Every finding on record at Avir at Luling

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 food and nutrition services. 1. The facility failed to ensure four packs of sliced bread and one pack of hotdog bread located on the bread rack in the facility kitchen was not past the best by dates. 2. The facility failed to ensure the handwashing sink was clean. 3. The facility failed to ensure there was a clean and functional step-on trash near the handwashing sink. 4. The facility failed to ensure the silver cart to distribute residents' food down the hall was clean. 4. The facility failed to ensure the blue crate to store dishes in the kitchen was clean. 5. The facility failed to ensure the AC in the unit in the kitchen was clean. These failures could place residents at risk of cross contamination, food borne illnesses and decreased quality of life.Findings include:Observation on 02/04/2026 at 09:16 AM reflected the handwashing sink had a brown stain around the drain and around the faucet. The step-on trash next to the handwashing sink had a brown sticky substance on the lid, the step-on was non-functional and had to open the lid by touching. Observation on 02/04/2026 at 09:22 AM in the facility's kitchen on the bread rack reflected the following:-One pack of thin sliced bread with best by date of Jan. 22, 2026-Two packs of sliced thin bread with best by date of Jan. 25, 2026-One pack of hotdog buns with best by date of Jan. 24, 2026 Observation on 02/04/2026 at 09:23 AM reflected the AC unit in the kitchen was covered with dust. Observation on 02/04/2026 at 09:24 AM reflected the silver cart used to distribute residents' food down the hall was stained with brownish substances on both sides of the cart. Observation on 02/04/2026 at 09:25 AM reflected the blue crate in the kitchen used to store dishes was stained with a brownish substance. Observation of lunch service on 02/04/2026 at about 11:04 AM revealed one slice of bread was about to be served by the Dietary Manager with best by date of Jan. 22, 2026. The Dietary Manager looked at the date on the bread pack and stated with the best by date being [DATE], it was not good to eat that day and pulled the bread from the serving line. The Dietary Manager was the morning [NAME] at the facility. During an interview on 02/04/2026 at 11:50 AM, the Dietary Manager/Cook stated all staff, especially the cook, was responsible for checking for expiration on food products. The Dietary Manager stated the bread was not safe to eat, if it expired by 1/22/26. The Dietary Manager stated the bread had been expired for almost a week. The Dietary Manager stated the residents were at risk for illness when they ate bread that had passed the best by date. The Dietary Manager said one resident liked bread and the one slice of bread was intended for the resident. The Dietary Manager stated she served chocolate pancakes for breakfast, so residents did not have the bread that day. The Dietary Manager stated all dietary staff were responsible for cleaning the sink and they all needed a constant reminder. The Dietary Manager stated it was dust on the AC and it would cause cross contamination to the food. The Dietary Manager stated the silver cart was no longer being used to transport food to the residents down the hall, the staff were taking the tray individually. The Dietary Manager stated the silver cart needed to be power washed and the kitchen needed to be deep cleaned. The Dietary Manager stated the blue crate was not cleaned like it was supposed to be and that was where they stored dirty dishes. She stated she would notify the Administrator to get a new crate for the food and in-service her staff on cleaning. The Dietary Manager stated she was responsible to ensure the kitchen and equipment were clean. During an interview on 02/04/2026 at 12:11 PM, the Dietary Aide stated the Cooks and Dietary Manager were responsible for checking food for expiration dates. The Dietary Aide stated the step on trash had been broken for about a week or more. The Dietary Aide stated the AC unit looked dusty. She stated the silver food cart had a lot of dirt and it did not look good to her, and she sometimes wiped the cart down. The Dietary Aide stated the blue crate was for dishes when the residents were done eating and it did not look clean to her. The Dietary aide stated the brownish substance on the trash was dirt, and all the dietary staff were responsible for cleaning the sink, the cart, crate, and trash. During an interview on 02/04/2026 at 1:20 PM, the Administrator stated food should be dated so the staff could know when it came in, when it was opened and when to use it. The Administrator stated the best by date was controversial. The Administrator stated the best by date indicated the product was not in the best quality or condition. The Administrator stated if not used by the use by date, the product had to be thrown out. He also stated if not used by the best by date, just toss the product. The Administrator stated serving anything to a resident a week after the best by date would have a negative impact on the resident, depending on the product. The Administrator stated the facility should be following the sanitation guidelines. The Administrator stated he would make sure cleaning the AC unit in the kitchen was added to the Maintenance Director's cleaning list. The Administrator stated the sinks in the kitchen should be cleaned at all times and the Dietary Manager was responsible to ensure cleaning was done in the kitchen. The Administrator stated the step on trash was there so the staff would not touch the trash after washing their hands, and if broken it was defeating the purpose and would cause cross contamination. The Administrator stated the trash should be cleaned and in a functional condition. Record review of the facility's policy titled Food Receiving and Storage, dated November 2022, reflected: Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices.Dry Food Storage- Dry foods that are stored in bins are removed from original packaging, labeled and dated ('use by' date). Such foods are rotated using a 'first in - first out' system. Record review of the facility's policy titled Sanitation, dated November 2022, reflected: Policy StatementThe food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation1. All kitchens, kitchen areas arid dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.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.3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.13. Kitchen waste that are not disposed of by mechanical means are kept in clean, leakproof, non-absorbent, tightly closed containers and disposed of daily.14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered).15. Areas used for garbage disposal are free from odors and waste fats and maintained to prevent pests.

Based on observation, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment and provide maintenances services to maintain sanitary, orderly and comfortable interior for 4 of 8 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for homelike environment and resident rights. The facility failed to ensure Resident #1, Resident #2, Resident #3, and Resident #4 had functioning toilets and sinks in the bathrooms of their resident rooms. This failure could place residents at risk of living in an unclean or unsanitary environment, decreased quality of life, or shame. Findings included: 1. Record review of Resident #1's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of depression (mood disorder, characterized by persistent sadness, loss of interest in activities) generalized anxiety disorder (a mental health condition characterized by chronic excessive and uncontrollable worry), and paraplegia (paralysis affecting the lower half of the body). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15 which indicated no cognitive impairment. Record review of Resident #1's care plan, dated 12/10/2025, reflected Resident #1 had disturbed sensory perception (brain misinterprets or alters sensory input) with interventions to determine risks related to sensory perception deficit. 2. Record review of Resident #2's face sheet reflected a [AGE] year-old male re-admitted on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery (condition that impairs blood flow and reduces oxygen delivery to the heart), difficulty walking, other lack of coordination, anxiety disorder (mental health conditions characterized by excessive persistent fear and worry), major depressive disorder (severe common mood disorder characterized by persistent feeling of sadness), unspecified dementia (significant cognitive decline such as memory loss or thinking problems), and post-traumatic stress disorder (mental health condition triggered by experiencing or witnessing terrifying events). Record review of Resident #2's unspecified MDS, dated [DATE], reflected no BIMS score. Record review of Resident #2's care plan, dated 07/24/2025, reflected the resident had anxiety and was at risk for fluctuation of mood with interventions to listen to resident's concerns. Review reflected Resident #2 had post-traumatic stress disorder with interventions to create a relaxing environment. 3. Record review of Resident #3's face sheet reflected a [AGE] year-old male re-admitted on [DATE] with diagnoses of cerebral infarction (occurs when blood clot blocks brain artery and blocks oxygen and nutrients), need for assistance with personal care, unsteadiness on feet, and generalized anxiety disorder (a mental health condition characterized by chronic excessive and uncontrollable worry. Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 13 which indicated no cognitive impairment. Record review of Resident #3's care plan, dated 07/24/2025, reflected a self-care deficit with interventions to provide assistance with ADLS/IADLs as needed. 4. Record review of Resident #4's face sheet reflected a [AGE] year-old female re-admitted on [DATE] with diagnoses of Alzheimer's disease (a progressive neurodegenerative disorder characterized by memory loss, cognitive decline and behavioral changes), Parkinson's Disease (progressive neurodegenerative disorder leading to tremors slowness of movement or balance problems), muscle weakness, difficulty walking, and major depressive disorder (severe common mood disorder characterized by persistent feeling of sadness). Record review of Resident #4's annual MDS, dated [DATE], reflected a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #4's care plan, 06/27/2025 reflected Resident #4 was a risk of self-care deficits with interventions to maintain a consistent schedule with daily routine and provide assistances with ADLS and IADLS. During an observation and interview on 01/20/2026 at 10:07 a.m., Resident #1 stated he has no had water in his sink or a working toilet in six weeks. Resident #1 stated that he had to flush his toilet by removing the lid from the tank of the toilet and pouring a gallon of water in it. Resident #1 stated that he was paraplegic and felt he should not have to do that. Resident #1 stated he was unhappy about not having working toilets or sink in his room. Resident #1 stated that he showered in the shower room and that the water worked in the shower room. Resident #1 stated that he told everyone that his toilet and sink did not work. Observation revealed that the toilet in Resident #1's bathroom did not flush and no water came out of the sink. During an observation and interview on 01/20/2026 at 10:18 a.m., Resident #2 stated that the water was not working in his room. He stated sometimes it worked and sometimes it did not. Resident #2 stated that it has not been working for a few months. Resident #2 stated that the toilet takes forever to fill up and that he cannot always flush it. Resident #2 stated that he felt it was unsanitary and a health hazard. Resident #2 stated that he had to go to another hall to take a shower or wash his hands. Resident #2 stated that he was not been able to brush his teeth in his bathroom. Observation revealed the toilet in Resident #2's bathroom did not flush and no water came out of the sink. During an observation and interview on 01/20/2026 at 10:28 AM, Resident #4 stated he had no hot water in his sink and his toilet was full. Resident #4 stated staff brought water into the bathroom to pour into the toilet. Observation revealed that Resident #4's toilet was full of fecal matter and urine and had a foul odor when the door was opened. During an observation and interview on 01/20/2026 11:14 a.m., Resident #3 stated his only issue at the facility was his bathroom. Resident #3 stated his toilet did not flush and water did not coming out of his sink faucet and when it did it was not hot. Resident #3 stated that he had to go to the shower room to brush his teeth and wash his hands or go to the bathroom. Resident #3 stated his bathroom often smelled foul because the toilet did not flush and urine or feces were left sitting in the toilet. Resident #3 stated sometimes the smell was in his room and he did not like it. Resident #3 stated there were gallons of water to flush the toilet but that he had to remove the top of the toilet and pour the water in there. Resident #3 stated staff only flushed the toilet once a day. Observation of Resident #3's bathroom revealed that the water in the sink did not work and the toilet did not flush During an observation and interview on 01/20/2026 at 2:48 p.m., Resident #4's toilet had not been flushed and foul odor remained in his bathroom. Resident #4 stated that no one had come to flush his toilet. During an interview on 01/20/2026 at 2:48 p.m., the MD stated that he put work orders in and that the facility needed replumbing. The MD stated that the facility just had another bid done for the work on the pipes. MD stated that bids were only good for a month and after the month passed, another bid had to be done. The MD stated that the last bid was 01/19/2026. MD stated that it was only the toilets on the right side of the long hallway and the last room on the left side of the long hallway. MD stated that water bottles were being used to flush the toilets. The MD stated that the lid was taken off the tank on the back of the toilet and water was poured to flush to toilet. MD stated that any time a resident had their call light on and asked for the toilet to be flushed, it was flushed by staff. MD stated that he went and told residents to ask if they needed their toilet flushed and not to do it themselves. MD stated a lot of the sinks had low pressure. MD stated the facility had problems with the pipes. MD stated that water bottles were put in the resident bathrooms to flush the toilets. MD stated that when the CNAs made room rounds they were also supposed to flush the toilets if needed. During an interview on 01/20/2026 at 2:58 p.m., CNA A stated that staff flushed toilets with resident rooms regularly with the water bottles that were in their rooms. CNA A stated that it should be done if a resident asked and during room rounds. CNA A stated the MD was responsible to ensure the water bottles were filled. CNA A stated that there was an issue with the toilets for a week. CNA A stated she saw a few companies come out but was unsure if it was an issue with the pipes. CNA A stated there were two communal bathrooms that residents were able to use, brush their teeth and wash their hands. During an interview on 01/20/2026 at 3:00 p.m., CNA B stated that she was an agency employee and she knew nothing about the building and had never worker at the facility before. CNA B stated that she did not know about flushing the toilets at a certain time or with water bottles. During an interview on 01/20/2026 at 3:28 PM, CNA C stated that she started at the facility on 01/06/2026 and that was not trained regarding flushing toilets or rounding to ensure they were flushed. During an interview on 01/20/2026 at 3:31 p.m., LVN D stated that she worked as an agency nurse but had been coming to the facility on and off for a few months. LVN D stated that she worked from 6:00 a.m. to 6:00 p.m LVN D stated that she knew there were some plumbing issues going on and the first she heard of it was last week. LVN D stated she heard there was a company out on 01/19/2026. LVN D stated that she thought because of the colder weather something happened with the pipes and a sink was backed up. LVN D stated she was not made aware of issues with toilets not flushing. LVN D stated that residents had the right to have functioning equipment. LVN D stated that she knew there were water bottles and assumed it was used to fill the tank of the toilet and flush them but did not ask what the water bottles were for. LVN D stated that no one informed her to do any type of rounding for flushing the toilet with the water bottles. During an interview on 01/20/2026 at 3:42 p.m., CNA E stated that issues with the residents toilets was dependent on water pressure and that every day was different. CNA E stated that some days were good and some days there was just no water pressure. CNA E stated there were jugs of water for backup in resident bathrooms and they were used to flush the toilets. CNA E stated this was an issue for a month and a half to two months. CNA E stated during rounds, staff was to check the toilets as well. The DON told the staff to use the water jugs. CNA E stated she did not notice any strong odors from Resident rooms. CNA E stated that Resident #1 complained about his toilet not flushing and that staff helped him flush it last night (01/19/2026). CNA E stated the house keeping team and aides helped with flushing the toilets. CNA E stated that staff had basins they could use to brush their teeth. CNA E stated there were also shower rooms on the halls that residents could use that had toilets as well. During an interview on 01/20/2026 at 3:51 p.m., LVN F stated that she usually worked 2:00 p.m. to 10:00 p.m LVN F stated that she was aware there was pluming issues on the long hall and that the facility had received some bids. LVN F stated that depending on the water pressure if the toilets were able to flush. LVN F stated there was back up bottles of water to flush the toilet with. LVN F stated that water was put into the top of the toilet in the tank to flush it if needed. LVN F stated that staff had to check if the toilet flushed daily. LVN F stated a risk to having the toilet not flush with fecal or urine in it was an infection control risk and would be a hazard to the resident if it sat in the toilet and was not flushed for a prolong period of time. LVN F stated that residents had a right to have equipment work in their rooms. LVN F stated that the toilets were an issue off and on for a few months. LVN F stated she had not observed any strong odors and that usually the residents told her when they needed to use the bathroom and the toilet did not flush. During an interview on 01/20/2026 at 4:25 p.m., the ADM stated the toilets on the long hall were good some days and some days they were not. The ADM stated the regional maintenance director was out on 01/19/2026 with a plumbing company. The ADM stated that it was inconsistent because sometimes the water pressure was good and sometime it was not. The ADM stated the facility was getting bids to re-pipe. The ADM stated because of the size of the project corporate requested at least two bids. The ADM stated when the water pressure was not good, there were water bottles available and staff were told to check toilets when they did their rounding. The ADM stated that housekeeping usually checked in each room a few times a day. The ADM stated he told the MD to also make rounds as well. The ADM stated nurses were also told to round and check toilets as well. The ADM stated that the water bottles were used to fill up the back of the tank on the toilet to flush. The ADM stated that residents were offered bottled water to brush their teeth. The ADM stated he was not sure if the DON completed in-service with staff on providing bottled water for residents to brush their teeth, and if not, he would conduct one. The ADM stated that the water pressure issue fluctuated and it was going on from a few weeks to a month. The ADM stated the residents told him when the toilet did not flush and he tried to give them as much information as possible and did not expect for them to flush the toilets themselves with the bottles of water. The ADM stated that staff tried not to have feces or urine sitting in the toilets and stated that he did not know what the risk would be and that it would not be different with the toilet being unable to flush versus the resident not flushing the toilet when it worked. Record review of facility policy titled Quality Control, Environmental Services, with revision date of December 2009 reflected, 1. To assist in maintaining a standard of excellence, our housekeeping and laundry departments have developed a quality control program. Record review of facility policy titled Resident Rights with revision date of February 2021 reflected residents shall be treated with kindness, respect and dignity and have the right to a dignified existence. Record review of facility in-services, dated December 2025 to January 20, 2026, reflected there were no in-services conducted on rounding and ensure toilets were flushed or offering alternatives to brushing teeth and washing hands. Record review of facilities grievances, dated December 2025 to January 20, 2026, reflected no grievances related to concerns with resident bathrooms.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition. 1. The facility failed to ensure refrigerator #2 maintained a safe storage temperature and not allow food items to be improperly stored.2. The facility failed to ensure the inside kitchen freezer maintained a safe storage temperature and did not allow food items to thaw. These failures pose a risk to all residents of the facility who eat food from the kitchen as they are at risk for food borne illnesses. Findings included: Observation on 9/23/2025 at 7:20 AM, Refrigerator #2 silver in color, temperature revealed to be at 52 degrees. Observation on 9/24/2025 at 12:45 PM, refrigerator #2 silver in color, temperature revealed to be at 58 degrees and second freezer in dry pantry room reflected 30 degrees. Interview conducted with DM at 1:17pm, surveyor advised DM the temperature on the freezer in the dry storage area was out of compliance that food was thawing. DM stated the electric breaker box must have triggered off causing the freezer temperature to be out of compliance for a little while, DM stated maintenance has been made aware of the issue. The surveyor advised DM the silver refrigerator was out of compliance, DM stated she think the thermometer inside is not working, she placed another thermometer, and the temperature was still out of compliance at 58 degrees. Interview conducted with ADM at 1:20 PM, he was notified of the concerning refrigerator temperatures. ADM stated he was contacting a company to come out to check the refrigerator this day. Observation and interview on 9/25/2025 at 8:25 AM, Refrigerator #2 silver in color, temperature revealed to be at 60 degrees on outside thermometer and 58 degrees on inside thermometer. DM stated at 5:30 AM, the temperature reads at 39 degrees. DM stated maintenance came by and adjusted the seal. DM stated the repair company did not come out yesterday. DM stated she will remove the items out of the refrigerator until it was repaired. DM stated the refrigerator should be at 41 degrees and below. DM stated the potential harm of not having appropriate temperature could lead to food spoiling. She said if the food spoils if could make the residents sick. An interview was conducted with ADM on 9/25/2025 at 3:18 PM, ADM stated the maintenance director cleaned the silver refrigerator coils, and it was working in the morning as reported by the DM. ADM was advised the refrigerator temperature was out of compliance again. ADM stated the service man was not able to come on yesterday but was scheduled to come later in the afternoon. ADM stated the potential harm from food being stored at inappropriate temperatures can cause residents to become ill. Record review of facility policy on 9/25/2025 named Food Receiving, and Storage indicated: 1.Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness.2. PHF/TCS foods are stored at or below 41 F, unless otherwise specified by law.Record review of facility policy on 9/25/2025 named Refrigerators and Freezers indicated:This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.1. Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 F and freezers keep frozen foods frozen solid.2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures.3. Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and action taken. The last column will be completed only if temperatures are not acceptable.4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.5. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 36 of 90 days (third quarter 2025) reviewed in that: The facility failed to ensure they had a RN on duty daily for 36 days of the 90 days in the third quarter from 04/2025 through 06/2025.This deficient practice placed residents at risk of missing nursing assessments, resident supervision and skilled nursing treatment. Findings included:Review of the facility's RN staffing hours for the third quarter of 2025 reflected no RN hours for the following days: 04/06 (SU); 04/12 (SA); 04/13 (SU); 04/19 (SA); 04/20 (SU); 04/24 (TH); 04/25 (FR); 04/26 (SA); 04/27 (SU); 04/28 (MO); 04/29 (TU); 04/30 (WE), 05/03 (SA); 05/04 (SU); 05/07 (WE); 05/09 (FR); 05/10 (SA); 05/11 (SU); 05/13 (TU); 05/14 (WE); 05/17 (SA); 05/18 (SU); 05/21 (WE); 05/24 (SA); 05/25 (SU); 05/26 (MO); 05/27 (TU); 05/31 (SA), 06/01 (SU); 06/07 (SA); 06/08 (SU); 06/14 (SA); 06/15 (SU); 06/21 (SA); 06/22 (SU); 06/28 (SA); 06/29 (SU). In an interview on 09/24/2025 at 11:24 AM the Administrator stated the RN days listed on the PBJ staffing did not have RN coverage. He stated he was unable to get an RN for those days and has tried to recruit one with aids. The Administrator stated he was not using agency for this and was working on getting a waiver. He stated the facility did not have a policy for RN coverage that the facility used the TAC. The Administrator stated the facility should have an RN on duty 8 hours a day 7 days a week. Review of the TAC Title 26 S554.901 of this chapter (relating to Quality of Care) reflected . (2) Registered nurse. (A) The facility must use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, except when waived under paragraph (5) or (6) of this subsection.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label and date all food items located in refrigerators, freezers and in the dry food pantry area on 9/23/2025, 9/24/2025, and 9/25/2025. 2. The facility failed to discard expired food items located in the refrigerator and in the dry food pantry area. 3. The facility failed to ensure the trash containers were covered with lids on 9/23/2025, 9/24/2025, and 9/25/2025. 4. The facility failed to clean and sanitize its food storage areas, to include the freezers in the outside storage room on 9/23/2025, 9/24/2025, and 9/25/2025. These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.The findings included: Observation during the initial tour of the kitchen on 9/23/2025 beginning at 7:20 AM, revealed the following was observed: 2 trash containers with trash inside, no lids. Refrigerator #1 white in color noted to have 12 unlabeled bowls that looked like pudding and applesauce. Refrigerator #2 silver in color, temperature was noted to be at 52 degrees, above required temp, this refrigerator reflected:1 container of tuna dated 9/17/2025, with shelf life of 3 days, 6 days past the discard date1 container of ham salad 9/17/2025, with shelf life of 3 days, 6 days past the discard date1 gallon container of salad dressing, 1/4 left, not labeled, not dated.2 sour creams, not labeled, not dated.1 ham sandwich, dated 9/17/25, shelf life 3 days, 6 days past discard date1-gallon plastic ice cream container, labeled chicken alfredo with a 9/17 label, no discard date4 frozen bags of unknown yellow/orange substance, bottom of refrigerator, not labeled on package, metal container holding items stated eggs 8/28, no discard date DM led the surveyor to the outside freezer storage room:Freezer 1, -no thermometer, dirty residue inside of refrigerator, 3 bags of peas not labeled, not dated.Freezer 2- large plastic bag of fish, not labeled, not dated.Freezer 3 - very dirty inside doors with dark brown residue with dead bugsFreezer 4 -7 unboxed waffles no label, not labeled, not dated, large bag of meatballs with stamp date 4/28/2025, no label or date to clarify if the stamped date is a produced date or expiration date.5 bags of white cake mix with a written date of 8/30/2024, not clear if its received or discard date. During a follow-up tour of kitchen on 9/24/2025 beginning at 10:50AM, the following was observed: A second freezer in the kitchen dry pantry area was observed:1 large freezer bag with open spam meat, labeled 4 bags of spam, 9/10, no discard date1 opened bag of meat strips, labeled chicken 9/15/25, no discard date1 pack of [NAME] labeled 9/15/25, no discard date1 opened box of hamburger patties labeled, open 1/2 gone, no dates1 large bag resembling zucchini, labeled shelf life 9/15/25 During an additional tour of the kitchen on 9/24/2025 beginning at 12:45 PM, observation/interview occurred:Refrigerator #2 silver in color, temperature was noted to be at 58 degrees on outside thermometer and 52 degrees noted on inside thermometer, above required temp, this refrigerator reflected: 1 container of cooked meatballs from the previous day lunch, no discard date1 energy drink (belonged to staff)2 20 oz soft drinks (appeared to belong to staff)1 can of soft drink (appeared to belong to staff)1 large bowl of opened fruit cocktail dated 9/23/25, no discard date2 bowls of uncovered pureed fruit, not labeled or dated.1 large bag of breakfast sausage patties, not labeled or dated2 remaining bags of unknown yellow/orange substance, bottom of refrigerator, not labeled on package, metal container holding items stated eggs 8/28, no discard date Second freezer in kitchen dry pantry area was observed:Temperature was at 30 degrees, out of compliance.6 bags of waffles appeared to be thawing, not labeled or dated2 bags of pancakes appeared to be thawing, not labeled or dated1 package of [NAME] starting to thaw Dry Pantry area:9 loaves of bread, with received date only, no discard date2 packages of hamburger buns, with best buy date of 9/22/2025. Outside freezers:Freezer 1, thermometer added, dirty residue inside of refrigerator, 3 bags of peas not labeled, not dated.Freezer 2- large plastic bag of fish, not labeled, not dated.Freezer 3 - very dirty inside doors with dark brown residue with dead bugs Interview conducted with DM at 1:17pm, surveyor advised DM the temperature on the freezer in the dry storage area was out of compliance that food was thawing. DM stated the electric breaker box must have triggered off causing the freezer temperature to be out of compliance for a little while, DM stated maintenance has been made aware of the issue. Surveyor advised DM the silver refrigerator was out of compliance, DM stated she think the thermometer inside was not working, she placed another thermometer, and the temperature was still out of compliance at 58 degrees. Interview conducted with ADM at 1:20 PM, he was notified of the concerning refrigerator temperatures. ADM stated he was contacting a company to check out the refrigerator. ADM was advised that the temperature of the food will need to be checked immediately. Observation/Interview with DM at 1:25 PM, revealed DM checked the temp of the dairy products in the refrigerator:Milk was at 57 degreesLactose milk at 55 degreesSausage at 60 degreesDM stated she will discard the food if needed. An interview was conducted with DA on 9/25/2025, at 12:13PM DA stated they have worked at the facility for 16 years. DA stated they all are responsible for labeling and dating food products in the kitchen. She explained that all food items are to be labeled with the date received. Once opened, the item should be labeled with the open date and discarded within three days. She reported that expired food was discarded as required. The DA further stated that staff food was not permitted to be stored in the kitchen refrigerators. The DA stated that staff are expected to clean daily inside the kitchen; however, there was no specific written cleaning schedule. She reported that cooks are responsible for cleaning the outside freezers, while she was assigned her own refrigerator inside to maintain. She stated that expired food was discarded when found. When asked about the potential harm of serving expired food, she responded that she has never given anyone expired food but acknowledged it could make a resident very sick. The DA stated she was aware of the required refrigerator and freezer temperatures and provided the correct ranges. She also stated that trash cans are required to have lids. She stated that the trash can located by the dishwasher on her side did not come with a lid; she stated covers it with a trash bag instead. The DA stated that she has informed the administrator several times after previous State visits that she needs a trash can with a lid but has not yet received one. She identified the potential harm of not having a lid on the trash can as odor and germ issues, which could negatively affect residents. An interview was conducted with DON on 9/25/2025 at 2:56 PM when the DON was asked if she was familiar with the labeling, dating, and discarding of food policy in the kitchen. She stated that she has not reviewed the policy. DON was asked her expectation of the dietary staff when labeling, dating, and discarding of expired. She stated, I would hope they will follow whatever the policy says. DON was asked the potential risk to residents if the labeling, dating, and discarding of the expired food products are not followed the DON stated residents can have gastric and bowel issues, she also stated bad dairy products could open the door to so many variables. Interview conducted with ADM on 9/25/2025, at 3:18 PM when the ADM stated he was familiar with the labeling and dating policies for the kitchen. He explained that food items should be labeled and dated with the open date, use-by and discard date. He further stated expired items should be thrown away by dietary staff. ADM stated his expectation is for dietary staff to keep the kitchen areas clean, and he expects the Dietary Manager to create and maintain a cleaning schedule. The ADM stated trash cans in the kitchen are supposed to have lids. When asked about potential resident harm, the Administrator stated that serving expired or contaminated food could result in residents becoming ill. Interview conducted with DM on 9/25/2025, at 3:46PM. DM stated her first day back at the facility was on Tuesday, when survey started. DM stated she worked at the facility previously. DM stated she was not familiar with this facility's labeling, dating, and storage policy. She explained that in her previous facilities, items were labeled with the date received, the open date, and the discard date. DM stated trash cans in the kitchen are required to have tight-fitting lids. She stated the kitchen staff is to be trained by the dietary manager. DM stated she will be responsible for conducting all future training. She added that she will need to retrain staff and explain her expectations moving forward. DM stated her goal for the week was to complete a deep cleaning of the kitchen. She identified the potential harm of serving outdated food as food poisoning and illness for residents. She further noted that not having a trash can with a lid could cause cross-contamination. DM stated all refrigerators and freezers should have temperature logs, with temperatures monitored daily in the mornings and afternoons. She stated the potential harm of improper temperatures was that food can spoil[BH11] , and residents could become sick with foodborne illnesses, such as salmonella. Interview conducted with [NAME] B on 9/25/2025, at 4:36 PM, [NAME] B stated she has been employed at the facility since January 2025. [NAME] B reported that she was trained by a dietary aide who was no longer employed at the facility. [NAME] B stated she was trained to label and date items with the open date, and that items are discarded after the third day. [NAME] B stated she does label receive dates as she was not at work when food was delivered. She identified the potential harm of serving residents outdated food as residents becoming sick. This interview with [NAME] B ended; as she was not cooperative. Record review of facility policy on 9/25/2025 named Sanitation revealed:Policy StatementThe food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. Record review of facility policy on 9/25/2025 named Food Receiving, and Storage revealed: Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation1. Critical Control Point means a specific point, procedure, or step in food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. 2.Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. 3. Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times.Dry Food4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in - first out system.Refrigerated/Frozen StorageI. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date).2. PHF/TCS foods are stored at or below 41 F, unless otherwise specified by law.

