This nurse [sic] asked resident how she sustained those redness [sic]. Resident states 'He [sic] was sucking on my neck' Asked resident to show this nurse who was sucking on her neck and she pointed resident [sic] '[Resident #2's initials]'. Notified Administrator, DON, ADON. [sic] Also informed NP C with [Dr. E's] services and NP D with [Psych ]. Order received to monitor and separate residents. Informed residents responsible party [Resident #1's RP]. - 06/18/25 at 8:23 PM, LVN A wrote: Called 911 Non-emergency service called to report the incident. - 06/18/25 at 8:43 PM, LVN A wrote: [City Name] Police here [Police Officer's Name] and this nurse informed him of situation. Police requested for both parties information which was given by this nurse. This nurse also gives her personal information to the cop, then escorted/assisted him to female resident room to question/investigate situation. This nurse informs resident that the police officer is her [sic] to question her about the redness on her neck. Per resident, and [sic] she states. 'He came into my room, in my bed before lunch and pulled up my dress touching down there, he played with my titties, he started to hold my neck down to kiss me and I called for help and he left. After dinner, watching [sic] television he choked my neck, wanting to kiss me I didn't let him, so he suck my neck [sic], He [sic] tried to touch me down there and I didn't let him. Resident also stated that male resident never took off his clothes only used his hands [sic], when asked by the police officer. Police report Service [sic] number [police report number] [Police officer's Name and badge number]. - 06/18/25 at 9:13 PM, LVN A wrote: Received order from [Dr. E/NP C] to transfer resident to [Hospital Name F], possible protocol for a rape kit test to be carried out if applicable. This nurse informs [sic] RP of transfer and she agreed to transfer. - 06/18/25 at 11:21 PM, LVN A wrote: Resident out of the facility to [Hospital Name G] per facility transport. - 06/19/25 at 9:00 AM, the DON wrote: Writer along with regional interviewed resident regarding incident from last night. Resident was asked what happened, resident stated 'he tried to kiss me, he tried to suck on my neck, he tried to choke me, he tried to screw me, he tried to pull my diaper to the side, she stated she fought him off by crossing legs [sic] and he left, When [sic] asked Resident [sic] cannot remember who it was, and stated 'I am okay and I am sleepy. [sic] - 06/19/25 at 12:08 PM, RN I wrote: Resident arrived back to facility @ 0900 with after care papers. Assisted resident into assigned bed .no pain reported by resident; resident stated 'No .I'm ok' when asked if she had any pain .bruises around neck; skin intact, no bleeding, reddish skin discoloration around neck .Hourly resident rounds by this nurse. - 06/19/25 at 12:22 PM, RN I wrote: Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: [sic] Bruise Bruise: Note location of any noted areas. Enter measurements in box provided.: [sic] Bruise 1 neck area, Bruise 2 right, lateral chin Record review of a Trauma Informed Care Assessment for Resident #1, dated 06/19/25, reflected the following: Have you ever experienced, witnessed, learned about a physical assault? Other- 'I fought him'. Unable to determine context .Have you ever experienced, witnessed, learned about a sexual assault? Other- 'I don't want to have sex'. Unable to determine context .Did any of these events bother you? Yes .Comment on events resident was bothered by: Unable to determine context. When prompted with, 'How did that make you feel?' she stated 'Violated.' Record review of Resident #1's Hospital Records, dated 06/19/25, reflected: Patient is a [AGE] year-old female with a past medical history of schizophrenia and dementia who presents from her skilled nursing facility/nursing home for evaluation of endorsed sexual assault. History is somewhat limited secondary to patient's cognitive decline, endorses that a male resident in her nursing facility 'tried to kiss my neck', states 'he tried to kiss my titties', states 'he tried to force my legs open but I kept them crossed'. Patient is unable to confirm if sexual or vaginal or anal penetration occurred, does not endorse oral penetration. Per nursing home staff (transportation staff), nursing home staff has been notified, patient is kept in a secure memory unit, nursing staff is investigating alleged perpetrator for any other information regarding the case .Skin: Superficial bruising of anterior neck .has superficial abrasions over the anterior neck Observation and interview on 06/19/25 at 5:44 PM revealed Resident #1 lying down in her bed. Resident #1 had multiple red marks and purplish/reddish bruises, about the size of quarters, to the right and left sides of her neck. Resident #1 was asked what happened to her neck. Resident #1 replied, He sucked my neck and choked me. Resident #1 said this happened in the TV Room and in her room. Resident #1 said he held her down because he tried to kiss her and she would not let him. Resident #1 said earlier in the day he tried to push her on the bed, he lifted up her dress and touched her breasts, so she hollered out and yelled and then he left. Resident #1 said she had not seen this person at the facility anymore. Resident #1 said she felt safe and was not in any pain. Interview on the phone on 06/19/25 at 1:12 PM with Resident #1's RP revealed she received a call from a nurse at the facility who told her the resident had [NAME]-like bruises to her neck. Resident #1's RP said she was told the facility was going to file a police report and sent the resident to the hospital for further evaluation. Resident #1's RP said she saw the resident had a bruise on her chin towards the right side of her face, a few scratches on her neck, and hickeys on her collar bone and neck area. Resident #1's RP said she did not notice any changes to the resident's behavior when she saw her earlier in the day. Record review of Resident #2's face sheet, dated 06/19/25, reflected Resident #2 was a [AGE] year-old male who originally admitted to the facility on [DATE], readmitted on [DATE], and was discharged on 06/19/25. Record review of Resident #2's Quarterly MDS Assessment, dated 06/09/25, reflected a BIMS score was not calculated. Further review reflected he had no behaviors of any kind towards anyone. His active diagnoses included non-alzheimer's dementia (refers to any form of dementia other than Alzheimer's disease) and cerebellar stroke syndrome (occurs when there's a disruption of blood flow to the cerebellum at the back of the brain). Record review of Resident #2's care plan, edited 06/13/25, reflected the following: Problem Start Date: 10/03/24, Category: Behavioral Symptoms, [Resident #2] display inappropriate sexual behavior toward another female resident. [Resident #2] has risk for inappropriate sexual behaviors towards others including staff, and fellow female residents .Approach: Encourage activity involvement to for [sic] pleasurable distractions. Please ensure activity is at level of understanding for the resident. New orders and medications adjustment review with changes. 15 minutes check for the next 24 hours and tele visit from Psych NP. Record review of Resident #2's progress notes reflected the following: - 10/03/24 - A Previous DON wrote: Charge nurse reported housekeeping witnessed resident grab a female resident and forcefully give her a kiss on the mouth. Residents were separated, resident was place on q 15 min checks, MD, psych NP and family were notified - 06/18/25 at 8:43 PM, LVN A wrote: This nurse was summoned by assigned aide, upon walking towards aide on hallway this nurse noted redness to [Resident #1], female residents neck area [NAME]/Love Bite. This nurse asked female resident [Resident #1's room number] how she sustained those redness [sic]. Resident states ' He [sic] was sucking on my neck' Pointing to this male resident. Female resident, [Resident #1's initials and room number] pointed at this male resident 3 times in the television room. After separating both parties, This [sic] nurse asked male resident of what happened between him and female resident but he denies every question and states, 'I don't know anything with both hands up in the air' [sic]. Notified Administrator, DON, ADON. Also informed [NP C] with [Dr. E's] services and [NP D] with [Pysch]. Call placed to [Resident #2's Main RP] Voice [sic] message left but spoke with [Resident #2's Alternate RP and phone number]. Order received to monitor this resident Q 15 minutes and separate both parties, This [sic] nurse moves resident from [Resident #2's original room number] to [Resident #2's new room number]. Head to assessment [sic] completed, noted redness to left lower lip skin intact but red. - 06/18/25 at 9:15 PM, LVN A wrote: [City Name Police] here, [Police officer's name] and this nurse informed him of situation. Police requested for residents information [sic] which was given by this nurse. This nurse also gives [sic] her personal information to the cop, then escorted/assisted him to male residents room [Resident #2's new room number]. The police officer questioned this resident regarding what happened earlier on but resident states 'Nothing happened' Police officer asked him if he was being inappropriate with a female resident? Resident states 'I don't know a female resident' Resident threw both hands in the air that he doesn't know anything and he don't' [sic] remember anything. Police officer asked him if he had breakfast, lunch or dinner he replies saying 'No I don't, no food here' This nurse reminds him that he requested for extra pasta today from this nurse during dinner and asked if he remembers that, resident states 'OKAY' [sic]. Resident unable to give any detail or account of situation that transpired. Per police officer, I could arrest him but due to his condition they won't keep him but advised he needs a male unit. Resident continues to be 1:1/Q 15 MINS Supervision [sic]. - 06/19/25 at 12:52 AM, LVN J wrote: Res remains in room with 1 on 1 assigned. Res in bed with eyes closed .No attempted to get OOB or leave room noted. No episodes of sexual inappropriateness, aggression or agitation noted. - 06/19/25 at 10:41 AM, RN I wrote: No unusual behavior. Q15 monitoring checks in progress during this shift .surveillance program for wandering residents in progress .One on one sitter in room [Resident #2's new room number]. - 06/19/25 at 11:28 AM, the SW wrote: The social worker contacted [Resident #2's RP] didn't answer and the social worker left a message for her to call the facility back. - 06/19/25 at 11:31 AM, the SW wrote: The social worker fax [sic] the resident clinicals to [a different NF] . - 06/19/25 at 1:32 PM, the DON wrote: The social worker contacted another family member for the resident to inform [them] that due to the incident that happened on yesterday the resident will be transferred to a sister facility. The resident has been approved and gave the family member the name and address to the moving facility. - 06/19/25 at 1:34 PM, RN I wrote: Q15 surveillance checks ongoing during this shift. One on One [sic] sitter at all times during this shift. Instructed by Admin and DON [the DON] to pack up resident's belongings. No unusual behaviors .cooperative during this shift. Spent shift in assigned bed .Hourly rounds by this nurse. - 06/19/25 at 2:05 PM, RN I wrote: Resident discharged Observation and interview on 06/19/25 at 11:45 AM revealed Resident #2 was in his room lying in bed. The ADON was standing in his doorway a few feet away from him. Resident #2 said he was doing good today and felt safe in the facility. Resident #2 said he had never tried to touch or kiss anyone at the facility. Resident #2 said he did not have any of those desires and had never tried to hurt anyone. Attempted interview on 06/19/25 on the phone at 1:28 PM with Resident #2's Main RP was unsuccessful as she did not answer. Attempted interview on 06/19/25 on the phone at 1:29 PM with Resident #2's Alternate RP was unsuccessful as she did not answer. Interview on 06/19/25 at 2:12 PM with LVN J revealed she worked the 10:00 PM to 6:00 AM shift overnight and was told by the previous shift that around dinner time in the TV room, Residents #1 and #2 were together and Resident #1 was found to have hickeys on her neck. LVN J said she was told Resident #1 told staff Resident #2 had sucked on her neck and tried to touch her down there. LVN J said staff called the police and that was when Resident #1 told staff before lunch there was an incident where she hollered for help and Resident #2 left her room because he was trying to touch her down there and played with her titties. LVN J said she never noticed any physical or sexual behaviors from Resident #2 towards anyone at the facility before this, so she was surprised to hear about it. LVN J said Resident #2 was placed on one-to-one observations and staff sat with him overnight after it happened to keep eyes on him. LVN J said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were, who and when to report abuse. Interview on 06/19/25 at 2:22 PM with RN I revealed she was at the facility when Resident #1 came back from the hospital this morning and did a skin assessment on her. RN I said when she asked Resident #1 if she was in pain the resident reported she was not. RN I said she had not observed any changes to Resident #1's behaviors so far during this shift. RN I said the skin assessment she completed revealed redness around Resident #1's neck area and a purple-ish bruise to the right side of her lower cheek. RN I said Resident #1 did not have those bruises yesterday morning when she cared for her. RN I said she never observed or knew about Resident #2 having any physical or sexual behaviors towards anyone at the facility. RN I said Resident #2 mostly stayed in his bed in his room during her shift. RN I said she did not observe any interactions between Residents #1 and #2 during her shift yesterday (06/18/25). RN I said she did not believe Resident #2 went to Resident #1's room at all near lunch time because not only was she working and an aide working, but the ADON and Administrator were also present as well. RN I said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were , who and when to report abuse . Interview on 06/19/25 at 1:36 PM with CNA M revealed she worked on the unit yesterday (06/18/25) during the 6:00 AM to 2:00 PM shift. CNA B said she knew nothing about the situation involving Residents #1 and #2. CNA M said normally both residents laid in their own beds in their own rooms during her shift. CNA M said she did notice Resident #1 had bruises to her neck when she saw her today that were not there yesterday. CNA M said Resident #2 never showed any sexual or physical behaviors towards anyone, but if he had she would have immediately reported it to her nurse and stopped it. CNA M said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were, who and when to report abuse. Attempted interview on the phone on 06/19/25 at 2:39 PM with CNA K who worked with both Residents #1 and #2 was unsuccessful as she did not answer or call back. Attempted interview on the phone on 06/19/25 at 2:40 PM with LVN L who worked with both Residents #1 and #2 was unsuccessful as she did not answer or call back. Interview on 06/19/25 at 2:56 PM with CNA B revealed she was working the 2:00 PM to 10:00 PM shift yesterday (06/18/25). CNA B said she took a few residents out for their smoke break around 6:30 PM and came back inside at 6:45 PM. CNA B said she was going to start her next set of rounds on residents and saw Resident #1, Resident #2 and Resident #3 sitting in the TV room together. CNA B said she noticed Resident #1 had bruises and redness that looked like two hickeys, scratches, and other marks to her neck that were not there before during her shift, so she alerted LVN A. CNA B said LVN A came over and asked Resident #1 what happened. CNA B said Resident #1 told LVN A what happened and pointed to Resident #2 saying he sucked on [her] neck and choked her. CNA B said Resident #2 was just sitting in the TV room like nothing had happened. CNA B said LVN A called the police and they came to talk to both residents. CNA B said LVN A told her Resident #2 was put on every 15-minute checks and then someone came to sit in his room with him the rest of the night. CNA B said it was normal for Residents #1, #2 and #3 to all be in the TV room sitting together watching TV after dinner. CNA B said Resident #1 was sent to the hospital and Resident #2 stayed in his room the rest of the shift. CNA B said she was in-serviced and knew what to do in regards to: identifying/reporting/stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were, who and when to report abuse. Interview on 06/19/25 at 3:17 PM with LVN A revealed she worked the 2:00 PM to 10:00 PM shift yesterday (06/18/25). LVN A said after dinner Resident #1 wanted to go to the TV room to watch TV like she normally did every evening. LVN A said she saw Resident #1 sitting there in the chair like she always had. LVN A said she started to make her rounds on the residents and noticed Resident #2's TV was not working for some reason and would not turn on, so she asked if he instead wanted to watch TV in the TV room which he did. LVN A said later on in the shift she heard CNA B asking for her near the TV room, so she went to the area and saw Resident #1's neck was red. LVN A said she asked Resident #1 what happened because her neck was not like that a few minutes ago. LVN A said Resident #1 pointed to Resident #2 and said he sucked on her neck. LVN A said she took Resident #1 to her room to further assess her and asked her again what happened. LVN A said she had also asked CNA B to take Resident #2 to his room, although his room was right next door to Resident #1 so they moved him across the hall to be able to watch him better and so he would be in an empty room. LVN A said she assessed Resident #1 further and asked her what happened but Resident #1 appeared to be ashamed and shut down, not talking. LVN A said she called the Administrator who was the Abuse Coordinator for the facility and then was told to call the police. LVN A said the police came to the facility and she went into the room with Resident #1 to talk to the police officer. LVN A said Resident #1 told them Resident #2 came to her room before lunch and tried to touch her by pulling up her dress and touched her titties and kissed her and choked her. LVN A said the police officer asked Resident #1 if she ever lost consciousness and the resident said yes, and she had also screamed for help but then Resident #2 got up and ran out of the room. LVN A said Resident #1 continued by saying after dinner and in the TV room, Resident #2 came again and tried to pull her dress up again but she crossed her legs and did not let him go down there but he played with her titties again and tried to kiss her, but she fought him off. LVN A said Resident #1 explained Resident #2 began to suck on her neck and she pushed him away. LVN A said during the skin assessment she completed earlier there were no additional findings of an assault, physical or sexual that she could see. LVN A said Resident #1's neck had 4 places where there were bruises that looked like hickeys on one side of her neck and small circles on the other that were consistent with someone holding a person down. LVN A said Resident #1's story matched the injuries she sustained, and she had no history of making up stories. LVN A said she was not told about anything that happened during the previous shift around lunch time and since she was not there, she was not sure what happened. LVN A said she only knew of one other situation involving Resident #2 kissing a different female resident which was a long time ago. LVN A said after that situation happened, Resident #2 was put on every 15-minute checks until the psych provider could see him. LVN A said since then, Resident #2 never gave any indication he would do something like that again. LVN A said she was in-serviced and knew what to do in regard to identifying, reporting, stopping sexual or physical behaviors from residents towards others, supervising residents at all times but especially in common areas, and what the types and signs of abuse were , who and when to report abuse. Interview on 06/19/25 at 3:44 PM with the ADON revealed yesterday (06/18/25) evening, after dinner, CNA B noticed some bruising to Resident #1's neck and alerted LVN A. The ADON said LVN A assessed Resident #1 and after explaining what happened to her, the nurse alerted the Abuse Coordinator who was the Administrator. The ADON said Resident #1 told LVN A Resident #2 put his hands on her neck and sucked on her neck and was inappropriate with her. The ADON said Resident #2 was placed on every 15-minute checks and once they secured a staff member they sat with him one-on-one until he discharged from the facility. The ADON said Resident #2 was discharged today (06/19/25). The ADON said Resident #1 was sent to the hospital for an evaluation, both residents' families were notified, and the MD was also notified. The ADON said she herself saw Resident #1's injuries when she came back from the hospital today and noticed there were red dime-sized marks on her neck that were not there before. The ADON said she was not sure if the injuries were the result of Resident #2 sucking or choking on Resident #1's neck. The ADON said Resident #2 was involved in another incident with a different resident last year in either September or October where he kissed a resident. The ADON said after that happened, Resident #2 was placed on every 15-minute checks until the psych provider could see him. The ADON said the facility took the same approach with the situation that happened with Resident #1, except he was also placed on one-to-one until he discharged . The ADON said when she asked Resident #2 what happened, he could not recall anything but that was normal for him. The ADON said she did not have the opportunity to talk to Resident #1 about what happened. The ADON said the facility also in-serviced all staff regarding abuse/neglect, resident-to-resident altercations, and sexual behaviors. The ADON said she was on the unit yesterday (06/18/25) during the lunch meal service around 11:15 AM or 11:30 AM and never saw Resident #2 out of his room nor did she see Residents #1 and #2 together at any point. The ADON said Resident #2 was discharged to a sister facility that had an all-male secured unit and the family was agreeable to the move. Interview on 06/19/25 at 4:03 PM with the DON revealed she received a call yesterday from the Administrator saying LVN A reported CNA B went to get Resident #1 out of the TV room and noticed marks to her neck. The DON said LVN A asked Resident #1 who did that to her neck and the resident pointed to Resident #2. The DON said the staff on duty automatically separated the two residents and staff began arranging for Resident #2 to be placed on one-on-one. The DON said Resident #1 was sent to the hospital, but they could not conduct a rape kit because there was only evidence of a physical assault, not a sexual assault. The DON said Resident #1 told staff he grabbed her neck and touched her, he tried to kiss her on her neck, he sucked on her titties, he had tried to screw [her], he tried to pull her diaper to the side and get on top of her but the resident crossed her legs and he left out of the room. The DON said she asked Resident #1 what he looked like, and she said the man was white with