Based on observation, interview, and record review the facility failed to ensure a safe, clean, comfortable, and homelike environment for four (Resident #6, Resident #14, Resident #31, and Resident #42) of eight residents reviewed for safe operating patient care equipment and for 1 of 1 kitchen reviewed for safe operating condition. A) The facility failed to ensure Resident #6, Resident #14, Resident #31, and Resident #42 had a functioning toilet in their rooms. This failure could place residents at risk of unsanitary conditions, and these failures pose a risk to all residents of the facility who eat food from the kitchen as they are at risk for food borne illnesses. Findings included: A) Record review of Resident #6's Face sheet printed on 09/25/2025 revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Cerebral Infarction (temporary lack of blood flow to the brain), Type 2 Diabetes (disorder related to abnormal blood sugar levels), and bipolar disorder (mental illness that causes extreme mood changes). Record review of Resident #6's Other Payment Assessment MDS dated [DATE] reflected a BIMS score of 13 (no to minimal cognitive decline). Record Review of Resident #6's Care Plan printed on 09/25/2025 reflected a Focus area of Self-Care Deficit: Bathing, Dressing, Feeding Date Initiated: 07/24/2025. Related interventions reflected, Provide assistance with ADLs/IADLs (activities of daily living/ instrumental activities of daily living) as needed Date Initiated 07/24/2025. Record review of Resident #14's Face sheet printed on 09/25/2025 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease (dementia that damages the brain), Type 2 Diabetes (disorder related to abnormal blood sugar levels), and bipolar disorder (mental illness that causes extreme mood changes). Record review of Resident 14's Other Payment Assessment MDS dated [DATE] reflected a BIMS score of 7 (severe cognitive decline). Record Review of Resident 14's Care Plan printed on 09/25/2025 reflected a Focus area of Self-Care Deficit: Bathing, Dressing, Feeding Date Initiated: 06/27/2025. Related interventions reflected, Maintain consistent schedule with daily routine Date Initiated 07/28/2025. Record review of Resident #31's Face sheet printed on 09/23/2025 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes (disorder related to abnormal blood sugar levels), Need for Assistance with Personal Care, and Difficulty in Walking. Record review of Resident #31's Other Payment Assessment MDS dated [DATE] reflected a BIMS score of 10 (moderate cognitive decline). Record Review of Resident #31's Care Plan printed on 09/25/2025 reflected a Focus area of Self-Care Deficit: Bathing, Dressing, Feeding Date Initiated: 06/25/2025. Related interventions reflected, Provide assistance with ADLs/IADLs (activities of daily living/ instrumental activities of daily living) as needed Date Initiated 06/25/2025. Record review of Resident #42's Face sheet printed on 09/25/2025 reflected a [AGE] year-old male, admitted on [DATE]. Diagnoses included Type 2 Diabetes (disorder related to abnormal blood sugar levels), Dementia, and Constipation. Record review of Resident #42's Other Payment Assessment MDS dated [DATE] reflected a BIMS score of 10 (moderate cognitive decline). Record Review of Resident #42's Care Plan printed on 09/25/2025 reflected a Focus area of Self-Care Deficit: Bathing, Dressing, Feeding Date Initiated: 07/09/2025. Related interventions reflected, Provide assistance with ADLs/IADLs (activities of daily living/ instrumental activities of daily living) as needed Date Initiated 07/29/2025. Record review of Grievances for the last six months reflected no Maintenance related grievances related to the bathrooms/toilets. In an observation and interview with Resident #14 on 9/23/2025 at 12:18PM, revealed that the toilet for Resident #14 did not flush. There was urine visible in the toilet bowl. Odor of urine is present in the bathroom. Resident #14 stated that the toilet in his room had been broken since 09/18/2025. He stated that he had told someone but was not sure who it was. He stated he was using the public restroom in the hallway. Observation on 09/24/2025 at 8:50 AM revealed that Resident #14's toilet did not flush. There is urine visible in the toilet bowl. Odor of urine is present in the bathroom. Resident #14 was not in the room at that time. In an interview with MD on 09/24/2025 at 09:00AM, he stated the facility called a service out to review the water pressure and toilet issue on 09/23/2025. He stated that the town had known water pressure issues. He stated that after their review, it was communicated to him that due to the water pressure and variations in the level of sediment buildup from hard water and years of use, some of the toilets on the right side of the 100 hall were having trouble flushing. He stated that the facility was waiting for the invoice from the company to start the work of replacing the pipes for the facility. He stated that he changed the float valve and ruled out other causes for the toilets that would cause the toilets not to flush. He stated that the sink in the bathroom for Resident #14 gets water, but not the toilet. He stated that it was common for the toilet to go first when there are plumbing issues related to pressure and corrosion. He stated that the toilet for Resident #14 was the only toilet not working at that time. He stated that he was working on a plan to have bottled water available for staff to use to refill the toilet tank to allow the toilets to flush. He stated that the facility would do this for residents until the toilets were able to be fixed. He stated that he did not want to leave the water out for safety reasons, where residents could access it directly. He stated that he was informed by Resident #14 the day prior that the toilet was no longer able to flush. During an interview with Resident #14 on 09/24/2025 at 9:10 AM, he stated that having the staff refill the toilet tank after use to flush the toilets was an okay solution. He stated he does not mind using the shower room restroom down the hall, but he stated that he does not like the smell of the stagnant urine in the toilet in his room. Observation on 09/25/2025 at 08:38AM for the toilet shared by Resident's #6, Resident #31, and Resident #42 revealed that the toilet would not flush. The toilet was clean with no odors in the bathroom. There is no water in the tank of the toilet. In an interview with CNA C on 09/25/2025 at 08:41AM, she stated that she was not aware the toilet for the restroom shared by Resident's #6, Resident #31, and Resident #42 was not working. She stated that she knew there were water pressure issues with the toilet in the past, but she did not know that it was not functioning. She stated that Resident's #6, Resident #31, and Resident #42 were the only residents who used that bathroom. She stated that Resident #14 was the only resident who toileted himself in the bathroom for his room. Observation and interview with the MD on 09/25/2025 at 08:46PM revealed that there was a gallon jug of water under the counter for the sink in the resident bathroom for Resident's #6, Resident #31, and Resident #42. He used the water to fill the back tank of the toilet and then flush the toilet. He stated that he was working on a schedule for staff to refill the toilets temporarily. He stated that he told the residents to let the nurses know when they use the restroom so that staff could refill and flush the toilets. In an interview with Resident #6 on 09/25/25 at 08:49AM, he stated that having the staff fill the toilet tank from water jugs was a fine solution. He stated that he usually uses the shower room restroom in the hallway. In an interview with Resident #31 on 09/25/2025 at 08:58AM, with interpreter services from HHSC Spanish language interpreter #47477, he stated that the toilet works sometimes and then breaks down again. He stated that it was hard for him to put the water in the toilet tank on his own. He stated that he was not sure if it bothered him enough to want another room. He stated that he would like to speak to the woman that runs the place to discuss the issue further. In an interview with Resident #42 on 09/25/2025 at 09:01AM, he stated that he was using the shower room restroom in the hallway. He stated that he was fine with that solution at that time. In an interview with Resident #14 on 09/25/2025 at 09:09AM, he stated that he was using the hallway bathroom. He stated that the staff had not emptied the toilet and there was a bad smell in there again. In an interview with the DON on 09/25/2025 at 09:25AM, she stated that she spoke to the resident in Spanish and she informed him that he can tell staff when he uses the restroom so that they can fill the toilet to flush it if he needs help. She stated that they were waiting for the invoice from the plumbing company that was there on 09/23/2025 so that they can start repairs. Observation of the shower room restroom on the 100 hall on 09/25/2025 at 01:50PM revealed that the toilet seat for the toilet was not attached on one side. In an interview with the ADON on 09/25/2025 at 03:37PM, she stated that the toilet seat in the shower room for 100 Hall had been repaired by MD. She stated that there is no privacy available for the shower room bathroom. She stated the door does not lock. She stated that residents have the right to a private working toilet. She stated it was not sanitary to have nonfunctioning toilets for residents. In an interview with the DON on 09/25/2025 at 03:56PM, she stated that residents have the right to a private working toilet. She stated that residents can use their restroom and have staff add the water to the tank to flush the toilet. She stated that she had in serviced the CNAs to monitor the rooms for Resident#14, Resident's #6, Resident #31, and Resident #42. She stated that the CNAs would check the bathroom every two hours with resident rounds. She stated that they are working on the bathroom situation. She stated that residents are able to use the shower room restroom if they choose. She stated that she knew that the bathrooms could not lock for privacy due to safety concerns. She stated that residents could walk in on each other while using the restroom in that bathroom. She stated that there are other working restrooms in the facility that residents can use if they ask the staff. She stated that the potential impact to residents of not having a private working toilet would be that they might hold their urine or become frustrated with the situation. In a follow up interview with MD on 09/25/2025 at 03:58PM, he stated that he was informed earlier that day that the toilet seat was broken. He stated that it was fixed at that time. He stated that the door does not lock from the inside for safety reasons. He stated that the restroom is more public that the restrooms in the resident rooms. In an interview with the ADM on 09/25/2025 at 04:01PM, he stated that residents have the right to a private working bathroom. He stated that the facility was working to correct the plumbing problems with the restrooms on the 100 hall. He stated that using the shower restroom in the 100 hallway was an acceptable solution temporarily. He stated that it was an all-male facility, so it was fine that the door did not lock. He stated that if there were women in the facility it would not be acceptable. He stated that privacy could be provided with a closed door or closed curtain. Record review of facility policy for Quality Control, Environmental Services dated 12/2009 does not address environmental concerns not related to housekeeping and laundry services. Record review of facility policy for Resident Rights dated 02/2021does not address resident rights related to environmental conditions.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 (Residents #51, Resident #38, and Resident #26 ) of 8 residents reviewed for care plans. 1.The facility failed to ensure that Resident #51's central venous catheter (a temporary access placed into a large vein in the neck or chest) for dialysis care was addressed in the comprehensive care plan. 2. The facility did not ensure Resident #38 had a care plan that identified possible triggers when Resident #38 had a history of trauma. 3. The facility failed to ensure that Resident #26's parole-issued ankle monitor was addressed in the comprehensive care plan. This failure could place residents at risk of not receiving necessary care or receiving incorrect care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: 1. Record review of Resident #51's Face sheet printed on 09/24/2025 reflected a [AGE] year-old male, admitted on [DATE]. Diagnoses included: pneumonia (lung infection), end stage renal disease (late-stage kidney failure), and cognitive communication deficit (problem with communication caused by cognition rather than a language or speech deficit). Record review of Resident #51's quarterly MDS dated [DATE] reflected a BIMS score of 12 (moderate cognitive impairment). Section O indicated the resident required hemodialysis (a medical procedure that cleans the blood and removes extra fluid when the kidneys have failed). Record review of Resident #51's Physician Orders printed on 09/24/2025, reflected an order dated 09/24/2025, which stated, wipe insertion site with alcohol, cover with 2x2, tape on three sides. Side not taped is the lumen side for care related to the central venous catheter for dialysis access. An order dated 08/06/2025, stated, Dialysis provided by [designated dialysis center]. Dialysis days are Monday, Wednesday, Friday with a chair time of 10am. Days may vary based on holidays and dialysis center schedule. Record Review of Resident #51's care plan printed on 09/24/2025 reflected no Focus areas, Goals, or Interventions/Tasks related to the central venous catheter (a flexible tube inserted into a large vein, usually in the neck, chest, or groin, that ends in a large vein near the heart) for dialysis access. Record Review of Resident #51's Progress Notes reflected a note on 09/17/2025 at 09:54PM indicating Resident #51 was being readmitted from the hospital and reflected, [Resident #51] has a perma catheter (CVC for dialysis use) to left side chest wall, dressing intact. In an observation and interview with Resident #51 on 09/23/2025 at 08:22AM, he stated that he receives dialysis three times a week. He stated that he was happy with the care from the facility. In an observation of Resident #51's CVC for dialysis use on 9/23/2025 at 01:00PM revealed a gauze dressing with paper tape on three sides, as described in the physician orders. Dressing was clean, dry, and intact. In an interview with TN on 09/25/2025 at 09:12AM, she stated that she was not sure who updates the care plans. She stated that her responsibility was to update wound care recommendation orders from the contracted wound care nurse practitioner who visits the facility. She stated that she does not initiate or resolve wounds in the care plans. She stated that she communicates updates with wound care orders to the DON. She stated that medical devices should be a part of the care plan for a resident. 2. Record review of Resident #38's Face sheet printed on 09/24/2025 reflected a [AGE] year-old male, originally admitted on [DATE]. Initial admission date is listed as 04/10/2025. The most recent admission date is listed as 09/17/2025. Diagnoses included atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), auditory hallucinations, major depressive disorder (persistent low mood or lack of interest in activities, significantly affecting a person's ability to function in daily life), anxiety disorder (a mental health condition where feelings of intense fear and worry are constant, overwhelming, and interfere with daily life), unspecified mood disorder (a mental health condition where feelings of intense fear and worry are constant, overwhelming, and interfere with daily life), and post-traumatic stress disorder (PTSD). The diagnosis for PTSD has an onset date of 06/02/2022 and is categorized as During Stay. Record review of Resident #38's Discharge (return anticipated) MDS dated [DATE] and signed by ADON, reflected an active diagnosis of anxiety disorder and Post Traumatic Stress Disorder under Section I in the Psychiatric/Mood Disorder category. Record review of Resident #38's Care Plan printed on 09/24/2025 reflected there was no focus area in the care plan for PTSD with related person-centered goals and interventions or possible triggers for the PTSD. In an interview with Resident #38 on 09/23/2025 at 9:36AM, he stated that he had no concerns for nursing care in the facility. He stated that the staff treated him well. In an interview with DON on 09/25/2025 at 03:17PM, she stated that the ADON was responsible for everything related to care plans. She stated that she bears some responsibility for care plans but has not been trained on how to use the care plan system yet. She stated that new wounds, new dialysis access, and anything new related to care should be part of the resident's care plan with individualized goals and interventions. She stated that if care plans are not updated with new diagnoses or resident needs that residents may receive incorrect care. In an interview with ADON on 09/25/2025 at 03:37PM, she stated that care plans should be updated with any new medical devices, wounds, new diagnoses, PASARR results, refusals, behaviors, hallucinations and/or delusions. She stated that Resident #51 should have care plan areas and interventions related to the wound to his left arm and his new dialysis access device. She stated that she was not in the building when Resident #51 returned from the hospital. She stated she was only in the facility one day between her return from her time off to the start of the survey. She stated that the impact to the residents of not updating care plans accordingly then resident care could be missed or overlooked. In an interview with ADM on 09/25/2025 at 04:01PM, he stated that he believed the ADON updated and monitored care plans. He stated he was not sure how new areas were started for resident care plans. He stated that the care plans should be updated with new medical devices, new diagnoses of PTSD, and for new treatments. He stated that if care plans are not updated with current care needs for a resident, then it could result in potential harm to the resident. Record review of the facility policy for Trauma Informed Care and Culturally Competent Care dated 2001, reflected, Resident Care Planning 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns (e.g. substance abuse, eating disorders, anxiety and depression). 4. Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. For example: a. food preparation and choices; b. clothing preferences such as covering hair or exposed skin; c. physical contact or provision of care by a person of the opposite sex; or d. cultural etiquette, such as avoiding eye contact or not raising the voice. 3. Record Review of Resident 26's Face sheet dated 09/24/2025 revealed and admission date of 05/13/2025 with diagnoses of Cirrhosis of Liver (late stage of liver disease with severe scarring), Gastro-Esophageal Reflux Disease (acid reflux), and Schizoaffective Disorder, Bipolar Type (hallucinations and delusions). Record Review of Resident #26's MDS assessment, dated 08/12/2025, reflected Resident #26 had a BIMS score of 4 out of 15, indicating severe cognitive impairment. Record Review of Resident #26's comprehensive care plan on 09/24/2025, lacked documentation of the presence of the paroled issued monitor, the potential impact on skin integrity, safety, and daily care, or any staff interventions to monitor and report concerns. Record Review of Resident #26's progress notes on 09/24/2025, reflected on 5/17/2025, Parole could not get a signal, it was discovered that resident removed his ankle monitor stating it had hurt his leg. Observation conducted on 9/23/2025 at 9:27 AM, Resident #26 was observed wearing an ankle monitor. Interview conducted on 09/25/2025 at 10:40 AM, CNA C stated that Resident #26 was admitted from prison with a parole-issued ankle monitor. The CNA stated staff were not provided with information about the reason for the monitor, only that the parole department calls the facility and asked the staff to take the resident outside when the device needs to be reset. The CNA further reported that the facility instructed staff to ensure the monitor remains charged. She stated that she personally checks the resident's skin under the monitor because it is a foreign object on the resident's body; however, she had not been given written instructions or guidance in the care plan regarding this intervention. The CNA stated that in her opinion, the ankle monitor should be included in Resident #26's care plan, as it is part of the resident's daily care and could affect the resident's well-being if not monitored for tightness, irritation, or skin breakdown. Interview conducted on 09/25/2025 at 2:31 PM, the ADON stated she has not been trained completely on completing care plans as she has been working in two different positions. She confirmed Resident #26 was admitted from prison with the ankle monitor and stated parole comes to the facility to check placement. She reported the parole monitoring system calls the facility when the monitor does not register and instructs staff to move the resident to another location to reset the device. She stated the resident is required to wear the battery for only one hour per day. The ADON acknowledged that the ankle monitor should have been included in the care plan and reported she contacted corporate earlier the same day to ask about this issue. She was told that ankle monitors had not been included in care plans previously but confirmed that the device was added to Resident #26's care plan today, along with another resident's monitor. The ADON stated potential harm from not including the monitor in the care plan could result in skin breakdown or pressure injuries. Interview conducted on 09/25/2025 at 3:06 PM, the ADM stated the facility did not have a policy in place for residents with parole-issued ankle monitors. He stated Resident #26 was admitted with the monitor from prison. ADM stated when they receive residents from prisons, they are sent clinical records, and they are screened for medical necessity. ADM further stated in all the years he has worked in the nursing facility; the ankle monitor has never been included in a comprehensive care plan. The Administrator explained that if redness occurred, a CNA would notify the charge nurse, who would then contact parole, and parole has previously advised the facility to cut off a monitor if it caused problems. He further stated the battery charging of the monitor was the resident's responsibility, not the facilities, but parole may call at any hour, including 3 AM, to request staff assist in resetting the resident's monitor if it's does not pick up signal. When asked about agency nursing being unfamiliar with the device, the Administrator stated, If everyone in nursing were doing their jobs, there may not be a need for the monitor to be care planned. He stated weekly skin assessments are conducted, and since the facility does not supply the monitor, he did not believe there was potential harm in not including it in the comprehensive care plan, as long as staff checked skin as expected. Record review of the facility policy on Care Plans, Comprehensive Person-Centered dated 2001, reflected: Policy Statement A 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 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. Review of the facility's policy Care Plans, Comprehensive Person-Centered dated 03/2022 reflected A 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.The comprehensive, person-centered care plan . includes measurable objectives and timeframes. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including; services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The interdisciplinary team reviews and updates the care plan. when the desired outcome is not met.

Based on observations, record review and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 5 pureed diets of 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure [NAME] A and DM refrained from adding an unmeasured amount of liquid to spaghetti and meatballs, and green bean pureed meals during lunch service on 9/23/2025. This failure could place residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss Findings included: In an observation and interview conducted with Resident #3 on 9/23/2025, at 8:42 AM revealed Resident #3 was observed in his room drinking his coffee after completing his breakfast. Resident stated the food was pitiful. Observation on 9/23/2025, at 10:35 AM, revealed [NAME] A poured an unmeasured amount of milk into the spaghetti noodles without measuring. After mixing, the spaghetti was noted to be loose; [NAME] A then tore slices of bread and pureed them into the mixture. The DM walked over and subsequently added additional milk, also without measuring. For the green beans, [NAME] A added slices of bread to thicken the mixture; when it became too thick, she added another unmeasured amount of milk. [NAME] A was then observed preparing meatballs, adding an unmeasured amount of milk twice, followed by pieces of a hamburger bun to the pureed mix. Interview was conducted with [NAME] A on 9/23/2025, at 1:18 PM, stated she had been employed at the facility since November 2024 and that this was her last day (today). She stated feeling she had no support in the dietary department. When asked about her training on the puree process, [NAME] A stated she was shown the procedure by a temporary dietary manager who was not certified.Cook A stated that during the lunch service on 09/23/2025 during meal preparation, she estimated she prepared enough for five puree diet residents but did not consult the recipe. When asked about adding bread to multiple items, she stated she was instructed to use bread and was aware it was not according to the recipe but was told to follow the process she had been shown. She stated that prior to about a month ago, she had not pureed food with bread and that the facility always used milk in the puree process because broth was never available. She stated she was told residents Need bread anyway, so it doesn't hurt to mix it in. When asked about potential effects of not following the recipe, [NAME] A stated it could change the flavor of the food and potentially create chewing issues, choking hazards, or risk of aspiration for residents. A Test tray was requested and received on 9/24/2025 at 11:30 AM. The meal served was homemade tamale pie. Test trays were received for both a regular texture diet and a pureed diet. The regular diet plate was flavorful and tasted as expected. The pureed diet plate had a sticky texture and had a bland taste; it did not replicate the regular diet taste. Interview conducted with DON on 9/25/2025, at 2:56 PM, who stated they had been with the facility since May 2025. DON was asked if she could explain the facility puree process for the residents ordered pureed diets. The DON stated she knows there was a pureed policy, but she was not able to say what it included verbatim. She explained they have a dietician that comes once a week to work with the cooks. DON also stated the tray ticket and food are checked by the nurse before being given to the residents. When asked if she knew what should be used to puree food, she stated she was unsure. DON stated she expects the dietary department to follow the recipes. When asked what could happen if the puree diet recipe was not followed, she stated that residents could potentially lose calories if too much liquid was used. DON also added that the taste and nutritional value of the food may be affected. Interview conducted with ADM on 9/25/2025, at 3:18 PM, ADM stated the pureed diet should be of a pudding, mashed potato consistency. ADM stated his expectation was for dietary staff to follow the recipes as written. He explained that if the pureed diet was not prepared according to the recipe, the potential harm to residents was that they may not receive the correct caloric intake or adequate nutritional value. Interview conducted with DM on 9/25/2025, at 3:46PM. DM stated her first day back at the facility was on Tuesday, when survey started. DM stated she worked at the facility previously. DM stated she does not know if the cooks were trained properly on preparing diet textures. DM stated the dietary manager was responsible for training all dietary staff. DM stated moving forward it will be her providing the training and in-services. DM stated her expectations was for all dietary staff to follow the recipes. DM stated she will also retrain herself from policies. DM manager stated they will be incorporating broth and gravy into puree recipes to enhance the flavors. DM stated the potential risk of harm from not following the recipe could lead to nutrition being affected and possible choking. Record Review of facility diet order conducted on 09/23/2025, revealed there were 5 residents on pureed diets. Review of facility's diet and nutrition care manual reflected:1. Pureed foods are generally cohesive, moist mashed potato or pudding-like consistency for people who cannot tolerate regular or mechanical soft foods. Food is pureed in a food processor to achieve a consistent smooth and easy-to-swallow product. Fluid may be added, or commercial thickening agents can be used to assure the proper consistency is achieved.2. Pureed food should appear and taste like real food (as close to the regular diet as possible), while easing the chewing and swallowing process. Formed pureed foods can be purchased or prepared in house. Standardized pureed recipes are the first step to assure a product that is consistent in taste, appearance, consistency and nutrient content.

Based on, interviews, and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 4 residents (Resident # 38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening that identified possible triggers when Resident #38 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of Resident #38's Face sheet printed on 09/24/2025 reflected a [AGE] year-old male, originally admitted on [DATE]. Initial admission date is listed as 04/10/2025. The most recent admission date is listed as 09/17/2025. Diagnoses included atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), auditory hallucinations, major depressive disorder (persistent low mood or lack of interest in activities, significantly affecting a person's ability to function in daily life), anxiety disorder (a mental health condition where feelings of intense fear and worry are constant, overwhelming, and interfere with daily life), unspecified mood disorder (a mental health condition where feelings of intense fear and worry are constant, overwhelming, and interfere with daily life), and post-traumatic stress disorder (PTSD). The diagnosis for PTSD has an onset date of 06/02/2022 and is categorized as During Stay. Record review of Resident #38's Discharge (return anticipated) MDS dated [DATE] and signed by ADON, reflected an active diagnosis of anxiety disorder and Post Traumatic Stress Disorder under Section I in the Psychiatric/Mood Disorder category. Record review of Resident #38's Care Plan printed on 09/24/2025 reflected there was no focus area in the care plan for PTSD with related person-centered goals and interventions or possible triggers for the PTSD. In an interview with Resident #38 on 09/23/2025 at 9:36AM, he stated that he had no concerns for nursing care in the facility. He stated that the staff treated him well. In an interview with ADON on 09/24/2025 at 3:35PM, she stated that Resident #38 should have PTSD as part of his care plan. She stated that she started working at the facility in January 2025. She stated she was responsible for all aspects of resident care plans. She stated that the DON and the nurses do not update the care plans at this time. She stated that without updating the care plan with new resident needs or diagnoses, their care can be missed or overlooked. In an interview with DON on 09/25/2025 at 3:17PM, she stated that the ADON was responsible for everything related to care plans. She stated that she bears some responsibility for care plans but has not been trained on how to use the care plan system yet. She stated that PTSD should be part of the resident's care plan with individualized goals and interventions. She stated that if care plans are not updated with new diagnoses or resident needs, that residents may receive incorrect care. In an interview with ADMIN on 09/25/2025 at 4:01PM, he stated that care plans should be updated with a diagnosis of PTSD. He stated that not having the appropriate care plan updates and interventions could result in potential harm to the residents. Record review of the facility policy for Trauma Informed Care and Culturally Competent Care dated 2001, reflected, Resident Care Planning1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns (e.g. substance abuse, eating disorders, anxiety and depression).4. Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. For example: a. food preparation and choices; b. clothing preferences such as covering hair or exposed skin; c. physical contact or provision of care by a person of the opposite sex; or d. cultural etiquette, such as avoiding eye contact or not raising the voice.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #13 and Resident #25) reviewed for infection control. The facility failed to ensure:1. TN used clean, sanitized scissors during wound care for Resident #25 on 09/24/2025.2. LVN D performed hand hygiene prior to preparing an injection for Resident #13 on 09/24/2025. 3. LVN D wore proper gloves (PPE) while administering an injection for Resident #13 on 09/24/2025. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections. Findings included: Record review of Resident #25's Face sheet printed on 09/24/2025 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes (disorder related to abnormal blood sugar levels), Sever Dementia, and Pressure Ulcer of Left Heel. Record review of Resident #25's Significant Change MDS dated [DATE] reflected a BIMS score of 2 (severe cognitive decline). Section I for Active Diagnoses included a pressure ulcer of left heel. Record review of Resident #25's Care Plan reflected a Focus are stating, I am at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment/ skin desensitized to pain or pressure, slow healing process R/T (related to) DX (diagnosis) of Diabetes Mellitus. Date Initiated: 05/26/2025 There was an additional Focus are for Wound management - Unstageable to right heel Date Initiated 05/24/2025. Related interventions reflected, Monitor ulcer for signs of infection Date Initiated 05/24/2025. Record review of Resident #25's Physician Orders printed on 09/24/2025 reflected and order for WOUND CARE: Cleanse L) (left) heel with wound cleanser, pat dry. Apply Medi honey medical grade honey fiber to wound be, secure with kerlix and tape, this to be done 3Xweek (three times a week), and PRN (as needed) with a date of 09/19/2025. Additional order with a start date of 09/17/2025 reflected the resident be admitted to hospice services related to Alzheimer's (dementia that damages the brain) diagnosis. Record review of Resident #13's Face sheet printed on 09/25/2025 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes (disorder related to abnormal blood sugar levels), Dementia, and Hypertension (high blood pressure). Record review of Resident #13's Quarterly MDS dated [DATE] reflected a BIMS score of 14 (no cognitive decline). Record review of Resident #13's Care Plan printed on 09/25/2025 reflected a Focus area for Impaired Physical Mobility dated 04/23/2025, with related goal stating, Resident's Skin Will Remain Intact Date Initiated: 04/17/2025 Target Date: 11/09/2025. Record review of Resident #13's Physician Orders printed on 09/25/2025, reflected an order for NovoLIN R Injection Solution (Insulin Regular (Human)) Inject as per sliding scale : if0 - 150 = 0 units; 151 - 200= 2 units; 201 - 250 = 4units; 251 - 300 = 6 units;301 - 350 = 8 units; 351 -400 = 10 units; 401 - 450 =12 units; 451 - 500 = 14units; 501+ IF BLOODSUGAR IS GREATER THAN 501, CALL MD, subcutaneously (into the fatty layer under the skin) three times a day related to TYPE 2 DIABETES MELLITUS. During an observation of wound care for Resident #25 on 09/24/2025 at 9:20AM revealed TN used a clean pair of scissors to cut the gauze dressing off of Resident #25's left foot. She then used the soiled scissors to cut the Manuka honey impregnated dressing that was applied directly to the exposed wound bed on Resident #25's left heel. During an observation of medication administration for Resident #13 on 09/24/2025 at 10:57AM revealed that LVN D returned to the medication cart after checking Resident #13's blood sugar. When exiting the room, she removed the gloves that she was wearing for the blood sugar check and a sanitary wipe at that time to clean the glucose monitor. Then, she used a sterilely packaged insulin syringe and reusable, multidose vial of Novolin R insulin to draw up the prescribed amount of medication for Resident #13. In an interview with LVN E on 09/25/2025 at 9:27AM, who stated that she was a travel nurse. She stated that she had been coming to the facility periodically since June 2025. She stated she was trained in wound care and able to perform wound care for residents, if needed. She stated that hand hygiene should be performed before and after care and before and after removing gloves. She stated that it was a standard of care to wear gloves during blood sugar checks and while giving medication injections to a resident. She stated that if scissors are used during a dressing change or other procedure, she would clean the scissors after using them for a dirty portion of the procedure. She stated that the potential risk to residents of not performing hand hygiene appropriately, not wearing appropriate PPE during medication injections, and using soiled supplies for a dressing change could all potentially result in an infection for the residents. In an interview with TN on 09/24/2025 at 9:37AM who stated that she did not clean her scissors during Resident #25's wound care. She stated that she cleaned the scissors prior to the wound care and after the wound care was completed. She stated that she should have cleaned the scissors after she used them to cut off the soiled dressing and prior to using the scissors to cut the clean dressing that was applied directly to the wound. She stated the impact to the residents could be possible cross contamination. In an interview with the DON on 09/25/2025 at03:17PM, who stated that all supplies for dressing changes should be cleaned before and after use. She stated that scissors that are used during a dressing change should be cleaned between using them with dirty dressings and clean dressing supplies. She stated that the potential risk to residents of not using clean supplies during a dressing change could be possible infection. She stated that nurses should perform hand hygiene before preparing anything for a resident, including injectable medications. She stated it is best practice to wear gloves while administering an injection. She stated that the risk to residents of not using proper hand hygiene and PPE during injections was the potential for infection and cross contamination. In an interview with ADMIN on 09/25/2025, he stated that hand hygiene should be performed before and after injections and after cleaning the glucose monitors. He stated that he would have to defer to his clinical team regarding the use of gloves for injections. He stated that the risk to the residents of not performing hand hygiene and wearing appropriate PPE for injections could potentially cause an adverse effect for the residents. Record review of facility policy for Infection Control dated 4/2013 reflected: General Guidelines1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes.3. Employees must wash their hands for ten (10) to fifteen ( 15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:a. Before and after direct contact with residents;b. When hands are visibly dirty or soiled with blood or other body fluids;c. After contact with blood, body fluids, secretions, mucous membranes, or non intact skin;d. After removing gloves;e. After handling items potentially contaminated wi.th blood, body fluids, or secretions; Record review of the facility policy dated 2001 reflected: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene1. Hand hygiene is indicated:a. immediately before touching a resident;b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);c. after contact with blood, body fluids, or contaminated surfaces;d. after touching a resident;e. after touching the resident's environment;f. before moving from work on a soiled body site to a clean body site on the same resident; andg. immediately after glove removal.4. Single-use disposable gloves should be used:a. before aseptic procedures;b. when anticipating contact with blood or body fluids; andc. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. Record review of facility policy for Wound Care dated 10/2010, reflected: Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 1. Dressing material, as indicated (i.e., gauze, tape, scissors, etc.); It does not address the cleaning of scissors and when to do so in the policy. Record review of facility policy for Insulin Administration, dated 09/2014, did not address the PPE required for subcutaneous (the fatty layer just under the skin) injections. The policy stated hand washing should be performed prior to blood glucose check and after the disposing of the needle post injection.

Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents reviewed for catheters (Resident #43). The facility failed to ensure Resident #43's received care to prevent Urinary Tract Infections when they stored his catheter bag on the floor. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition. Findings Included: Review of Resident #43's Face Sheet reflected he was admitted on [DATE] and readmitted on [DATE] with the following diagnoses cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain.) encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.) and retention of urine (inability to urinate). Review of Resident #43's Quarterly MDS dated [DATE] reflected Resident #43 was assessed to have a BIMS score of one 12 indicating moderate cognitive impairment. Resident #43 was assessed to require partial to moderate assistance with transfers. Resident #43 was assessed to have an indwelling urinary catheter. Review of Resident #43's Comprehensive Care Plan dated 07/09/2025 reflected a focus area Bladder Incontinence- with the presence of catheter: [x] indwelling, has one of the following DX: Obstructive Uropathy, retention. Interventions reflected Change catheter/ drainage bag/ tubing per MD orders. Encourage adequate hydration. Ensure staff are aware of correct placement of catheter gravity drainage bag and tubing. Keep tubing/ bag below the bladder, do not kink tubing.Monitor urine for odor, color, sediments, amount of urine, etc. and report any abnormalities to MD. Review of Resident #43's Consolidated Physician orders reflected an order dated 09/24/2025 FOLEY: change catheter 16fr 10ml bulb and drainage bag based on clinical indications such as infection, obstruction, or when the closed system is compromised. one time a day every 3 month(s) starting on the 24th for 84 day(s) for retention change every 3 months on the 24th. Observation on 09/23/2025 at 10:30 AM revealed Resident #43 in bed asleep. Resident #43's indwelling catheter bag was lying on the floor next to his bed. Observation and interview on 09/24/2025 at 9:25 AM revealed Resident #43 in his room in bed. Resident #43's indwelling catheter bag was lying on the floor next to his bed. Resident #43 stated he put himself in bed. When asked about the catheter bag on the floor he stated he did not know what to do with it. Observation on 09/24/2025 at 2:55 PM revealed Resident #43 in bed. Resident #43's indwelling catheter bag was lying on the floor next to his bed. In an interview on 09/24/2025at 3:00 PM CNA C stated she worked with Resident #43. She stated that his catheter bag should not be on the floor. She stated Resident #43 only gets out of bed for smoke breaks then goes right back to bed. CNA C stated she should go check on Resident #43 after smoke breaks to make sure his catheter bag is positioned properly by hanging from the bed. She stated she did not think about it to be honest. CNA C stated with Resident #43's catheter bag being on the floor it could cause infections, and it could cause him to fall and trip on it or cause him trauma. In an interview on 09/25/2025 at 9:40 AM the DON stated Resident #43's catheter bag should not be on the floor, and it was her expectation that the staff check on him frequently to ensure the bag is not on the floor. She stated failure to ensure the catheter bag is stored properly could lead to infections, and trauma. Review of the facility's policy Catheter Care, Urinary dated 07/2024 The purpose of this procedure is to prevent catheter-associated urinary tract infections. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observations, interviews, and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 1 (Resident #43) of 6 residents reviewed for comprehensive care plan revisions. The facility failed to update Resident #43's care plan to reflect his current need for assistance with his indwelling catheter bag placement after self-transfers. This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need. Findings included: Review of Resident #43's Face Sheet reflected he was admitted on [DATE] and readmitted on [DATE] with the following diagnoses cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain) encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.) and retention of urine (inability to urinate). Review of Resident #43's Quarterly MDS dated [DATE] reflected Resident #43 was assessed to have a BIMS score of 12 indicating moderate cognitive impairment. Resident #43 was assessed to require partial to moderate assistance with transfers. Resident #43 was assessed to have an indwelling urinary catheter. Review of Resident #43's Comprehensive Care Plan dated 07/09/2025 reflected a focus area Bladder Incontinence- with the presence of catheter: [x] indwelling, has one of the following DX: Obstructive Uropathy, retention. Interventions reflected Change catheter/ drainage bag/ tubing per MD orders. Encourage adequate hydration. Ensure staff are aware of correct placement of catheter gravity drainage bag and tubing. Keep tubing/ bag below the bladder, do not kink tubing.Monitor urine for odor, color, sediments, amount of urine, etc. and report any abnormalities to MD. Review of Resident #43's Consolidated Physician orders reflected an order dated 09/24/2025 FOLEY: change catheter 16fr 10ml bulb and drainage bag based on clinical indications such as infection, obstruction, or when the closed system is compromised. one time a day every 3 month(s) starting on the 24th for 84 day(s) for retention change every 3 months on the 24th. Observation on 09/23/2025 at 10:30 AM revealed Resident #43 in bed asleep. Resident #43's indwelling catheter bag was lying on the floor next to his bed. Observation and interview on 09/24/2025 at 9:25 AM revealed Resident #43 in his room in bed. Resident #43's indwelling catheter bag was lying on the floor next to his bed. Resident #43 stated he put himself in bed. When asked about the catheter bag on the floor he stated he did not know what to do with it. Observation on 09/24/2025 at 2:55 PM revealed Resident #43 in bed. Resident #43's indwelling catheter bag was lying on the floor next to his bed. In an interview on 09/24/2025at 3:00 PM CNA C stated she worked with Resident #43. She stated that his catheter bag should not be on the floor. She stated Resident #43 only gets out of bed for smoke breaks then goes right back to bed and transfers himself most of the time. CNA C stated she should go check on Resident #43 after smoke breaks to make sure his catheter bag is positioned properly by hanging from the bed. She stated she did not think about it to be honest. CNA C stated with Resident #43's catheter bag being on the floor it could cause infections, and it could cause him to fall and trip on it or cause him trauma. In an interview on 09/25/2025 at 9:40 AM the DON stated Resident #43's catheter bag should not be on the floor, and it was her expectation that the staff check on him frequently to ensure the bag is not on the floor. She stated the care plan should reflect his need for staff to check his catheter bag placement after self-transfers. She stated failure to ensure the catheter bag is stored properly could lead to infections, and trauma. In an interview on 09/25/2025 at 9:47 AM the ADON stated she oversaw the updating of care plans. She stated Resident #43 does put himself to bed after smoke breaks and staff should go check on him to ensure his catheter bag is not on the floor. She stated his need for staff to assist with his catheter bag placement should be on the care plan to ensure staff know to go check on him and position his catheter bag correctly. She stated she did not know why the care plan was not updated but she would update the care plan. Review of the facility's policy Care Plans, Comprehensive Person-Centered dated 03/2022 reflected A 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.The comprehensive, person-centered care plan . includes measurable objectives and timeframes. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including; services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The interdisciplinary team reviews and updates the care plan. when the desired outcome is not met.

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #38) reviewed for PASRR assessments. The facility did not refer Resident #38 to the appropriate state-designated mental health authority for review when he received a new diagnosis of post-traumatic stress disorder (condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) or during readmission to the facility on [DATE]. This failure could place residents at risk of not being evaluated and receive needed PASRR services.Findings included:Record review of Resident #38's Face sheet printed on 09/24/2025 reflected a [AGE] year-old male, originally admitted on [DATE]. Initial admission date is listed as 04/10/2025. The most recent admission date is listed as 09/17/2025. Diagnoses included atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), auditory hallucinations, major depressive disorder (persistent low mood or lack of interest in activities, significantly affecting a person's ability to function in daily life), anxiety disorder (a mental health condition where feelings of intense fear and worry are constant, overwhelming, and interfere with daily life), unspecified mood disorder (a mental health condition where feelings of intense fear and worry are constant, overwhelming, and interfere with daily life), and post-traumatic stress disorder (PTSD). The diagnosis for PTSD has an onset date of 06/02/2022 and is categorized as During Stay. Record review of Resident #38's Discharge (return anticipated) MDS dated [DATE] and signed by ADON, reflected an active diagnosis of anxiety disorder and Post Traumatic Stress Disorder under Section I in the Psychiatric/Mood Disorder category. Record review of Resident #38's Care Plan printed on 09/24/2025 reflected no focus area for PTSD with related person-centered goals and interventions. Record review of Resident #38's only PASRR Level I, dated 11/08/2018, reflected he did not have any mental illness. In an interview with Resident #38 on 09/23/2025 at 09:36AM, he stated that he had no concerns for the nursing care in the facility. He stated that staff treated him well. In an interview with ADON on 09/24/2025 at 03:35PM, she stated that Resident #38 did not have PTSD when he was admitted in 2018. She stated that she just started working at the facility in January 2025. She stated that she was responsible for PASRR related duties at the facility. She stated that she recently completed a self-study to train for PASRR and was still learning. She stated that she thought Resident #38 should have been positive for mental illness in 2018 due to the admitting diagnoses of major depressive disorder and anxiety. She stated that she was not sure if he should have had been evaluated for PASRR with readmissions to the facility. She stated that she was not aware that he had not had an evaluation since 2018 before she was asked by the survey team. In an interview with DON on 09/25/2025 at 03:17PM, she stated that a PASRR evaluation should be completed with a new diagnosis of PTSD. She stated that the impact to the resident is that he may not receive the services he needs, because those special services were not identified with the PASRR evaluation. In a follow-up interview with ADON on 09/25/2025 at 03:37PM she stated that Resident #38 should have been screened for PASRR with a new mental health diagnosis, especially PTSD. She stated that not providing PASRR screening with a new mental health diagnosis could lead to the resident not being screened for or provided services related to the resident's mental health diagnosis. In an interview with ADM on 09/25/2025 at 04:01PM, he stated that a PASRR evaluation should be done for a new diagnosis of PTSD for a resident. He stated that the potential impact of not receiving an evaluation with a new mental health diagnosis of PTSD is that they may not receive services that could affect their quality of life. Record review of the facility policy for PASRR dated 07/29/2025 reflected: Purpose The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. Procedure1. admission Process:a). Exempted hospital discharge happens when a physician at an acute care hospital (a medical acute care hospital, not a psychiatric hospital) has determined the person might need a nursing facility stay of 30 days or less for rehabilitation purposes. b). Expedited admission is for those discharged from a medical acute care hospital or a nursing facility transfer. There are seven expedited admission categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite and coma. c). Preadmission happens when a person is coming from the community (psychiatric hospital, home, group home, jail, assisted living, etc.). This includes anywhere other than a medical acute care hospital or another nursing facility. The person, coming from the community with a PASRR Level 1 that indicates suspicion of IDD, and/or mental illness must also have a completed PASRR Evaluation submitted before they can be admitted to a nursing facility. This process must be followed to ensure people coming from a community setting can receive education about other placement alternatives before nursing facility admission. d). Negative indicates the person has a negative PL 1 screening, and is not suspected of having an intellectual disability, developmental disability and/or mental illness. 2. Screening Process: a). Level I Screening: This initial screening determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission. b). Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is pe1fonned by a qualified mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate. 3. Documentation: Facilities must maintain thorough documentation of the PASRR assessments, including the Level I and Level II evaluations, as well as the recommendations made. 4. Care planning: Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Collaboration with mental health professionals and Local Authority to ensure continuity of care. 5. Ongoing Review: Residents who are admitted under PASRR guidelines may undergo periodic reviews to ensure that their needs are met and that they continue to require nursing home care. 6: Compliance: Nursing homes must comply with all federal and state regulations regarding PASRR. Failure to do so can result in penalties or loss of funding. The facility follows HHS PASRR For Nursing Facility guidelines. Record review of the facility policy for Trauma Informed Care and Culturally Competent Care dated 2001, reflected, Resident Care Planning 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns (e.g. substance abuse, eating disorders, anxiety and depression). 4. Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. For example: a. food preparation and choices; b. clothing preferences such as covering hair or exposed skin; c. physical contact or provision of care by a person of the opposite sex; or d. cultural etiquette, such as avoiding eye contact or not raising the voice.

Based on observation, interviews, and record review, the facility failed to ensure resident rights to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 8 residents (Resident #25) reviewed for resident rights. The facility failed to ensure Resident #25's door was closed when provided personal care to provide respect and dignity. This failure could place residents at risk of feeling uncomfortable, embarrassed and decreased privacy.Findings included:Review of Resident 25's Face sheet dated 09/24/2025 reflected an admission date of 05/12/2025 with diagnoses of type II diabetes mellitus with diabetic chronic kidney disease, Alzheimer's disease with early onset (brain disease that affects memory, thinking), and unspecified dementia (cognitive decline).Review of Resident 25's MDS assessment, dated 08/18/2025, reflected Resident #25 had a BIMS score of 2 out of 15, indicating severe cognitive impairment.Review of Resident 25's comprehensive care plan on 09/24/2025, reflected resident's ADL care will be met by staff.Observation on 9/23/2025 at 9:21 AM, revealed CNA C provided personal care to Resident #25 with his door open.Interview conducted on 09/25/2025 at 10:31 AM, CNA C revealed that she had been trained on resident rights. CNA C stated that when providing personal care, staff should knock on the door before entering, inform the resident of the care to be provided, and close the door to ensure privacy. When surveyor advised her of the observation of her providing personal care to Resident #25 on 9/23/2025 with the door open, the CNA stated she did not recall the specific incident. She reported she had assisted the resident with applying pressure booties at the request of the wound nurse. Surveyor described the steps to CNA C that were completed with Resident #25, which included opening the resident's brief on both sides and adjusting it, rolling resident over with brief exposed all while putting a pad under him while the door remained open. The CNA acknowledged that not closing the door could affect the resident's dignity, stating it could be embarrassing for the resident and would affect his sense of respect, noting that all residents would want privacy just like we do.Interview conducted on 09/25/2025 at 2:50 PM, the DON stated her expectation of nursing staff is to always knock on residents' doors and close the doors when providing care. She said staff are expected to show respect, be kind, and treat residents as if they were their own family members. The DON acknowledged that failure to close a resident's door during care could constitute a dignity infraction and lead to psychosocial issues for the resident. She stated the facility usually does a good job with maintaining dignity.Review of facility's dignity policy reflected 1. Residents are treated with dignity and respect at all times .11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to ensure all residents were free from physical abuse for one (Resident #1) of four resident reviewed for abuse. 1. 1. The facility failed to ensure Resident #1 was not physically abused by Resident #2 on 07/12/2025.2. 2. The facility failed to implement interventions to ensure Resident #1 was not physically abused by Resident #2 on 07/13/2025. This failure could place residents at risk of ongoing abuse, injury and psychosocial harmBased on interview and record review, the facility failed to ensure all residents were free from physical abuse for one (Resident #1) of four resident reviewed for abuse. 1. 1. The facility failed to ensure Resident #1 was not physically abused by Resident #2 on 07/12/2025. 2. 