grey hair and a beard which matched Resident #2's description. The DON said Resident #3 was also in the room, but he was not a reliable witness as he was not interviewable due to his condition. The DON said Resident #1's injuries were to both the right and left sides of her neck and on the front too. The DON said Resident #1's injuries looked like one side was where she was choked and the other was where she had been sucked on causing the hickeys. The DON said she was not sure if that was exactly what happened but that was what it sort of looked like. The DON said she always saw Resident #2 in his bed in his room and since she had only been there for about 4 months, she was not aware of the prior incident where he had kissed another resident months ago. The DON said she believed Resident #1 had her times mixed up as to when the lunch incident happened because the ADON, a housekeeper, and a therapist were there around the same time as the nurse and aide as well and none of the staff saw the residents interacting in any way. The DON said she thought the earlier incident happened before dinner, if it happened at all. The DON said Resident #2 had to be discharged because of the extent of him violating Resident #1's privacy and attacking her. The DON said the facility also in-serviced all staff regarding abuse/neglect, resident-to-resident altercations, and sexual behaviors. The DON said what Resident #2 did to Resident #1 was considered abuse. Interview on 06/19/25 at 4:43 PM with the Administrator revealed she was on her way home yesterday (06/18/25) when she got a call from LVN A saying CNA B came in from smoking the residents and started doing her rounds to get everyone cleaned up. The Administrator said CNA B took Resident #1 from the TV room and noticed she had bruising to her neck, so she called LVN A over to assess the resident. The Administrator said LVN A and CNA B took Resident #1 to the dining room and asked her what happened to which they were told Resident #2 sucked on her. The Administrator said Residents #1, #2 and #3 were in the TV room together which was normal for them to be in that room after dinner together as it's a common area. The Administrator said due to Resident #3's condition he was not able to be interviewed or recall anything that happened. The Administrator said after Resident #1 identified Resident #2 as the Alleged Perpetrator, the staff started him on every 15-minute checks while the ADON tried to find staff to sit with him one-on-one until he could be discharged . The Administrator said LVN A called the doctor to let them know what happened and sent Resident #1 to the hospital to be further evaluated. The Administrator said LVN A also called the police department, and an officer arrived at the facility. The Administrator said the police officer explained there was no signs of a sexual assault, only a physical assault. The Administrator said the hospital explained since there was no penetration they would not be able to complete a rape kit exam. The Administrator said Resident #1 returned to the facility this morning around 9 AM while the facility was working on transferring Resident #2 out of the facility. The Administrator said she was sent pictures by LVN A of Resident #1's injuries and saw it looked like she had hickeys on her neck. The Administrator said she believed Resident #1 had her times mixed up and the lunch incident did not happen at that time but might have happened before dinner instead. The Administrator said she was on the unit a lot yesterday (06/18/25) and never saw anything that seemed unusual between Residents #1 and #2. The Administrator said nothing else was reported to her about the 2:00 PM to 10:00 PM shift from yesterday. The Administrator said Resident #1 did not have a history of making up stories and Resident #2 did not have a history of any sexual or physical behaviors with anyone. The Administrator said there was only one incident where Resident #2 kissed another resident on the lips months ago which had already been reported and investigated. The Administrator said it was normal for the residents to be sitting in the TV area together and nothing had ever happened prior to this incident amongst any of them. The Administrator said the facility also in-serviced all staff regarding abuse/neglect, resident-to-resident altercations, and sexual behaviors. The Administrator said all residents had the right to be free from abuse, the facility was their home, and they deserved to be in a safe environment with quality of care and life. The Administrator said all staff were responsible for ensuring residents were free from abuse. The Administrator said if Resident #2's actions were intentional this situation would be considered a form of abuse. The Administrator said if residents were not free from abuse that could cause some type of harm to them either emotionally or physically. The Administrator said staff were constantly monitoring residents to ensure they were free from any abuse. The Administrator said all staff were trained to monitor residents at all times. Record review of resident safe surveys reflected 14 were completed with residents on 06/19/25 with no additional findings of any other abuse in the facility. Record review of an in-service, dated 06/19/25, reflected 35 staff were in-serviced regarding resident-to-resident altercations, sexual expression, and abuse and neglect. Record review of a post test completed by 35 staff reflected they understood the facility's policy and procedures regard[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 7 of 55 residents reviewed for rights to forms of communication with privacy. The facility failed to deliver mail to the resident within twenty-four hours of delivery on premises or the facility's post office box according to their policy. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life. Findings included: During a confidential group interview, 7 of 7 residents stated mail was not distributed at the facility, 6 of 7 residents stated mail was never distributed to them. Confidential resident stated mail was distributed to her only once since she's been at the facility. All 7 residents stated mail was not distributed on Saturday (10/26/2024) or any other day. The residents stated they were unaware who was responsible for distributing mail. In an interview on 10/29/2024 at 3:00 p.m. with the AD she stated she was responsible for distributing mail to residents. She stated there was no specific day when mail was delivered to residents, but residents received their mail once a week. She stated packages were delivered to residents as soon as the package was delivered to the facility. She stated the mail was kept in the business office manager's office. The AD did not explain why the mail was not delivered on the same day it was delivered. In an observation and interview on 10/29/2024 at 3:15 p.m. with the BOM she stated she was responsible for retrieving the mail upon delivery from the postal service. She stated once the mail was received from the postal service, her, and the AD sorted through the mail before the mail was distributed to residents. She stated there was no set day for mail to be delivered to residents, but mail was typically delivered to residents on Wednesdays. She stated because she did not work on weekends, mail delivered on Saturday was sorted on Monday. During an observation of a plastic storage tote, a pile of mail was observed in the bin that have not been distributed to residents. The BOM confirmed the mail in the tote was resident's mail that was delivered on Friday (10/25/2024). She stated the mail from Friday would be delivered to residents this week. The BOM did not explain why the mail was not delivered on the same day it was delivered. In an interview on 10/29/2024 at 3:54 p.m. with the ADM, she stated her expectations of residents receiving mail should take place often . She stated residents should be receiving mail at least once a week. She stated her expectations would be for the BOM or the SW to deliver mail to residents. She stated she was unsure of the current policy on residents receiving mail. She did not state how this could affect residents. Record review of the facility's Mail and Electronic Communication Policy dated revised May 2017, Policy Statement: Residents are allowed to communicate privately with the individuals of their choice and may send and receive personal mail, email, and other electronic forms of communication confidentially. 1. Mail and packages will be delivered to the resident within twenty-four hours of delivery on premises or the facility's post office box (including Saturday deliveries).

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen , reviewed for food safety. 1. The facility failed to thaw food under proper conditions (in cooking process, in cooler, under cold running water, microwave and immediately cook afterward); not at room temperature. 2. The facility failed to ensure food items in the refrigerators were labeled with the item description and preparation date, open date, or expiration date . 3. The facility failed to ensure raw meat was stored on the bottom shelf to prevent contamination of other foods. 4. The facility failed to discard open items stored in the refrigerator and freezers that were not sealed . 5. The facility failed to ensure clean dishware was not exposed to a contaminated item . 6. The facility failed to house dented cans in the separate area for dented cans . 7. The facility failed to ensure the ice machine was clean and free of lime and mildew. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the kitchen on 10/28/2024 at 7:30 p.m. revealed the following: -5 packaged lunch meat thawing in the kitchen sink at room temperature. - 1 used glove on a dish cart with clean plate covers. Observation of the reach in refrigerators on 10/29/2024 at 9:05 a.m. revealed the following: -Refrigerator #1- 1 32 fl oz 2.0 high calorie malnutritional drink was open with no open date or expiration date. -Refrigerator #2- 3 plastic cups of juice and milk on a serving tray had no item description or preparation date. -Refrigerator #2- 1 large zip top bag of sliced ham, approximatly an inch or more of juice/water was noted at the bottom of the bag, dated 10/25/2024, stored on the top shelf above the dairy products. -Refrigerator #2- 1 5lb bag of grated parmesan cheese was exposed to the air. Observation of the reach in freezers on 10/29/2024 at 9:10 a.m. revealed the following: -Freezer #1- 1 10lbs box of pork hotdogs were exposed to air. -Freezer # 2- 1 12.50lbs of bread sticks were exposed to air. Observation of the walk-in freezer on 10/29/2024 at 9:20 a.m. revealed the following: -Freezer #3- 1 16lb box of peanut butter cookie dough was exposed to the air. -Freezer #3- 1 14lb box of churros was exposed to the air. -Freezer #3- 1 10lb box of cheese and garlic biscuit dough was exposed to air. -Freezer #3- 1 10lb box of pie dough was exposed to the air. Observation of the dry storage on 10/29/2024 at 9:38 a.m. revealed the following: -1 6lb can of pinto beans was dented on the top left. -1 6lb can of cheddar cheese sauce was dented on the bottom left. Observation of the ice machine on 10/29/2024 at 9:47 a.m. revealed the following: The ice machine inner guard had pink and black build up along the top of the inner guard. In an interview with DA C on 10/28/2024 at 7:40 p.m., she stated the lunch meat was thawing in the sink to prepare snacks for the residents. She stated the lunch meat was put out to thaw today at approximately 3:00 p.m. The DA C stated when thawing food, the food should be placed in running water. She stated when the lunch meat was put in the sink to thaw by other kitchen staff it was put in running water . The DA C stated once the meat was thawed it should be placed in the refrigerator. DA C identified the designated area for clean dishes. She stated the plate covers were cleaned on the dish cart with the used glove . Interview with the DM on 10/29/2024 at 9:35 a.m., she stated when thawing food, staff was expected to place the food item in cold running water. She stated once the food item was thawed, it was cooked or packaged in a zip top bag, labeled, and placed in the refrigerator. She stated staff was expected to use the designated areas for clean and dirty dishes. She stated it was not okay for dirty items to be stored with clean dishes. Interview with the DM on 10/29/2024 at 9:50 a.m., she stated kitchen staff was responsible for wiping down the outside of the ice machine. She stated maintenance was responsible for cleaning the inside of the ice machine. She stated the ice machine was cleaned weekly but hasn't been cleaned this week. She stated she would let maintenance know to clean the ice machine today. She stated the proper sanitation of the ice machine and kitchen was important to prevent illnesses. Interview with [NAME] D on 10/29/2024 at 11:26 a.m., she stated when thawing food, staff should place the food in the sink with cold running water. She stated once the food was done thawing, the food should be cooked or placed in the refrigerator. She stated defrosted food should be cooked within 1-3 days . Record review of the facility's Nutrition & Foodservice Policy, dated October 1, 2018,: Revision June 1, 2019, reflected Policy Statement: 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. Policy Interpretation and Implementation: 1. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 2. Store raw meats and eggs on the bottom shelf to prevent contamination of other foods.To avoid cross-contamination, store raw uncooked food produce away from and below prepared or ready to eat food. 3. Food thawing under proper conditions (in cooking process, in cooler, under cold running water, microwave and immediately cook afterward); not at room temperature.4. Trays, dinnerware, cups, and utensils in good condition, stored properly to prevent contamination. 5. Ice machine clean with no lime, rust, or mildew. 6. Damaged cans stored in designated area for return to vendor, food purchased from vendors that meet federal, state, or local approval Record review of the U.S. FDA Food Code 2022 reflected: Chapter . section 3-501.13 Thawing (A). Under refrigeration that maintains the food temperature at 5c(41F) or less or (B) completely submerged under running water. Chapter 3 . section 3-201.11 Compliance and Food Law . C. Packaged Food shall be labeled as specified in LAW , including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 4 shower rooms (the North and South shower rooms) and 2 of 8 resident rooms (rooms #111 and #150) reviewed for the pest control program. 1. The facility failed to ensure live roaches were not in the South Shower room and room [ROOM NUMBER]. 2. The facility had live flies observed in the North Shower room. These failures could place residents at risk for the spread of infection, cross-contamination and decreased quality of life. Findings included: An observation on 10/29/24 at 11:21 AM revealed a live roach in the bathroom of Resident #49's, room [ROOM NUMBER]. Resident #49 was not interviewable. An observation on 10/30/24 at 11:18 AM of the South Shower Room revealed a small live roach was near the main shower drain of the shower room. An observation on 10/30/24 at 11:21 AM of room [ROOM NUMBER] revealed a live roach was observed running back underneath the toilet in the residents' bathroom. An observation on 10/30/24 at 11:23 AM of the North Shower Room revealed 14-16, live small flies gathered in the right hand corner of the room, on the wall directly above the main drain of the shower room. In a confidential group meeting with 7 residents revealed the residents observed live roaches and flies in their rooms, bathrooms and shower rooms. Residents stated they informed staff of roaches and flies in the facility . An interview on 10/29/24 at 11:38 AM with Resident #38 revealed she saw roaches in her room and her bathroom, and she told staff about the roaches a few times but could not remember which staff members she mentioned it to. Se stated that she did not like having roaches or flies in her room or in the facility, she stated that it was nasty. An interview on 10/29/24 at 11:44 AM with Resident #44 revealed he saw roaches in his bathroom, but had not reported it to anyone. An interview on 10/29/24 at 11:48 AM with Resident #47 revealed she saw roaches in her bathroom on a few occasions. She stated she told staff several times about the roaches she saw in her bathroom. An observation and interview on 10/30/24 at 11:38 AM of the North Shower Room with the ADON revealed 14-16 live flies on the walls above the drain. The ADON stated she had not noticed all of the flies in the shower room before, she stated no other staff reported the live flies in the shower room. She stated the staff did not use a pest sighting log , but generally informed the Maintenance Supervisor about any pests in the building, and she would inform the Maintenance Supervisor about the flies at that time. An interview on 10/31/24 at 2:57 PM with the ADM revealed staff were expected to log pest sightings in the maintenance log , or staff would call her or notify the Maintenance Supervisor in person. An interview on 10/31/24 at 3:08 PM with LVN A revealed she did not know what a pest sighting log was and if she saw a roach or a fly, she would notify housekeeping . An interview on 10/31/24 at 3:15 PM with CNA B revealed she saw live roaches in the facility. She further stated she was not aware of a pest sighting log, but she would notify housekeeping . An interview on 10/31/24 at 3:32 PM with the ADON, she revealed if pests were seen inside the facility, the staff were expected to put the sighting in the maintenance log so the Maintenance Supervisor could be notified to contact pest control. She stated live roaches or flies could cause cross-contamination and could make residents upset about where they live . She stated that she thought that pest control visited the facility at least once a month. An interview on 10/31/24 at 3:44 PM with the DON, she revealed pest sightings were supposed to be logged by staff in the maintenance log. She stated roaches or flies could cause cross contamination in resident's food and could cause mental anguish in residents that saw roaches or flies in their rooms or bathrooms. An interview on 10/31/24 at 4:11 PM with the Housekeeping Manager, she revealed residents and staff told her about roaches or flies in the facility and she then went and told the Maintenance Supervisor. She stated she did not write it down anywhere but told the Maintenance Supervisor if she saw any type of insects in the facility. An interview on 10/31/24 at 4:23 PM with the Maintenance Supervisor revealed he was usually told about pests inside the facility by staff or by residents. He stated sometimes the staff might write down pest sightings in the maintenance log and he checked the maintenance log every day. He stated he had not seen any reports recently in the maintenance log about pests in the facility . He stated that the contract with the pest control company was active and that pest control came to the facility at least once a month or more often if he call them in. Record review of the Maintenance Log for the facility reflected no entries related to insects, roaches or flies in the facility for the last three months found no entries related to insects sighted in the facility. Receipts for pest control visits were found up to 7/16/24, no other receipts could be found for any visits after that date. Review of the Grievance files x 3 months found no grievances related to pests in the facility. Record review of the facility's policy, revised July 2013, and titled Pest control, reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program for insects and rodents

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in resident bathrooms for 2 of 4 halls (100 Hall south and 100 Hall south) reviewed for environment. The facility failed to ensure floors and walls were in good repair and clean for resident bathrooms #110, #111 and #150. This failure could place residents at risk for a diminished quality of life due to the lack of a well-kept environment. Findings include: An observation on 10/29/24 at 11:21 AM of the bathroom for Resident #49, room [ROOM NUMBER] revealed the floor was discolored around the perimeter of the floor with what appeared to be built up of grime or dirt . The wall to the right of the toilet was missing approximately 1.5 feet of the base board exposing a 1.5 inch gap between the floor and the bottom of the wall . The toilet was missing a seal between the floor and the bottom edge of the toilet left a 0.5 inch gap and a live roach was observed retreating to twice during several observations . Resident #49 was not interviewable. An observation on 10/29/24 at 11:42 AM of the bathroom of Resident #34, room [ROOM NUMBER] revealed a sticky brown substance seeping out between all of the tiles on the bathroom floor with hairs and other material stuck in the substance. Resident #34 was not in the facility at the time of the observations. An observation and interview on 10/29/24 at 11:48 AM with Resident #9 and Resident #47 (roommates) revealed both residents complained their shared bathroom was always dirty, there were holes in the walls and they saw roaches and other insects in their bathroom. An observation of room [ROOM NUMBER] revealed a dark discoloration around the perimeter of the floor and built-up of grime in all four corners of the bathroom. The wall to the right of the toilet had a very uneven surface where the wall appeared to have protruded out towards the interior of the bathroom by 2-3 inches, which revealed a large gap above the base board. A 3 X 2-inch hole was observed in the wall behind the toilet. In a confidential group meeting with 7 residents revealed the residents complained their personal bathrooms needed to be cleaner and were in need of physical repairs . An interview on 10/31/24 at 2:57 PM, the ADM revealed it was important to keep the facility clean and in good repair at all times as a dirty facility might decrease the quality of life for the residents . He stated that he bathrooms were in process of being refurbished, but that it was taking a while to complete. He stated that the housekeeping staff cleans all resident bathrooms at least twice daily. An interview on 10/31/24 at 4:11 PM, the Housekeeping Manager stated she tried to keep the facility as clean as possible, she stated in the course of cleaning the facility the other housekeepers and herself would report things might need repair to the Maintenance Supervisor. She stated if the facility was dirty or in disrepair it could affect the moods or feelings of the residents in a bad way. An interview on 10/31/24 at 4:23 PM with the Maintenance Supervisor, he stated staff generally told him if something needed to be fixed in the facility, and staff would also write down maintenance problems in the maintenance log book. He stated he was aware of the wall in the bathroom in room [ROOM NUMBER] and the floor in room [ROOM NUMBER]. He explained he just had not had the time to address the holes/damage to the walls in room [ROOM NUMBER] and the substance leaking between the tiles in room [ROOM NUMBER] was glue from replacing the tiles in that bathroom. He stated he was unaware of the missing baseboard in the bathroom for room [ROOM NUMBER] . Record review of the facility policy, Homelike Environment, revised February 2021, reflected: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment.

Based on record reviews, and interviews, the facility failed to ensure a resident's environment remained free of accidents or hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #22) reviewed for transfers in that: 1. The facility failed to ensure CNA O provided adequate supervision and transfer assistance for Resident #22 attempting to conduct a transfer without assistance or without an assistive device. 2. The facility failed to ensure that CNAs were knowledgeable about locating the resident's safe transfer status requirements for Resident #22. An immediate jeopardy existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, and hospitalization . Findings included: Review of Resident #22's Face sheet dated [DATE] reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnosis that included Cerebral Infarction (stroke), Displaced fracture of the greater tuberosity of right humerus (fracture of the neck of the upper arm bone that did not break the skin), Pain, Muscle wasting and atrophy left thigh and left lower extremity, Adult failure to thrive, Hemiplegia and hemiparesis following Cerebral Infarction (paralyzation following a stroke). Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] reflected in section GG titled Functional Abilities and Goals Resident #22 had limited range of motion and impairment on both sides of her body and required the use of a wheelchair. Resident #22 required substantial/maximal assistance to totally dependent in the following areas: Toileting hygiene, Shower/bathe, lower body dressing, and putting on/taking off footwear. Resident #22 required total dependent assistance (or the assistance of 2 or more helpers) to roll left or right, sit to lying, lying to sitting on edge of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Review of Resident #22's Care Plan dated [DATE] reflected Problem/Category: ADL's Functional Status/Rehabilitation Potential Resident #22 had self-care deficits and is at risk for a decline in ADL function related to physical impairments due to Cerebral Vascular Accident with HP and UE Fx. Resident #22 may require more assistance some days more than others. Approach: Transfers: mechanical lift (2 person assist). Further review of Resident #22's care plan revealed a newer entry dated [DATE] regarding transfers . Problem/Category: ADL's Functional Status/Rehabilitation Potential [Resident #22] is unable to use mechanical lift sling with transfer. Requires 6 staff members to transfer using sheet to wheelchair from bed .Approach: Transfer to w/c using sheet with 6 staff for assistance. Review of the Incident Accident report dated [DATE] to [DATE] Revealed Resident #22 suffered a fracture on [DATE] as the result of an improper transfer. Record Review of a written statement dated [DATE] signed and dated by CNA O and RN S reflected that . [CNA O] entered [Resident #22's] room and began to transfer Resident #22. CNA O sat resident #22 on the side of the bed, wrapped arms around the resident, began to move from bed to wheelchair. Resident #22's chair began to move slightly backwards, CNA O began to lower Resident #22 and braced her with knee, when she heard a pop. Resident #22 was positioned in wheelchair and charge nurse [LVN P] was notified. CNA O states she was not assigned to that hallway and was unaware Resident #22 was a Hoyer lift. Review of Resident #22's nursing progress notes revealed that CNA O reported to LVN P that she had heard a pop when transferring Resident #22 from the resident's bed to the resident's wheelchair. LVN P and the RN S assessed the resident and notified the MD and ordered an x-ray. The x-ray revealed a displaced closed fracture of Resident #22's right humerus. An attempt at an interview on [DATE] at 11:00 AM revealed that CNA O's listed contact phone number was disconnected. In an interview and observation on [DATE] at 11:12 AM Resident #23 was observed being transferred via a mechanical lift. CNA K and CNA L were observed to apply mechanical lift sling to the supine resident for transfer from bed to wheelchair. Bed put in lowest pos, resident raised without incident by both staff members. Resident appeared to tolerate transfer well no signs of pain or mental duress. Resident stated she had never had a problem with being transferred by the mechanical lift, being lifted was scary the first couple of times but now she stated she was used to being lifted. She stated that she felt safe at the facility and had no complaints regarding her care or treatment at the facility. In an interview and observation on [DATE] at 1:08 PM Resident #24 was observed being transferred via a mechanical lift device from her wheelchair to her bed. CNA M and CNA L were observed performing the transfer. Sling placed on resident, bed to lowest pos, resident legs kept closed by CNA during transfer and steadying/guiding Resident #24 to the bed while the other CNA lifted and pushed the machine. Resident observed to have tolerated the transfer well. No signs of pain or mental duress. Resident stated she had been lifted many times at the facility and had never felt in danger, the CNA's knew how to do it. She stated she had no complaints about her care or treatment at the facility. In an interview and observation on [DATE] at 3:01 PM Resisdent #25 was observed being assisted with with a transfer by CNA N. Resident# 25 was able to assist with her transfer with assistance from CNA N. Resident's wheel chair was set with brake engaged next to bed. Resident #25's bed was observed to be lowered to level of wheel chair, resident assisted to edge of bed and steadied by CNA N, resident was able to stand with assistance and guided to a seated posistion in wheel chair without incident. Resident #25 stated that the staff knew her routine well and assisted her many times without incident to her wheel chair and back to bed. She stated that she had no complaints about her care or treatment at the facility. In an interview on [DATE] at 4:19 PM the Regional RN stated that all of the CNAs had had access to resident profiles that listed if a resident is mechanical lift, two person assist, or minimal assist. The Regional RN new CNAs were trained during orientation training to have ben able to access resident profiles to see what level of assistance residents required. The Regional RN stated that the the Former Administrator had been in charge at the time of the incident and the current Administrator had been at he facility for only 6 days. The incident had occurred nearly a month before the current Administrator came to the facility. In an interview on [DATE] at 4:24 PM, the DON stated that CNA O had been immediately suspended during the investigation, did not return to the facility or answer any phone calls from the facility, and had been terminated that evening. Review of CNA O's personnel file revealed that CNA O started work at the facility on [DATE], and was terminated as a result of the transfer incident on [DATE]. No other incidents or complaints were discovered in her employee file. In an interview on [DATE] at 11:24 AM, LVN P stated that CNA Q, the CNA that was on that hall the evening that CNA O had the incident with Resident #22 and had asked CNA O to help assist with changing Resident #22. He stated that CNA O had come and reported to him that she had heard a pop while transferring Resident #22. He stated that he and RN S had then gone and immediately assessed Resident #22. He stated that mechanical lift residents were posted behind he nurses stations and that CNA's had access to resident profiles in the facility computer system An interview on [DATE] at 11:27 AM with CNA Q revealed she had been the CNA on Resident #22's hallway that day and that Resident #22 requested to be changed by a different aide, so she had asked CNA O to come and assist her with changing Resident #22. Resident #22 must had indicated to CNA O that she wanted to be transferred to her wheelchair before she had been able to get to Resident #22's room. She stated that CNA O was just supposed to start setting up the equipment needed to change and clean Resident #22. She stated that Resident #22 had been a Hoyer lift for a long time and that there were lists of residents that required Hoyer lifts posted behind every nurse station. She further stated, after the incident, all of the staff had been trained on Hoyer lifts, where to look up resident profiles, she had been observed performing Hoyer lifts and other transfers, and she had taken and passed a competency test. Review of sign in sheets for the following in-service trainings between the dates of [DATE] to [DATE] revealed that 89 staff involved in patient care were in serviced on the following topics: Proper Hoyer Lift Procedure, Abuse and Neglect, Pain, Hoyer Transfers and Safety, Gait Belt Use, How to Access Transfer Code Care Assist and Care for Resident #22's Arm Sling. Review of Observation/Competency Checks for Hoyer Lifts Procedures, Transfer Safety, Accessing Patient Care Profiles, revealed 89 staff members involved in patient care were tested and observed for all for the above competencies. All Competency tests/observations were signed by the ADM, DON, ADON and Regional Nurse. The results showed that staff had been retrained successfully. Review of Safe Surveys of 52 residents, representing the entire resident population dated [DATE] to [DATE] Entitled Transfer Safety found no negative findings about transfers from the residents. Interviews were conducted with 8 RNs, 11 CNAs, and 1 MA were conducted on [DATE]. All staff interviewed were able to recount all In-Service topics, stated that they had a pre-test before the in-services and after the in-services. All interviewed staff stated that they had been observed conducting Hoyer and other transfers while being observed by the Regional RN, DON or ADON. All staff were able to identify where and how to access residents' profile information. Review of the facility Safe Resident Handling/ Transfers policy last revised ,d+[DATE] revealed: .It is the policy of this community to ensure that patients/residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the patient/resident while keeping the team members safe in accordance with current standards and guidelines . - All patients/residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the team members that assist them. The use of mechanical lifts is a safer alternative to manual lifting for patients, residents, and caregivers . Compliance Guidelines: - The interdisciplinary team or designee will evaluate and assess individual mobility needs, considering other factors as well, such as weight and cognitive status . - The mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations . - Team members will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur . - Team members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment . - Lifting and transferring will be performed according to the individualized plan of care

Based on interview, and record review, the facility failed to provide services by sufficient numbers of nurses and CNAs on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for one (Resident #1) of six residents reviewed for care and services. The facility did not provide sufficient staff for Resident #1 on the 6AM-2PM shift on 08/16/21 and on the 10PM-6AM shift on 08/16/21-08/17/21. Resident #1 fell on both shifts, sustaining injuries, while only a NA/CNA were on the floor working by themselves in the secured unit. Resident #1 fell twice on 08/16/21. The first fall resulted in a skin tear to the elbow and redness/bruising on her right temple. The second fall resulted in significant facial bruising, swelling and a hematoma to her forehead which required a transfer to the ER due to concerns of a possible skull fracture. This failure placed residents with dementia and gait/imbalance issues at risk for inadequate supervision which could result in falls with injuries. Findings included: Review of Resident #1's quarterly MDS assessment, dated 07/31/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had unclear speech and was rarely understood and rarely understood others. She had short and long-term memory impairment and severely impaired cognitive skills for decision making. She had signs of [CONDITION(S)] which included fluctuating disorganized thinking and continuously present altered levels of consciousness. Resident #1 had no indicators of [CONDITION(S)], physical or verbal behaviors, rejection of care or wandering. She required one to two-person extensive physical assistance for activities of daily living and was always incontinent of bowel and bladder. She was not steady with balance during transitions or walking and but was able to stabilize without staff assistance. She had no functional limitations in her range of motion. She was 5 foot 4 inches and weighed 88 pounds and had weight loss identified. Resident #1 received antipsychotic, antianxiety and antidepressant medications. The MDS reflected no falls since admission. Review of Resident #1's care plan dated 02/18/21 and revised 08/06/21 reflected the following problems and interventions: Walking: The Resident has unsteady gait related to weakness. - Ambulate 300 feet with hand held assistance from staff; Problem: Resident is at high risk for falls r/t cognitive decline, [CONDITION(S)] medications, poor safety awareness and history of falls. Goal(s)-Resident will remain free of major injuries related to falls; Approach: Offer snacks and supplements when resident is displaying increased anxiety. Resident enjoys oatmeal cakes, Ambulate resident with assist of one and a gait belt when resident is displaying signs of increased anxiety, Frequently redirect resident when unsafe behaviors are noted. Review of Resident #1's clinical chart and the facility's incident and accident log revealed she had falls on 04/05/21, 4/16/21, 04/21/21, 06/19/21, 08/13/21 and twice on 08/16/21 which required a hospital visit due to extensive injuries. Review of a Facility Event Report (Incident Report) completed by ADON A and dated 08/16/21 reflected at 8:16 AM, Resident #1 had a witnessed fall by a CNA where she fell and bumped her right temple on the handrails. Her right temple was noted to be red and her right elbow had a skin tear. Review of Resident #1's nursing progress notes reflected a late entry by LVN G on, 08/17/2021 02:57 AM This nurse was notified by CNA that resident had fallen and was on the floor. Upon entering the secure unit, nurse noted resident to be on the floor in the middle of the hallway with the left side of her face on the floor crying out in pain. This nurse helped the resident to a sitting position and took her vitals. This nurse noted that the resident had a huge knot in the center of her forehead that was starting to bruise and sweat as well as bruising to the inner canthus of both eyes, as well as the bridge of her nose. This nurse used [MD] standing orders and gave the resident two 325mg tabs of Tylenol for the pain. This nurse also applied a cool compress consisting of ice, towel, and a plastic bag to the resident's forehead which was not measuring 7cm in diameter. This nurse notified the ADON, DON, as well as NP for [MD]. Awaiting call back. Resident in the nurses station with CNA. Resident will keep on follow up on resident's VS as well has monitoring of resident's swelling. A nursing progress note on 08/17/21 at 6:31 AM reflected, Resident now has extensive bruising to her forehead, eyes, and cheeks. A nursing progress note on 08/17/21 at 8:15 AM reflected, This nurse noted that the resident face continued to bruise with mild swelling and there was no orders in place to request a x-ray. This nurse noted resident to have increased bruising and mild swelling to resident's face. This nurse activated the emergency response to transport resident to the hospital for evaluation and treatment. An interview with the ADM on 08/18/21 at 9:30 AM revealed he got report from report that Resident #1 was running down the hall in the locked unit and she fell and did a face plant. He said the CNA on the hall eye witnessed the resident running before she fell and at that time, then a nurse was coming through the locked unit and did neuro checks. The ADM said Resident #1 was sent to the hospital, but he did not know what he condition was. He said Resident #1 had a huge goose egg then her face turned black and blue. An interview with the CRN C on 08/18/21 at 11:32 AM revealed he had visited with Resident #1 prior to the fall incident when he was at the facility one day because he wanted to see for himself, what she was like. He said he was walking with her and then all of a sudden, she took off down the hall. He said she moved fast. CRN B said the facility tried everything but nothing was making her situation improve related to falls. An interview with Resident #1's POA on 08/18/21 at 1:33 PM revealed he was notified that on 08/15/21 that she had grabbed a shower curtain and fell and they were going to bandage her up and he was okay with that. Then on Monday 08/16/21, he said she fell again and the facility told him they were going to get x-rays because she had a laceration but did not need stitches. The POA said Resident #1 was sent out the next day to the hospital. He was told she had fallen again and the facility doctor said she needed to be evaluated or they couldn't get x-rays done or something. He said that was good she was being sent out because she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The POA said Resident #1 was prone to falls and had fallen in multiple facilities and without one on one care, she is going to fall. He said, She bruises like a peach and the facility had told him she had some bruises on her legs from the fall. He denied concerns with abuse but said, What we would like to see are one or two more staff on the secured unit. He said the last time he visited Resident #1 (date not recalled), there was just one charge nurse and maybe a CNA who was back and forth between long term and memory care. He said the hospital had told him that Resident #1's blood work came back normal, she had no cracked skull and everything looked good, no internal bleeding even though she hit her head pretty hard. He stated the hospital still needed to do a workup on her hips and legs. An interview with ADON A on 08/18/21 at 3:24 PM revealed Resident #1 constantly walked around the secured unit. ADON A said, She walks, walks, walks and leans. It's dangerous, so we tried to put her in a program where we walk her around the building. She likes it and she will hold our arm. She said Resident #1 would walk until she was exhausted. She said Resident #1 had a short attention span where she will change directions mid-walk in where she was headed. She said when Resident #1 fell in the past, it was usually a freak accident. She said the staff tried to re-direct her when she constantly walks, but she will seldomly sit down and eat and if she does, it was only for a few moments. Interview with LVN D on 08/19/21 at 12:00 PM revealed she was at the facility the morning of 08/16/21 when Resident #1 had a fall. LVN D said she was not on the secured unit when it occurred, because she had to split her shift working two halls, the secured unit and a hall not on the secured unit. She said she tried to split her shifts where she rotated on the secured unit every two hours, then the non-secured hall every two hours. She said she has 11 residents to oversee on the secured unit when she was back there and 12 on the north hall. LVN D said NA F came to get her on the north hall and said Resident #1 had fallen. She said Resident #1 had an unsteady gait and had fallen and bumped her head on the hand rail in the hallway. When LVN D arrived to the secured unit, she assessed Resident #1 and noted she had a reddened area on her right temple and a laceration to her elbow. She said Resident #1 just got wild and agitated while they tried to calm her down and call the physician. She said she had one of the CNAs with Resident #1 because she was trying to get up and walk, so they had to do one on one supervision. LVN D said when Resident #1 walked the halls of the secured unit, staff had to try and use a gait belt with her because she is a fall risk real bad. LVN D said when the fall incident occurred, she thought that NA F was the only staff on the secured unit. LVN D said when she saw Resident #1's gait get unsteady in the past, she knew what was going to eventually happen and it is scary. She said she would give Resident #1 a snack if she saw her gait become unsteady and give her something to drink and she would usually go and sit down for a few minutes, but then she would be up again walking. LVN D was asked if she was on the secured unit at the moment Resident #1 fell , did she think she could have helped prevent the fall incident. She replied yes and that when she was on the secured unit working, I monitor her more