2. The facility failed to implement interventions to ensure Resident #1 was not physically abused by Resident #2 on 07/13/2025. This failure could place residents at risk of ongoing abuse, injury and psychosocial harm. Findings include: Review of Resident #1's face sheet dated 07/21/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of cerebral infarction (condition where part of the brain doesn't receive enough blood flow), dysphagia (difficulty swallowing), anxiety disorder (group of mental health conditions characterized by excessive fear and worry), major depressive disorder (serious mental illness characterized by persistent sadness or loss of interest in activities), and difficulty in walking and unsteadiness on feet. Review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 14 which indicated no cognitive impairment. Review reflected Resident #1 exhibited no physical or behavioral symptoms directed towards others. Review of Resident #1's care plan dated 06/20/2025 reflected he had impaired social interaction with intervention to encourage resident to participate in social situations and monitor interactions with others. Review of a progress note for Resident #1 by ADON dated 07/12/2025 reflected raised voices were heard from dining area and AD was presented and informed ADON that Resident #2 hit Resident #1. Resident #2 was observed yelling and cussing at the AD. ADON escorted Resident #1 away from the area and Resident #1 reported to ADON that he asked about the television and Resident #2 started to cuss and swing his hand at Resident #1 and hit his arm and leg. ADON performed a skin assessment, and no redness was observed. Review of an incident report dated 07/12/2025 by ADON reflected raised voices were heard from the dining area. AD present and informed ADON that Resident #2 hit Resident #1. Resident #2 was observed yelling and cussing at AD and Resident #1. Resident #1 had a skin assessment completed and no redness was observed. Resident #1 indicated he asked about the television and Resident #2 started to cuss at Resident #1 and Resident #2 swung his hand at Resident #1 and hit him on the arm and leg. Review of a progress note for Resident #1 dated 07/13/2025 by LVN A reflected Resident #1 notified LVN A there was an incident and both residents were separated. LVN A assessed Resident #1 and redness and tenderness was noted to Resident #1's left upper arm with complaints of pain to sight. Review of an incident report dated 07/13/2025 by LVN A reflected Resident #1 notified LVN A that he was hit by Resident #2. Resident #1 reported he got up from his table without his walker and touched Resident #2's wheelchair handle and Resident #2 stated keep your hands off my fucking chair, next time imma kill you then Resident #2 punched Resident #1 with a closed fist and hit Resident #1 with an opened hand to Resident #1's left upper arm. Resident #1 stated that arm had already bothered him and Resident #2 made it worse. LVN A performed a skin assessment and noted redness and handprint to left upper arm of Resident #1 and the area was tender to touch. Resident was provided with PRN pain medication. Review of a psychiatric progress note for Resident #1 for telecommunication visit dated 07/13/2025 reflected Resident #1 discussed two incidents that involved being hit by Resident #2 and since the incident Resident #1 reported feeling unsafe, anxious and hypervigilant around Resident #2. Resident #1 also reported difficulty sleeping and feeling shaky. Resident #1 expressed sadness and emotional distress about his lack of safety in the environment. Review of Resident #1's progress notes reflected no follow up by facility staff (social worker, DON, ADM) were documented after incidents with Resident #2. During an interview on 07/21/2025 at 10:17 AM, Resident #1 stated that he had two incidents with Resident #2. Resident #1 stated that he was in the dining room and tried to get by Resident #2's chair and put his hands on the handle of Resident #2's chair and that Resident #2 stated get your fucking hands of my chair and then Resident #2 hit him on the shoulder and arm. Resident #1 stated the previous day Resident #2 hit Resident #1 on the leg. Resident #1 stated AD was present the first day that Resident #2 hit Resident #1 on the leg. Resident #1 stated he felt Resident #2 knew Resident #1 had a bum shoulder. During a subsequent interview on 07/21/2025 at 10:59 AM, Resident #1 stated that he felt safe when Resident #2 was not around. Resident #1 stated he now preferred to eat his meals in his room because Resident #2 ate in the dining room. Resident #1 stated he felt Resident #2 could easily beat him up. Resident #1 stated that on Saturday (07/12/2025) Resident #2 watched television previews and was not watching any shows and Resident #1 asked Resident #2 what he wanted to watch and Resident #2 stated to Resident #1 fuck you I'm watching this and hit him on the leg. During an interview on 07/21/2025 at 2:51 PM, Resident #1 stated that he was scared of Resident #2 and that he wanted Resident #2 to quit being a bully. Resident #1 stated if he saw Resident #2 in the dining room he would leave and go back to his (Resident #1's) room. Resident #1 stated he would leave the area if he saw Resident #2 show up. Resident #1 stated he was afraid Resident #2 was going to hit him again. Review of Resident #2's face sheet dated 07/21/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified diastolic (congestive) heart failure (condition where the heart cannot function properly), chronic respiratory failure (condition when the lungs cannot adequately exchange oxygen and carbon dioxide over a long period), acute kidney failure (sudden rapid decrease in kidney function), schizophrenia (chronic mental disorder that disrupts a person's ability to thinking clearly and manage emotions) and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities that interfere with daily life). Review of Resident #2's significant change MDS dated [DATE] reflected a BIMS score of 8 which indicated a moderate cognitive impairment. Further review reflected Resident #2 did not exhibit any physical or verbal behavioral symptoms directed at others in the 7 days prior to the assessment. Review of Resident #2's care plan dated 07/17/2025 reflected Resident had episodes of verbal aggression and hitting with interventions to anticipate behaviors and redirect when in close proximity to others that might invoke aggression, ensure staff is aware of behaviors and increase in behaviors noted. Further review of care plan dated 05/29/2025 reflected Resident #2 had a risk for harm directed at self or others. Goals included no harm to self or others and residents would be free of physically aggressive behaviors and verbally aggressive behavior. Interventions included to minimize environmental stimuli and monitor for signs or symptoms of agitation, and utilize diversion techniques. Review of Resident #2's psychiatric progress note dated 07/09/2025 reflected reason for follow up was for insomnia and behavior issues. Further review reflected Resident #2 had difficulty falling asleep and mood disturbance. Review reflected staff reported mood issue that include aggression and anger outbursts. Review of a progress note by ADON for Resident #2 dated 07/12/2025 reflected that she heard raised voices in the dining are and AD stated that Resident #2 hit Resident #1. ADON observed Resident #2 yell and cuss at AD and Resident #1. Resident #2 stated that mother fucker changed the channel and I hit him. I will beat his ass if he does it again or looks at me. Resident #2 was escorted from the dining area and a visual was kept on him. Review of the incident report dated 07/12/2025 by ADON, reflected ADON heard Resident #2 yell and curse at AD and Resident #1 and Resident #2 stated I will beat his ass if he does it again or looks at me. ADON escorted Resident #2 out of dining area to calm down and kept visual on him and notified ADM, DON, MD and psychiatric provider. Review of a progress note for Resident #1 by LVN A dated 07/13/2025 reflected Resident #1 notified LVN A that Resident #2 hit Resident #1 because he touched Resident #2's wheelchair. Resident #2 denied hitting Resident #1 for touching his wheelchair. Police were notified and while Resident #2 waited to speak to the police he stated I don't care if the policy are here, I'll still beat your ass. Resident was placed on 1:1. Review of the incident reported dated 07/13/2025 by LVN A reflected Resident #1 informed her that Resident #2 hit him. Residents were separated and Resident #2 removed from dining area. Resident #2 refused vitals and admitting to hitting Resident #1 due to Resident #1 touching his wheelchair. LVN A notified ADM, MD and psychiatric provider. Review of a progress note dated for Resident #2 07/14/2025 reflected Resident #2 remained on 1:1. No information regarding Resident #2's behaviors or lack of were documented. Further review of progress notes for Resident #2 reflected no ongoing information regarding Resident #2's 1:1 supervision and whether Resident #2 had any behaviors or no behaviors while on 1:1 supervision. Review of a psychiatric progress note for Resident #2 for telecommunication visit dated 07/15/2025 reflected Resident #2 was referred due to recent behavior that involved physical aggression. Review reflected the incident was triggered by another resident changing the television and this occurred after another confrontation in which the residents argued about tea. Staff reported increasing irritability, poor frustration tolerance and escalating verbal hostility in the days leading up to these events. Review of a psychiatric progress note for Resident #2 dated 07/16/2025 reflected Resident #2 was seen due to behavior disturbance and was placed on one-on-one due to escalation with another resident. Resident #2 reported severe anger outburst with no triggers. Resident denied any want to harm himself or harm to others at the time of the visit. Staff reported Resident #2 had mood issue with aggression and anger outburst. Note reflected Resident #2 was not in acute danger to self or others however condition may change related to worsening medical condition and psychosocial stressors. Note indicated Resident #2 should be monitored closely for any acute/sudden change in mood behavior, and interaction. Review of Resident #2 physician orders reflected behavior monitoring order with a start date of 07/21/2025 to document in progress note every shift any interventions related to antipsychotic behavior that included danger to self or danger to others and striking out/hitting. During an interview on 07/21/2025 at 10:31 AM, Resident #2 stated that he got along with other residents so-so. Resident #2 stated he got into it with Resident #1. Resident #2 stated he sat in the dining room watching television and Resident #1 changed the channel and that made him mad so he hit Resident #1. Resident #2 said he intentionally hit Resident #1 . Resident #2 stated this was the only time he hit Resident #1 and denied hitting him any other times. During an interview on 07/21/2025 at 12:58 PM, the AD stated that on Saturday (07/12/2025) she was on her way out and heard Resident #2 curse at Resident #1 and she asked Resident #2 to stop cussing. The AD stated Resident #2 continued to curse and made a fist at her. The AD stated that Resident #2 then hit Resident #1 with an open hand on the leg and arm. The AD stated this happened around noon. The AD stated that Resident #2 cursed at her and ADON then came out and removed Resident #2. The AD stated that she stayed with Resident #1. The AD stated that when residents got into an altercation first thing was to remove the residents from the situation and try to help the residents calm down. The AD stated that she has never observed Resident #2 become physically aggressive and this was a new behavior for him. The AD stated that she received an in-service and information was reviewed to intervene if something happened and how to de escalate the issue and to report immediately to the ADM. The AD stated that an example of physical abuse was hitting or touching a resident. The AD stated she left after she checked on Resident #1. During an interview on 07/21/2025 at 1:08 PM, the ADON stated that on 07/12/2025 around 11:15 AM she heard a raised voice say I'm going to kick your ass and saw the AD with Resident #1 and Resident #2 in the dining room by the television. The ADON stated she approached the area and saw Resident #2 swing at Resident #1. The ADON removed Resident #1 from Resident #2 and assessed Resident #1 for injuries. The ADON stated after she removed Resident #1, Resident #2 still cursed in the dining area. The ADON stated that Resident #2 went outside and was cursing while he left the building and cursed at staff. The ADON stated it took about 10 minutes for Resident #2 to calm down. The ADON stated she called the DON, MD and psychiatric NP. The ADON stated that Resident #2 told her Resident #1 changed the channel and he just did not like Resident #1 . The ADON stated she reported the incident to the ADM and was instructed to keep Resident #1 and Resident #2 separate. The ADON stated that Resident #1 was closely monitored and that Resident #1 and Resident #2 were separated as interventions to the incident. The ADON stated all staff were informed to keep the residents separated. The ADON stated that she did not think she put the incident on the 24-hour report and verbally passed it on to oncoming staff. The ADON stated she did not work on 07/13/2025 and she received a call from LVN A on 07/13/2025 at 11:17 AM that Resident #2 hit Resident #1. The ADON stated she called DON and was instructed to place Resident #2 on 1:1 supervision. The ADON stated she notified LVN A to place Resident #1 on 1:1 supervision. ADON stated she notified the MD, and psych services. ADON stated that she believed Resident #1 was on 1:1 supervision until 07/17/2025 or 07/18/2025. The ADON stated an example of physical abuse was causing harm or hitting someone. The ADON stated that additional staff were brought in to help with 1:1 and that the 1:1 was not documented because staff switched who was assigned throughout the shift. During an interview on 07/21/2025 at 1:40 PM, LVN A stated that Resident #1 reported to her that he was on his way to the kitchen door and touched Resident #2's wheelchair to keep his balance and when Resident #1 touched Resident #2's wheelchair he threatened and cussed at him not to touch his wheelchair and Resident #2 hit Resident #1. LVN A stated that during her assessment of Resident #1, she observed a red mark in the shape of a hand print on his arm. LVN A stated she administered PRN pain medication to Resident #1. LVN A stated that neither resident wanted to leave the dining room so she gathered CNAs and they stood in the dining room. LVN A stated that she called the ADON and ADM and the police. LVNA A stated she received instruction to keep the residents separated. LVN A stated Resident #2 sat in front of the nurses station and watched Resident #1 speak with police and as Resident #1 walked back to his room Resident #2 told Resident #1 I don't care if police offices are here I'll kill you. LVN A stated this occurred right before noon. LVN A stated that Resident #2 was placed on 1:1 supervision. LVN A stated that 15 minutes checks were implemented for Resident #2 as well and the CNA who sat with him filled out a form and LVN A assumed it was turned into the DON. LVN A stated she believed she wrote 1:1 supervision for Resident #2 on the 24 hour report and gave report to the oncoming nurse. LVN A stated that when she arrived for her shift on 07/13/2025 she was not aware than an incident occurred with Resident #1 and Resident #2 previously and stated that there were no supervision guidelines for either resident that she was made aware of. LVN A stated an example of physical abuse was putting hands on another resident. During an interview on 07/21/2025 at 2:15 PM, the DON stated that she was notified of the first incident between Resident #1 and Resident #2 that Resident #2 hit resident #1 regarding a television show and that residents were in the dining room. The DON stated that the nurse reached out to her and notified her of the incident. The DON stated she believed interventions for the first incident was that Resident #2 was put on 1:1 supervision but was not sure if that happened during the first or second incident. The DON stated that for the second incident with Resident #1 and Resident #2 she was informed that Resident #1 tried to get to his (Resident #1)'s place in the dining room and he used furniture instead of his walker and touched Resident #2's wheelchair. The DON stated that Resident #2 hit Resident #1 because Resident #1 had touched Resident #2's wheelchair. The DON stated she was not aware of any injuries from the incident. The DON stated she followed up regarding how the residents were doing and spoke with Resident #1 and Resident #2 face to face. The DON stated she saw the note indicated red mark on Resident #1's arm but had no seen any ongoing bruising. The DON stated Resident #2 was put on 1:1 supervision and that 1:1 supervision meant that Resident #2 could be seen at all times. The DON stated that the staff rotated hours for 1:1 and that the ADON set the 1:1 up. The DON stated if Resident #2 did have behaviors it would be documented in the progress notes. The DON stated that she was not sure how documentation looked for 1:1 supervision for Resident #2 but knew staff would switch every hour and would defer to ADON as to when Resident #2 came off 1:1 supervision. The DON stated residents were protected from further abuse or neglect by evaluations, completing BIMS assessments on admission and every quarter and behaviors (if any) being discussed with the psychiatric provider and MD. The DON stated the social worker would also talk to residents to ensure there were no psychological needs. The DON stated that psychiatric NP talked with Resident #1 and Resident #2 and that the social worker talked with Resident #1 and it should be documented under progress notes. The DON stated she spoke to Resident #1 and Resident #2 several days, multiple times a day and stated Resident #1 had not talked about the incidents for a few days. The DON stated that the incident on 07/12/2025 was discussed in shift report and ADON was in contact with the nurses. The DON stated she expected information about the incidents to be on the shift report. The DON stated nurse that worked on 07/13/2025 should have been aware that an incident occurred with Resident #1 and Resident #2 on 07/12/2025. Requested any documentation related 1:1 supervision at this time. During an interview on 07/21/2025 at 2:30 PM, the ADM stated he was notified on 07/12/2025 at 11:30 AM by the nurse that Resident #1 and Resident #2 were in the dining room and had an argument, The ADM stated that it was reported that Resident #1 changed the channel as Resident #2 watched previews and Resident #2 hit him with an open hand. The ADM stated no medical intervention was needed and there was no redness and no pain. The ADM stated he spoke with AD and the ADON took statements from Resident #1 and Resident #2 and an in-service was started on abuse and neglect and resident to resident altercation. The ADM stated interventions were to encourage Resident #1 and Resident #2 to stay away from each other since they already resided on separate halls. The ADM stated oncoming staff were informed of incident because it was noted on the 24 hour report and huddles during shift changes and constant flow of calls and the ADON follow up with staff. The ADM stated it was the charge nurses responsibility to notate incidents on the 24-hour report because they were responsible for informing the CNAs. The ADM stated that on 07/13/2025 he was notified by a nurse and the ADON than an incident occurred. He stated it was reported that Resident #1 stumbled and grabbed a wheelchair to brace himself and Resident #2 hit Resident #1 on the left arm. The ADM stated it was reported by ADON there were no witnesses. Resident #1 reported to the ADM that he was hit on 07/13/2025 but Resident #2 reported he hit Resident #1 on 07/12/2025 and not on 07/13/2025 . The ADM stated there was no injury on 07/13/2025 to Resident #1. The ADM stated it was decided to place Resident #2 on 1:1 supervision because at the time the ADM was under the impression Resident #1 was hit by Resident #2. The ADM stated he was aware of redness to Resident #1 on 07/13/2025 but did not hear about a handprint. The ADM stated he reviewed incident reports and probably skimmed over the incident report for the 07/13/2025 incident. The ADM stated incidents were discussed during morning meetings. The ADM stated for the situations that occurred he sought counsel with regional nurse consultant, regional vice present and see what interventions needed to be put into place and it was discussed to put Resident #2 on 1:1 supervision until he could speak with the psychiatric nurse practitioner. The ADM stated that 1:1 supervision was when the staff stayed close to the resident and close enough to intervene to de-escalate a situation. He ADM stated he expected staff to document every shift regarding 1:1 and if there were any concerns. The ADM stated that ADON reported extra staff were brought in for 1:1 supervision and rotated every hour. The ADM stated he spoke with the psychiatric NP after in-person visits and she was comfortable to take Resident #2 off 1:1 supervision. The ADM was unsure of the date Resident #2 was removed from 1:1 supervision. During an interview on 07/21/2025 at 2:35 PM, the regional nurse consultant stated that documentation was expected to be that 1:1 occurred each shift in a progress note. Review of the staffing schedule for 07/13/2025, 07/14/2025, 07/15/2025, 07/16/2025 and 07/17/2025 did not reflect who was assigned or who was responsible for 1:1 supervision of Resident #2. Review of the staffing schedule for 07/15/2025 reflected a note written that Resident #2 remained on 1:1 and aides needed to rotate every hour. The note did not reflected who it was written by. Review of the 24 hour report dated 07/12/2025 and 07/13/2025 reflected to call police if Resident #2 hit another resident and case number was listed. Review reflected Resident #1 was very upset and to keep him away from Resident #2 and must have 1:1. CNA had log and must turn into ADM in AM. No presence or lack of additional behaviors noted. The note did not reflected who it was written by. Review of the 24-hour reported dated 07/14/2025 reflected under 10:00 pm to 6:00 am note Resident #2 was 1:1 with staff for incident with Resident #1. Presence or lack of behaviors not notated. Further review under 2:00 pm to 10:00 pm nursing remarks reflected Resident #2 was 1:1 with no distress noted. The note did not reflected who it was written by. Review of the 24-hour report dated 07/15/2025 reflected under 10:00 pm to 6:00 am nursing remarks Resident #2 had altercation with another resident, and Resident #2 was 1:1 and resting. The note did not reflected who it was written by. Review of the 24-hour report dated 07/16/2025 reflected under 10:00 pm to 6:00 am nursing remarks Resident #2 was on 1:1 due to altercation with another resident. No information regarding presence or lack of behaviors noted. The note did not reflected who it was written by. Review of the PIR dated 07/17/2025 reflected Resident #1 and Resident #2 were in the dining room and Resident #2 hit Resident #1 on the upper arm and upper thigh. Review of steps taken to immediately ensure residents were protected reflected residents were separated and that residents calmed down within a few minutes and psychiatric consults were scheduled. Review of the PIR dated 07/18/2025 reflected Resident #1 grabbed Resident #2's wheelchair to brace himself in the dining room and Resident #2 became upset and hit Resident #1 with slight redness noted to Resident #1's arm. Review of steps taken to immediately ensure residents were protected were noted as residents being separated, psychiatric consults scheduled and Resident #2 was placed on 1:1 supervision pending in-person psychiatric consult. PIR included discharge note dated 07/14/2025 was provided to Resident #2 with date of discharge at 08/13/2025. Review of the facility in-service dated 07/07/2025 reflected topic of ANE power point was reviewed with all staff. Review of power point included definition of abuse as the willful infliction of injury that results in physical harm, pain or mental anguish. Further review reflected facility responsibility included to documentation all relevant facts and actions. Review of the facility in-service dated 07/12/2025 reflected in-service was conducted with staff over facility policies related to resident-to-resident altercations and abuse, neglect and exploitation. Review of the facility in-service dated 07/13/2025 reflected in-service was conducted with staff over facility policies related to resident-to-resident altercations and abuse, neglect and exploitation. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with revision date of 04/2021 reflected there was a facility -wide commitment to support the protection of residents from abuse, neglect and exploitation and included abuse from other residents. Further review reflected the facility should implement measures to address factors that may lead to abuse situations.Review of the facility policy titled Resident-to-Resident Altercations with revision date of September 2022 reflected staff monitored resident for aggressive / inappropriate behaviors towards other residents or staff. If residents are involved in an altercation staff should separate the residents and institute measures to calm the situation, review the events with the nursing supervisor and DON and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents. Review reflected staff were to document in the resident's clinical record all interventions and their effectiveness.

Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for accidents and hazards. A) The facility failed to ensure Resident #1 did not leave the facility without supervision and/or staff knowledge as Resident #1 was returned to the facility by a community member on 04/03/2025. B) The facility failed to ensure staff were educated that Resident #2 was a high elopement risk and implement interventions. C) The facility failed to ensure Resident #3's bed was in a low position with a fall mat in place when he fell on [DATE] and sustained a left hip fracture. A & B) These failures resulted in an Immediate Jeopardy (IJ) situation on 04/16/2025. The IJ template was provided on 04/16/2025 at 4:43 PM. C) This failure resulted in an Immediate Jeopardy (IJ) situation on 05/05/2025. The IJ template was provided on 05/05/2025 at 1:17 PM. While the IJs were removed on (A&B) 04/18/2025, and (C) 05/06/2025 the facility remained out of compliance at a scope of pattern and severity level of not actual due to the need to evaluate corrective systems. These failures could place resident at risk of unsafe elopements, falls, injuries, hospitalization , and/or death. Findings include: A) Review of Resident #1 face sheet reflected at [AGE] year-old male admitted on [DATE] and discharged on [DATE] with diagnoses of muscle wasting and atrophy (decrease in size and mass of skeletal muscle tissue leading to a loss of strength and function), difficulty in walking, unsteadiness on feet (difficulty with balance and coordination), other lack of coordination, and unspecified dementia (cognitive decline, impacting memory, thinking and problem-solving skills that are severe enough to impact daily functioning). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS 10 which indicated a moderate cognitive impairment. Review reflected Resident #1 used a walker as a mobility device. Resident #1 required supervision or touching assistance (helper provides verbal cues, touching or steadying) when Resident #1 walked 10 feet - 150 feet. Review of Resident #1's baseline care plan dated 03/04/2025 reflected resident did not have a history of wandering or elopement. Review of Resident #1's admission elopement risk assessment dated [DATE] reflected Resident #1 had a score of five which indicated Resident #1 was at risk of elopement. Further review reflected care plan interventions to apply were routine monitoring of resident. Review of Resident #1's elopement risk assessment dated [DATE] reflected Resident #1 was a high risk for elopement. Review of Resident #1's comprehensive care plan dated 04/04/2025 reflected Resident #1 was a risk for injury related to identified elopement risk and/or exit seeking behavior. Review of map reflected that the gas station was 1.2 miles from the facility and near several businesses and resturants. The residential streets have a speed limit of 30 mph. The highway has a speed limit of 55 mph. During an interview on 04/16/2025 at 1:04 PM, CNA D stated that she worked the shift Resident #1 eloped. CNA D stated her shift was from 6:00 PM to 6:00 AM. CNA D stated Resident #1 went to smoke break at 6:30 PM. CNA D stated when a community member brought Resident #1 back to the facility that was when she found out Resident #1 had been gone. CNA D stated it was around 9:00 PM when Resident #1 was brought back. CNA D stated that Resident #1 was ambulatory, and he usually walked back and forth in the facility or sat in the living room or dining room, but she did not see him on that day (04/03/2025). During an interview on 04/16/2025 at 1:17 PM, CNA C stated he was working when Resident #1 had run off and someone found him at the corner store. CNA C stated he did not remember seeing Resident #1 on his shift. During an interview on 04/16/2025 at 1:26 PM, MA B stated she was already off her shift when Resident #1 returned. MA B stated that apparently the elopement happened right after she left. MA B stated she last saw Resident #1 around 7:30 PM as he was sitting outside with her. MA B stated she was charting and Resident #1 was sitting outside. MA B stated she then clocked out but she stated she did not remember if Resident #1 was sitting outside when she left and stated she was not paying attention. During an interview on 04/16/2025 at 1:37 PM, the DOR stated that Resident #1 was on physical therapy prior to his elopement. The DOR stated that Resident #1 was slow when he walked with a walker. The DOR stated Resident #1 had balance issues and that was the reason he was on service with physical therapy. The DOR stated Resident #1's last therapy progress note reflected he was slow and took a while to walk 150 feet in the facility. During an interview on 04/16/2025 at 2:00 PM, LVN A stated that her shift started at 2:00 PM on 04/03/2025 and dinner was 5:00 PM. LVN A stated that smoke break was at 6:30 PM and she last saw Resident #1 sitting in the living room at 6:30 PM in the living room watching television. LVN A stated that aides went on break around 7:30 PM. LVN A stated Resident #1 returned to the facility around 9:20 PM - 9:30 PM. LVN A stated that the community member stated they had worked in the facility earlier in the day as a contractor and recognized Resident #1 when he drove by the gas station. LVN A stated that resident had a slow walk with his walker, but felt he was stable when he walked. During an interview on 04/16/2025 at 3:02 PM, the ADON stated she did not know how long Resident #1 was gone because it was not reported to her. The ADON stated Resident #1 was returned to the facility by a community member. The ADON stated that CNAs completed rounds every two hours and nurses should complete rounds every hour or two and this included putting an eye on residents to just check on them. During an interview on 04/16/2025 at 3:10 PM, the ADM stated that Resident #1 was returned to the facility around 9:45 PM or 9:50 PM on 04/03/2025. The ADM stated a few staff members were outside at 7:30 PM and took a break and came in and that was the last time ADM was aware any staff saw Resident #1. The ADM stated aides should round on residents every two hours and nurses should have rounded on the off hour. The ADM stated he expected the nurse to be aware of where residents were as best as possible due to the population of the facility. B) Review of Resident #2 face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of cerebral infarction (type a stroke where brain tissue dies due to lack of blood and oxygen), muscle weakness, other lack of coordination, unsteadiness on feet (difficulty with balance and coordination), aphasia (loss of ability to understand or express speech), and hemiplegia (complete paralysis on one side of body) and hemiparesis (partial weakness on one side of body) following cerebral infarction (stroke) affecting right dominate side. Review of Resident #2 admission MDS dated [DATE] reflected BIMS score of 4 which reflected severe cognitive impairment. Review of Resident #2 elopement risk assessment dated [DATE] reflected Resident #2 was a high risk for elopement and had statements and/or threats to leave the facility. Review of Resident #2 care plan dated 04/04/2025 reflect no information about Resident #2's high risk for elopement and interventions were not included. Review of Resident #2 MD progress note dated 04/11/2025 reflected Resident #2 was restless with anxiety and walked and moved around constantly, risk of elopement on close observation. During an interview on 04/16/2025 at 1:04 PM, CNA D stated that there were not any residents who were considered a high elopement risk. During an interview on 04/16/2025 at 1:17 PM, CNA C stated there were not any residents who were a high elopement risk. During an interview on 04/16/2025 at 1:26 PM, MA B stated there were no other residents that were a high risk of elopement. During an interview on 04/16/2025 at 2:00 PM, LVN A stated there were no other residents who were deemed a high risk for elopement. During an interview on 04/16/2025 at 3:02 PM, ADON stated elopement assessments were completed with all residents and there were a couple who were high risk. During an interview on 04/16/2025 at 3:10 PM, DON and Regional Nurse stated that Resident #2 was the only resident deemed a high risk for elopement. Review of provider investigation report dated 04/04/2025 included statement from LVN A which reflected on 04/03/2025 a community member brought Resident #1 to the nurses station. Resident #1 had his walker and had grass and mud on his pants and shoes. LVN A wrote that Resident #1 was by the gas station down the street from the facility. LVN A's statement reflected that the community member recognized him from the facility. LVN A's statement reflected Resident #1 had a head-to-toe assessment and no injuries were found. Review reflected elopement assessments were conducted with all residents and care plans were to be updated if residents were found a high risk for elopement. In-service dated 04/04/2025 conducted with all staff, reflected all residents wanting to go out on pass and leave the facility needed MD approval, RP approval and any legal entity approval. Residents also needed to sign out with the nurse in the sign-out book and provide who was taking the resident out, the resident's name, where they were going, time they left, when they would return, a phone number and information that failure to comply would result in the facility finding alternative placement. In-service dated 04/03/2025 reflected in-service was completed with staff on wandering and elopement. Review of facility policy with revision dated 2001 and titled Wandering and Elopements' reflected the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review reflected if resident was identified as risk for elopement care plan will include strategies to maintain safety. C) Review of Resident #3 reflected a [AGE] year-old man readmitted on [DATE] with diagnoses of need for assistance with personal care (need for assistance with care such as bathing, dressing or eating), dysphagia (difficulty swallowing), unspecified fractures of shaft of right femur (break in main part of the right thigh bone), history of falling, unsteadiness on feet (difficulty with balance and coordination), other lack of coordination. Review of Resident #3 quarterly MDS dated [DATE] reflected BIMS of 10 which indicated moderate cognitive impairment. Review reflected Resident #3 was dependent for most ADLs (bathing, toileting, upper/lower body dressing and personal hygiene). Resident #3 was substantial/maximum assistance (helper does more than half the effort) for toilet, chair/bed-to chair transfers. Review of Resident #3 care plan dated 02/21/2024 reflected Resident #3 was a risk for falls due to history of falls. Review reflected increased staff supervision with intensity based on resident need. Care plan did not include to keep resident's bed in low position or to ensure fall mat was at bedside. Review of Resident #3 physician orders in Matrix with a start date of 02/21/2024 reflected mat on floor at beside every shift with no discontinue date. Review of Resident #3 physician orders in PCC with a start date of 04/10/2025 reflected fall mat on floor at bedside every shift for fall precautions. Further review reflected order with a start date of 04/17/2025 for low bed with fall mat while in bed for fall safety every shift. Review of incident report dated 04/02/2025 completed by LVN E, reflected CNA called LVN E to Resident #3's room. Resident #3 was noted on floor near door with wheelchair at side without complaints of pain. Further review reflected bed not in low position and fall mat not on floor. Review of admission summary dated 04/04/2025 reflected Resident had