closely, not just let her rattle down the hall, she is fast and goes into other resident rooms. She has to be watched closely. LVN D did not recall any staff other than NA F in the secured unit at the time of the incident to provide supervision to the residents. An interview with CNA E on 08/19/21 at 12:25 PM revealed she had worked in the secured unit for [AGE] years at the facility. She stated she was not working the day Resident #1 was sent to the hospital but had heard she was running and fell forward. CNA E said some mornings, Resident #1 could be fidgety and would walk up and down the hallway but she did not bother anyone or anything, she just liked to walk. CNA E said, But for the past few days before the fall, she was leaning, I guess because she gets tired, you try to sit her down but she has days when she won't stay still and you have to walk with her. An interview with NA F on 08/19/21 at 12:38 PM revealed she was not a certified CNA was and had been working on the secured unit since January 2021. She said she took a 72-hour course to get a temporary certification as a CNA, but was only a nurse aide presently. NA F said she was working on the 6a-2p shift on 08/16/21 when Resident #1 fell , but it was not the fall that sent her to the hospital. She said on her shift, Resident #1 had been leaning back and lost her balance and fell . She said it happened quickly and she hit her head on the hand rail in the hallway. NA F said at the time of the fall, she was in another resident's room helping her with incontinent care/getting dressed and she heard Resident #1 call out. NA F went out the resident's room and saw that Resident #1 was on the floor. NA F said, I was on my own when she fell . She said being by herself on the secured unit, Honestly, it is like that a lot, where I am alone. There are PRNs. but sometimes I am back here by myself 80% of the time. She said LVN D had to work both two halls with another nurse on the south hall and the ADON helped a lot and did CNA work but at the time of the fall with Resident #1, she was alone. She was asked if there had been another staff member on the floor, could the fall for Resident#1 have been prevented. She replied, Yes ma'am. [Resident #1] is really a one on one resident, but I can't bring her in the room when doing patient care. I am always scared if I have to be by myself and do patient care, I try to leave the door cracked and try to keep a look out and do I quick care. Further interview with NA F revealed when she arrived to work for the 6a-2p shift on 08/17/21, there were no staff present on the secured unit to give her report, and LVN G was on the north hall (from the overnight shift). NA F said she started walking the hall and bedrooms to check on the residents and she saw Resident #1 sitting in the dining area on a chair with her legs crossed. She said her entire face, eyes and chin were all bruised and she had two black and purple eyes. She said she asked Resident #1 what happened and responded she did not know. NA F said, I just held her. Her whole face was swollen and bruised. She had a knot on her forehead. She looked like she had been in the ring with [NAME] [NAME]. NA F said she then saw LVN G on the north hall off the secured unit and asked her what happened to Resident #1 and the nurse said it was worse the night before. NA F said EMS came to transport the resident to the hospital but she did not have any further details on what had transpired the night before. An interview with ADON A on 08/19/21 at 2:22 PM revealed on the overnight shift on 08/16/21, LVN G had arrived to work late and was getting report on the north hall and was not working on the secured unit yet. She said LVN G had clocked in and was going to go back to the secured unit after she got report. She said CNA H was on the secured unit by herself until then. ADON A said she had just clocked out for her shift around 10:43 PM and had left the facility. She was told that LVN G was not on the unit but heard the incident while another nurse was giving her report. ADON A was asked if there it was the facility's policy to have one CNA only to work the secured unit. She said during the morning and afternoon shifts, there should always be two CNAs when the residents were up and moving around. She said Resident #1 needed frequent monitoring and if she was up and walking, staff needed to be up and walking with her. ADON A said the facility was currently using non-certified nurse aides for some positions. She said those individuals, like NA F, could do anything as long as they were with a licensed staff or certified staff. ADON A said a nurse aide could not be on the floor by themselves on the secured unit. Further interview with ADON A on 08/19/2 at 3:24 PM revealed she was in charge of staffing for the facility and she staffed the secured unit with a nurse and two CNAs from 6AM-2PM and on the overnight shift, she staffed it with one CNA and one nurse. She said she also tried to put a floater in the building overnight that can go to each hall and help. She said when there was a lack of staff, she would stay until 8 PM or 9 PM and would bring Resident #1 out of the secured unit and walk her around because she needed constant re-direction while the other staff in the secured unit tended to the other residents. ADON A said one of the overnight nurses would be the secured unit nurse and the nurse for the north wing, but she sat in the secured unit unless she had to come to north hall, but an aide was always on the floor. She said the secured unit nurse came off the secured unit twice, once at midnight and once for 6 am med pass. A confidential interview with a facility staff member on 08/19/21 revealed when Resident #1 sustained a second fall on the 10p-6a shift on 08/16/21, the nurse scheduled to work the unit (LVN G) was late to her shift and did not arrive until close to 11 pm, not 10 pm when her shift started. The staff member stated LVN G was a PRN agency nurse and was the only nurse scheduled to work on the secured unit that night. The staff member said the CNA who worked that night was CNA H who reported Resident #1 took off running and she could not catch her and she subsequently fell . The staff member said the secured unit was often staffed with only one person and the facility management was aware of it. An interview with the BOM on 08/19/21 at 1:31 PM revealed ADON A was the staffing coordinator for the nursing staff. He reviewed the punch time detail and schedule for the 08/16/21 morning and overnight shifts and verified who was scheduled and worked on the secured unit during Resident #1's falls. He confirmed that NA F was not a certified CNA. Review of the facility schedule and punch time detail on 08/16/21 for the 6AM-2PM shift reflected NA F and LVN D were working on the secured unit, with LVN D also working the north hall off the secured unit. There was no indication CNA E was working that shift. The punch time detail for the facility reflected there were three CNAs in the building, one nurse aide (NA F), one med aide and two nurses for the census of approximately 50 residents including the secured unit). Review of the punch time detail for the overnight shift (10 PM-6AM) on 08/16/21 through 08/17/21 reflected LVN G was late to work and clocked in at 11:18 PM. Only CNA I and LVN G were scheduled to work in the secured unit for that shift. Review of CNA I's punch time detail reflected she clocked into work at 10:38 PM. The punch time detail for the facility reflected there were three CNAs and two nurses for the census of approximately 50 residents (including the secured unit). An attempt to contact CNA I twice on 08/19/21 were unsuccessful. A message was left with no return call. An interview with the DON on 08/19/21 at 3:38 PM revealed there had been challenges hiring nurses, so the facility was making due with a medication aide. He said there was supposed to be two CNAs on the unit so the nurse could leave the unit and pass medications on the north hall. He said using a nurse aide on the floor who was not a CNA in the secured unit was not recommended, but again, considering the issues with staffing everywhere, because if they were not trained as nurse aides, there would be no staff in here and we have to be thankful for what we have. He was asked if he felt the secured unit was appropriately staffed on the morning and overnight shifts when Resident #1 fell . He responded there were about 14 residents in the secured unit and, I think you can't call anything appropriately staffed so I don't know. An interview on 08/19/21 at 4:16 PM with the ADM and CRN C revealed the secured unit was supposed to be staffed with a dedicated two dedicated staff back there and they realized that did not happen on 08/16/21 at the time when Resident #1 sustained two falls. CRN C said Resident #1 falls on 08/16/21 could not have been prevented. He said, No one prevents a fall falls are not preventable in my estimation. We can put interventions in place, but preventing an injury is the goal. Both the ADM and CRN said even if there had been another staff member in the secured unit at the time of Resident #1's falls, they would not have been able to prevent a fall with and injury. The facility management team was asked to provide a staffing policy on 08/19/21 at 4:30 PM but was unable to provide one.

Based on interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for falls. The facility failed ensure there was adequate supervision when Resident #1 fell twice on 08/16/21. The first fall resulted in a skin tear to the elbow and redness/bruising on her right temple. The second fall resulted in significant facial bruising, swelling and a hematoma to her forehead which required a transfer to the ER due to concerns of a possible skull fracture. These failures could place residents who require supervision assistance due at risk for falls with injuries, hospitalization and a decreased quality of life. Findings included: Review of Resident #1's quarterly MDS assessment, dated 07/31/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses of [CONDITION(S)] with behavioral disturbance, major depressive disorder, [CONDITION(S)], delusional disorder, unspecified [CONDITION(S)], anxiety disorder, malnutrition and cognitive communication deficit. She had unclear speech and was rarely understood and rarely understood others. She had short and long-term memory impairment and severely impaired cognitive skills for decision making. She had signs of [CONDITION(S)] which included fluctuating disorganized thinking and continuously present altered levels of consciousness. Resident #1 had no indicators of [CONDITION(S)], physical or verbal behaviors, rejection of care or wandering. She required one to two-person extensive physical assistance for activities of daily living and was always incontinent of bowel and bladder. She was not steady with balance during transitions or walking and but was able to stabilize without staff assistance. She had no functional limitations in her range of motion. She was 5 foot 4 inches and weighed 88 pounds and had weight loss identified. Resident #1 received antipsychotic, antianxiety and antidepressant medications. The MDS reflected no falls since admission. Review of Resident #1's care plan, dated 02/18/21 and revised 08/06/21, reflected the following problems and interventions: Walking: The Resident has unsteady gait related to weakness. - Ambulate 300 feet with hand held assistance from staff; Problem: Resident is at high risk for falls r/t cognitive decline, [CONDITION(S)] medications, poor safety awareness and history of falls. Goal(s)-Resident will remain free of major injuries related to falls; Approach: Offer snacks and supplements when resident is displaying increased anxiety. Resident enjoys oatmeal cakes, Medication evaluation and GDR as appropriate, Ambulate resident with assist of one and a gait belt when resident is displaying signs of increased anxiety, Frequently redirect resident when unsafe behaviors are noted. Review of Resident #1's clinical chart and the facility's incident and accident log from April 2021 through August 2021 revealed she had falls on 04/05/21, 4/16/21, 04/21/21, 06/19/21, 08/13/21 and twice on 08/16/21 which required a hospital visit due to extensive injuries. Review of a Facility Event Report (Incident Report), dated 08/16/21 and written by ADON A reflected at 8:16 AM, Resident #1 had a witnessed fall by a CNA (not named) where she fell and bumped her right temple on the hand rails. Her right temple was noted to be red and her right elbow had a skin tear. Review of Resident #1's nursing progress notes written by LVN G reflected a late entry on 08/17/2021 02:57 AM This nurse was notified by CNA that resident had fallen and was on the floor. Upon entering the secure unit, nurse noted resident to be on the floor in the middle of the hallway with the left side of her face on the floor crying out in pain. This nurse helped the resident to a sitting position and took her vitals. This nurse noted that the resident had a huge knot in the center of her forehead that was starting to bruise and sweat as well as bruising to the inner canthus of both eyes, as well as the bridge of her nose. This nurse used [MD] standing orders and gave the resident two 325mg tabs of Tylenol for the pain. This nurse also applied a cool compress consisting of ice, towel, and a plastic bag to the resident's forehead which was not measuring 7cm in diameter. This nurse notified the ADON, DON, as well as NP for [MD]. Awaiting call back. Resident in the nurses station with CNA. Resident will keep on follow up on resident's VS as well has monitoring of resident's swelling. A nursing progress note by LVN G on 08/17/21 at 6:31 AM reflected, Resident now has extensive bruising to her forehead, eyes, and cheeks. A nursing progress note by LVN G on 08/17/21 at 8:15 AM reflected, This nurse noted that the resident face continued to bruise with mild swelling and there was no orders in place to request a x-ray. This nurse noted resident to have increased bruising and mild swelling to resident's face. This nurse activated the emergency response to transport resident to the hospital for evaluation and treatment. An interview with the ADM on 08/18/21 at 9:30 AM revealed he got report from report that Resident #1 was running down the hall in the locked unit and she fell and did a face plant. He said the CNA on the hall eye witnessed the resident running before she fell and at that time, the nurse was coming through the locked unit and did neuro checks. The ADM said Resident #1 was sent to the hospital, but he did not know what the condition was. He said Resident #1 had a huge goose egg then her face turned black and blue. An interview with the CRN C on 08/18/21 at 11:32 AM revealed he had visited with Resident #1 prior to the fall incident when he was at the facility one day (date not recalled) because he wanted to see for himself, what she was like. He said he was walking with her and then all of a sudden, she took off down the hall. He said she moved fast. CRN B said the facility tried everything, but nothing was making her situation improve related to falls. An interview with Resident #1's POA on 08/18/21 at 1:33 PM revealed he was notified that on 08/15/21 that she had grabbed a shower curtain and fell , and they were going to bandage her up and he was okay with that. Then on Monday 08/16/21, he said she fell again, and the facility told him they were going to get x-rays because she had a laceration but did not need stitches. The POA said Resident #1 was sent out the next day to the hospital. He was told she had fallen again, and the facility doctor said she needed to be evaluated or they couldn't get x-rays done or something. He said that was good she was being sent out because she had a history of UTIs which usually caused her to get unbalanced and aggressive. The POA said Resident #1 was prone to falls and had fallen in multiple facilities and without one on one care, she is going to fall. He said, She bruises like a peach and the facility had told him she had some bruises on her legs from the fall. He denied concerns with abuse but said, What we would like to see are one or two more staff on the secured unit. He said the last time he visited Resident #1, there was just one charge nurse and an aide who was not on the hall regularly and was leaving the unit to tend to other halls. He said the hospital had told him Resident #1's blood work came back normal, she had no cracked skull and everything looked good, no internal bleeding even though she hit her head pretty hard. He stated the hospital still needed to do a workup on her hips and legs. An interview with ADON A on 08/18/21 at 3:24 PM revealed Resident #1 constantly walked around the secured unit. ADON A said, She walks, walks, walks and leans. It's dangerous, so we tried to put her in a program where we walk her around the building. She likes it and she will hold our arm. She said Resident #1 would walk until she was exhausted. She said Resident #1 had a short attention span where she will change directions mid-walk in where she was headed. She said when Resident #1 fell in the past, it was usually a freak accident. She said the staff tied to re-direct her when she constantly walks, but she will seldomly sit down and eat and if she does, it was only for a few moments. Interview with LVN D on 08/19/21 at 12:00 PM revealed she was at the facility the morning of 08/16/21 when Resident #1 had a fall. LVN D said she was not on the secured unit when it occurred, because she had to split her shift working two halls, the secured unit and a hall not on the secured unit. She said she tried to split her shifts where she rotated on the secured unit every two hours, then the non-secured hall every two hours. She said she has 11 residents to oversee on the secured unit when she was back there and 12 on the north hall. She said having the nurse work two halls, one off and one on the secured unit was normal. LVN D said NA F came to get her on the north hall and said Resident #1 had fallen. She said Resident #1 had an unsteady gait and had fallen and bumped her head on the handrail in the hallway. When LVN D arrived to the secured unit, she assessed Resident #1 and noted she had a reddened area on her right temple and a laceration to her elbow. She said Resident #1 just got wild and agitated while they tried to calm her down and call the physician. She said she had one of the CNA's with Resident #1 because she was trying to get up and walk, so they had to do one on one supervision. LVN D said when Resident #1 walked the halls of the secured unit, staff had to try and use a gait belt with her because she is a fall risk real bad. LVN D said when the fall incident occurred, she thought that NA F was the only staff on the secured unit. LVN D said when she saw Resident #1's gait get unsteady in the past she knew what was going to eventually happen and it is scary. She said she would give Resident #1 a snack if she saw her gait become unsteady and give her something to drink and she would usually go and sit down for a few minutes, but then she would be up again walking. LVN D was asked if she was on the secured unit at the moment Resident #1 fell , did she think she could have helped prevent the fall incident and she replied yes and that when she was on the secured unit working, I monitor her more closely, not just let her rattle down the hall. She is fast and goes into other resident rooms. She has to be watched closely. LVN D did not recall any staff other than NA F in the secured unit at the time of the incident to provide supervision to the residents. An interview with CNA E on 08/19/21 at 12:25 PM revealed she had worked in the secured unit for [AGE] years at the facility. She stated she was not working the day Resident #1 was sent to the hospital but had heard she was running and fell forward. CNA E said some mornings, Resident #1 could be fidgety and would walk up and down the hallway, but she did not bother anyone or anything, she just liked to walk. CNE E said, But for the past few days before the fall, she was leaning, I guess because she gets tired, you try to sit her down but she has days when she won't stay still and you have to walk with her. An interview with NA F on 08/19/21 at 12:38 PM revealed she was not a certified nurse aide was and had been working on the secured unit since January 2021. She said she took a 72-hour course to get a temporary certification as a CNA but was only a nurse aide presently. NA F said she was working on the 6a-2p shift on 08/16/21 when Resident #1 fell , but it was not the fall that sent her to the hospital. She said on her shift, Resident #1 had been leaning back and lost her balance and fell . She said it happened quickly and she hit her head on the handrail in the hallway. NA F said at the time of the fall, she was in another resident's room helping her with incontinent care/getting dressed and she heard Resident #1 call out. NA F went out of the resident's room and saw that Resident #1 was on the floor. NA F said, I was on my own when she fell . She said being by herself on the secured unit, Honestly, it is like that a lot, where I am alone. There are PRNs but sometimes I am back here by myself 80% of the time. She said LVN D had to work two halls with another nurse on the south hall and the ADON helped a lot and did CNA work but at the time of the fall with Resident #1, she was alone. She was asked if there had been another staff member on the floor, could the fall for Resident#1 have been prevented and she replied, Yes ma'am. [Resident #1] is really a one on one resident, but I can't bring her in the room when doing patient care. I am always scared if I have to be by myself and do patient care. I try to leave the door cracked and try to keep a look out and do I quick care. Further interview with NA F revealed when she arrived to work for the 6a-2p shift on 08/17/21, there were no staff present on the secured unit to give her report, and LVN G was on the north hall (from the overnight shift). NA F said she started walking the hall and bedrooms to check on the residents and she saw Resident #1 sitting in the dining area on a chair with her legs crossed. She said her entire face, eyes and chin were all bruised and she had two black and purple eyes. She said she asked Resident #1 what happened and responded she did not know. NA F said, I just held her. Her whole face was swollen and bruised. She had a knot on her forehead. She looked like she had been in the ring with [NAME] [NAME]. NA F said she then saw LVN G on the north hall, off the secured unit, and asked her what happened to Resident #1 and the nurse said it was worse the night before. NA F said EMS came to transport the resident to the hospital, but she did not have any further details on what had transpired the night before. An interview with ADON A on 08/19/21 at 2:22 PM revealed on the overnight shift on 08/16/21, LVN G had arrived to work late and was getting report on the north hall and was not working on the secured unit yet. She said LVN G had clocked in and was going to go back to the secured unit after she got report. She said CNA H was on the secured unit by herself until then. ADON A said she had just clocked out for her shift around 10:43 PM and had left the facility. She was told that LVN G was not on the unit but heard the incident while another nurse was giving her report. ADON A was asked if it was the facility's policy to have one CNA only to work the secured unit. She said during the morning and afternoon shifts, there should always be two CNAs when the residents were up and moving around. She said Resident #1 needed frequently monitoring and if she was up and walking, staff needed to be up and walking with her. An confidential interview with a facility staff member on 08/19/21 revealed when Resident #1 sustained a second fall on the 10p-6a shift on 08/16/21, the nurse scheduled to work the unit (LVN G) was late to her shift and did not arrive until close to 11 pm, not 10 pm when her shift started. The staff member stated LVN G was a PRN agency nurse and was the only nurse scheduled to work on the secured unit that night. The staff member said the CNA who worked that night was CNA H who reported Resident #1 took off running and she could not catch her, and she subsequently fell . The staff member said the secured unit was often staffed with only one person and the facility management was aware of it. An interview on 08/19/21 at 4:16 PM with the ADM and CRN C revealed the secured unit was supposed to be staffed with a dedicated two staff and they realized that did not happen on 08/16/21 at the time when Resident #1 sustained two falls. CRN C said Resident #1's falls on 08/16/21 could not have been prevented. He said, No one prevents a fall; falls are not preventable in my estimation. We can put interventions in place, but preventing an injury is the goal. Both the ADM and CRN C said even if there had been another staff member in the secured unit at the time of Resident #1's falls, they would not have been able to prevent a fall with an injury. Review of the facility's policy titled, Managing Falls and Fall Risk revised July 2019, reflected, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and caused and try to prevent the resident from falling and try to minimize complications from falling; .Fall Risk Factors .2. Resident conditions that may contribute to the risk of falls include: .c. [CONDITION(S)] and other cognitive impairment; .g. medication side effects; .Resident Centered Approaches to Managing Falls and Fall Risk- .4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Residents #1) of six residents reviewed for supervision. On 07/14/16, staff failed to supervise Resident #1, a resident with severe cognitive impairment, when he was out on a courtyard in direct sun for approximately 2.75 hours. As a result, the resident was found with blisters to his arms and legs and was transferred to a local hospital. He was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 07/25/16. While the IJ was removed on 07/28/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still implementing its Plan of Removal. This failure could affect all 33 residents, who had access in the courtyard, by placing them at risk of severe sunburns, pain and/or death. Findings included: Review of Resident #1's face sheet record revealed Resident #1 was a [AGE] year-old male diagnosed with [REDACTED]. The resident was admitted to the facility on [DATE]. Resident #1's MDS, dated [DATE], revealed he had severe cognitive impairment. The resident was alert to name only, and required one-person assistance with activities of daily living. Review of Resident #1's Care Plan dated 06/16/16, revealed Resident #1 wandered throughout the facility looking for his room with the goal of being kept from injury to self through monitoring, diversional activities, and removal of dangerous objects or chemicals from reach. The resident was also care planned for dementia, which included minimizing the risk of sustainment of injuries related to wandering, anxious or agitated behavior, and behavioral outbursts. Review of an Incident and Accident Report, dated 07/14/16, revealed Resident #1 had blisters on his right forearm and left leg, above the knee. Review of the Incident/Accident Final Disposition Report revealed CNA A saw the resident sitting outside at 2:30 p.m. and asked him if he wanted to go inside, twice. The resident refused. At that time, CNA A gave Resident #1 water to drink and came back to check on the resident around 4:45 p.m. to bring the resident inside. The reported cause of the occurrence was the resident's [DIAGNOSES REDACTED]. The resident was immediately given a head-to-toe assessment on 07/14/16, was given fluids, and transferred to the hospital. The resident returned to the facility the same day; he received treatments for blisters. According to the Weather Undergound, on 07/14/16, the high temperature was 97 degrees Fahrenheit. The information was accessed on 08/10/16 at www.weatherundergrond.com. Review of the comprehensive Pain Assessment Form, dated 07/14/16, reflected Resident #1 was a cognitively impaired resident with confused mental status. The resident was outside at the documented incident time of 4:45 p.m. on 07/14/16, and was found by CNA A who reported the incident to LVN B. The resident was noted sitting in the smoke area (courtyard) in direct sun. His vital signs revealed his blood pressure was 114/74, Pulse 130 beats per minute, with respirations at 19, and his temperature at 98.2. He sustained blisters to his arms and left knee. His family and physician were notified, and the resident was transferred to the hospital. Resident #1's nurses' notes, dated 07/14/16, reflected also revealed that he was given oxygen prior to being transferred to the hospital. The Health & Hospital System After Visit Summary for Resident #1, dated 07/14/16, reflected the resident's [DIAGNOSES REDACTED]. According to the Merck Manual, Consumer Version, section titled Burns, thermal burns are injuries to skin or other tissue cause by any external heat source. Symptoms of a second-degree burn included pink or red, swollen, and extremely painful. Within 24 hours (often shortly after the burn), blisters develop that may ooze a clear fluid. The burned area may blanch when touched (also called partial-thickness burns) extend into the middle layer. The information was accessed on 08/08/16 at http://www.merckmanuals.com/. Interview with CNA A on 07/19/16 at 11:02 a.m. revealed at 2:30 p.m., she asked Resident #1 to come inside, but the resident refused. She stated Resident #1 did not generally refuse to follow directives; however, if Resident #1 did not want to do something, he would not do it. She said he seemed like his normal self. She stated she asked the resident to move to the shade and the resident refused to move. She stated she gave him ice water. She stated she told LVN B the resident was outside and refused to come into the facility. She said she checked on Resident #1 between 5:00 p.m. and 5:15 p.m. She said he was not responsive and she went to get the charge nurse. LVN B assessed the resident while she got a wheelchair and an aide to come and assist to bring the resident inside the building. She stated she had not supervised him between 2:30 p.m. and the time she discovered him unresponsive between 5:00 p.m. and 5:15 p.m. Review of the witness statement by LVN B, dated 07/14/16, revealed CNA A had not informed him Resident #1 was sitting outside. CNA A approached him and was sweating and out of breath as she explained that Resident #1 was outside and refused to come inside. He said the CNA stated she informed him twice that the resident was outside, but this statement is false; she told him once and when she did, he took action to remove the resident from outside. Interview with LVN B on 07/19/16 at 12:19 p.m. confirmed the above written statement. He added that after the incident, Resident #1 acted as though he had difficulty, but he was alright; he was groggy. He was assisted to standing, and then transferred to a wheelchair and taken inside the facility. The DON and ADON were asked to come assess the resident. They assessed him, provided fluids, checked his vital signs, and used a cold compress. LVN B called 9-1-1 while the ADON and DON assessed the resident. Interview with the DON on 07/19/16 at 8:42 a.m. revealed after staff took Resident #1 to his room, she and the ADON were called to assess him. He was given a cold compress, fluids, and ate dinner. He did not complain of pain, but was sent to the hospital. She said he returned to the facility that night. The facility took wound cultures as she thought the blisters could be a result of a condition called [DIAGNOSES REDACTED]. She said the facility was waiting on the lab results to come back. Resident #1 did not typically like to be outside. He was a safe wanderer inside of the building. According to the Merck Manual, Consumer Version, [DIAGNOSES REDACTED] is an [DIAGNOSES REDACTED] disease that causes blistering of the skin. The information was accessed on 08/08/16 at <http://www.merckmanuals.com/> During a subsequent interview with LVN B on 07/19/16 at 9:02 a.m. he said Resident #1's left arm had completely dried out, but his right arm had not. The wound doctor came to the facility on ce a week, every Tuesday, until the wounds healed. He saw the facility's treatment nurse daily. It was out of the ordinary for Resident #1 to go outside. Occasionally, he would need to be redirected and would comply, but it was also dependent on his dementia. If he did not want to come back in the facility when CNA A asked him to come in, she should have reported to someone whom he related to. He should have been shaded or covered until the situation could be changed. Observation of Resident #1 on 07/19/16 at 10:16 a.m. revealed the Wound Care Doctor and Treatment Nurse were with the resident. There were wounds on Resident #1's left leg above the knee, going up toward the inner thigh, in three separate shapes with various open wounds and blisters. There were three scabbed wounds on the left forearm near the fold of the arm. The right arm had open wounds beginning mid-forearm up to the fold of the arm. During the observation on 07/19/16, Resident #1 said the wounds did not hurt, but stung until cream was applied. The resident did not remember how the wounds got there, but stated, It feels like I got them from hot water. Interview with the Wound Care Physician on 07/19/16 at 10:18 a.m. revealed the wounds looked like a burn, but it could be a reaction to a potential [DIAGNOSES REDACTED] disease. She had treated the type of issue before, but the triggers were different. Resident #1's clinical record revealed a laboratory report for a test done on 07/15/16. The document revealed there was no growth or positive culture on the right arm. Interview on 07/19/16 at 10:08 a.m. with CNA D revealed he smoked the residents every morning. In the heat of the day, a resident could go outside for a few minutes. The resident must come in out of the sun in a relatively short amount of time. Residents were hydrated when they were outside. The staff were to check anytime they walked past the smoking courtyard. He also stated that leaving the resident outside was neglect. Review of the undated Resident Smoking Schedule revealed scheduled smoke breaks were at 8:30 a.m., 1:00 p.m., 6:30 p.m. and 8:30 p.m. There were no scheduled smoke breaks during the timeframe Resident #1 was in the courtyard (approximately 2:30 p.m. and 5:15 p.m.). Observation on 07/19/16 at 8:35 a.m. of the courtyard revealed it was in the center of the facility. There were two entrances to the courtyard. One entrance faced the front door of the facility and was accessible by the administrative office. The other entrance was accessible to the facility day room which was flanked on either side by a nurses' station where LVN stations were located. An interview with LVN B on 07/19/16 at 9:02 a.m. revealed there was a 12:1 ratio outside for care when residents were in the courtyard. Review of in-service records revealed the staff were trained the day after Resident #1 was discovered in the courtyard on 07/14/16. The in-service topics on 07/15/16 were abuse and neglect, Charge Nurse Duties, [DIAGNOSES REDACTED] (auto-immune disease), heat exhaustion, and behavioral assessment. There was no evidence the facility in-serviced staff regarding procedures to implement in the event a resident wanted to remain outside on a day when a resident was at risk of sunburn and hydration issues due to the elevated temperatures. An IJ was identified on 07/25/16 at 12:25 PM. The Administrator was notified of the IJ. A Plan of Removal was requested. Plan of Removal (PoR) was accepted on 07/27/16 at 5:45 PM. The PoR reflected the following Action Taken: LVN B and CNA A were suspended after the occurrence on 7/14/16. They were asked to come to the building on 7/15/16 to write their statements and informed they would be suspended through the investigation. After the investigation, the ADM and DON met with LVN B and CNA A on 7/19/16 and terminated them. On 7/25/2016, Residents in all three units were reassessed for wandering and behavior using the wandering and elopement risk assessment tool. According to the assessments, the only resident found with a change in assessment is Resident #1 who was placed on the Secured Unit. For the residents not in the secured unit, the facility implemented the same procedures of intervention and redirection as outlined by the behavior management policy revised and put in place in this plan of removal. The POR listed six residents who were assessed on 7/25/16 and did not reside on the secured unit, and were identified as refusing care and exhibiting behaviors but not wandering or exit seeking behavior: Resident #2 assessed by LVN W, Residents #3, #4 and #5 assessed by LVN J, and Residents #6 and #7 assessed by LVN U. The PoR reflected the following in-service was started on 07/25/16 by RNC: Behavior Management crisis which includes dementia care approaches and communication, using policy dated 2012. It noted all training would be completed on 7/29/16. RNC would compare the signature list to a current list of employees and report to the Administrator upon completion. Employees would not return to work until in-services are completed. All new employees would be covered for this in-service in new hire orientation. Out of the 80 employees, they had 26 remaining that need to be completed. To ensure comprehension of the in-services completed, validation testing of Staff was completed for understanding of completed in-services. The PoR reflected in-services would be conducted every quarter for one year and annually thereafter, as well as incorporated into new hire orientation for newly hired employees. The ADM would be responsible for ensuring this continued training. The PoR reflected Interventions to remove the IJ: --To remove the immediacy of a resident being left outside unattended, we (all staff) are closely monitoring all residents. --Resident #1 was assessed along with other residents in the facility to ensure proper placement and he was the only one that met the criteria to be placed in the secure unit. He was immediately transferred for safety. --On July 26, 2016, key pads have been placed on the courtyard to ensure safety and maintain residents rights. The Policy and Procedure for Keypad operation is attached. The Director of Maintenance will check the keypads for functionality per policy. --In-services identified above have been started to ensure the deficient practices do not occur. The facility is ensuring that all staff are trained by marking a checklist by employee roster. All staff will be in-serviced by July 29, 2016 and ongoing training will be provided as previously stated. --The facility is monitoring on weekends with interviews conducted by WRN V. This weekend monitoring includes supervision of staff for appropriate training as assessed by randomly asking staff questions from the validation test included in the attachment. The WRN V will also make round through the building to monitor the residents location. Reports will be provided to Administrator/DON for review on Monday. Any issues identified on the weekend will be corrected through further training and reported Administrator/DON immediately. --The facility staff monitor residents daily and staff note changes of condition on the 24 hour report. If a resident has a change of condition, a full assessment is completed on that resident. This process of noting the change of condition will trigger a domino effect that will place a resident who has a change of condition and is no longer appropriate for the open unit on the secured unit for increased safety, and also include updating the plan of care. If no change of condition is noted, each resident has a full assessment quarterly and annually. If a decline is found at that point, residents presenting with a decline that results in wandering or the potential to wander will be placed on the secured unit. The DON is responsible for monitoring this process. --A QAPI was held on 07/25/16 and will continue monthly x 3 months to validate ongoing compliance. --DON and Administrator will interview staff daily to ensure competency. To confirm the facility implemented the Plan of Removal the following observations, interviews and records reviews were conducted: Review of the staff in-service training report and post test, dated 7/27/16, revealed the facility in-serviced CNAs, LVNs, Housekeepers, Administrative, and Activities staff on the subject 'Dementia Care: Approaches and Communication Technique' and Behavior Management using the facility's Behavior Assessment- Management interventions policy, dated 03/2012. Interviews with facility staff on 07/27/16 beginning at 1:35 p.m. confirmed the staff had received the above training and had understanding of the training. The staff interviewed were as follows: - 6:00AM- 2:00PM Included CNA S, MA T, LVN I - 8:30AM- 3:00PM included HK L - 2:00PM-10:00PM included CNAs K, R, and LVN J - 10:00AM-6:00AM included CNAs F, G, O, P and LVNs E, H, N, FT X - Weekend Double Shift Supervisors 6:00 AM to 10:00 PM included LVN Q. Observations on 07/27/16 and 07/28/16, revealed residents were supervised while outside and were provided fluids as needed. On 07/28/16, the IJ was removed. On 07/28/16 at 5:11 p.m., the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope pattern because the facility still implementing its Plan of Removal. Form CMS-672, Resident Census and Conditions of Resident, dated 07/19/16, identified 33 residents with cognitive impairments.