diagnoses of intertrochanteric fracture left femur (left hip fracture). Review of Resident #3's discharge information dated 04/04/2025 reflected resident had a hip fracture treated with ORIF (where pieces of fractured bones are surgically aligned and held in place with implants like screws, plates or rods). Observation 04/17/2025 at 10:26 AM, revealed CNA G lowered Resident #3's bed to the lowest position via manual crank at the foot of the bed, under the footboard. Observation revealed control Resident #3 had access to adjust the head and foot of the bed and Resident #3 would have been unable to raise the height of the bed on his own. During an interview on 04/17/2025 at 10:12 AM, LVN E stated that she was on shift the morning of Resident #3's fall. She stated she received a call from a CNA that Resident #3 had fallen. She stated she believed the CNA was CNA F that called her. LVN E stated that Resident #3 was on his left hip and tried to move himself. LVN E stated CNA F called her between 6:00 AM and 6:15 AM and she had not yet done her morning rounds as she was counting medications. LVN E stated interventions to prevent falls for Resident #3 were to have his bed in low position and a fall mat at bedside. LVN E stated that Resident #3's bed was not in low position, and he did not have fall mat. LVN E described the height of the bed as where an aide would have raised it to change a resident. LVN E stated that Resident #3 had no complaints of pain, but due to the height of the bed, his age and prior fall she suggested sending him out to the ER and MD agreed. During an interview on 04/17/2025 at 10:19 AM, CNA F stated she had just started her shift at 6:00 AM and heard Resident #3 yelled out. CNA F stated she saw Resident #3 on the floor and she called for the nurse. CNA F stated Resident #3 would raise his bed up and down on his own. CNA F stated she did not see a floor mat in his room that day. CNA F stated she did not usually work with CNA F but went to assist because she heard him yell. During an interview on 04/17/2025 at 10:26 AM, CNA G stated she usually worked with Resident #3. She stated his fall interventions included to put a mat on the floor and to have his bed in the lowest position. CNA G stated Resident #3 raised his own bed and had a control to raise it. CNA G stated she did not think Resident #3 had a bed that lowered all the way to the ground. During an interview on 04/17/2025 at 11:45 AM, the DON stated Resident #3 was found on the floor at shift change. The DON stated that Resident #3 was sent to the ER for evaluation and stated he should have a low bed and fall as those were interventions prior to the fall on 04/02/2025. The DON stated it was discussed with the nurse that Resident #3 was a fall risk and to have his bed in a low position and fall mat in place because of his history of falls. The DON stated it was discussed verbally with the nurses and CNAs. The DON stated that the facility is going through a change in HER systems. She stated that with the old system she would have looked at the incident report for Resident #3. The DON stated with the new system it looked like she and the ADM reviewed it. The DON stated that she wanted to discuss with MD if Resident #3 had osteopenia because the level he fell from should not have resulted in a hip fracture. The DON stated it was reported to her that Resident #3's bed was in a low position, but she did not recall who reported that to her. The DON stated she did not review the incident report and stated I did not know how to. The DON stated she was not aware the incident report reflected that Resident #3's bed was not in a low position and that he did not have a fall mat in place at the time of his fall. A phone interview was attempted with the MD on 04/16/2025 at 4:13 PM and 04/17/2025 at 12:06 PM, but the phone call was not returned. During an interview on 05/05/2025 at 2:58 PM, CNA F stated that Resident #3 was near the door and stated that he screamed and that his wheelchair was tipped over on the floor. CNA F stated Resident #3 had fallen out of bed and it looked like he crawled to the door in his room. CNA F stated that Resident #3 was usually helped up by the 6:00 AM - 2:00 PM shift and he was not up when she got to the facility at 6:00 AM for her shift. During an interview on 05/05/2025 at 2:59 PM, LVN E stated that when CNA F called her to Resident #3's room he was near his doorway with his hands maybe a foot from his doorway. CNA F stated that the 6:00 am - 2:00 pm shift got Resident #3 up for the day. LVN E stated that it looked that Resident #3 had crawled from where his bed way. LVN E stated it was obvious based Resident #3 crawled and fell out of bed. LVN E stated Resident #3 head was toward the door of the room and he leaned on his right side. LVN E stated that Resident #3's was folded up and on it's side tipped over. Review of facility policy titled Falls and Fall Risk, Managing with revision date of March 2018 reflected, based on previous evaluations and current data, the staff with identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. Review reflected environmental fall risk factors included incorrect bed height or width. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls. Review of facility policy with revision date of July 2017 and titled Safety and Supervision of Residents reflected our facility strives to make the environment free from accident hazards as possible. Resident safety and supervisions and assistance to prevent accidents are facility-wide priorities. Review reflected interventions to reduce accident risks and hazards included ensuring interventions were implemented and documenting interventions. A&B) The ADM, ADON and regional nurse were notified on 04/16/2025 at 4:54 PM, that an IJ had been identified. An IJ template was provided, and a POR was requested. C)The ADM, and regional nurse were notified on 05/05/2025 at 1:17 PM, than an IJ had been identified. An IJ template was provided, and a POR was requested. A&B) The following POR was approved on 04/18/2025 at 9:59 AM and indicated: [Facility] IJ Plan of Removal F689 4/16/25 Resident #1 was discharged to a secured facility on 4/8/25. All entrances to the facility have been key- pad locked as of 4/4/25 and residents are not allowed out of the facility without an assigned staff member being with them. There is currently one (1) resident who is high risk for elopement and on 4/16/25 at 5:30 PM he was placed on 1:1 monitoring until secure placement is located for him. The facility has sent information to three (3) other facilities and placement has not yet been secured. On 4/4/25, all resident elopement assessments were completed, and one (1) resident was identified as high risk as identified below. On 4/16/25, the identified high risk residents care plan was formulated. Any resident care plans requiring updates was done at this time. On 4/16/25, the administrator in-serviced department heads and100% of facility staff were in-serviced on interventions for the identified high risk resident including 1:1 monitoring, updated care plan indicating 1:1, and Kardex update so that CNAs can be alerted. Also included in this in-service was notifying the administrator of any resident exhibiting high risk behavior or scoring high risk (score over 10) on an elopement assessment so that interventions can be identified and staff informed. Staff not available in person were contacted by phone and verbally in-serviced. Staff are informed that the administrator/designee will notify staff through the above measures and through an in-service if any other resident is deemed high risk for elopement. PRN, agency staff, and new hires will be educated on this process as they are assigned to work by the administrator, DON, or an administrative staff member. Initial comprehension of understanding was done by the administrator on 4/17/25, by questioning staff regarding training. The administrator/designee will interview staff two times (2) a week for one (1) month on their understanding and retention of education given to them on elopement and where to find information on residents at high risk for elopement. The Regional Nurse will monitor new admission elopement assessments for high risk residents, weekly, for one month and randomly thereafter to validate that interventions are in place and communication is in the EMR system. The administrator will document this on an audit form. On 4/16/25, the regional nurse in-serviced the administrator and the director of nursing on reviewing any new admission elopement assessments within twenty-four hours of admission to identify a resident scoring ten (10) or more. Included in this in-service is ensuring that any new staff are educated to the interventions of a resident deemed high-risk for elopement. Initial comprehension of education with the administrator and the DON was completed on 4/17/25, with questioning on understanding of the training by the regional nurse consultant. The regional nurse will document compliance using an audit form. On 4/16/25 at 6:00 PM a Ad.Hoc QAPI meeting was completed with the IDT and the medical director to discuss this plan of removal. C)The follow POR was approved on 05/06/2025 at 3:15 PM and indicated the following: IJ Plan of Removal F689 5/5/25 On 5/5/25, an abbreviated survey was re-opened at facility. On 5/5/25, the surveyor provided an immediate jeopardy (IJ) template notification that the regulatory services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure Resident #1s bed was in the lowest position and had fall mat in place when he fell on [DATE] and fractured his left hip. Resident #1s fall care plan interventions and Point of Care Kardex were reviewed and updated to reflect the resident's current condition. On 5/5/25, the Regional Nurse Consultant/ADON, reviewed the facility fall assessment report to identify residents at risk of falls and to validate that current interventions are in place on the resident care plan and Point of Care Kardex. The RNC and the ADON reviewed all facility residents to validate that their fall interventions were care planned and that the Point of Care Kardex was updated to list the fall interventions. This audit was documented utilizing the PCC Fall Assessment score report. Twelve (12) additional residents were identified as at risk for falls. Each had a care plan developed with interventions added to their POC Kardex. On 5/5/25, the RNC/administrator educated 100% of facility staff regarding where to find the information for fall interventions. Staff not receiving the initial education will receive if before starting their next assigned shift. Nurses were instructed to review the care plan, and CNAs were instructed to review the Point of Care Kardex. 100% of the interdisciplinary team (IDT) were given a list of resident fall interventions by the RNC, to refer to while making rounds on their regularly assigned residents before the morning stand-up meeting and reporting any concerns during that meeting. The IDT manager on duty will make rounds on the weekend to identify and immediately resolve concerns with fall interventions. The administrator verified the initial Comprehension of staff training by questioning staff and documenting it on an audit form. The administrator and the RNC will document these tasks on a facility created audit form for record keeping purposes. The RNC will review falls weekly, for one (1) month to ensure that the care plan is updated with a new intervention and that those interventions, if applicable, are carried over to the Point of Care Kardex. Any concerns will be corrected immediately and re-education given to the management team. This will be documented on an audit flow sheet. Education understanding will be completed three (3) times a week for one (1) month by the administrator by questioning the facility staff about where they can find the fall intervention information. The RNC will complete education understanding with the management IDT by questioning them two (2) times a week for one (1) month regarding IDT rounds and identifying problems with fall interventions specifically. This will be documented on an audit flow sheet. On 5/5/25, an Ad.Hoc QAPI meeting was held with the medical director and the IDT to discuss this plan of removal. A&B) Monitoring for the POR occurred on 04/17/2025 and 04/18/2025 as followed: Observation on 04/17/2025 at 10:05 AM, revealed door was secured and required a code from staff to answer or exit. Observations conducted between 04/17/2025 and 04/18/2025 reflected ongoing 1:1 oversight with Resident #2 and staff. Review of Ad.Hoc QAPI sign-in sheet dated 04/16/2025 reflected meeting completed. Review of Resident #2's care plan reflected he was a high elopement risk and interventions included 1:1 oversight. Review of in-service dated 04/16/2025 by regional nurse completed with ADM, and DON reviewed within 24 hours of admission, elopement assessment must be reviewed by nursing administration for any resident deemed high risk for elopement and communication with staff. New employees with receive the training on high risk residents and where to find the information, interventions and communication. Review of in-service dated 04/16/2025 completed with all staff reflected Resident #2 was a high risk for elopement and was currently on 1:1. In-service included any resident who had the potential to elope must be reported to the ADM immediately for interventions to be implemented. Information regarding elopement could be found on Kardex on PCC and in the resident's care plan. Resident deems high risk will have a care plan formulated, added to Kardex in PCC and verbal communication with front line staff. Review of in-service dated 04/16/2025 completed with nurses reflected any resident who scored a 10 or high on elopement assessment or exhibits any elopement possibilities must be communicated to the ADM and DON immediately and interventions will be put in place and communicated to staff. Review of Audit Log dated 04/18/2025 reflected six employees were tested for retention over in-service and elopement. During interviews conducted between 04/17/2025 and 04/18/2025, 4 LVNs, 4 CNAs, 1 HSK ADON, DON, ADM and regional nurse, revealed that Resident #2 is the only resident currently a high risk for elopement and he currently is on 1:1. Staff interviewed stated they can determine who was a high elopement risk by looking at the resident's Kardex or in PCC. Nurses interviewed stated that any resident who scored a 10 or high and was deemed a high elopement risk on the elopement assessment would notified the DON and ADM immediately. Staff stated that any changes in behavior or increase in wandering should be notified to the charge nurse and then the DON and ADM immediately. During interviews conducted on 04/18/2025, regional nurse, DON and ADM stated that any new admission will be reviewed by regional nurse within 24 hours. They stated nurses have been in-serviced to notify the DON and ADM immediately of any residents who scored high-risk for elopement. The care plan should also be updated and this included their baseline care plan. Resident #2 was currently 1:1. They stated education will be on going and staff will be tested for retention. C)Monitoring for POR occurred on 05/06/2025 as followed: Review of 12 residents identified as at risk for falls indicated fall evaluation was completed and care plans included that the residents were a fall risk and interventions for each resident. Review of in-service sign-in sheet dated 05/05/2025 at 05/06/2025 reflected subject of fall interventions completed with staff on shift and prior to the start of their next shift. Information reviewed included staff is to ensure residents are safe by ensuring their fall interventions are always in place. Nurses can find residents fall interventions on their care plan as well as the resident Kardex in PCC. CNAs can find fall interventions on the resident point of care Kardex in PCC. Staff should round at the start of their shift and at least every two hours to ensure listed fall interventions are in place. In-service included list of residents who had interventions in place such as a low bed or fall mat. Review of initial comprehension questionnaire dated 05/05/2025 and 05/06/2025 reflected ADM tested comprehension of POR information reviewed with nurses, aides and IDT. Review of QAPI meeting dated 05/05/2025 reflected IDT members and medical director attended. Review of in-service sign-in sheet dated 05/05/2025 reflected subject of fall interventions and rounds completed with IDT reflected IDT should round prior to the morning meeting to assigned ground of rooms and weekends when assigned as weekend manager. Rounds include fall hazards in the resident room, medications at bedside, water or fluid on the floor, anything left out that can be a hazard, fall interventions and to notify nursing management / administrator if interventions are not in place. During interviews on 05/05/2025 with IDT members, BOM, HR, AD, maintenance director and DOR reflected they were provided a list of residents who had fall interventions in place and were responsible to round prior to morning meeting during the week and on weekends when assigned weekend manager. IDT members stated that they can also find fall interventions in the residents care plans. IDT members stated that if interventions were not in place and it was something they could fix they would fix it, but if not they would notify the nurse, ADM or DON. During interviews on 05/06/2025 with 2 CNAs, 2 LVNs, and 1 cook reflected they received an in-service on fall interventions on 05/05/2025 or 05/06/2025 provided by the ADM. Staff stated that they can find fall interventions on the Kardex in PCC or in the resident's care plan. They stated they should round at least every two hours and at the beginning and end of their shift and look that fall interventions are in place. Staff stated they can fix interventions they see out of place and if they see something that could cause harm they would notify the ADON or ADM. During an interview on 05/06/2025 at 3:49 PM, regional nurse stated that ADM would in-service any agency or new hire staff prior to working their first shift on falls and interventions. Regional nurse stated that when fall interventions are put in place, the Kardex and care plan would be updated and an updated IDT list would be provided by the ADM and discussed during morning meeting. She stated staff will have comprehension completed two times a week for a month. Regional nurse stated that falls would be reviewed during daily IDT and discussed and regional nurse until a DON is hired. Regional nurse stated if an issue were found during a fall audit depending on the issue, remedy could include re-educate, if incident report had issue nurse would be reeducated if care plan didn't have interventions MDS nurse would be educated. During an interview on 05/06/2025 4:04 PM, ADM stated that agency or new staff would be informed of residents who were at risk for falls by ongoing fall prevention in-service being included on the 24-hour report to catch any new or agency staff. ADM stated staff would be informed of update during morning h [TRUNCATED]

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified for two (Resident #2 and Resident #3) of five residents reviewed for care plans. 1. The facility failed to ensure Resident #2's elopement risk and interventions were included on his care plan. 2. The facility failed to ensure Resident #3's fall interventions were included on his care plan. These failures could place residents at risk of not receiving appropriate interventions to meet their needs. Findings include: 1. Review of Resident #2 face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of cerebral infarction (type a stroke where brain tissue dies due to lack of blood and oxygen), muscle weakness, other lack of coordination, unsteadiness on feet (difficulty with balance and coordination), aphasia (loss of ability to understand or express speech), and hemiplegia (complete paralysis on one side of body) and hemiparesis (partial weakness on one side of body) following cerebral infarction (stroke) affecting right dominate side. Review of Resident #2 admission MDS dated [DATE] reflected BIMS score of 4 which reflected severe cognitive impairment. Review of Resident #2 elopement risk assessment dated [DATE] reflected Resident #2 was a high risk for elopement and had statements and/or threats to leave the facility. Review of Resident #2 care plan dated 04/04/2025 reflect no information about Resident #2's high risk for elopement and interventions were not included. Review of Resident #2 MD progress note dated 04/11/2025 reflected Resident #2 was restless with anxiety and walked and moved around constantly, risk of elopement on close observation. Review of QAPI action plan dated 04/04/2025 reflected DON to update all resident elopement assessments and DON/ADON to update all care plans of residents with a score of high risk on elopement assessments with completion date of 04/04/2025. During an interview on 04/16/2025 at 1:04 PM, CNA D stated that there were not any residents who were considered a high elopement risk. During an interview on 04/16/2025 at 1:17 PM, CNA C stated there were not any residents who were a high elopement risk. During an interview on 04/16/2025 at 1:26 PM, MA B stated there were no other residents that were a high risk of elopement. During an interview on 04/16/2025 at 2:00 PM, LVN A stated there were no other residents who were deemed a high risk for elopement. During an interview on 04/16/2025 at 3:02 PM, ADON stated elopement assessments were completed with all residents and there were a couple who were high risk. During an interview on 04/16/2025 at 3:10 PM, DON and Regional Nurse stated that Resident #2 was the only resident deemed a high risk for elopement. 2. Review of Resident #3 reflected a [AGE] year-old man readmitted on [DATE] with diagnoses of need for assistance with personal care (need for assistance with care such as bathing, dressing or eating), dysphagia (difficulty swallowing), unspecified fractures of shaft of right femur (break in main part of the right thigh bone), history of falling, unsteadiness on feet (difficulty with balance and coordination), other lack of coordination. Review of Resident #3 quarterly MDS dated [DATE] reflected BIMS of 10 which indicated moderate cognitive impairment. Review reflected Resident #3 was dependent for most ADLs (bathing, toileting, upper/lower body dressing and personal hygiene). Resident #3 was substantial/maximum assistance (helper does more than half the effort) for toilet, chair/bed-to chair transfers. Review of Resident #3 care plan dated 02/21/2024 reflected Resident #3 was a risk for falls due to history of falls. Review reflected increased staff supervision with intensity based on resident need. Care plan did not include to keep resident's bed in low position or to ensure fall mat was at bedside. Review of Resident #3 physician orders with a start date of 02/21/2024 reflected mat on floor at beside every shift. Review of Resident #3 physician orders with a start date of 04/10/2025 reflected fall mat on floor at bedside every shift for fall precautions. Further review reflected order with a start date of 04/17/2025 for low bed with fall mat while in bed for fall safety every shift. During an interview on 04/17/2025 at 12:40 PM, LVN E stated that either the DON, or ADON would have notified her of new interventions or any new interventions would be on the 24 hour report. LVN E stated that she looked at care plans for interventions that should be in place or information about the resident. LVN E stated she expected to find if a resident required a fall mat and to have their bed in low position. During an interview on 04/17/2025 at 12:46 PM, CNA H stated he believed interventions for falls were on the resident's care plan, but he could also ask the nurse. CNA H stated he believed Resident #3 had a floor mat in his room and his bed should be low to the ground. During an interview on 04/17/2025 at 4:15 PM, LVN A stated the purpose of a care plan was to tell the staff exactly what the resident could do, if they were alert, required assistance, if they were a high risk for elopement or a fall risk. LVN A stated interventions for the mentioned would also be included. LVN A stated the ADON was responsible to update the care plan. During an interview on 04/17/2025 at 4:23 PM, LVN I stated that the care plan was supposed to let staff know how to best care for the resident and best interventions. She stated she expected to find falls and elopement risk along with interventions on the care plan. During an interview on 04/17/2025 at 4:49 PM, ADON stated that she was responsible to update care plans. ADON stated a care plan had anything regarding a resident's care. She stated that a care plan should have falls, skin issues, wounds, code status and anything important. She stated that most of the time she is made aware of the interventions through meetings or if the nurse or aides notified her. ADON stated fall interventions should have been on the care plan and elopement risk with interventions. During an interview on 04/17/2025 at 4:57 PM, the DON stated that the purpose of a care plan was to have patient-centered things that staff were going to do for them while the resident was in the facility. The DON stated she was responsible to initiate the care plan and ADON was responsible for updating when there was a change. The DON stated if residents had falls, there should have been interventions related to falls on the care plan. The DON stated if a resident was a high elopement risk it should also be on the care plan with interventions. During an interview on 04/17/2025 at 5:16 PM, the ADM stated the purpose of a care plan was an individualized plan of care for the resident to include what their needs were. The ADM stated if fall interventions and high elopement risk were applicable to the resident then he expected interventions to be on the care plan. Review of facility policy titled Falls and Fall Risk, Managing with revision date of March 2018 reflected, based on previous evaluations and current data, the staff with identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. Review reflected environmental fall risk factors included incorrect bed height or width. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls. Review of facility policy titled Care Plans, Comprehensive Person-Center with revision date of March 2022 reflected a resident's comprehensive care plan included services for the resident to attain to maintain their highest practicable physical, mental, and psychosocial well-being, reflects currently recognized standards of practice for problem areas and conditions, when possible interventions to address underlying sources of problem areas and not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 8 of (03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025 ) 33 days reviewed for RN coverage. The facility failed to ensure they had an RN charge nurse on 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025. This failure could place residents a risk of missed nursing assessments, interventions, care and treatment. Findings included: Review of daily sign-in schedule for March 15, 2025 through April 17, 2025, reflected zero hours work by an RN charge nurse on the following days: 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025. During an interview on 04/17/2025 at 3:20 PM, the ADON reflected that between 03/15/2025 and 04/17/2025 there was not an RN that worked at the facility on the weekends. The ADON stated between that time, an agency RN worked on 04/05/2025 and the DON was at the facility on 04/05/2025 and 04/06/2025. During an interview on 04/17/2025 at 4:49 PM, the ADON stated that she was responsible for MDS, transportation, staffing/scheduling and worked as an ADON. The ADON stated that the facility had no circumstances that required an RN onsite. The ADON stated if the facility did, they would reach out to regional nurse and DON as they lived close by. The ADON stated she did not know what the protocol was when the facility did not have an RN available to work the required 8 consecutive hours a day. The ADON stated the facility did not get residents who were a high acuity, so the facility did not have residents that required services provided by an RN. During an interview on 04/17/2025 at 4:57 PM, the DON stated that the facility had no had any care come up that required an RN. The DON stated she would have handled it if something came up that required RN intervention. The DON stated that she brought up to management that the facility needed an RN for weeks and stated the facility tried to actively hire an RN for coverage on the weekends. The DON stated she was at the facility Monday through Friday from at least 8:00 am to 5:00 pm and usually longer. During an interview on 04/17/2025 at 5:16 PM, the ADM stated the facility did not take on any resident who required 24 hour RN care. The ADM stated if there was items that needed to be completed by an RN the DON or regional nurse would come in or the DON from a nearby sister facility. The ADM stated that the facility had an ongoing job posting on several platforms. The ADM stated that he tried to employee an RN for years but because of the rural area it made it difficult. The ADM stated the facility did not have a weekend RN that came into work. During an interview on 04/17/2025 at 5:17 PM, regional nurse stated the facility did not have a specific policy regarding RN coverage and that the facility followed state guidelines.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the resident for one (Resident #1) of three residents reviewed for baseline care plans. 1. The facility failed to ensure Resident #1's elopement risk and interventions were included on his baseline care plan. This failures could place residents at risk of not receiving appropriate interventions to meet their needs. Findings include: Review of Resident #1 face sheet reflected at [AGE] year-old male admitted on [DATE] and discharged on [DATE] with diagnoses of muscle wasting and atrophy (decrease in size and mass of skeletal muscle tissue leading to a loss of strength and function), difficulty in walking, unsteadiness on feet (difficulty with balance and coordination), other lack of coordination, and unspecified dementia (cognitive decline, impacting memory, thinking and problem-solving skills that are severe enough to impact daily functioning). Review of Resident #1 admission MDS dated [DATE] reflected a BIMS 10 which indicated a moderate cognitive impairment. Review of Resident #1's admission elopement risk assessment dated [DATE] reflected Resident #1 had a score of five which indicated Resident #1 was at risk of elopement. Further review reflected care plan interventions to apply were routine monitoring of resident. Review of Resident #1's baseline care plan dated 03/04/2025 reflected resident did not have a history of wandering or elopement and did not include Resident #1's elopement risk as indicated from his admission elopement assessment. Review of provider investigation report dated 04/04/2025 reflected Resident #1 eloped from the facility on 04/03/2025 and was returned by a community member. During an interview on 04/17/2025 at 12:40 PM, LVN E stated that either the DON, or ADON would have notified her of new interventions or any new interventions would be on the 24 hour report. LVN E stated that she looked at care plans for interventions that should be in place or information about the resident. During an interview on 04/17/2025 at 4:15 PM, LVN A stated the purpose of a care plan was to tell the staff exactly what the resident could do, if they were alert, required assistance, if they were a high risk for elopement or a fall risk. LVN A stated interventions for the mentioned would also be included. LVN A stated the ADON was responsible to update the care plan. During an interview on 04/17/2025 at 4:23 PM, LVN I stated that the care plan was supposed to let staff know how to best care for the resident and best interventions. She stated she expected to find falls and elopement risk along with interventions on the care plan. During an interview on 04/17/2025 at 4:49 PM, ADON stated that she was responsible to update care plans. ADON stated a care plan had anything regarding a resident's care. She stated that a care plan should have falls, skin issues, wounds, code status and anything important. She stated that most of the time she is made aware of the interventions through meetings or if the nurse or aides notified her. ADON stated fall interventions should have been on the care plan and elopement risk with interventions. During an interview on 04/17/2025 at 4:57 PM, the DON stated that the purpose of a care plan was to have patient-centered things that staff were going to do for them while the resident was in the facility. The DON stated she was responsible to initiate the care plan and ADON was responsible for updating when there was a change. The DON stated if residents had falls, there should have been interventions related to falls on the care plan. The DON stated if a resident was a high elopement risk it should also be on the care plan with interventions. During an interview on 04/17/2025 at 5:16 PM, the ADM stated the purpose of a care plan was an individualized plan of care for the resident to include what their needs were. The ADM stated if fall interventions and high elopement risk were applicable to the resident then he expected interventions to be on the care plan. Review of facility policy titled Care Plans, Comprehensive Person-Center with revision date of March 2022 reflected a resident's comprehensive care plan included services for the resident to attain to maintain their highest practicable physical, mental, and psychosocial well-being, reflects currently recognized standards of practice for problem areas and conditions, when possible interventions to address underlying sources of problem areas and not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change.