Based on observation, interview and record review, it was determined the facility failed to provide one (Resident #14) of seven residents reviewed for falls with adequate supervision to prevent accidents. The facility failed to ensure care planned intervention developed to address Resident #14's history of falls was implemented. Resident #14 fell and fractured his left hip after being left alone in his room in a wheelchair. This failure had the potential to affect the 53 residents who required staff assistance with transfers by placing them at risk for injuries including fractures, pain and decreased quality of life. Findings included: Review of Resident #14's closed clinical record revealed a discharge summary dated 04/18/16. The summary reflected the resident was discharged on [DATE] after being transferred to the hospital on [DATE]. Further review of the closed record revealed the most recent Minimum Data Set assessment was dated 03/23/16. The assessment reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Additionally, the assessment reflected Resident #14 had functional limitations of the upper and lower extremities on one side, required the physical assistance of two persons for transfers and cognitive skills for daily decision making were severely impaired. A comprehensive care plan initiated 02/15/16 addressed a recent fall on 02/15/16. Interventions included keeping Resident #14 close to the nurse's station when he was out of bed. The care plan reflected a review date of 03/24/16. Documentation on the care plan reflected interventions were to be continued for the next 90-days. The most recent fall risk assessments were dated 03/23/16 and 04/14/16. According to the legend on the assessments a score of 10 or greater indicated a high risk for falls. Resident #14's scores were 17 and 15 respectively. Review of incident/accident tracking and trending logs for the past 90-days revealed Resident #14 had experienced falls on 02/15/16 and on 04/14/16. Review of the incident/accident report dated 04/14/16 reflected on 04/14/16 at 6:15 a.m. the resident was attempting to stand from a sitting position in a wheelchair, lost his balance and fell on to the floor of his room. An x-ray report dated 04/14/16 reflected the fall resulted in a fracture of the left hip. An interview conducted with Licensed Vocational Nurse (LVN) G on 04/27/16 at 5:35 p.m. revealed she was the day shift charge nurse and had been responsible for providing care for Resident #14. She stated the resident was cognitively impaired; talked to and referred to himself in the third person and would frequently just stand up from sitting in the wheelchair. LVN G further stated the resident had a history of [REDACTED]. An interview with Certified Nurse Aide (CNA H) on 04/28/16 at 11:35 a.m. revealed she had provided care for Resident #14. CNA H stated she had assisted Resident #14 up from bed and into the wheelchair on the morning of 04/14/16. She further stated on 04/14/16 after she assisted the resident into the wheelchair she heard another resident call out for help. She left Resident #14 in the wheelchair in his room and then went to check on a resident across the hall. Additionally, CNA H stated the resident across the hall wanted her lights turned off. After CNA H turned the lights off she turned to leave the room across the hall and observed Resident #14 standing and then fall. CNA H stated she was aware Resident #14 would frequently stand up from sitting in the wheelchair and the resident was not safe to stand without assistance. She stated she always placed the resident near the nurse's station so he could be observed more closely due to his tendency to stand up without warning. CNA H stated she had not been informed of any special care or given any instructions related to keeping Resident #14 near the nurse's station when the resident was out of bed. An interview with LVN I on 04/29/16 at 12:40 p.m. reveled she was the night shift charge nurse and had been on duty during morning of 04/14/16 when Resident #14 fell . She stated CNA H informed her of the resident's fall. LVN I further stated she recalled someone told her the resident should be kept in plain sight. Additionally, LVN I stated it would not have been appropriate for the resident to be up in a wheelchair in his room alone. The facility's fall prevention policy/procedure (P/P) dated effective January 2008 was provided by the Director of Nurses (DON) on 04/29/16 and identified as current. The P/P reflected residents would be evaluated for their risk for falls and interventions for prevention would be developed. The P/P reflected the goal of developing interventions was to prevent falls if possible and to avoid any injury related to falls. The CMS-672 (Resident Census and Conditions of Residents), signed by LVN F on 04/28/16, reflected 11 residents were totally dependent on staff for transfers, and 42 residents required the assistance of one or two staff for transfers.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for one (Resident #4) of two residents reviewed for pressure ulcers. The facility failed to develop a care plan and implement inteventions to prevent Resident #4, who was at high risk for developing pressure ulcers and had a new prosthesis, from developing pressure ulcers. The facility failed to assess Resident #4's skin on 02/18/14, when his skin assessment was due. When a pressure ulcer was seen on Resident #4's knee under his prosthesis, the facility failed to promptly assess the pressure ulcer, failed to notify the physician of the new pressure ulcer and obtain treatment orders, and failed to notify the company who provided his prosthesis, until surveyor intervention. Resident #4 had a Stage II pressure ulcer, which was causing him pain. These failures could affect the two residents, who had pressure ulcers, by placing them at risk for pain, infections, delayed healing and worsening of the pressure ulcer. Findings included: Resident #4's MDS assessment, dated 08/09/13 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. He had severe cognitive impairment, was usually understood and able to understand others. The resident required supervision with ADLs, had a prosthetic limb, was at risk for pressure ulcers, but did not currently have any pressure ulcers. Although Resident #4's MDS assessment reflected he was at risk for pressure ulcers, the resident's Care Plan, dated 08/13/13 updated 02/03/14, did not address he was at risk for pressure ulcers. Resident #4's Skin Assessment sheet, dated 02/11/14, reflected his skin was intact. During initial tour of the Secured Unit on 02/18/14 at 9:20 AM, LVN D stated Resident #4 was ambulatory, was a below the knee [MEDICAL CONDITION], and had no skin problems. The resident was observed wearing a prosthesis on his left knee. The resident pointed to the top portion of the prosthesis and complained he had pain in this area. When Resident #4 removed his prosthesis, there was an open circular pressure ulcer, which was the size of a dime to the outer aspect of his left knee. On 02/19/14 at 1:00 PM, Resident #4 removed his prosthesis and the pressure ulcer on the left side of his knee was uncovered and in direct contact with the gel liner of his prosthesis. When asked if it was painful, the resident replied, "Yes." On 02/19/14 at 2:30 PM, more than 24 hours after the discovery of the pressure ulcer, the surveyor asked LVN E to measure the pressure ulcer. LVN E measured the pressure ulcer, which measured 1.0 cm by 0.5 cm. The pressure ulcer was red, open, circular and was a Stage II. LVN E stated he was unaware the resident had a pressure ulcer. LVN E stated he would call the physician and obtain treatment orders. A confidential interview revealed staff were informed the prosthesis was rubbing the resident and causing a pressure ulcer. http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm reflected, "A pressure ulcer is an area of skin that breaks down when something keeps rubbing or pressing against the skin...Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated...." (retrieved on 03/06/14) Review of Resident #4's Skin Assessment sheet, dated 02/01/14, revealed the assessment was not updated to reflect the Stage II pressure ulcer on his knee. On 02/19/14 at approximately 2:00 PM, Resident #4's Treatment Sheet, dated 02/19/14, was reviewed and did not reveal a treatment was administered to the pressure ulcer found on 02/18/14. Resident #4's Care Plan, dated 08/13/13 and updated 02/03/14, did not reflect the pressure ulcer identified on 02/18/14. On 02/20/14 at 7:50 AM, LVN D was asked why the physician was not notified, why no treatment orders were obtained and why Resident #4's skin assessment was not updated. LVN D stated she was responsible for the skin assessments for residents in "A-bed." LVN D revealed Resident #4 was in a "B bed," and the 2:00 PM to 10:00 PM shift nurse assessed residents' skin in "the B-bed." LVN D stated she informed LVN E of Resident #4's pressure ulcer. The facility's current policy, Skin Integrity Monitoring System, revised March 2012, reflected, "...when a pressure ulcer is identified the assessment of the ulcer must be documented on the skin assessment flow sheet ...the care plan is to be updated...the physician is to be notified, treatment orders are secured and the resident's care plan is to be amended to reflect the treatment interventions." The policy also reflected friction injuries may be reduced by using protective padding. An interview with the Owner of the Prosthetic company on 02/19/14 at 12:50 PM revealed the company fitted the resident with the prosthesis in November 2013. He stated the facility was informed at that time to call them if the resident had any problems with the prosthesis. He revealed he had not received any calls from the facility. The Owner stated if the resident developed an open area, he should not be wearing the prosthesis as it did not allow the skin to breathe. In an interview on 02/19/14 at 12:15 PM it was revealed the Resident # 4's family was not notified of the pressure ulcer. On 02/19/14 a physician's telephone order was obtained to clean the wound to the left lateral knee with wound cleanser, apply non-adherent pad and secure with tape until healed. The Wound Care Specialist Evalution, dated 02/20/14, reflected, "...Consulted for left, lateral knee wound...has a shear wound of the left, lateral knee of at least 1 days duration. There is light serous exudate associated with the wound. There is no indication of pain associsciated (sic) with this condition...WOUND SIZE (L (length) X (by) W (width) X D (depth)): 1.3 x 0.8 x 0.1 cm...No treatment will be effective unless prosthesis is re-fitted. Please refer to orthotist...Please refer to orthotist for prosthesis re-fit...." On 02/20/14 at 2:30 PM, the Owner of the Prosthetic company stated they would re-evaluate Resident #4's prosthesis and possibly provide padding to protect the pressure ulcer. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated and completed by the Administrator on 02/18/14, reflected two residents had pressure ulcers.