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving exploitation or mistreatment were reported immediately, but not later than 24 hours after the allegation was made, if the events that caused the allegation did not involve abuse or result in serious bodily injury, to the State Survey Agency in accordance with state law through established procedures for 1 (Resident #1) of 3 residents reviewed for misappropriation of property. The facility failed to report to the state agency when the facility was notified that CNA A requested and accepted money from Resident #1 on the weekend of 11/09/24 and 11/10/24. This failure could place residents at risk for further misappropriation. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE], went out to another facility on 11/01/24, and was readmitted on [DATE]. His diagnoses included hypertension (high blood pressure), diabetes mellitus (a condition that affects the way the body processes blood sugar), cerebrovascular accident (stroke), hemiplegia (paralysis of one side of the body), post-traumatic stress disorder, borderline personality disorder (a disorder that affects the way one feels about themselves, relates to others, and behaves), and difficulty walking. Review of Resident #1's quarterly MDS assessment, dated 10/15/24, Section C (Cognitive Patterns) reflected a BIMS score of 10 indicating moderately impaired cognition. Review of Resident #1's comprehensive care plan, revised 09/04/24, reflected in part. Problem: Resident has episodes of adverse behaviors - fabricates/facts/unreliable historian/manipulates staff. Goal: the number of behavioral episodes will decrease throughout the next quarter. Approach: Two staff for care whenever possible, redirect, psych services . Review of an email dated 11/12/24 at 11:18 AM from the ADM to the RDO reflected the CEO from the [hospital name] reported, One of her staff members (who knows CNA A) saw Resident #1 give CNA A money. The staff member reported to the charge nurse. The charge nurse went and talked with Resident #1 who then told the charge nurse it was none of his business. The charge nurse told Resident #1 he wanted to make sure he was not being exploited. Resident #1 confirmed he gave money to CNA A. Resident #1 stated CNA A had a deadbeat husband and kids. She needed the money. Resident #1 stated they were friends, and he has done it before . During an interview on 01/07/25 at 11:45 AM, the ADM stated he was notified by the CEO of the hospital where Resident #1 was receiving care. The ADM was informed that CNA A was observed requesting and receiving money from Resident #1. He stated he received statements from the staff at the hospital and spoke with CNA A. He stated CNA A made the statement, He will never say he gives me money. The ADM stated the resident was not in his facility so technically he was not a resident at the time. He stated the resident had planned on returning to the facility. He stated CNA A was an employee of his facility at the time, but she had since been terminated. He stated since the termination, CNA A continued to have contact with Resident #1. The ADM stated he investigated all complaints of ANE and reported to the state within two hours if there was an injury and within 24 hours for non-injury incidents . During an interview on 01/07/25 at 12:24 PM, Resident #1 stated he wished everyone would mind their own business about the money. He stated he did not give CNA A any money, but it is his money, and he can do what he wants with it. He stated he did not get much money because the facility took it all. He stated he felt bad because she lost her job and got evicted. During a telephone interview on 01/07/24 at 3:17 PM, the RDO stated he did recall the allegation of a CNA taking money from a resident who was not at the nursing facility when it happened. He stated after the CEO from the hospital reported it to the facility ADM, they went to the other hospital to interview the resident. He stated it took several follow-ups. He stated he could not remember if the incident was reported to the state since the resident was not at their facility at the time. He stated the aide was suspended during the investigation and terminated. He stated the administrator was responsible for reporting to the state. Review of the facility policy, Preventing Resident Abuse, revised 02/2023, reflected in part, Our facility will not condone any form of resident abuse and will continually monitor facility's policies, procedures, training programs, systems, etc. to assist in preventing abuse. Review of the facility policy, Resident Rights, revised 02/2021, reflected in part, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of property, and exploitation .: The polices provided did not address reporting of abuse, neglect, or exploitation. Review of Resident #1's progress note dated 12/18/24 at 1:15 PM reflected, Parole officer was in today to visit with Resident #1. Parole officer advised ADON that he would not be approving any day passes with relatives or family members of CNA A.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was not missing from the facility on 10/07/24 for an unknown amount of time until EMS contacted and notified them that he was approximately .9 miles away and had fallen and found on the railroad tracks. Approximately 500 feet from the facility was a busy highway with through traffic of commercial vehicles to include semi-trucks. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/10/24 at 2:47 PM and an IJ template was given. While the IJ was removed on 10/11/24 at 2:38 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, history of falling, Parkinson's disease (a movement disorder that affects the nervous system and worsens over time, cerebral infarction (stroke), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's quarterly MDS assessment, dated 08/14/24, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section E (Behavior) reflected the behavior of wandering was not exhibited. Review of Resident #1's quarterly care plan, dated 09/17/224, reflected he was at risk for falls r/t poor safety awareness and mobility with an intervention of therapy to evaluate and treat. Review of Resident #1's most recent Fall Risk Assessment, dated 06/09/24, reflected a score of 14 (a score of 10 or higher represented a high risk for falls). Review of Resident #1's Elopement Risk Assessment, dated 12/01/23, reflected a score of 3 (a score of 5 or higher represented a high risk of elopement). Review of Resident #1's Elopement Risk Assessment, dated 10/10/24, reflected a score of 13 (a score of 5 or higher represented a high risk of elopement). Review of Resident #1's progress notes in his EMR, dated 10/07/24 at 1:15 PM and documented by LVN A, reflected the following: [Resident #1] left facility without signing out and facility staff received a call that [Resident #1] had fell while he was away . During an observation and interview on 10/10/24 at 9:55 AM, revealed Resident #1 sitting on his bed with his head dropped down towards his chest. He was asked if he remembered leaving the facility a few days ago and he had a blank stare. He was asked if he had fallen and he nodded his head yes. He was asked if he had been injured and he shook his head no. When he was asked if he could explain what happened in more detail, he began drawing with his finger on his blanket. He continued to have a blank stare. During an interview on 10/10/24 at 10:06 AM, LVN B stated she was familiar with Resident #1. She stated she was not working the day he went missing but she did hear about it. She stated she did not believe he signed out or notified anyone that he was leaving. She stated he sometimes is was alert and oriented x3 (person, place, and time) but his baseline was alert and oriented x2. She stated he would absolutely not be safe to be walking out in the community by himself. She stated when residents leave OOP, they need to sign out and notify the nurse. During an interview on 10/10/24 at 10:18 AM, the RRC stated on 10/07/24 she got a call from a staff member that Resident #1 was gone and was found by the (grocery store) about a mile away. She stated she, the HR Director, and AD went to go get him. She stated when they arrived, he was sitting in his rolling walker with EMS. She stated he told them he was going to (grocery store) for some ice cream. She stated the EMT's informed them he had been found on the railroad tracks and the train station had contacted the police, who had contacted them. The EMT's informed them he was okay and they took him back to the facility. She stated when residents leave OOP, they were expected to notify their nurse and sign themselves out. She stated she was not sure if he did that as she had not followed up on that part. She stated she was not sure how long he was gone but did believe he had the ability to leave the facility unsupervised. During a telephone interview on 10/10/24 at 10:34 AM, the MD stated Resident #1 looked normal, but when you assessed him in detail - he was slow to think. He stated he was not always oriented and was often confused. He stated the streets around the facility were extremely busy and he would need supervision if he left the facility grounds. During a telephone interview on 10/10/24 at 10:51 AM, Resident #1's FM C stated she was notified that he left the faciity on [DATE]. She stated, in her opinion, he should not be able to leave the facility alone at all due him hardly being able to walk. She stated he was not safe to be unsupervised outside of the facility. She stated she last saw him in August (2024). An attempt to interview CNA D by telephone was made on 10/10/24 at 11:59 AM and 2:01 PM. A returned call was not received prior to exit. CNA D worked the morning Resident #1 left the facility (10/07/24). During a telephone interview on 10/10/24 at 2:06 PM, CNA E stated he worked the afternoon shift on 10/07/24. He stated Resident #1 may sometimes have the ability to be unsupervised if he left the facility, but he was sometimes nonverbal. He stated his cognition varied day-to-day. He stated Resident #1 would not be able to remember the rules to sign out before leaving OOP. During an interview on 10/10/24 at 2:27 PM, the NP stated he was notified of the incident with Resident #1 on 10/07/24. He stated he did not remember if he was told how long he had been gone from the facility. He stated he did not believe Resident #1 could be out in the community unsupervised due to both physical and cognitive reasons, but more so cognitively. He stated he was very cognitively impaired and was not there. He stated he did not believe he could understand the process of signing out even if you were to explain it to him. He stated it was a very unsafe area to be out in. NP stated he definitely believed the facility needed to come up with safer protocols should the residents want to leave the facility. During a telephone interview on 10/10/24 at 3:54 PM, LVN A stated she worked the morning of 10/07/24. She stated it was her first time working at the facility as she was an agency nurse. She stated the other scheduled nurse that day had called out to work so she was the only nurse working the shift and it was a very hectic morning. She stated she did not know around what time Resident #1 left the facility but knew he returned around 11:45 AM. LVN A stated due to it being her first time to work at the facility, she was unable to speak on Resident #1's cognitive abilities. During an interview on 10/10/24 at 2:34 PM, the CRN stated the facility found out Resident #1 was missing on 10/07/24 when EMS called to inform them, he (Resident #1) was found on the railroad tracks approximately a mile from the facility. The CRN stated the train station contacted the police who then contacted EMS. The CRN stated he was assessed with no injuries and brought back to the facility. The CRN stated (and the ADM agreed) that the definition of elopement was a resident who left the facility and was in harm's way mainly because of their cognition or could not make good decisions because of a diagnosis of dementia. The ADM stated if a resident wanted to leave, and they were their own RP, and their BIMS was high enough, then they were able to leave. The ADM stated the importance of notifying the staff they were leaving was to help them make good decisions. The ADM stated he thought Resident #1 did sign out but did not tell anyone where he was going. The ADM stated no one really knew how long he had had been missing, but he could not imagine it had been more than one hour. The ADM stated a negative outcome of a resident not following their OOP protocols was that they could get very hurt. Observation made on 10/10/24 at 8:30 AM revealed the highway approximately 500 feet from the facility was busy and saturated with cars. Review of the facility's Signing Residents Out Policy, Revised August 2006, reflected the following: 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. 2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return. The ADM and CRN were notified on 10/10/24 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 10/10/24 at 5:47 PM: On 10/10/24, an abbreviated survey was initiated. 0n 10/10/24, the surveyor provided an Immediate Jeopardy notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate states jeopardy as follows: The facility failed to ensure that resident #1 was not missing from the facility for an unknown amount of time until contacted by EMS. Action: Resident #1 was immediately placed on 1:1 oversight. A full- house the interdisciplinary team completed check to validate that all residents were accounted for. The resident is on therapy and received treatment by physical therapy on 10/7/24. Start Date: 10/10/24. Completion Date: 10/10/2024 Responsible: Administrator Action: A secured facility will be located for resident #1 Start Date: 10/10/2024. Completion Date: open (1:1 oversight will remain until placement is found) Responsible: Administrator Action: All residents residing in the facility will have an updated Elopement Assessment completed and reviewed by the Administrator and the Regional Nurse for being at risk of leaving the facility. The Any nursing management nurses completed these assessments. Residents identified as being at risk as identified by a score over a 5 on the risk assessment will be evaluated further by the IDT to determine safety interventions. Residents will have an elopement assessment completed with their quarterly MDS and with any change of condition by nursing management. All scores and concerns will be reviewed by the interdisciplinary team and recommendations/interventions implemented. The regional nurse educated the administrator on processes for the residents to follow. The administrator educated the residents on the process of notifying facility staff of their desire to leave the facility for any reason. The facility staff will then sign off with the resident in the sign out book. Any concerns will be discussed with the administrator/designee before the resident will be given permission to leave the facility. The nursing management educated the facility staff on the process for residents signing out and monitoring the residents at least every hour to validate that everyone is accounted for. Any concerns will be brought to the attention of the administrator/designee. Staff, including PRN and agency not receiving the initial education will be required to receive it before starting their next assigned shift. Start Date: 10/10/2024. Completion Date: 10/11/24 Responsible: Administrator Action: An ad hoc QAPI meeting was completed with the medical director and the interdisciplinary team to discuss this plan of removal. Start Date: 10/10/24. Completion Date: 10/10/24 Responsible: Administrator Action: Any new admissions, ongoing, will have an elopement assessment completed, and interventions implemented if indicated, upon admission. The administrator/designee will review the elopement assessment to determine concerns. Start Date: 10/10/24 Completion Date: Ongoing Completion Date Responsible: Administrator Action: The administrator initiated an Abuse and Neglect in-service with facility staff. Start Date: 10/10/24 Completion Date: 10/11/24 Responsible: Administrator The Surveyor monitored the POR on 10/11/24 as followed: Observations made on 10/11/24 from 12:38 PM - 2:31 PM revealed CNA F outside Resident #1's room while he was sleeping. She stated when he left his room, she stayed with him to ensure his safety. During an interview on 10/11/24 at 12:42 PM, the CRN stated elopement risk assessments had been completed on all residents and there was only one (excluding Resident #1) who scored as high. She stated the resident often went out on pass and was very responsible. She stated he always notified a nurse that he was going to the (grocery store) and signed himself out and in when he returned. She stated all staff, including agency staff, were being in-serviced before their shifts. She stated the ADM had spoken with residents in groups to remind them of the OOP protocols. During interviews on 10/11/24 from 12:50 PM - 2:18 PM, staff from all shifts, including the AD, one HSK, three LVNs, and three CNAs all stated they were in-serviced prior to their shift on abuse and neglect and residents leaving the facility and resident supervision. All staff members knew that their ADM was their Abuse and Neglect Coordinator and that he should be notified any time there were any suspicions of abuse or neglect. They were all able to give examples of abuse such as verbal, physical, emotional, and psychosocial. They all stated a head count should be completed for each resident at least every hour. They all knew that if a resident wanted to leave the facility, the charge nurse needed to be notified and the resident needed to sign out. They all stated the importance for the protocols was to ensure all residents were accounted for, the staff knew where all residents were, who they went with, where they went, and an ETA for their return. The nurses stated they knew which residents were able to go OOP independently by the residents' elopement risk assessments and there was also a list in the sign-out book. All staff stated the facility was responsible for the residents' safety at all times. Review of the facility's QAPI meeting agenda, dated 10/10/24, reflected the ADM, the CRN, the RRC, the ADON, the AD, the HRD, and MD were in attendance. Review of four residents' (including Resident #1) Elopement Risk Assessments in their EMR, on 10/11/24, reflected they had all been completed on 10/10/24. Review of in-services dated 10/10/24 - 10/11/24 and conducted by the ADM, reflected all staff were in-serviced on ANE - All allegations must be reported immediately to the ADM, the Abuse Coordinator. Review of in-services, dated 10/10/24 - 10/11/24 and conducted by the CRN, reflected all staff were in-serviced on the following: It is our responsibility at (facility) to keep the residents safe from harm. The interdisciplinary team and front-line nursing staff must regularly round to identify any residents that are missing and quickly intervene. Staff will follow this process: 1. If a resident wants to leave the facility grounds, they have been instructed to notify a staff member. That staff member must sign off in the sign out book as well as the resident signing. 2. If you are not sure if a resident can sign himself out and leave the grounds, you must ask a management team member; ADM, DON, ADON, HR, before agreeing to allow them to leave the facility grounds. 3. Any concerns must be brought up to the immediate attention of the management or the nurse in charge, if management is not available. 4. Walking rounds must be done every hour to make sure that all residents are accounted for and on facility grounds. Any concerns must be acted upon immediately. Review of in-services, dated 10/10/24 and conducted by the ADM, reflected residents were in-serviced on the following: Any resident who leaves the facility and does not sign out and provide information such as where you are going, when you will return, and who you are going with will be placed in another facility which may be a secure unit. Staff and resident will enter the entry in the sign-out book. While the IJ was removed on 10/11/24 at 2:38 PM, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure and attain or maintain the highest practicable physical, mental and psychological well-being of each resident related to sufficient staffing during a coronavirus outbreak for 17 of 17 residents (Resident #,[DATE]) reviewed for COVID-19 and assessments and and 2 of 2 (shorthall, long hall) halls reviewed for sufficient staffing. 1. The facility failed to ensure there was enough licensed staff on duty to ensure resident assessments and resident monitoring were done to identify changes of condition in medically unstable COVID-19 positive residents 2. The facility failed to have sufficient staff working on the covid-positive unit and allowed staff to work on both the covid-positive and negative units, and failed to have sufficient direct care staff to meet the residents care needs. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scop of pattern due to a need for ongoing monitoring. These failures could place residents at risk for extended discomfort, physical and psychosocial decline, death and further spread of an infectious disease. Findings include: Review of facility self-reported incidents reflected the following covid-positive test results reported to the State Agency: [DATE] one staff tested positive; [DATE] five residents tested positive; [DATE] a second staff tested positive; [DATE] a third staff tested positive. During an interview on [DATE] at 11:58 am, the ADM stated that there had been some more covid-positive staff and residents. He did not mention that the facility was experiencing difficulty with maintaining sufficient staffing. Review of facility roster for [DATE] reflected that there were 37 residents in the facility. Observation on [DATE] at 9:09 revealed screening was conducted and admission granted into the non-isolation area of the facility by HA B. The facility was a t-shaped facility with two wings of resident rooms, the kitchen, dining area, and offices between them, and the small front wing holding a common room. The middle wing (known as the short hall) was the non-isolation hall, and the back wing (known as the long hall) was serving as an isolation wing behind a plastic barrier with one zipper through the middle, dividing the plastic sheet in half. The first three resident rooms on that hall were on the outside of the plastic barrier with door signs on which was printed, Quarantine Room. There was a set of plastic drawers on the outside of the plastic barrier with PPE inside. There were no signs regarding the use of PPE or hand hygiene and no alcohol-based hand rub near the PPE. The plastic sheeting had a one and a half inch hole against the zipper and another one inch-wide hole on the right side of the sheeting. There was no staff seen performing frequent high-touch surface sanitization. Observation of nurse staffing information posted on a facility whiteboard on [DATE] at 10:00 am reflected that there was one LVN, two CNAs, zero RNs, and 0 MAs present. During an interview on [DATE] at 9:12 am, the ADON stated that she is working as the charge nurse and is the only nurse in the building as well as the only management staff present. She stated the DON comes in at 2 pm, because she is working as the evening charge nurse. She stated that there are 19 covid-positive residents in the isolation wing of the facility, and she is providing nursing care for both them and the 18 residents who tested negative. She stated there are also residents in quarantine pending test results who had been in rooms with positives. She stated that these quarantined residents are in rooms just outside the isolation barrier. She stated that she knows that there should be designated staff to assist only the covid-positive residents and staff to assist only the covid-negative residents, but they just don't have anyone available. She stated that there is one CNA and one un-certified aide in the facility, and they are both working on both the isolation wing and the regular wing of the building. She stated that 12 staff have been taken off the schedule after testing positive for COVID-19. She stated they have no permanent people working in isolation, and the hall probably may be entirely without staff at this time. She stated that she doesn't not know if the other administration requested any strike force staff, but she has been working the floor nonstop and has had no time to perform managerial tasks. She stated that the nurse practitioner has been in the building to assess residents once per week. She stated that she has been doing resident assessments on her shift, and that these can be found in the electronic medical record and the MAR. During an interview on [DATE] at 10:55 am, the DON stated that skilled nursing assessments were being done each shift. She stated the assessments were in the EMR. Observation of the covid-positive isolation wing on [DATE] at 11:07 am revealed that there were no staff present inside the wing prior to the ADON assistance with entrance. When the ADON went out the back door to return to her tasks in the non-isolation wing, there were again no staff persons on the wing until meal service began at 11:24 am, at which point the ADON and HA B entered the isolation unit. During interviews on [DATE] between 11:07 am and 12:05 pm, seven of 13 residents (Residents #1, 6, 7, 11, 12, 13, and 17) on the isolation hall stated that they had not received a shower or bath, including a bed bath, in at least a week. During an interview on [DATE] at 12:07 pm, the RVP stated that have two staffing agencies with whom they contract, and these staffing agencies do not have anyone available. He stated that he believes that two staff came over from a sister facility. He stated that, when they received the test results indicating that 12 staff were positive for [DIAGNOSES REDACTED]-Cov-2, he asked the DON to contact the health department to see if they could utilize asymptomatic staff in the covid-positive isolation wing. He stated that they had received permission to utilize their asymptomatic positive staff in the covid-positive isolation unit, but the staff were refusing to come back. He stated that he had offered what incentives he could, but they were all still saying they wouldn't come back. A list was provided to the RVP at this time requesting the following for covid-positive residents: bed bath log, NP notes, any progress notes, vital signs log, emergency staffing plan, and staffing agency correspondence. During an interview on [DATE] at 1:10 pm, the DON stated there are 15 residents with pending test results due to being symptomatic or being roommates of a resident who already tested positive. She stated that there were 18 positive residents currently in the facility, and they are all in the isolation wing. She stated there are 14 pending staff members right now. She stated that the weekend RN, five CNAs, one dietary aide, one MA, and two HKs are all out with COVID-19. She stated they also have the AD who was the facility's first positive and has been out since June. She stated that the first three residents tested positive on [DATE], and then the next day there were 2 more positive resident tests. She stated that they did facility-wide testing on [DATE] after a nurse tested positive, and they received several more positive resident test results on Monday [DATE] as well as all the positive staff results on Tuesday. She stated they initially had people working only in the covid-positive isolation unit, but they became so short-staffed that they could no longer do that. She stated she doesn't know why no one from the facility has been trying to get help for staffing until the last day or two. She stated they reported the staffing deficiency up to their superiors, but they hadn't heard anything. She stated they need three total CNAs and at least one additional LVN. She then stated they actually need two LVNs, because they need to designate staff on the isolation unit. She stated that she thought the skilled nursing assessments for covid-positive residents were in the EMR, and she agreed to try to find them. A second request was also made at this time for bathing logs or shower sheets for all covid-positive residents. Bed bath logs were requested twice for all covid-positive residents on [DATE] but not provided prior to survey exit. Observation on [DATE] at 9:00 am revealed that the IDON was present working at one medication cart in the non-isolation wing of the building, and the ADON was working at the other, also in the non-isolated wing of the building. During an interview on [DATE] at 9:00 am the IDON stated that the DON was now out with covid-like symptoms, and she would be covering in her absence. During an interview on [DATE] at 9:08 am, the ADON stated that there was one CNA, one NA (not certified), and one HA present in the building. She stated that she and the IDON were the two nurses present. During an interview on [DATE] at 1:02 pm, the RVP stated that he is aware there is a staffing shortage at the facility. He stated that he thought he had instructed the ADM and DON to reach out to the State Agency to request staffing assistance, but he has discovered that had not occurred. He stated that he is aware that care plans and MDS assessments have not been updated in a while. He stated that they have a regional staff person working on the MDS and care plan issue, because the people in the facility who should have been doing that job have had to work the floor, but that regional staff had just taken over the updating. He stated he is discovering that there are also several things that the DON is responsible for and has not gotten done. He stated that the DON has acted as a charge nurse on certain shifts, but she has mobility issues that would prevent her from responding in an emergency. He stated that she can probably perform resident assessments, because she does not have to hurry to get to those rooms, but she is not able to perform urgent resident care or other hands on nursing tasks. He stated he did not know that no one was documenting the skilled nursing assessments. He stated that these should be documented in the EMR. He agreed to attempt to locate them. He stated that he understands that vital signs logs are distinct from full nursing assessments. During an interview on [DATE] at 2:30 pm, the IDON stated that the facility had received nine more positive resident results for COVID-19. During a confidential interview, an anonymous staff person stated that she has been working by herself often or only with a nurse aide who took the online training but doesn't really know all of the skills of caring for residents. She stated she works on both the isolation wing with covid-positive residents and the non-isolation wing with covid-negative residents every single shift. She stated that the staff are overworked and afraid of being exposed to COVID-19, but they are doing the best they can. She stated they have not been receiving guidance or being updated on what to expect, because the administrator is rarely at the building, and the staff who is present is just trying to make sure the residents are alright. She stated that management has not given them any indication that more staff will be coming to the building any time soon. Review of Facility Assessment staffing tab dated [DATE] reflected that there should be two LVNs on the 6 am-2 pm shift, one LVN on the 2 pm-10 pm and 10 pm-6 am shifts, five CNAs on the 6 am-2 pm shift, four CNAs on the 2 pm-10 pm, two CNAs on the 10 pm-6 am shift, and two MAs per day. Review of staffing sheets reflected the following nurse staffing: [DATE] 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN, two CNAs [DATE] 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN, two CNAs [DATE] 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN, one CNA [DATE] 6 pm-2 pm one LVN, two CNAs, one MA; 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN, two CNAs [DATE] 6 pm-2 pm one LVN, two CNAs, one MA; 2 pm-10 pm shift one LVN, two CNAs; 10 pm-6 am shift one LVN, two CNAs [DATE] 6 am-2 pm ADON is the only charge nurse present; 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN, one CNA [DATE] 6 am-2 pm ADON is the only charge nurse present; 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN, one CNA [DATE] 6 am-2 pm ADON is the only charge nurse present; 10 pm-6 am shift one LVN [DATE] 6 am-2 pm ADON is the only charge nurse present; 2 pm-10 pm shift one LVN, two CNAs; 10 pm-6 am shift one LVN, two CNAs [DATE] 6 am-2 pm ADON is the only charge nurse present; 2 pm-10 pm shift one LVN, three CNAs, one MA; 10 pm-6 am shift one LVN, two CNAs [DATE] 6 am-2 pm shift one LVN, two CNAs, one MA; 2 pm-10 pm shift one LVN, three CNAs, one MA; 10 pm-6 am shift one LVN, one CNA [DATE] 6 am-2 pm shift one LVN, two CNAs, one MA; 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN, two CNAs [DATE] 2 pm-10 pm shift one LVN, two CNAs, one MA; 10 pm-6 am shift one LVN (ADON), two CNAs [DATE] 6 am-2 pm ADON is the only charge nurse present; 2 pm-10 pm shift one LVN, one CNA, one MA; 10 pm-6 am shift one LVN, two CNAs [DATE] 6 am-2 pm ADON is the only charge nurse present, two CNAs, one MA; one LVN (DON), two CNAs, one MA (ADON); 10 pm-6 am shift one LVN, two CNAs [DATE] Review of the EMR reflected that, as of [DATE], none of the 19 covid-positive residents in the facility had MDS assessments to reflect a change in condition. Review of the EMR reflected that, as of [DATE], none of the 19 covid-positive residents in the facility had care plans updated to reflect their covid-positive status. Review of the EMR reflected that, as of [DATE], none of the 19 covid-positive residents in the facility had skilled nursing assessments for all of [DATE]. Review on of progress notes for all 19 covid-positive residents reflected that 15 of the 19 residents had no progress notes since their [DIAGNOSES REDACTED]. Review of NP notes provided on [DATE] by the ADON reflected that only 9 of the 19 covid-positive residents had been seen by the NP An attempt was made on [DATE] at 3:15 pm and again on [DATE] at 3:15 pm to contact the NP by telephone and text. Review of correspondence between the facility and the local health department reflected an email sent by the DON to the health department epidemiologist: I wanted to touch base with you regarding recent cases I have reported to the health department. On [DATE], I call to report three residents who had tested positive for COVID-19. Today, I called to report a staff member who test positive last night. I Have not heard from the health department since reporting these cases and wanted to ensure we are following any recommendations you may have. Thank you for your assistance. A reply from the epidemiologist later that day was sent to the DON, ADM, RVP, and RNC and contained the following guidance: Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least three times daily to identify and quickly manage serious infections . Maintain ongoing, frequent communication with residents, families, and HCP on the situation and facility actions . Identify HCP who will be assigned to work only on the COVID-19 care unit. The correspondence provided did not include any requests by the facility for staffing assistance. During an interview on [DATE] at 3:30 pm, the health department epidemiologist stated that she has not yet encountered a situation in which a facility had so little staff that they had to allow staff to work with both covid-positive and covid-negative residents and that she did not think this was a problem with this facility. She stated that she spoke to the DON who did not request any assistance with staffing even when the epidemiologist let her know that staffing assistance was available. She then verified that the facility did not request assistance with staffing through any electronic means. Review of COVID-19 results for the facility reflected that, as of [DATE], a total of 33 residents had tested positive of the 37 in the facility, and that five of these had expired. Facility policy on staffing was requested on [DATE], and the RVP provided a staffing schedule for the weekend, but no policy related to staffing. Facility emergency staffing plan was requested on [DATE] but never provided. Facility policy dated [DATE] and titled Infection Control Guidelines for All Nursing Procedures reflected the following: To provide guidelines for general infection control while caring for residents. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and expressions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Transmission based precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection. The RVP was notified on [DATE] at 4:00 pm an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the RVP on [DATE] at 4:04 pm. The following Plan of Removal was submitted by the RNC on [DATE] and accepted on [DATE] at 10:52 am. IMMEDIATE ACTION 1. On [DATE], sufficient staff have been secured so that staffing patterns of at least one (1) nurse and (1) CNA will be dedicated to the Covid-10 isolation unit with a med aide present from ,[DATE] and ,[DATE] shift. One (1) nurse and (1) CNA will be assigned to the remaining non-Covid residents with a med aide present from ,[DATE] and ,[DATE] shift. 2. On [DATE], the holes in the Covid hall plastic sheathing barrier were repaired. 3. On [DATE], PPE donning stations were replenished immediately upon discovery and a nursing staff in-service was started by the ADON. 4. Trash and Laundry receptacles with foot-controls were placed on the Covid-19 hall on [DATE]. 5. On [DATE], appropriate signage was placed on the Covid-19 hall. 6. On [DATE], the dirty laundry was immediately removed, and staff in-service was started by the ADON. 7. The facility will follow a daily schedule of e-misting the facility, including high touch surfaces, resident rooms, and resident equipment e.g. Hoyer lifts and scales. 8. Approved disinfectant bottles that have been clearly labeled have been placed where staff can access and use with kill time clearly written. Approved disinfectant wipes have been placed on the nursing carts so that glucometers and other nursing equipment. PPE bins will be wiped down by nursing staff, 2 (two) times a day and as needed. 9. On [DATE], facility staff were educated by the Regional VP of operations regarding disinfecting frequently used surfaces and kill times of the disinfectant. 10. Covid-19 patient care plans are being worked on with a completion date of [DATE]. Resident's requiring a Significant Change of Assessment, following the RAI rules, will have one completed by the MDS or the Regional Reimbursement Director. Residents will be reviewed by [DATE] to see which residents require this assessment. 11. The physician has been contacted so that residents, especially those exhibiting symptoms will be seen in person or by electronic facetime means for assessment and new orders, completion date for this will be [DATE]. 12. On [DATE], the ADON re-educated nurses regarding completing a temperature twice daily including a pulse oximetry to quickly identify changes of condition. Residents experiencing a change from the previous assessment will have a full assessment completed including; blood pressure, lung sounds, respirations, and any other assessment deemed necessary by the charge nurse and documented in the progress notes of the resident record. 13. The facility will immediately [DATE], test the eleven (11) residents that currently have no symptoms and reside outside the Covid unit with a ,[DATE] day turn around by the local hospital. On [DATE], the ADON educated nursing staff on contacting the Regional Nurse Consultant for any immediate signs and symptoms of Covid-19 for guidance and physician/RP notification Staff not receiving any of the above educations will be required to receive them before starting their next assigned shift. CONTINUED COMPLIANCE 1. The Regional VP of Operations and the Regional Nurse will be responsible for routine daily staffing calls to identify shortages of staff quickly. 2. The facility will solicit permission from the Health Department and HHSC to allow asymptomatic employees to work on the Covid-19 unit. 3. The PPE donning stations will be monitored three times a day by the nursing staff and the ADON to validate that supplies are available. Any concerns will be corrected immediately and brought to the attention of the Regional Nurse. Monitoring to validate ample supplies of approved disinfectant sprays and wipes will be done at these times as well and supplies replenished as needed. 4. The IDT will round the facility twice a day at assigned times to validate that there is no trash or dirty laundry on the floors or outside the facility. Any concerns will be corrected immediately and/or brought to the attention of the Regional VP of Operations. 5. The Regional Reimbursement Nurse will validate that care-plans have been completed for any newly identified Covid-19 residents. 6. The ADON will scan temperature and pulse oximetry checks to the Regional Nurse Consultant, daily, for review and guidance. 7. The e-misting log will be scanned daily to the Regional VP of Operations for review. 8. The Regional VP of Operations and the Regional Nurse will follow up to validate testing is completed. The survey team monitored the plan of removal from [DATE] through [DATE] as follows: Observation on [DATE] at 11:00 pm revealed that LVN C provided screening at the front door. She was using a misting device to sanitize all surfaces. No residents were observed out of their rooms in the non-isolation wing. CNA D was attending to resident needs. CDC signs had been posted around the front of the building. During an interview on [DATE] at 11:01 pm, LVN C stated that she is an employee of a sister facility out of town and has been assisting on overnight shifts at buildings with COVID-19. She stated that she was just called to work at the building on Friday [DATE]. She stated that one of her responsibilities is the disinfection using the mister each night. She will be working at the facility as long as they need her. During an interview on [DATE] at 11:06 pm, CNA D stated that having one LVN and one CNA on the non-isolation wing was enough staff to take care of resident needs on the overnight shift. She reported knowledge of the facility evacuation plan and stated she was only working on the non-isolation unit of the facility with residents who had not tested positive for COVID-19. She stated she is an employee of the facility who works PRN and hadn't picked up a shift in a couple weeks. Observation on [DATE] at 11:20 pm revealed that the isolation wing plastic sheeting had been replaced with new plastic sheeting and moved inwards to encompass three more resident rooms (which had been the quarantine rooms during the visit on [DATE]. There were no holes observed in this structure, and no zipper. CDC-generated signs had been posted near the plastic barrier. There was no entry at this location. Observation revealed that an entry station complete with alcohol-based hand rub, PPE, and signs indicating the proper way to perform hand hygiene and don PPE had been created at an outside door. Entry was granted by LVN E. CNA F was working in and out of resident rooms by bringing cups of water to each room. Both LVN E and CNA F were in gowns, N95 masks, face shields, and gloves. There were droplet isolation and PPE donning and doffing flyers affixed to the wall outside each resident door on the isolation wing. The PPE doffing station at the end of the isolation wing had a foot pedal operated, lidded bin for biohazard trash and biohazard linen. There was a decontamination table at the end of the hall with alcohol-based hand rub, and a second table outside of the hall with a sanitizing spray and more alcohol-based hand rub. During an interview on [DATE] at 11:21 pm, LVN E stated that she is the usual overnight nurse for the facility. She stated that she is now only working on the covid-positive isolation wing of the facility. She stated that she is able to manage the workload and perform assessments with herself and the one CNA. She stated she has already done assessments on the residents, and everyone looks good. She stated there was no one in any distress currently. She stated they have provided a break room for staff to sit and rest. She stated they are bringing their own drinks right now, and the facility hasn't provided anything else to them. During an interview on [DATE] at 11:22 pm, CNA F stated that she is now only working the covid-positive halls. She stated that she had been working with all the residents prior to Friday night. She stated that she is the regular overnight CNA for the facility. She stated that the facility provided her with enough PPE, but they aren't providing much else in the way of incentive to work. She stated that it is better only having to care for the residents in isolation, and that she can get more done. Observation on [DATE] at 4:40 pm revealed that the IDON performed screening before entry to the facility. She was using the mister to sanitize surfaces. There were two residents in the common area of the facility, both wearing masks. Two CNAs were observed working in the non-isolated wing of the facility. No residents were observed in any distress. The ADON was present and passing medication on the non-isolated wing of the facility. CNA J was working on the non-isolation hall. LVN G, CNA H, and CNA I were working on the isolation hall. During interviews on [DATE] between 4:45 pm and 4:58 pm, three CNAs present (CNAs H, I, and J) reported knowledge of the in-services provided on the topics of dedicated staffing, PPE, trash and dirty laundry, cleaning and disinfecting, and meal service protocol to the isolation wing. During interviews on [DATE] at 4:42 pm and 5:10 pm, the ADON and LVN G reported knowledge of the in-services provided on the topics of dedicated staffing, PPE, trash and dirty laundry, cleaning and disinfecting, and meal service protocol to the isolation wing as well as in-services related to assessments and COVID-19 monitoring. Observation on [DATE] at 11:17 am revealed that there were two CNAs (CNA K and L), one LVN (LVN M), and the IDON working in the non-isolated wing of the facility. In the isolation wing was the ADON, CNA N, and CNA H. CDC-generated signs had been placed on each resident door indicating droplet isolation. CDC-generated signs related to PPE donning, doffing, and disposal had been placed at strategic points throughout the facility. Oxivir wipes (hydrogen peroxide-based) had been placed on all treatment and medication carts (one treatment and two medication carts). A quaternary ammonium spray was also placed on top of several PPE carts throughout the facility. During interviews on [DATE] at 11:25 am., three CNAs reported knowledge of the in-services provided on the topics of dedicated staffing, PPE, trash and dirty laundry, cleaning and disinfecting, and meal service protocol to the isolation wing. Review of in-services provided by the IDON on [DATE] reflected the following: Immediate Jeopardy Education dated [DATE] with 21 signatures; COVID monitoring- for charge nurses dated /,[DATE] with six signatures; Dirty laundry cannot be placed on floor, must be taken directly to laundry when moved from bin dated [DATE] with 11 signatures; IDT rounds for trash on grounds & inside facility-twice daily dated [DATE] with 11 signatures; Dietary carts will enter covid unit, trays will be left on cart while items delivered to each pt., Do not take trays in rooms. Cart will exit through doors & sprayed allowed to dry & dietary member will pick up trays dated [DATE] with 22 signatures; PPE stations- See attached dated [DATE] with 10 signatures; Housekeeping disinfectant log will be utilized for all emisting performed daily dated [DATE] with 22 signatures; Disinfecting high traffic services by utilizing peroxide disinfectant. Needs to sit on surface for five minutes before wiping. If using DC33 disinfectant let sit for 10 minutes dated [DATE] with 23 signatures. Review of NP notes reflected that all residents in the facility had been seen by the NP on ,[DATE]-[DATE], and there were no serious health conditions noted. Review of care plans reflected that they were updated for all covid-positive residents with care planning related to monitoring of condition and psychosocial issues related to isolation. The RVP and the IDON were notified on [DATE] that the IJ had been lowered, and that the facility remained out of compliance at a severity of actual harm and a scope identified as a pattern due to a need for ongoing monitoring.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 37 of 37 residents (Resident # ,[DATE]), and 2 of 2 (short hall, long hall) halls reviewed for infection control, in that The facility failed to ensure that surfaces were sanitary, that frequent cleaning was being performed, and that cleaning and disinfecting supplies for hands and surfaces were readily available. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. These failures could place residents at risk for extended discomfort, physical and psychosocial decline, death and further spread of an infectious disease. Findings include: During an interview on [DATE] at 10:35 am, HK A stated she only cleans on the non-isolation wing and does not think anyone is cleaning on the isolation wing, because there is no other HK at the facility. She stated that she is busy cleaning individual rooms, and she does not know if there is anyone doing frequent disinfection of surfaces every two hours. She stated that she did not know if that was something they should be doing. Observation on [DATE] at 11:12 am revealed that there was a pile of damp, dirty laundry on the floor outside a resident room (room [ROOM NUMBER]) on the covid-positive isolation wing. The disposal cans at the end of the hall for discarding PPE and contaminated linens had standard trash bags in them and lids that required someone to lift them to dispose of PPE or linen. There were two canisters of disinfecting wipes at the end of the hall- one was empty, and one contained completely dry wipes. There were several flies (between five and ten) observed in this area, both in resident rooms and in the hall. There was no staff seen performing frequent high-touch surface sanitization and no visible sanitization supplies. During an interview on [DATE] at 12:05 pm, the HKS stated that she is doing the cleaning on the isolation hall and also doing all the laundry for the entire facility. She stated that she should have another housekeeper available, but they have one out due to being positive with COVID-19. During an interview on [DATE] at 1:02 pm, the RVP stated that he is aware there is a staffing shortage at the facility. He stated that he thought he had instructed the ADM and DON to reach out to the State Agency to request staffing assistance, but he has discovered that had not occurred. He stated that he is aware that care plans and MDS assessments have not been updated in a while. He stated that they have a regional staff person working on the MDS and care plan issue, because the people in the facility who should have been doing that job have had to work the floor, but that regional staff had just taken over the updating. He stated he is discovering that there are also several things that the DON is responsible for and has not gotten done. He stated that the DON has acted as a charge nurse on certain shifts, but she has mobility issues that would prevent her from responding in an emergency. He stated that she can probably perform resident assessments, because she does not have to hurry to get to those rooms, but she is not able to perform urgent resident care or other hands on nursing tasks. He stated he did not know that no one was documenting the skilled nursing assessments. He stated that these should be documented in the EMR. He agreed to attempt to locate them. He stated that he understands that vital signs logs are distinct from full nursing assessments. During an interview on [DATE] at 2:30 pm, the IDON stated that the facility had received nine more positive resident results for COVID-19. During a confidential interview, an anonymous staff person stated that she has been working by herself often or only with a nurse aide who took the online training but doesn't really know all of the skills of caring for residents. She stated she works on both the isolation wing with covid-positive residents and the non-isolation wing with covid-negative residents every single shift. She stated that the staff are overworked and afraid of being exposed to COVID-19, but they are doing the best they can. She stated they have not been receiving guidance or being updated on what to expect, because the administrator is rarely at the building, and the staff who is present is just trying to make sure the residents are alright. She stated that management has not given them any indication that more staff will be coming to the building any time soon. During an interview on [DATE] at 3:30 pm, the health department epidemiologist stated that she has not yet encountered a situation in which a facility had so little staff that they had to allow staff to work with both covid-positive and covid-negative residents and that she did not think this was a problem with this facility. She stated that she spoke to the DON who did not request any assistance with staffing even when the epidemiologist let her know that staffing assistance was available. She then verified that the facility did not request assistance with staffing through any electronic means. Review of facility roster for [DATE] reflected that there were 37 residents in the facility. Review of COVID-19 results for the facility reflected that, as of [DATE], a total of 33 residents had tested positive of the 37 in the facility, and that five of these had expired. Facility policy dated [DATE] and titled Infection Control Guidelines for All Nursing Procedures reflected the following: To provide guidelines for general infection control while caring for residents. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and expressions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Transmission based precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection. It also contained a link to the CDC website (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html) that reflected the following: CDC include prevention of healthcare associated infections as one determinant of bedside nurse staffing levels and composition, especially in high-risk units. In all areas where healthcare is delivered, provide supplies and equipment necessary for the consistent observance of standard precautions, including hand hygiene products and personal protective equipment. Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient and frequently touched surfaces in the patient care environment on a more frequent schedule compared to that for other surfaces. The RVP was notified on [DATE] at 4:00 pm an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the RVP on [DATE] at 4:04 pm. The following Plan of Removal was submitted by the RNC on [DATE] and accepted on [DATE] at 10:52 am. IMMEDIATE ACTION 1. On [DATE], sufficient staff have been secured so that staffing patterns of at least one (1) nurse and (1) CNA will be dedicated to the Covid-10 isolation unit with a med aide present from ,[DATE] and ,[DATE] shift. One (1) nurse and (1) CNA will be assigned to the remaining non-Covid residents with a med aide present from ,[DATE] and ,[DATE] shift. 2. On [DATE], the holes in the Covid hall plastic sheathing barrier were repaired. 3. On [DATE], PPE donning stations were replenished immediately upon discovery and a nursing staff in-service was started by the ADON. 4. Trash and Laundry receptacles with foot-controls were placed on the Covid-19 hall on [DATE]. 5. On [DATE], appropriate signage was placed on the Covid-19 hall. 6. On [DATE], the dirty laundry was immediately removed, and staff in-service was started by the ADON. 7. The facility will follow a daily schedule of e-misting the facility, including high touch surfaces, resident rooms, and resident equipment e.g. Hoyer lifts and scales. 8. Approved disinfectant bottles that have been clearly labeled have been placed where staff can access and use with kill time clearly written. Approved disinfectant wipes have been placed on the nursing carts so that glucometers and other nursing equipment. PPE bins will be wiped down by nursing staff, 2 (two) times a day and as needed. 9. On [DATE], facility staff were educated by the Regional VP of operations regarding disinfecting frequently used surfaces and kill times of the disinfectant. 10. Covid-19 patient care plans are being worked on with a completion date of [DATE]. Resident's requiring a Significant Change of Assessment, following the RAI rules, will have one completed by the MDS or the Regional Reimbursement Director. Residents will be reviewed by [DATE] to see which residents require this assessment. 11. The physician has been contacted so that residents, especially those exhibiting symptoms will be seen in person or by electronic facetime means for assessment and new orders, completion date for this will be [DATE]. 12. On [DATE], the ADON re-educated nurses regarding completing a temperature twice daily including a pulse oximetry to quickly identify changes of condition. Residents experiencing a change from the previous assessment will have a full assessment completed including; blood pressure, lung sounds, respirations, and any other assessment deemed necessary by the charge nurse and documented in the progress notes of the resident record. 13. The facility will immediately [DATE], test the eleven (11) residents that currently have no symptoms and reside outside the Covid unit with a ,[DATE] day turn around by the local hospital. On [DATE], the ADON educated nursing staff on contacting the Regional Nurse Consultant for any immediate signs and symptoms of Covid-19 for guidance and physician/RP notification Staff not receiving any of the above educations will be required to receive them before starting their next assigned shift. CONTINUED COMPLIANCE 1. The Regional VP of Operations and the Regional Nurse will be responsible for routine daily staffing calls to identify shortages of staff quickly. 2. The facility will solicit permission from the Health Department and HHSC to allow asymptomatic employees to work on the Covid-19 unit. 3. The PPE donning stations will be monitored three times a day by the nursing staff and the ADON to validate that supplies are available. Any concerns will be corrected immediately and brought to the attention of the Regional Nurse. Monitoring to validate ample supplies of approved disinfectant sprays and wipes will be done at these times as well and supplies replenished as needed. 4. The IDT will round the facility twice a day at assigned times to validate that there is no trash or dirty laundry on the floors or outside the facility. Any concerns will be corrected immediately and/or brought to the attention of the Regional VP of Operations. 5. The Regional Reimbursement Nurse will validate that care-plans have been completed for any newly identified Covid-19 residents. 6. The ADON will scan temperature and pulse oximetry checks to the Regional Nurse Consultant, daily, for review and guidance. 7. The e-misting log will be scanned daily to the Regional VP of Operations for review. 8. The Regional VP of Operations and the Regional Nurse will follow up to validate testing is completed. The survey team monitored the plan of removal from [DATE] through [DATE] as follows: Observation on [DATE] at 11:00 pm revealed that LVN C provided screening at the front door. She was using a misting device to sanitize all surfaces. No residents were observed out of their rooms in the non-isolation wing. CNA D was attending to resident needs. CDC signs had been posted around the front of the building. During an interview on [DATE] at 11:01 pm, LVN C stated that she is an employee of a sister facility out of town and has been assisting on overnight shifts at buildings with COVID-19. She stated that she was just called to work at the building on Friday [DATE]. She stated that one of her responsibilities is the disinfection using the mister each night. She will be working at the facility as long as they need her. During an interview on [DATE] at 11:06 pm, CNA D stated that having one LVN and one CNA on the non-isolation wing was enough staff to take care of resident needs on the overnight shift. She reported knowledge of the facility evacuation plan and stated she was only working on the non-isolation unit of the facility with residents who had not tested positive for COVID-19. She stated she is an employee of the facility who works PRN and hadn't picked up a shift in a couple weeks. Observation on [DATE] at 11:20 pm revealed that the isolation wing plastic sheeting had been replaced with new plastic sheeting and moved inwards to encompass three more resident rooms (which had been the quarantine rooms during the visit on [DATE]. There were no holes observed in this structure, and no zipper. CDC-generated signs had been posted near the plastic barrier. There was no entry at this location. Observation revealed that an entry station complete with alcohol-based hand rub, PPE, and signs indicating the proper way to perform hand hygiene and don PPE had been created at an outside door. Entry was granted by LVN E. CNA F was working in and out of resident rooms by bringing cups of water to each room. Both LVN E and CNA F were in gowns, N95 masks, face shields, and gloves. There were droplet isolation and PPE donning and doffing flyers affixed to the wall outside each resident door on the isolation wing. The PPE doffing station at the end of the isolation wing had a foot pedal operated, lidded bin for biohazard trash and biohazard linen. There was a decontamination table at the end of the hall with alcohol-based hand rub, and a second table outside of the hall with a sanitizing spray and more alcohol-based hand rub. During an interview on [DATE] at 11:21 pm, LVN E stated that she is the usual overnight nurse for the facility. She stated that she is now only working on the covid-positive isolation wing of the facility. She stated that she is able to manage the workload and perform assessments with herself and the one CNA. She stated she has already done assessments on the residents, and everyone looks good. She stated there was no one in any distress currently. She stated they have provided a break room for staff to sit and rest. She stated they are bringing their own drinks right now, and the facility hasn't provided anything else to them. During an interview on [DATE] at 11:22 pm, CNA F stated that she is now only working the covid-positive halls. She stated that she had been working with all the residents prior to Friday night. She stated that she is the regular overnight CNA for the facility. She stated that the facility provided her with enough PPE, but they aren't providing much else in the way of incentive to work. She stated that it is better only having to care for the residents in isolation, and that she can get more done. Observation on [DATE] at 4:40 pm revealed that the IDON performed screening before entry to the facility. She was using the mister to sanitize surfaces. There were two residents in the common area of the facility, both wearing masks. Two CNAs were observed working in the non-isolated wing of the facility. No residents were observed in any distress. The ADON was present and passing medication on the non-isolated wing of the facility. CNA J was working on the non-isolation hall. LVN G, CNA H, and CNA I were working on the isolation hall. During interviews on [DATE] between 4:45 pm and 4:58 pm, three CNAs present (CNAs H, I, and J) reported knowledge of the in-services provided on the topics of dedicated staffing, PPE, trash and dirty laundry, cleaning and disinfecting, and meal service protocol to the isolation wing. During interviews on [DATE] at 4:42 pm and 5:10 pm, the ADON and LVN G reported knowledge of the in-services provided on the topics of dedicated staffing, PPE, trash and dirty laundry, cleaning and disinfecting, and meal service protocol to the isolation wing as well as in-services related to assessments and COVID-19 monitoring. Observation on [DATE] at 11:17 am revealed that there were two CNAs (CNA K and L), one LVN (LVN M), and the IDON working in the non-isolated wing of the facility. In the isolation wing was the ADON, CNA N, and CNA H. CDC-generated signs had been placed on each resident door indicating droplet isolation. CDC-generated signs related to PPE donning, doffing, and disposal had been placed at strategic points throughout the facility. Oxivir wipes (hydrogen peroxide-based) had been placed on all treatment and medication carts (one treatment and two medication carts). A quaternary ammonium spray was also placed on top of several PPE carts throughout the facility. During interviews on [DATE] at 11:25 pm., three CNAs reported knowledge of the in-services provided on the topics of dedicated staffing, PPE, trash and dirty laundry, cleaning and disinfecting, and meal service protocol to the isolation wing. Review of in-services provided by the IDON on [DATE] reflected the following: Immediate Jeopardy Education dated [DATE] with 21 signatures; COVID monitoring- for charge nurses dated /,[DATE] with six signatures; Dirty laundry cannot be placed on floor, must be taken directly to laundry when moved from bin dated [DATE] with 11 signatures; IDT rounds for trash on grounds & inside facility-twice daily dated [DATE] with 11 signatures; Dietary carts will enter covid unit, trays will be left on cart while items delivered to each pt., Do not take trays in rooms. Cart will exit through doors & sprayed allowed to dry & dietary member will pick up trays dated [DATE] with 22 signatures; PPE stations- See attached dated [DATE] with 10 signatures; Housekeeping disinfectant log will be utilized for all emisting performed daily dated [DATE] with 22 signatures; Disinfecting high traffic services by utilizing peroxide disinfectant. Needs to sit on surface for five minutes before wiping. If using DC33 disinfectant let sit for 10 minutes dated [DATE] with 23 signatures. Review of NP notes reflected that all residents in the facility had been seen by the NP on ,[DATE]-[DATE], and there were no serious health conditions noted. Review of care plans reflected that they were updated for all covid-positive residents with care planning related to monitoring of condition and psychosocial issues related to isolation. Review of progress notes reflected that all residents in the facility had daily progress notes entered from [DATE] to [DATE] that included nursing assessments in each note. The RVP and the IDON were notified on [DATE] at 11:36 a.m. that the IJ had been lowered, and that the facility remained out of compliance at a severity of actual harm and a scope identified as a pattern due to a need for ongoing monitoring.

Based on observation, interview and record review the facility failed to implement policies and procedures to prohibit neglect for residents with personal histories that render them at risk for abusing other residents for one (1) of six (6) residents reviewed for neglect (Resident #1). Resident #1, a known sex offender for aggravated sexual assault offenses, had 3 known incidents over a 10 day period of inappropriate sexual behaviors with cognitively impaired female residents (Resident #2, Resident #3 and Resident #4) and the facility failed to develop intervention strategies and instruct staff to prevent occurrences of inappropriate sexual behaviors. An Immediate Jeopardy was identified to have existed from 05/02/14 through 05/16/14 for Resident #1. While the IJ was removed on 05/16/14 the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as pattern, because all staff had not been trained and care plans for sex offenders had not been created.. This deficient practice could place eight female residents, with moderate to severe cognitive impairment, at risk for sexual abuse or non-consensual sexual contact. The Findings Include: Review of a Face Sheet for Resident #1 reflected he was a [AGE] year old male with an admission date of [DATE]. Further review of the Face Sheet reflected [DIAGNOSES REDACTED]. Review of a Pre-Release Notification Form from the Texas Sex Offender Registration Program dated 05/01/14 reflected Resident #1 had a lifetime duty to register as a sex offender for offenses of Aggregative Sexual Assault. Further review reflected Resident #1 had signed and initialed the document to indicate an understanding of all the requirements and responsibilities for the Texas Sex Offender Program. Review of an admission MDS for Resident #1 dated 05/14/14, reflected Physical behavioral symptoms toward others; verbal behavioral symptoms towards others and other behavioral symptoms not directed towards others including public sexual acts. Behavioral symptoms impact on resident " significantly interfere with the resident ' s care and participation in activities and social interactions and intrude and disrupt the privacy or activity of others. Further review of the MDS reflected a BIMS score of 06; with a range of 00-15 (00-07 indicated severe cognitive impairment). Review of an undated Offender Summary report from the Texas Department of Corrections reflected the following: Resident #1 required assistance with ADLs to include set up for bathing and dressing. He was independent with eating, toileting, transfers and ambulated without assistance in a wheelchair. Review of care plans reflected a care plan had not been created for Resident #1 during his stay at the facility. During an interview on 05/27/14 at 12:40 pm the Administrator stated the facility had self-reported an incident on 05/24/14 and was in the process of completing their provider investigation for Resident #1. The DON added that the incident was regarding a recently admitted resident (Resident #1) that had kissed and made sexual advances towards female residents that could not give consent. The DON added Resident #1 was discharged on [DATE] back to the custody of the Texas Department of Corrections, due to his behaviors. Review of a Provider Investigation Report dated 05/26/14 reflected the following: The facility first learned of the incident on 05/12/14 and the date the report was submitted was 05/24/14. Resident #1 was admitted to the facility on [DATE] directly from the Texas Department of Corrections " reportedly because he required extensive assistance with his ADLs while incarcerated. Upon admission to the facility Resident #1 was alert, oriented and required minimal assistance with ADLs. " On the second day of admission (05/02/14) Resident #1 was seen in the dining room kissing Resident #2 on the lips while touching her arm. The residents were quickly separated and Resident #1 was counseled he was not to touch the resident in any way. He was instructed not to touch any of the female residents because he would not know of their ability to give consent. Review of a Face Sheet for Resident #2 reflected Resident #2 is an [AGE] year old female with [DIAGNOSES REDACTED]. Review of a MDS for Resident # 2 dated 05/24/14 reflected Severely Impaired Cognitive Skills for Daily Decision Making. Continued review of the Provider Investigation reflected on 05/06/14, Resident #1 was seen in the hallway kissing Resident # 3 on the lips. Once again, Resident #1 was counseled to not have physical contact with the female residents. Resident #1 was moved to the short hall where all male residents reside. During the weekend of 05/10/14 Resident #1 ' s parole officer visited him due to his behaviors and he instructed Resident #1 to not touch any of the female residents and suggested he eat his meals in his room. Review of a Face Sheet for Resident #3 reflected she is [AGE] years old with [DIAGNOSES REDACTED]. Review of a MDS dated [DATE] for Resident # 3 reflected total dependence on staff for all activities of daily living, severe cognitive impairment, and she was not interviewable. Further Review of the Provider Investigation Report reflected Resident #1 did not follow the parole officer ' s instructions and on 05/12/14 he was seen in the dining room rubbing Resident #4 ' s upper leg. Resident#4 was immediately removed from the area and Resident #1 ' s parole officer and the Texas Department of Corrections were notified of his continued behavior. On 05/16/14 Resident #1 was discharged to the Texas Department of Corrections. Review of a Face Sheet for Resident #4 reflected she is [AGE] years old with [DIAGNOSES REDACTED]. Review of a MDS dated [DATE] for Resident #4 reflected a BIMS score of 01 indicating severe cognitive impairment, was not interviewable and she required extensive assistance with all activities of daily living. During an interview on 05/27/14 at 10:15 am CNA Z stated Resident #1 was quiet and could self-propel his wheelchair throughout the facility. CNA Z stated she was not instructed to monitor Resident #1 closely. CNA Z stated there is no certain way to receive instructions for resident care or monitoring. Sometimes information is passed on from nursing staff or from one nurse aide to another. During an interview on 05/27/14 at 4:55 pm CNA W stated he had been working at the facility for [AGE] years and now works a few shifts per week. CNA stated he remembered Resident #1 but he had not been given any instructions to monitor him closely. During an interview on 05/27/14 at 5:08 pm MA V stated she had been employed by the facility for about 4 months. MA V stated she remembered Resident #1 but had not been given any instructions to monitor him closely. During an interview on 05/28/14 at 10:00 am CNA/ MA X stated she had witnessed Resident # 1 kissing Resident #2 on the lips and she was not capable of consenting. CNA X stated she knew of Resident #1 ' s history because of a time when she had to tell him he had a phone call from his parole officer and escorted Resident #1 to the telephone. CNA X stated she witnessed the conversation between Resident #1 and the parole officer and he was very alert and oriented when speaking with the officer and acknowledged his warnings. CNA X stated he was told by his parole officer to stay in his room and leave the female residents alone. CNA X stated she had not received any instructions to monitor Resident #1 closely. CNA X stated she had been informed by the DON on 05/27/14 of a male resident (Resident #5) in the facility that needed to be monitored closely and kept from female residents due to his history prior to being admitted . CNA X stated the resident had been in the facility for about a month. During an interview on 05/28/14 at 9:31am CNA Y stated she had been employed at the facility for five years. CNA Y further stated she witnessed an incident when she was assisting Resident #1 ' s roommate to his bed and observed Resident #1 in his bed masturbating. The privacy curtain was not pulled and the door to the hallway was open during the observation. CNA Y further stated she watched Resident #1 more closely because of this incident, but had not received instructions to do so from other staff. During an interview on 05/28/14 at 10:18 am LVN B stated she had recently returned to work for the facility in March, 2014 as a fulltime charge nurse. LVN B stated there was an incident when she was asked by CNA Y to come to Resident #1 ' s room because he was masturbating with the door open and the privacy curtain was not pulled. LVN B further stated she was not instructed to monitor resident closely and never told her staff to do so. During an interview on 05/28/14 at 10:00 am the DON stated she spoke with Resident #1 after each witnessed encounter of him touching and kissing female residents that cannot give consent. The DON stated Resident #1 would not honor her requests to stop touching female residents and he just " gave her a bad feeling and she wanted him to be discharged . " The DON stated Resident # 1 needed to be watched closely and kept away from female residents with cognitive impairment. The DON admitted Resident # 1 had moderate cognitive impairment according to his admission MDS, but felt like he was " faking " and could understand and honor her requests. When asked how the DON communicated to direct care staff the need to watch Resident #1 closely, she stated she didn ' t have anything in writing, he wasn ' t care planned to be monitored closely and there were no instructions for staff in the resident care books. The DON added, " We are like a small family here and staff know what to do and any special instructions regarding resident care are given verbally. " The DON further stated from her observations Resident #1 generally only came out of his room for meals. The DON also stated she had not assessed Residents #2, #3 and #4 after the incidents to determine if there were any injuries. The DON stated she felt her direct care staff would tell her if they found something out of the ordinary. She also stated the three female residents involved were interviewed by the Activities Director a couple of weeks after the incident during the facility ' s investigation, even though they were all severely cognitively impaired, " just in case they were able to tell us something " , which they didn ' t. In an interview on 05/27/14 at 3:15 pm the DON and Administrator stated there was no written plan or instructions for staff to monitor Resident #1 from the time of the first incident on 05/02/14 until his discharge on 05/16/14. . Review of a face sheet for Resident # 5 reflected he is [AGE] year old with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident # 5 dated 05/19/14 reflected a BIMS score of 11 out of a possible 15. Further review reflected Resident #5 is ambulatory without any assistance or devices and requires assistance for bathing, but is independent for all other ADLs. Observation on 05/27/14 at 5:00 pm revealed Resident #5 walking to the dining room and sitting down at a table with three female residents including Resident # and Resident # 3. Soon after he sat down he was asked by staff to move to a table with all male residents. During an interview on 05/27/14 at 5:00 pm CNA W stated Resident #5 is a relatively new resident and he is not to sit with female residents. CNA W stated he was told this in the " last couple of days " from another staff member but wasn ' t sure who it was. An observation on 05/28/14 at 8:00 am revealed Resident # 5 was sitting in the front lobby area watching television. An observation on 05/28/14 at 11:45 am revealed Resident # 5 sitting in the front living room dining area waiting for lunch. He was with all male residents and they were watching television. In an interview on 05/28/14 at 8:25 am the DON stated Resident #5 was recently admitted from another facility because he is a registered sex offender and the previous facility was located too close to a school. The DON stated she moved Resident #5 to the hall with all male residents on 05/27/14 and is in the process of in-servicing staff to have Resident #5 eat his meals with other male residents in the front living room area where there is a dining table. The DON stated Resident had been quiet, polite and had not exhibited any inappropriate sexual behaviors since his admission on 05/06/14. Review of the facility ' s Abuse/Neglect Policy dated 06/12/1013 reflected the following: ? The Interdisciplinary Team will use the MDS to identify residents with needs and behaviors that might lead to aggression or mistreatment, such as aggression, entering other residents ' rooms, self-injurious behaviors, communication disorders, those requiring heavy nursing care and those who are totally dependent on staff. Appropriate intervention strategies will be in the care plan. Residents will be reassessed periodically for changes that could trigger aggression or mistreatment. ? The facility will seek to identify situations in which resident mistreatment is more likely to occur in order to intervene to prevent mistreatment to include: Analysis of physical features of the environment, such as secluded areas; Deployment of staff on each shift in sufficient numbers and with appropriate knowledge to meet the needs of the residents. The facility Administrator and DON were notified on 05/28/14 at 1:16 pm that an IJ situation had been identified due to failure to develop and implement intervention strategies for residents whose histories render them at risk for abusing other residents to prevent occurrences and failure to instruct staff on the interventions. These failures placed Resident #1 in an IJ situation from 05/02/14 through 05/16/14. Resident #1 was discharged on [DATE].. The facility completed the following in-services to correct the non-compliance as follows: Review of a facility in-service dated 05/27/14 reflected the following: ? Staff instructed to remove residents from harm or potential harm. Report any potential abuse situations to the DON and the Administrator. Report all suspicious activity. Better to over report. ? Male sex offenders will rooms on the short hall. Ambulatory and independence with eating male sex offenders will eat in the front dining area. Only alert and oriented female residents may eat in this area with the men. ? Re-direct male sex offenders from confused females. In an interview on 05/27/14 at 12:17 pm the DON stated there were currently 5 registered sex offenders in the facility, but Resident # 5 is the only one that is ambulatory. The remaining 4 residents only get out of bed for showers and/or meals with extensive assistance and require assistance with meals, so staff are with them when they are out of bed and in common areas. The DON further stated all 5 residents are on the " short hall " where only male residents reside and the facility plans to keep the hall for male residents only. If the facility accepts any other male sex offender residents in the future they will be placed on this hall. The DON stated she is in the process of verbally in-servicing all staff on a one on one basis regarding Resident #5 and will update his care plan and the care plan book for CNAs to reflect he should be monitored closely and redirected when needed as well as have his meals with the other men in the living room area. The DON stated she is trying to decide what information to give staff regarding sex offender residents in order to " protect their privacy. " The DON provided a list of 5 male sex offenders currently residing at the facility. The DON provided a list of 8 female residents, out of a total of 13, they deemed to have moderate to severe cognitive impairment.