Based on interview and record review, it was determined the facility failed to implement the facility's written policies and procedures that prohibit mistreatment, neglect and abuse of one (Resident #1) of six residents reviewed for combative behaviors as evidenced by the following: On 04/06/11, Resident #1, who was upset, went outside the facility, using the door's keypad, but without signing out, and the ADON went after the resident and made her return to the facility. The resident did not want to come back into the building at that time, and attempted to hit the ADON and was yelling and cursing. The ADON did not leave the resident alone, and brought her into the facility. RA A then assisted the ADON in manually holding the resident in her wheelchair, which had a seat belt restraint in place, and the resident became even more combative, increasing the resident's emotional distress. The ADON's scrub top was torn by the resident. RA A and the ADON held the resident down, holding onto her wrists and wrapping an arm around her while in her wheelchair, taking her to her room, where the resident was administered [MEDICATION NAME] (anti-anxiety). The resident was discharged on [DATE] to family for yelling and cursing and kicking the Administrator's door. She was one-on-one and did not like it. She continued to refuse to go to the secure unit, and she was then discharged immediately to her family due to her behaviors. These failures could affect the 73 residents in the facility and placed them at risk for the potential of verbal, physical and mental abuse, when they demonstrated any behavioral problems, being man-handled and medicated without need, without effort being made to allow the resident to calm down by simply being left alone, otherwise resulting in the incident escalating beyond control, and requiring medication or even hospitalization . Findings included: A review of the facility's current abuse policy and procedure dated January 2005 revealed: "... Policies: The Resident has right to be free from corporal punishment and involuntary seclusion. The Resident has the right to be free from abuse: verbal, mental, physical or sexual. Procedure: The facility will upon admission, and periodically, inform the Resident of the definition of A. Verbal abuse which is the oral, written and gestured language which could be viewed as disparaging or derogatory intent which is directed towards the Resident, the Resident ' s family or within hearing or visual distance regardless of age, disability or ability to understand. Example: Threats of harm, instilling of fear, verbal, slander, etc. B. Physical abuse includes hitting, kicking, slapping, pinching, and controlling behaviors through corporal punishment. C. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. D. Mental abuse includes harassment, humiliation, demoralization, threats of punishment or depravation. E. Involuntary seclusion: Separated from Residents or room without Resident's consent or medical cause. 2. The facility will upon admission and periodically inform the Resident of the right to be free from abuse/corporal punishment/involuntary seclusion. 3. Emergency short-term monitored seclusion will not be considered abuse, provided that the facility had documented the following: a. The concern, which led the consideration of seclusion. b. The concern was due to failure to meet to needs of the resident, provided meaningful activities or manipulate the resident's environment. c. Reason for concern cannot be removed. d. If reason could not be removed, the facility attempted, without success to utilize alternatives to separation. e. When alternatives to separation. f. The resident or the resident's representative was involved in the care plan of behaviors or medical condition to the highest practicable extent. g. The facility monitors and modifies the resident's care in an attempt to utilize the least restricted means to manage care. 4. The facility Inter-Disciplinary Care Plan Team has utilized the RAP process to attempt identification of precursors to concern and least restrictive methods to manage concern and to plan care." A review of the facility's current Abuse guidelines Subject Behavior crisis effective date January 2005 revealed: Guidelines 1. Implement measures to ensure safety. 2. Summon additional staff if need. 3. Diffuse crisis through calming communication. 4. Assess need for additional intervention: Remove resident from situation Remove offending stimuli from resident Place resident in sage environment Remove onlookers from the area 5. Assess need for physical restraint. 6. Contact physician and facility on-call person for additional interventions. 7. Contact local police if behavior crisis requires immediate removal from facility. 8. Contact administrator/designee and family (if resident mentally incapable;otherwise defer to residents wishes.) 9. Document the crisis including description of incident, resident's perception, interventions, outcomes and steps taken to prevent reoccurrence. 10. Evaluate behavior crisis using the following guide A review of the facility's current policy and procedure manual, section abuse guidelines, effective date January 2005, entitled, "Subject Behavior Intervention General Guidelines" : 1. Careful assessment using the behavior symptom assessment assists in identifying causes for behavioral problem, which leads to the development of affective intervention. 2. Interventions for probable behavior symptoms. Respect individual's needs as a valued adult. Guidelines: 1. Interventions are developed based on information contained in the MDS triggered wraps, core program/discipline-specific assessments, and the behavioral symptoms assessment. 2. Interventions are recorded on the Individual Resident Care Plan as well as in the Interdisciplinary Progress Notes. 3. Results of interventions are recorded in the Disciplinary Progress Notes. 4. Additional approaches for dealing with behavioral problems are continued in the resource section of this manual. 5. Interventions are also found at the Computerized Care Plan Library. 6. Additional assessments and information sources for developing resident-specific interventions are listed below and are located in section 3 of this manual. Mini mental state assessment, dementia functional assessment, and resident personal profile. Procedure Guidelines: 1. Suggested intervention strategies include involving the resident council. Resident council, a self-governing body of persons residing in the facility that works towards common goals as they are related to the quality-of-life issues. Council involvement may be instrumental in providing a sense of integrity, involvement, and accomplishment. Encourage reminiscence. Reminiscence involves recapturing and reviewing one ' s past and may provide individual with experience which reconfirms significance and meaning of their life. Engage in support groups. Support groups allow individuals who share common concerns or have common problems to benefit from a group experience. Often these groups provide an outlet for emotional reactions and show individuals that they are not alone in what they are feeling. Involve in recreation programs. Recreation programs offer individuals the opportunity for social interactions with their peer group and provide a sense of continued involvement. Offer reality orientation. Reality orientation - provides reminders of basic current of personal information. This may help an individual make meaningful contact with the world around them. Provide re-motivation. Re-motivation allows individuals to benefit from focus group interaction while group leaders guide a discussion of familiar topics that may have emotional relevance. Utilize validation therapy. Validation therapy means validating, not correcting, an individual ' s response, thus adding to the person's sense of well-being. 2. The following chart demonstrates how validation therapy must be used to address behavior problems. Behavior - Hitting a staff who attempted to provide care. Emotional Need - Fear, inability to grasp what is expected, or a triggered memory of being mistreated. Validation Therapy Technique - Go away. Return in five to ten minutes. Explain calmly and step by step what you wish to do. Do distract by commenting on how much you like the feeling of her skin, color of her eyes, clothes he is wearing, etc. Behavior - " Go away. If you touch me, I will hit you with my cane. " Emotional Need - Fear, anger, powerlessness, or she does not like the staff person or the way she is being approached. Validation Therapy Technique - Stand away. Speak softly, gently, speaking resident ' s phrases and concerns. Do not argue or reprimand. Move closer as agitation decreases. Stroke arm and rub back as tolerated. 1) Resident #1, a [AGE] year-old female, was originally admitted to the facility on [DATE] and a most recent readmitted [DATE] per the admission face sheet dated 04/07/11 with diagnoses, which included: [MEDICAL CONDITION], Convulsions, Diabetes, [MEDICAL CONDITION], Anxiety, and [MEDICAL CONDITION]. Resident #1's care plan dated 11/04/10 reflected: "Resident had episodes of Resistance to ADL (Activities of Daily Living) care. Approach: Monitor for early warning signs of behavior. Provide a calm environment. Approach in a calm manner. Call by name. Speak slowly. Maintain eye contact. Talk while giving care and allow time for response. Do not rush. Encourage appropriate behavior. Discourage inappropriate behavior. When refuses ADLs care, re-approach at a later time. Psych consult per order." The care plan was reviewed on 02/02/11 and continued for another 90 days. A review of Resident #1's MDS assessment dated [DATE] revealed the resident usually understood and was usually understood by others. She had some impaired vision. She had some long-term memory deficits but had good short-term memory recall. She had inattention, which was present and fluctuated. She had disorganized thinking, which was not easily altered. She had altered level of consciousness, which fluctuated. She had psychomotor [MEDICAL CONDITION], which fluctuated. Resident #1 was assessed as not needed to be assessed for her mental status and had no evidence of change in her mental status. When the resident was interviewed about her mood, she only complained of feeling tired 2-6 days a week. Resident #1 exhibited verbal behavioral symptoms directed towards others one to three days a week. The MDS assessment reflected Resident #1 used a wheelchair for mobility and was independent for locomotion on and off the unit. Review of Resident #1's Geriatric Progress Note-Psychiatry dated 03/29/11 revealed the resident was fully oriented to person, place, date and time and current diagnoses, which included: [MEDICAL CONDITION] with Depressed Mood, [MEDICAL CONDITION] Disorder, Depression Disorder and [MEDICAL CONDITION]. Resident #1's consolidated physician's orders [REDACTED]. 2. The facility's Provider Investigation Report dated 04/07/11 reflected an incident involving Resident #1 occurred on 04/06/11 at 8:50 AM. The Report reflected an allegation of abuse had been made by the resident naming the facility's only ADON and RA A, who denied the allegation. The allegation was described as: "Staff used inappropriate techniques for resident behavior." The Investigation Findings confirmed the allegation. The Investigation Summary reflected Resident #1 was extremely upset, yelling and cursing, because someone had taken the adult briefs, which she considered to be hers even though they had been given to her by the facility. The Administrator and charge nurse were having difficulty calming her down. The Administrator finally took her to the social services director, where the social services director and the ADON spoke to the resident. The Administrator thought Resident #1 had calmed down and the continued with the stand up meeting. Resident #1 was observed from the Administrator's office outside the facility. The resident was asked if she had signed out. She said no and continued to swear. The Activity Director left the meeting to ensure Resident #1's safety, and they went to the convenient store so the resident could get some chips. The resident did not find what she wanted and left, and refused to let the Activity Director and another staff person help her back to the facility. The resident returned to the facility on her own although she was still yelling and cursing. The resident again decided to leave the facility and again did not use the accepted facility procedure. Staff again followed her out of the facility. The resident was still yelling and cursing. The resident appeared to look as though she were going to try to cross the street while there were cars passing. The resident was assisted back into the building. When asked if she (Resident #1) wanted to go to the secured unit, the resident's response was the secured unit was for "crazy people." The resident continued to swing her arms and attempt to hit staff, who were taking her back to her room. In the process, Resident #1 ripped the ADON's top. More staff were involved in handling the resident and getting her back to her room. The resident was administered a shot of [MEDICATION NAME] (anti-anxiety). And the resident calmed down. The resident remained calm until 04/08/11. She had been placed on one-on-one for being assessed as high risk for elopement. The resident was offered the secured unit, but the resident refused and yelled at staff. The Administrator told the resident she had left the facility without signing out and had to either go to the secured unit or be discharged . The resident continued to refuse to go to the secured unit. The resident was angry at being one-on-one. The Administrator had no success in finding placement for Resident #1. At 4 PM on 04/08/11, Resident #1 began yelling and cursing and kicking the Administrator's door, still refusing to go to the secured unit. The police were called and informed the Administrator they could do nothing. The Administrator got an order for [REDACTED]. The Administrator tried to provide information to the family and answer their questions and left, hearing the family member and the resident yelling and cursing. 2) In an interview with the facility's Administrator on 04/07/11 at 9:15 AM, she stated she was aware of the prior day's incident (04/06/11) at the nurses station with Resident #1. The Administrator stated there had been a verbal altercation between Resident #1 and another resident. The Administrator stated Resident #1 was upset over some incontinent briefs she thought had been stolen. The resident had left the facility and had been brought back by the (facility's only) ADON. The Administrator stated the nurses and "staff almost kind of restrained her." The Administrator was not present until after the staff had gotten Resident #1 to her room. The Administrator further stated Resident #1 alleged she had been choked by the ADON and RA A during the incident. She stated she had started to get statements from the witnesses and stated she was trying to figure out "Who did the choking?" In an interview with the ADON on 04/07/11 at 9:25 AM she stated Resident #1 had been upset over some pull-ups (briefs). She stated the staff were in their morning meeting and saw Resident #1 exit the facility. The door was key pad coded and the resident used the code to leave the facility. The ADON stated she had brought the resident back into the facility. She stated Resident #1 had ripped her shirt, because the resident was agitated. The ADON stated she was behind the resident when the resident grabbed her shirt. RA A was in front of the resident. In an interview on 04/07/11 at 9:45 AM with Resident #1, she stated she called the police this morning because "____ (the ADON) had choked her. A girl named ____ (RA A) did, too." Resident #1 acknowledged she had been upset. She stated RA A had "hold of her neck and hurt it." The resident pointed to the center of her neck and stated it had been hurting there. She stated, "They were going to give me a shot, and I didn't want a shot. I told them they were choking me. They told me they were going to put me on the unit (Secured). I don't want to go on the unit." A local policeman arrived at 9:55 AM on 04/07/11 to take Resident #1's statement. In an interview with RA A on 04/07/11 at 10:00 AM, she stated she had heard Resident #1 yelling and cursing. She stated the ADON was pushing Resident #1 down the hallway. She stated the ADON had said she was "sick of this cursing" and told her (Resident #1) to calm down. RA A stated Resident #1 was hitting at the ADON. RA A stated the ADON had told her (RA A) to get her (Resident #1's) wrists. RA A stated Resident #1 had gotten hold of the ADON's shirt and pulled the ADON down. RA A stated the ADON was behind the resident and ended up in front of her. She stated she had hold of Resident #1's wrists. In an interview with CNA B on 04/07/11 at 10:05 AM, she stated she was working on another hall and heard yelling. She said she looked through to the other hall, and there were people gathered around Resident #1. She stated she heard Resident #1 saying, "You're hurting me." CNA B said she saw the ADON and RA A specifically involved with Resident #1. In an interview with CNA C on 04/07/11 at 11:10 AM, she stated what she witnessed was "not professional." She stated she heard a commotion and went and looked at the other hallway. CNA C stated Resident #1 was sitting in her wheelchair in front of the nurses station. She stated she saw the ADON with her leg on Resident #1's wheelchair, straddling the resident. She stated RA A had her arm wrapped around Resident #1 from the back. CNA C stated the ADON was pushing her arm against Resident #1's chest. "____ (Resident #1) was yelling for them to let her go, and telling them to get off her." In an interview with LVN D on 04/07/11 at 11:35 AM, she stated she heard, "____ (Resident #1) yelling. 'Let me go! Let me go!' " LVN D stated she got up and saw the ADON in front of the nurses station on the opposite hall. Resident #1 was surrounded by LVN E, the ADON and other people. She stated the ADON was holding Resident #1's wrists, and RA A was behind the resident. LVN D said she went back to her nurses' station. In an interview with MA F on 04/07/11 at 11:45 AM, she stated she saw the ADON bring Resident #1 back inside the facility. The ADON was pushing the resident's wheelchair. MA F witnessed Resident #1 trying to hit the ADON while she (Resident #1) was sitting in her wheelchair being pushed by the ADON. MA F stated RA A was holding Resident #1 from behind, and Resident #1 was saying "Let go of me!" MA F stated the incident should have been looked into yesterday when it happened. She stated the ADON had her arms around Resident #1's upper body. MA F demonstrated what she had allegedly seen by wrapping her arms around a chair and pulling towards the chair. MA F stated it was RA A, who had her knee on Resident #1's wheelchair. In an interview on 04/07/11 at 2:18 PM with the facility's Director of Rehab, he stated he heard Resident #1 yelling when he was in the rehab room. When he went to see what was going on, he saw the resident swinging, and people were trying to hold the resident down. The Rehab Director stated Resident #1 had her seat belt on. He stated he did not know what instigated the behavior, but the behavior was abnormal for Resident #1. "She was so angry. I said, 'Leave her alone, and let her rest.' Staff were holding her down. A nurse and another girl. She (Resident #1) was still trying to swing." In an interview with CNA G on 04/08/11 at 10:30 AM, CNA G stated she had witnessed Resident #1 get agitated and combative a few weeks ago. She stated if people got out of her way and let her calm down, Resident #1 would come back and say "Sorry." In an interview with MA H on 04/08/11 at 10:40 AM, she was asked about the abuse training she had received at the facility. She stated if a resident was fighting (combative), they were told to leave them alone and make sure the resident had calmed down before "you re-approach them." Review of Resident #1's Injection Sheet dated April 2011 revealed the resident was administered [MEDICATION NAME] ([MEDICATION NAME]) 2 mg/ml vial 0.5 mg IM on 04/06/11 on the 6:00 AM - 2:00 PM shift. 3) The facility's room roster dated 04/07/11 revealed there were 73 residents in the facility.

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of six residents reviewed for combative behaviors was free from physical abuse by two (the facility's only ADON and RA A) staff members. On 04/06/11, Resident #1, who was upset, went outside of the facility, using the door's keypad, but without signing out, and the ADON went after the resident and made her return to the facility. The resident did not want to come back into the building at that time, and attempted to hit the ADON and was yelling and cursing. The ADON did not leave the resident alone, and brought her into the facility. RA A then assisted the ADON in manually holding the resident in her wheelchair, which had a seat belt restraint in place, and the resident became even more combative, increasing the resident's emotional distress. The ADON's scrub top was torn by the resident. RA A and the ADON held the resident down, holding onto her wrists and wrapping an arm around her while in her wheelchair, taking her to her room, where the resident was administered [MEDICATION NAME] (anti-anxiety). The resident was discharged on [DATE] to family for yelling and cursing and kicking the Administrator's door. She was one-on-one and did not like it. She continued to refuse to go to the secure unit, and she was then discharged immediately to her family due to her behaviors. These failures could affect the 73 residents in the facility and placed them at risk for the potential of verbal, physical and mental abuse, when they demonstrated any behavioral problems, being man-handled and medicated without need, without effort being made to allow the resident to calm down by simply being left alone, otherwise resulting in the incident escalating beyond control, and requiring medication or even hospitalization . Findings included: 1) Resident #1, a [AGE] year-old female, was originally admitted to the facility on [DATE] and a most recent readmitted [DATE] per the admission face sheet dated 04/07/11 with diagnoses, which included: [MEDICAL CONDITION], Convulsions, Diabetes, [MEDICAL CONDITION], Anxiety, and [MEDICAL CONDITION]. Resident #1's care plan dated 11/04/10 reflected: "Resident had episodes of Resistance to ADL (Activities of Daily Living) care. Approach: Monitor for early warning signs of behavior. Provide a calm environment. Approach in a calm manner. Call by name. Speak slowly. Maintain eye contact. Talk while giving care and allow time for response. Do not rush. Encourage appropriate behavior. Discourage inappropriate behavior. When refuses ADLs care, re-approach at a later time. Psych consult per order." The care plan was reviewed on 02/02/11 and continued for another 90 days. A review of Resident #1's MDS assessment dated [DATE] revealed the resident usually understood and was usually understood by others. She had some impaired vision. She had some long-term memory deficits but had good short-term memory recall. She had inattention, which was present and fluctuated. She had disorganized thinking, which was not easily altered. She had altered level of consciousness, which fluctuated. She had psychomotor [MEDICAL CONDITION], which fluctuated. Resident #1 was assessed as not needed to be assessed for her mental status and had no evidence of change in her mental status. When the resident was interviewed about her mood, she only complained of feeling tired 2-6 days a week. Resident #1 exhibited verbal behavioral symptoms directed towards others one to three days a week. The MDS assessment reflected Resident #1 used a wheelchair for mobility and was independent for locomotion on and off the unit. Review of Resident #1's Geriatric Progress Note-Psychiatry dated 03/29/11 revealed the resident was fully oriented to person, place, date and time and current diagnoses, which included: [MEDICAL CONDITION] with Depressed Mood, [MEDICAL CONDITION] Disorder, Depression Disorder and [MEDICAL CONDITION]. Resident #1's consolidated physician's orders [REDACTED]. 2. The facility's Provider Investigation Report dated 04/07/11 reflected an incident involving Resident #1 occurred on 04/06/11 at 8:50 AM. The Report reflected an allegation of abuse had been made by the resident naming the facility's only ADON and RA A, who denied the allegation. The allegation was described as: "Staff used inappropriate techniques for resident behavior." The Investigation Findings confirmed the allegation. The Investigation Summary reflected Resident #1 was extremely upset, yelling and cursing, because someone had taken the adult briefs, which she considered to be hers even though they had been given to her by the facility. The Administrator and charge nurse were having difficulty calming her down. The Administrator finally took her to the social services director, where the social services director and the ADON spoke to the resident. The Administrator thought Resident #1 had calmed down and the continued with the stand up meeting. Resident #1 was observed from the Administrator's office outside the facility. The resident was asked if she had signed out. She said no and continued to swear. The Activity Director left the meeting to ensure Resident #1's safety, and they went to the convenient store so the resident could get some chips. The resident did not find what she wanted and left, and refused to let the Activity Director and another staff person help her back to the facility. The resident returned to the facility on her own although she was still yelling and cursing. The resident again decided to leave the facility and again did not use the accepted facility procedure. Staff again followed her out of the facility. The resident was still yelling and cursing. The resident appeared to look as though she were going to try to cross the street while there were cars passing. The resident was assisted back into the building. When asked if she (Resident #1) wanted to go to the secured unit, the resident's response was the secured unit was for "crazy people." The resident continued to swing her arms and attempt to hit staff, who were taking her back to her room. In the process, Resident #1 ripped the ADON's top. More staff were involved in handling the resident and getting her back to her room. The resident was administered a shot of [MEDICATION NAME] (anti-anxiety). And the resident calmed down. The resident remained calm until 04/08/11. She had been placed on one-on-one for being assessed as high risk for elopement. The resident was offered the secured unit, but the resident refused and yelled at staff. The Administrator told the resident she had left the facility without signing out and had to either go to the secured unit or be discharged . The resident continued to refuse to go to the secured unit. The resident was angry at being one-on-one. The Administrator had no success in finding placement for Resident #1. At 4 PM on 04/08/11, Resident #1 began yelling and cursing and kicking the Administrator's door, still refusing to go to the secured unit. The police were called and informed the Administrator they could do nothing. The Administrator got an order for [REDACTED]. The Administrator tried to provide information to the family and answer their questions and left, hearing the family member and the resident yelling and cursing. 2) In an interview with the facility's Administrator on 04/07/11 at 9:15 AM, she stated she was aware of the prior day's incident (04/06/11) at the nurses station with Resident #1. The Administrator stated there had been a verbal altercation between Resident #1 and another resident. The Administrator stated Resident #1 was upset over some incontinent briefs she thought had been stolen. The resident had left the facility and had been brought back by the (facility's only) ADON. The Administrator stated the nurses and "staff almost kind of restrained her." The Administrator was not present until after the staff had gotten Resident #1 to her room. The Administrator further stated Resident #1 alleged she had been choked by the ADON and RA A during the incident. She stated she had started to get statements from the witnesses and stated she was trying to figure out "Who did the choking?" In an interview with the ADON on 04/07/11 at 9:25 AM she stated Resident #1 had been upset over some pull-ups (briefs). She stated the staff were in their morning meeting and saw Resident #1 exit the facility. The door was key pad coded and the resident used the code to leave the facility. The ADON stated she had brought the resident back into the facility. She stated Resident #1 had ripped her shirt, because the resident was agitated. The ADON stated she was behind the resident when the resident grabbed her shirt. RA A was in front of the resident. In an interview on 04/07/11 at 9:45 AM with Resident #1, she stated she called the police this morning because "____ (the ADON) had choked her. A girl named ____ (RA A) did, too." Resident #1 acknowledged she had been upset. She stated RA A had "hold of her neck and hurt it." The resident pointed to the center of her neck and stated it had been hurting there. She stated, "They were going to give me a shot, and I didn't want a shot. I told them they were choking me. They told me they were going to put me on the unit (Secured). I don't want to go on the unit." A local policeman arrived at 9:55 AM on 04/07/11 to take Resident #1's statement. In an interview with RA A on 04/07/11 at 10:00 AM, she stated she had heard Resident #1 yelling and cursing. She stated the ADON was pushing Resident #1 down the hallway. She stated the ADON had said she was "sick of this cursing" and told her (Resident #1) to calm down. RA A stated Resident #1 was hitting at the ADON. RA A stated the ADON had told her (RA A) to get her (Resident #1's) wrists. RA A stated Resident #1 had gotten hold of the ADON's shirt and pulled the ADON down. RA A stated the ADON was behind the resident and ended up in front of her. She stated she had hold of Resident #1's wrists. In an interview with CNA B on 04/07/11 at 10:05 AM, she stated she was working on another hall and heard yelling. She said she looked through to the other hall, and there were people gathered around Resident #1. She stated she heard Resident #1 saying, "You're hurting me." CNA B said she saw the ADON and RA A specifically involved with Resident #1. In an interview with CNA C on 04/07/11 at 11:10 AM, she stated what she witnessed was "not professional." She stated she heard a commotion and went and looked at the other hallway. CNA C stated Resident #1 was sitting in her wheelchair in front of the nurses station. She stated she saw the ADON with her leg on Resident #1's wheelchair, straddling the resident. She stated RA A had her arm wrapped around Resident #1 from the back. CNA C stated the ADON was pushing her arm against Resident #1's chest. "____ (Resident #1) was yelling for them to let her go, and telling them to get off her." In an interview with LVN D on 04/07/11 at 11:35 AM, she stated she heard, "____ (Resident #1) yelling. 'Let me go! Let me go!' " LVN D stated she got up and saw the ADON in front of the nurses station on the opposite hall. Resident #1 was surrounded by LVN E, the ADON and other people. She stated the ADON was holding Resident #1's wrists, and RA A was behind the resident. LVN D said she went back to her nurses' station. In an interview with MA F on 04/07/11 at 11:45 AM, she stated she saw the ADON bring Resident #1 back inside the facility. The ADON was pushing the resident's wheelchair. MA F witnessed Resident #1 trying to hit the ADON while she (Resident #1) was sitting in her wheelchair being pushed by the ADON. MA F stated RA A was holding Resident #1 from behind, and Resident #1 was saying "Let go of me!" MA F stated the incident should have been looked into yesterday when it happened. She stated the ADON had her arms around Resident #1's upper body. MA F demonstrated what she had allegedly seen by wrapping her arms around a chair and pulling towards the chair. MA F stated it was RA A, who had her knee on Resident #1's wheelchair. In an interview on 04/07/11 at 2:18 PM with the facility's Director of Rehab, he stated he heard Resident #1 yelling when he was in the rehab room. When he went to see what was going on, he saw the resident swinging, and people were trying to hold the resident down. The Rehab Director stated Resident #1 had her seat belt on. He stated he did not know what instigated the behavior, but the behavior was abnormal for Resident #1. "She was so angry. I said, 'Leave her alone, and let her rest.' Staff were holding her down. A nurse and another girl. She (Resident #1) was still trying to swing." In an interview with CNA G on 04/08/11 at 10:30 AM, CNA G stated she had witnessed Resident #1 get agitated and combative a few weeks ago. She stated if people got out of her way and let her calm down, Resident #1 would come back and say "Sorry." In an interview with MA H on 04/08/11 at 10:40 AM, she was asked about the abuse training she had received at the facility. She stated if a resident was fighting (combative), they were told to leave them alone and make sure the resident had calmed down before "you re-approach them." Review of Resident #1's Injection Sheet dated April 2011 revealed the resident was administered [MEDICATION NAME] ([MEDICATION NAME]) 2 mg/ml vial 0.5 mg IM on 04/06/11 on the 6:00 AM - 2:00 PM shift. 3) A review of the facility's current abuse policy and procedure dated January 2005 revealed: "... Policies: The Resident has right to be free from corporal punishment and involuntary seclusion. The Resident has the right to be free from abuse: verbal, mental, physical or sexual. Procedure: The facility will upon admission, and periodically, inform the Resident of the definition of A. Verbal abuse which is the oral, written and gestured language which could be viewed as disparaging or derogatory intent which is directed towards the Resident, the Resident ' s family or within hearing or visual distance regardless of age, disability or ability to understand. Example: Threats of harm, instilling of fear, verbal, slander, etc. B. Physical abuse includes hitting, kicking, slapping, pinching, and controlling behaviors through corporal punishment. C. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. D. Mental abuse includes harassment, humiliation, demoralization, threats of punishment or depravation. E. Involuntary seclusion: Separated from Residents or room without Resident's consent or medical cause. 2. The facility will upon admission and periodically inform the Resident of the right to be free from abuse/corporal punishment/involuntary seclusion. 3. Emergency short-term monitored seclusion will not be considered abuse, provided that the facility had documented the following: a. The concern, which led the consideration of seclusion. b. The concern was due to failure to meet to needs of the resident, provided meaningful activities or manipulate the resident's environment. c. Reason for concern cannot be removed. d. If reason could not be removed, the facility attempted, without success to utilize alternatives to separation. e. When alternatives to separation. f. The resident or the resident's representative was involved in the care plan of behaviors or medical condition to the highest practicable extent. g. The facility monitors and modifies the resident's care in an attempt to utilize the least restricted means to manage care. 4. The facility Inter-Disciplinary Care Plan Team has utilized the RAP process to attempt identification of precursors to concern and least restrictive methods to manage concern and to plan care." A review of the facility's current Abuse guidelines Subject Behavior crisis effective date January 2005 revealed: Guidelines 1. Implement measures to ensure safety. 2. Summon additional staff if need. 3. Diffuse crisis through calming communication. 4. Assess need for additional intervention: Remove resident from situation Remove offending stimuli from resident Place resident in sage environment Remove onlookers from the area 5. Assess need for physical restraint. 6. Contact physician and facility on-call person for additional interventions. 7. Contact local police if behavior crisis requires immediate removal from facility. 8. Contact administrator/designee and family (if resident mentally incapable;otherwise defer to residents wishes.) 9. Document the crisis including description of incident, resident's perception, interventions, outcomes and steps taken to prevent reoccurrence. 10. Evaluate behavior crisis using the following guide A review of the facility's current policy and procedure manual, section abuse guidelines, effective date January 2005, entitled, "Subject Behavior Intervention General Guidelines" : 1. Careful assessment using the behavior symptom assessment assists in identifying causes for behavioral problem, which leads to the development of affective intervention. 2. Interventions for probable behavior symptoms. Respect individual's needs as a valued adult. Guidelines: 1. Interventions are developed based on information contained in the MDS triggered wraps, core program/discipline-specific assessments, and the behavioral symptoms assessment. 2. Interventions are recorded on the Individual Resident Care Plan as well as in the Interdisciplinary Progress Notes. 3. Results of interventions are recorded in the Disciplinary Progress Notes. 4. Additional approaches for dealing with behavioral problems are continued in the resource section of this manual. 5. Interventions are also found at the Computerized Care Plan Library. 6. Additional assessments and information sources for developing resident-specific interventions are listed below and are located in section 3 of this manual. Mini mental state assessment, dementia functional assessment, and resident personal profile. Procedure Guidelines: 1. Suggested intervention strategies include involving the resident council. Resident council, a self-governing body of persons residing in the facility that works towards common goals as they are related to the quality-of-life issues. Council involvement may be instrumental in providing a sense of integrity, involvement, and accomplishment. Encourage reminiscence. Reminiscence involves recapturing and reviewing one ' s past and may provide individual with experience which reconfirms significance and meaning of their life. Engage in support groups. Support groups allow individuals who share common concerns or have common problems to benefit from a group experience. Often these groups provide an outlet for emotional reactions and show individuals that they are not alone in what they are feeling. Involve in recreation programs. Recreation programs offer individuals the opportunity for social interactions with their peer group and provide a sense of continued involvement. Offer reality orientation. Reality orientation - provides reminders of basic current of personal information. This may help an individual make meaningful contact with the world around them. Provide re-motivation. Re-motivation allows individuals to benefit from focus group interaction while group leaders guide a discussion of familiar topics that may have emotional relevance. Utilize validation therapy. Validation therapy means validating, not correcting, an individual ' s response, thus adding to the person ' s sense of well-being. 2. The following chart demonstrates how validation therapy must be used to address behavior problems. Behavior - Hitting a staff who attempted to provide care. Emotional Need - Fear, inability to grasp what is expected, or a triggered memory of being mistreated. Validation Therapy Technique - Go away. Return in five to ten minutes. Explain calmly and step by step what you wish to do. Do distract by commenting on how much you like the feeling of her skin, color of her eyes, clothes he is wearing, etc. Behavior - " Go away. If you touch me, I will hit you with my cane. " Emotional Need - Fear, anger, powerlessness, or she does not like the staff person or the way she is being approached. Validation Therapy Technique - Stand away. Speak softly, gently, speaking resident ' s phrases and concerns. Do not argue or reprimand. Move closer as agitation decreases. Stroke arm and rub back as tolerated. 4) The facility's room roster dated 04/07/11 revealed there were 73 residents in the facility.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (CNA I) of four CNAs reviewed demonstrated competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments. CNA I was provided with one day of orientation, instead of the minimum two days prior to being assigned to care for a resident (Resident #2), who required total assistance with transfers and ADL care. CNA I was given a sheet with resident information, but she threw it away. Resident #2, who was to be transferred with at least two staff and the use of a Hoyer lift, was dropped during a transfer. The resident suffered an acute fracture of his right ankle. CNA I had attempted to transfer the resident unassisted. This failure could have affected the other three residents on Resident #2's hall, placing them at risk for being transferred by CNA I, who would have had no knowledge of their cares, and would have attempted to provide cares for them without foreknowledge of their needs, as she had for Resident #2. This could have resulted in injury, fractures, lacerations, scrapes and the need for medical attention and even hospitalization . Findings included: Review of the personnel file for CNA I revealed she was hired on 03/28/11. A sheet in her personnel file reflected she completed "Proper lifting and moving techniques" training on that date. CNA I's time sheet reflected she worked four hours on 03/28/11, 7.15 hours on 03/29/11, and 7.58 hours on 03/30/11. An All Disciplinary Progress Note dated 03/30/11 reflected, "Called to room by aide, res (Resident #2) recied (sic) in bedroom on floor, aide transferring (Resident #2) from bed to chair, res slipped and fell on the floor, res denies hitting head, able to move extremities as before." The Incident/Accident Report for Resident #2, dated 03/30/11, reflected on that date at 10:45 a.m., the resident was on the floor. The witness was identified as CNA I. The Incident Type was reflected as "Slide out of shower seat." The ADL (Activities of Daily Living) section reflected the resident required the assistance of two staff for transfers. The Restraints/Assistive Devices section reflected the resident required a mechanical lift. The "Potential contributing factor(s) related to the occurrence of the resident's fall "was reflected as "Aide assisted resident alone." The Witness Statement of CNA I, dated 03/30/11, reflected: "While I was putting him in the shower chair he was at the end of the chair and he said no I cant (sic) and he started to slip so I slowly layed him down." Review of the Nurse Aide Care Plan for Resident #2 (no date) in the ADL book revealed Resident #2 required a Hoyer lift for transfers. The Incident Report dated 04/03/11 for Resident #2 reflected Resident #2 exhibited discoloration of his right ankle. The report reflected the x-ray revealed an acute [MEDICAL CONDITION] ankle. A Witness Statement dated 04/04/11 from CNA I, which was included, reflected she discovered a bruise on the resident's right ankle when she was providing care on that date. A Progress Note (Nursing) dated 04/03/11 reflected, "Skin discoloration noted to R (right) inner foot and ankle, area is warm to touch, denies pain, feet elevated on pillows to off load pressure." A Progress Note (Nursing), dated 04/04/11 at 10:00 a.m. reflected the nurse observed the resident's right foot was swollen and discolored. The x-ray report dated 04/04/11 reflected: "Acute right malleolar fracture." The MDS assessment dated [DATE] reflected Resident #2 required total physical assist from two or more staff for transfers. The MDS reflected the resident weighed 189 pounds at that time. The MDS reflected the resident exhibited impaired range of motion to both arms and legs. On 04/07/11 at 10:30 a.m., the investigator interviewed CNA B. CNA B had been assigned to work the south hall on 03/30/11. Regarding 03/30/11, CNA B stated, "The new girl was supposed to be on orientation, but we were short that day. The nurse gave her the center of the hall. We told her not to. The girl had ___ (Resident #2) she should not have gotten him (been assigned to him)." On 04/07/11 at 10:40 a.m., the investigator interviewed CNA K. She stated, "She (CNA I) was orienting. I told the nurse not to put her on the floor. We were splitting the hallway two ways. She was orienting and going to help us (CNAs K and B). ___ (LVN E) said, 'I am the nurse, and I am going to give her an assignment.' The halls were split three ways. She (CNA I) didn't know the people (residents). ____ (LVN E) wrote an assignment on a piece of paper towel." In an interview on 04/07/11 at 2:00 p.m. with LVN E, she was asked about the assignment for CNA I the day Resident #2 was dropped. She stated the CNA had her assignment written down. On 04/08/11 at 10:40 a.m., the investigator interviewed Resident #2. He could not recall the details, and stated, "I just hit the floor." On 04/08/11 at 10:51 a.m., the investigator interviewed the facility's only ADON. When asked about the orientation policy/procedure, she stated, "Before going to the floor, we go through the processes, then go to the floor for orientation with CNAs. Three days but require two. Third day for cushion." The investigator asked about CNA I's orientation. The ADON responded, "Went over the processes the day before. Verbalized understanding." She stated she was to be assigned to follow a staff member each day. The ADON stated during orientation, the orientee should not have a "patient load." She stated, "She (CNA I) shouldn't be by herself on the 29th or 30th. She should be with someone." She stated the charge nurse had given CNA I an assignment sheet with information about Resident #2, but CNA I had thrown it away. On 04/08/11 at 1:28 p.m., the investigator interviewed CNA J. She stated the residents who required Hoyer lift assist with transfers were to have a picture of the lift posted over the bed. At that time, CNA J and the investigator went to Resident #2's room. The investigator observed the picture of the Hoyer lift was on the floor under the bed. CNA J verbalized three other residents residing on the hall, who required Hoyer lift assist. Resident #3's room was observed. There was no picture posted or located upon search by CNA J. Resident #4's room was observed. There was no picture posted or located upon search by CNA J. Resident #5's room was observed. There was a picture of the lift posted on the wall behind the bed.