Based on observation, interview and record review the facility failed to implement policies and procedures to prohibit neglect for residents with personal histories that render them at risk for abusing other residents for one (1) of six (6) residents reviewed for neglect (Resident #1). A. Resident #1, a known sex offender for aggravated sexual assault offenses, had 3 known incidents over a 10 day period of inappropriate sexual behaviors with cognitively impaired female residents (Resident #2, Resident #3 and Resident #4) and the facility failed to develop intervention strategies and instruct staff to prevent occurrences of inappropriate sexual behaviors. An Immediate Jeopardy was identified to have existed from 05/02/14 through 05/16/14 for Resident #1. While the IJ was removed on 05/16/14 the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as pattern, because all staff had not been trained and care plans for sex offenders had not been created.. This deficient practice could place eight female residents, with moderate to severe cognitive impairment, at risk for sexual abuse or non-consensual sexual contact. B. The facility failed to immediately report to the State agency 3 known incidents of inappropriate sexual behaviors of a known sex offender (Resident #1) with 3 cognitively impaired residents. The incidents occurred on 05/02/14, 05/06/14, and 05/12/14 and the report to the State agency was initiated on 05/24/14. This deficient practice could place eight cognitively impaired female residents, who may be unable to report sexual advances or contact, at risk for abuse and neglect due to not reporting incidents of inappropriate sexual contact. The Findings Include: Review of the facility's Abuse/Neglect Policy dated 06/12/1013 reflected the following: Policy- The Facility will diligently attempt to prevent any and all residents from being subjected to mistreatment, abuse, neglect, sexual abuse, or mental abuse by anyone, including facility staff, other residents .. Prevention- The Interdisciplinary team will use the Minimum Data Set (MDS) to identify residents with needs and behaviors that might lead to mistreatment. Appropriate intervention strategies will be in the care plan. Residents will be reassessed periodically for changes that could trigger aggression or mistreatment. The facility will seek to identify situations in which resident mistreatment is more likely to occur in order to intervene to prevent mistreatment to include: Analysis of physical features of the environment, such as secluded areas; Deployment of staff on each shift in sufficient numbers and with appropriate knowledge to meet the needs of the residents. Identification: The Director of Nurses (DON) and the Administrator will review incident reports. Immediate Response: The person (s) observing an incident of resident abuse or suspected resident abuse must immediately remove the affected resident to a safe area and report the incident to the charge nurse. The report must include: Name of resident, when and where the incident occurred, name(s) of person(s) committing the act, names of witnesses, an examination of the residents involved to determine the extent of injury or the absence of injury. Physician notification. The charge nurse will examine the resident involved to determine the extent or absence of injury and take appropriate emergency interventions. The charge nurse will immediately notify the administrator of the incident, regardless of the hour or the severity of the allegation and/or injury. The charge nurse will complete the appropriate documentation, initiate an incident report, if indicated, and ask the reporting employee and witnesses to provide a signed and dated written statement regarding the allegations before departing the shift. Reporting- The facility administrator (or designee in the administrator ' s absence) will immediately obtain information required for a telephone report to the Texas Department of Human Services if indicated per regulations and make the report before further investigation. The facility administrator will ensure completion of the entire investigation and provide a comprehensive final written report to TDHS within 5 working days. The facility will review the facts determined by the administrator to determine what corrective actions, if any, should be made to prevent similar occurrences. A. Review of a Face Sheet for Resident #1 reflected he was a [AGE] year old male with an admission date of [DATE]. Further review of the Face Sheet reflected [DIAGNOSES REDACTED]. Review of a Pre-Release Notification Form from the Texas Sex Offender Registration Program dated 05/01/14 reflected Resident #1 had a lifetime duty to register as a sex offender for offenses of Aggregative Sexual Assault. Further review reflected Resident #1 had signed and initialed the document to indicate an understanding of all the requirements and responsibilities for the Texas Sex Offender Program. Review of an admission MDS for Resident #1 dated 05/14/14, reflected Physical behavioral symptoms toward others; verbal behavioral symptoms towards others and other behavioral symptoms not directed towards others including public sexual acts. Behavioral symptoms impact on resident " significantly interfere with the resident ' s care and participation in activities and social interactions and intrude and disrupt the privacy or activity of others. Further review of the MDS reflected a BIMS score of 06; with a range of 00-15 (00-07 indicated severe cognitive impairment). Review of an undated Offender Summary report from the Texas Department of Corrections reflected the following: Resident #1 required assistance with ADLs to include set up for bathing and dressing. He was independent with eating, toileting, transfers and ambulated without assistance in a wheelchair. Review of care plans reflected a care plan had not been created for Resident #1 during his stay at the facility. During an interview on 05/27/14 at 12:40 pm the Administrator stated the facility had self-reported an incident on 05/24/14 and was in the process of completing their provider investigation for Resident #1. The DON added that the incident was regarding a recently admitted resident (Resident #1) that had kissed and made sexual advances towards female residents that could not give consent. The DON added Resident #1 was discharged on [DATE] back to the custody of the Texas Department of Corrections, due to his behaviors. Review of a Provider Investigation Report dated 05/26/14 reflected the following: The facility first learned of the incident on 05/12/14 and the date the report was submitted was 05/24/14. Resident #1 was admitted to the facility on [DATE] directly from the Texas Department of Corrections " reportedly because he required extensive assistance with his ADLs while incarcerated. Upon admission to the facility Resident #1 was alert, oriented and required minimal assistance with ADLs. " On the second day of admission (05/02/14) Resident #1 was seen in the dining room kissing Resident #2 on the lips while touching her arm. The residents were quickly separated and Resident #1 was counseled he was not to touch the resident in any way. He was instructed not to touch any of the female residents because he would not know of their ability to give consent. Review of a Face Sheet for Resident #2 reflected Resident #2 is an [AGE] year old female with [DIAGNOSES REDACTED]. Review of a MDS for Resident # 2 dated 05/24/14 reflected Severely Impaired Cognitive Skills for Daily Decision Making. Continued review of the Provider Investigation reflected on 05/06/14, Resident #1 was seen in the hallway kissing Resident # 3 on the lips. Once again, Resident #1 was counseled to not have physical contact with the female residents. Resident #1 was moved to the short hall where all male residents reside. During the weekend of 05/10/14 Resident #1 ' s parole officer visited him due to his behaviors and he instructed Resident #1 to not touch any of the female residents and suggested he eat his meals in his room. Review of a Face Sheet for Resident #3 reflected she is [AGE] years old with [DIAGNOSES REDACTED]. Review of a MDS dated [DATE] for Resident # 3 reflected total dependence on staff for all activities of daily living, severe cognitive impairment, and she was not interviewable. Further Review of the Provider Investigation Report reflected Resident #1 did not follow the parole officer ' s instructions and on 05/12/14 he was seen in the dining room rubbing Resident #4 ' s upper leg. Resident#4 was immediately removed from the area and Resident #1 ' s parole officer and the Texas Department of Corrections were notified of his continued behavior. On 05/16/14 Resident #1 was discharged to the Texas Department of Corrections. Review of a Face Sheet for Resident #4 reflected she is [AGE] years old with [DIAGNOSES REDACTED]. Review of a MDS dated [DATE] for Resident #4 reflected a BIMS score of 01 indicating severe cognitive impairment, was not interviewable and she required extensive assistance with all activities of daily living. During an interview on 05/27/14 at 10:15 am CNA Z stated Resident #1 was quiet and could self-propel his wheelchair throughout the facility. CNA Z stated she was not instructed to monitor Resident #1 closely. CNA Z stated there is no certain way to receive instructions for resident care or monitoring. Sometimes information is passed on from nursing staff or from one nurse aide to another. During an interview on 05/27/14 at 4:55 pm CNA W stated he had been working at the facility for [AGE] years and now works a few shifts per week. CNA stated he remembered Resident #1 but he had not been given any instructions to monitor him closely. During an interview on 05/27/14 at 5:08 pm MA V stated she had been employed by the facility for about 4 months. MA V stated she remembered Resident #1 but had not been given any instructions to monitor him closely. During an interview on 05/28/14 at 10:00 am CNA/ MA X stated she had witnessed Resident # 1 kissing Resident #2 on the lips and she was not capable of consenting. CNA X stated she knew of Resident #1 ' s history because of a time when she had to tell him he had a phone call from his parole officer and escorted Resident #1 to the telephone. CNA X stated she witnessed the conversation between Resident #1 and the parole officer and he was very alert and oriented when speaking with the officer and acknowledged his warnings. CNA X stated he was told by his parole officer to stay in his room and leave the female residents alone. CNA X stated she had not received any instructions to monitor Resident #1 closely. CNA X stated she had been informed by the DON on 05/27/14 of a male resident (Resident #5) in the facility that needed to be monitored closely and kept from female residents due to his history prior to being admitted . CNA X stated the resident had been in the facility for about a month. During an interview on 05/28/14 at 9:31am CNA Y stated she had been employed at the facility for five years. CNA Y further stated she witnessed an incident when she was assisting Resident #1 ' s roommate to his bed and observed Resident #1 in his bed masturbating. The privacy curtain was not pulled and the door to the hallway was open during the observation. CNA Y further stated she watched Resident #1 more closely because of this incident, but had not received instructions to do so from other staff. During an interview on 05/28/14 at 10:18 am LVN B stated she had recently returned to work for the facility in March, 2014 as a fulltime charge nurse. LVN B stated there was an incident when she was asked by CNA Y to come to Resident #1 ' s room because he was masturbating with the door open and the privacy curtain was not pulled. LVN B further stated she was not instructed to monitor resident closely and never told her staff to do so. During an interview on 05/27/14 at 10:00 am the DON stated she spoke with Resident #1 after each witnessed encounter of him touching and kissing female residents that cannot give consent. The DON stated Resident #1 would not honor her requests to stop touching female residents and he just " gave her a bad feeling and she wanted him to be discharged . " The DON stated Resident # 1 needed to be watched closely and kept away from female residents with cognitive impairment. The DON admitted Resident # 1 had moderate cognitive impairment according to his admission MDS, but felt like he was " faking " and could understand and honor her requests. When asked how the DON communicated to direct care staff the need to watch Resident #1 closely, she stated she didn ' t have anything in writing, he wasn ' t care planned to be monitored closely and there were no instructions for staff in the resident care books. The DON added, " We are like a small family here and staff know what to do and any special instructions regarding resident care are given verbally. " The DON further stated from her observations Resident #1 generally only came out of his room for meals. The DON also stated she had not assessed Residents #2, #3 and #4 after the incidents to determine if there were any injuries. The DON stated she felt her direct care staff would tell her if they found something out of the ordinary. She also stated the three female residents involved were interviewed by the Activities Director a couple of weeks after the incident during the facility ' s investigation, even though they were all severely cognitively impaired, " just in case they were able to tell us something " , which they didn ' t. In an interview on 05/27/14 at 3:15 pm the DON and Administrator stated there was no written plan or instructions for staff to monitor Resident #1 from the time of the first incident on 05/02/14 until his discharge on 05/16/14. . Review of a face sheet for Resident # 5 reflected he is [AGE] year old with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident # 5 dated 05/19/14 reflected a BIMS score of 11 out of a possible 15. Further review reflected Resident #5 is ambulatory without any assistance or devices and requires assistance for bathing, but is independent for all other ADLs. Observation on 05/27/14 at 5:00 pm revealed Resident #5 walking to the dining room and sitting down at a table with three female residents including Resident # and Resident # 3. Soon after he sat down he was asked by staff to move to a table with all male residents. During an interview on 05/27/14 at 5:00 pm CNA W stated Resident #5 is a relatively new resident and he is not to sit with female residents. CNA W stated he was told this in the " last couple of days " from another staff member but wasn ' t sure who it was. An observation on 05/28/14 at 8:00 am revealed Resident # 5 was sitting in the front lobby area watching television. An observation on 05/28/14 at 11:45 am revealed Resident # 5 sitting in the front living room dining area waiting for lunch. He was with all male residents and they were watching television. In an interview on 05/28/14 at 8:25 am the DON stated Resident #5 was recently admitted from another facility because he is a registered sex offender and the previous facility was located too close to a school. The DON stated she moved Resident #5 to the hall with all male residents on 05/27/14 and is in the process of in-servicing staff to have Resident #5 eat his meals with other male residents in the front living room area where there is a dining table. The DON stated Resident had been quiet, polite and had not exhibited any inappropriate sexual behaviors since his admission on 05/06/14. The facility Administrator and DON were notified on 05/28/14 at 1:16 pm that an IJ situation had been identified due to failure to develop and implement intervention strategies for residents whose histories render them at risk for abusing other residents to prevent occurrences and failure to instruct staff on the interventions. These failures placed Resident #1 in an IJ situation from 05/02/14 through 05/16/14. Resident #1 was discharged on [DATE].. The facility completed the following in-services to correct the non-compliance as follows: Review of a facility in-service dated 05/27/14 reflected the following: ? Staff instructed to remove residents from harm or potential harm. Report any potential abuse situations to the DON and the Administrator. Report all suspicious activity. Better to over report. ? Male sex offenders will rooms on the short hall. Ambulatory and independence with eating male sex offenders will eat in the front dining area. Only alert and oriented female residents may eat in this area with the men. ? Re-direct male sex offenders from confused females. In an interview on 05/27/14 at 12:17 pm the DON stated there were currently 5 registered sex offenders in the facility, but Resident # 5 is the only one that is ambulatory. The remaining 4 residents only get out of bed for showers and/or meals with extensive assistance and require assistance with meals, so staff are with them when they are out of bed and in common areas. The DON further stated all 5 residents are on the " short hall " where only male residents reside and the facility plans to keep the hall for male residents only. If the facility accepts any other male sex offender residents in the future they will be placed on this hall. The DON stated she is in the process of verbally in-servicing all staff on a one on one basis regarding Resident #5 and will update his care plan and the care plan book for CNAs to reflect he should be monitored closely and redirected when needed as well as have his meals with the other men in the living room area. The DON stated she is trying to decide what information to give staff regarding sex offender residents in order to " protect their privacy. " The DON provided a list of 5 male sex offenders currently residing at the facility. B. Review of a Provider Investigation Report dated 05/26/14 reflected the following: The facility first learned of the incident on 05/12/14 and the date the report was submitted was 05/24/14. Resident #1 was admitted to the facility on [DATE] directly from the Texas Department of Corrections " reportedly" because he required extensive assistance with his Activities of Daily Living (ADLs) while incarcerated. Upon admission to the facility Resident #1 was alert, oriented and required minimal assistance with ADLs. On the second day of admission (05/02/14) Resident #1 was seen in the dining room kissing Resident #2 on the lips while touching her arm. The residents were quickly separated and Resident #1 was counseled he was not to touch the resident in any way. He was instructed not to touch any of the female residents because he would not know of their ability to give consent. On 05/06/14 Resident #1 was seen in the hallway kissing Resident # 3 on the lips. Once again, Resident #1 was counseled to not have physical contact with the female residents. Resident #1 was moved to the short hall where all male residents reside. During the weekend of 05/10/14 Resident #1 ' s parole officer visited him due to his behaviors and he instructed Resident #1 to not touch any of the female residents and suggested he eat his meals in his room. Resident #1 did not follow the parole officer ' s instructions and on 05/12/14 he was seen in the dining room rubbing Resident #4 ' s upper leg. Resident#4 was immediately removed from the area and Resident #1 ' s parole officer and the Texas Department of Corrections were notified of his continued behavior. On 05/16/14 Resident #1 was discharged to the Texas Department of Corrections. During an interview on 05/27/14 at 12:40 pm with the Administrator and Director of Nursing (DON) the Administrator stated the facility had self-reported an incident on 05/24/14 for Resident #1 and were in the process of completing their provider investigation. The DON further stated the incident was regarding a recently admitted resident (Resident #1) that had kissed and made sexual advances towards female residents that could not give consent. The DON added Resident #1 was discharged on [DATE] back to the custody of the Texas Department of Corrections, due to his behaviors. During an interview on 05/27/14 at 10:00 am the DON stated she spoke with Resident #1 after each witnessed encounter of him touching and kissing female residents that cannot give consent. The DON stated Resident #1 would not honor her requests to stop touching female residents and he just "gave her a bad feeling and she wanted him to be discharged ." The DON stated she had not assessed the female residents after the incidents to determine if there were any injuries and incidents reports were not completed. The DON stated she felt her direct care staff would tell her if they found something out of the ordinary during routine care. She also stated the 3 female residents involved were interviewed by the Activities Director a couple of weeks after the incident during the facility ' s investigation, even though they were all severely cognitively impaired, " just in case they were able to tell us something " , which they didn ' t. The DON stated that even though Resident #1 was a known repeat sex offender and he gave her a " bad feeling " she did not feel incident reports were indicated on 05/02/14, 05/06/14 and 05/12/14. During an interview on 05/27/14 at 3:30 pm with the Administrator and DON the Administrator stated the decision was made on 05/24/14, "after much discussion" to report the 3 incidents involving Resident #1 because "just in case" " it was the best thing to do. When the Administrator was asked how he determined which incidents are reportable or if he was aware of CMS Provider Letter - 0643 for guidance on reporting to the State agency, he stated he doesn ' t receive Provider Letters and was unaware of any for guidance on reporting. The Administrator further stated he had obtained information on how to access Provider Letters, but was unable to navigate the website and hasn ' t made any more attempts. The DON provided a list of 8 female residents, out of a total of 13, they deemed to be have moderate to severe cognitive impairment.

Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and effciently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 13 residents reviewed for abuse (Resident #1). The facility Administrator failed to supervise and monitor the Director of Nurses's (DON) investigation of an allegation of sexual abuse and failed to ensure the abuse protocol was implemented. The DON, who is the abuse coordinator, failed to immediately report an allegation of abuse to the State survey agency, complete a thorough investigation, and protect Resident #1 from the alleged perpetrator, certified nurse aide (CNA B), who remain working with the resident and other residents from the date of the incident 03/16/13 through 03/21/13. This failure resulted in an Immediate Jeopardy (IJ) on 03/21/13. While the IJ was removed on 03/22/13, the facility remained out of compliance at no actual harm with potential for more than minimal harm with a scope identified as widespread. This deficient practice placed all 50 residents at risk for abuse, who were dependent on staff for some type of assistance. Findings Include: Review of the facility ' s undated policy and procedure for abuse reflects the following: On page 3 under (E) Protection it stated the Administration will assess the situation to determine what protections is needed for the resident (s) involved during the investigation. Employees accused of resident abuse will be suspended from work and prohibited form (the facility) until the administrator completes the investigation and the Quality Assurance Committee meets to review the results of the investigation. The Quality Assurance Committee will meet within 5 days of the report of the incident. Under (F) Reporting it states the facility administrator or designee in the administrator ' s absence will immediately obtain basic information required for a telephonic report to the Texas Department of Human Services if indicated per regulations and make the report before further investigation. The facility administrator will ensure completion of the entire investigation and provide a comprehensive final written report to TDHS with 5 working days. Review of Resident #1's Facesheet reflected an admission date of [DATE], a date of birth of 12/13/52 and the following Diagnoses: [REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected the following: Resident #1 needs extensive assist with transfers, dressing, eating, and hygiene. He as limited range of motion and none ambulatory. The MDS also reflected Resident #1 is severely cognitively impaired and was coded a 3 (behavior of this type occurred daily) for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. Review of the Comprehensive Care Plan, last reviewed 10/10/12 reflected the following: Resident #1 is a full code, has memory deficits, max assist with activities of daily living, at risk for falls, receives [MEDICATION NAME] tube feeding via gastrostomy tube, care deficit for oral care, the use of medications may cause side effects, potential for [MEDICAL CONDITION], potential for contractors, head of bed up at least 45 degrees, anxiety at times, [MEDICAL CONDITION] (says the police are coming to arrest him and take him to jail). The Care Plan included an additional problem area added on 03/17/13 that included "Resident made statement that staff trying to put finger in rectum...." In an interview on 03/21/13 at 10:27 AM Resident #1 stated he did not want the facility to get into trouble as this was the only home the resident has. Resident #1 stated a new, black female aide, a big girl, (CNA B) came in about 10:30 at night and asked him if he had been charged with anything. Resident #1 told CNA B that he was charged with murder. CNA B then asked him if there was anything else he was charged with and he told her child molestation. Resident #1 stated that CNA A was also in the room. Resident #1 stated, " She (CNA B) hit me in the jaw (he showed the hit to the left jaw line) and then stuck her finger in my butt hole." He stated, "It embarrassed me but it did not hurt me." Resident #1 stated, "This is my home and I don ' t want to be labeled as a snitch. There was no mark left on my jaw and I don ' t want to have to leave here as this is the only home I have." The resident stated CNA A was cleaning him up when CNA B hit him and stuck her finger in his rectum. The resident could not remember the date of the incident, but it was a few days before. Observation on 3/21/13 at 10:27 AM revealed Resident #1 in bed, clean, and without any bruises or reddened areas to his jaw. During an interview on 03/21/13 at 9:55 AM, when asked about the allegation of sexual abuse to Resident #1, the Administrator stated she is not the abuse coordinator and referred the investigator to the DON. In an interview on 03/21/13 at 2:35 PM the DON stated the allegation of sexual abuse of Resident #1 occurred on 03/16/13 after supper. She stated the allegation was reported on 03/17/13 by CNA C, who reported the allegation to the charge nurse. The allegation was reported that CNA A and CNA B were involved. The DON stated she had not reported the allegation of sexual abuse to the state and she did not suspend the CNA ' s pending an investigation. When the DON was asked about the investigation, the DON stated the investigation was started on 3/17/13 and that "this is my investigation " and provided the investigator with a packet of written staff statements. The DON stated she told CNA A that he was not supposed to be working on the short hall with Resident #1. The DON stated CNA A was off until the 20th which was his regular days offs and they (CNAs A and B) both worked the long hall (opposite hall) from Resident #1 on 03/20/13. The DON stated CNA A did not work the 17th, 18th or 19th. Review of three of six written staff statements provided by the DON reflected Resident #1 identified CNA B as the perpetrator. The written statements also includes those by CNAs A and B. In an interview on 03/21/13 at 1:20 PM CNA C stated she reported Resident #1 ' s accusation on 03/17/13 to the charge nurse on duty. She stated Resident #1 told her "The new black girl did it; she stuck her finger in my butt and put a sheet over his face and hit him in the jaw." Resident #1 stated that CNA A was also in the room when CNA B stuck her finger in the resident's butt. CNA C stated she called the DON after she notified the charge nurse. The DON, who is the abuse coordinator, told CNA C to write out a statement and put it under her door on Sunday, 03/17/13. In an interview on 03/21/13 at 2:50 PM CNA A stated Resident #1 was facing him during incontinent care, at which time Resident #1 accused CNA B of sticking her finger in his butt and started yelling "rape. CNA A stated that Resident #1 was turned with his bottom to CNA B, but he did not see anything. He told Resident #1 he would not let anyone do that to him. CNA A stated he was not paying attention as he was too busy cleaning the resident up. Medication Aide (MA) C came into the room after Resident #1 made his allegation and told Resident #1 to, "Cut that out, they are her to help." CNA A stated Resident #1 had told his past before, but did not recall CNA B asking the resident about his past or recall her saying anything to him. CNA A stated he was off Sunday, 03/17/13, and he worked the next day Monday (3/18/13), Tuesday (3/19/13), Wednesday (3/20/13) and today (03/21/13). CNA A stated he was not told to not work with Resident #1 until this afternoon when he came on his shift (03/21/13). He stated he and CNA B had been assigned to the long hall and not the short hall where Resident #1 resided. Then CNA A stated he made a mistake and he was off on Monday and worked Tuesday, Wednesday and today (03/21/13). CNA A added that he did assist another unidentified aide on Wednesday that included the short hall. CNA A stated he did not report the allegation because Resident #1 says so much stuff and he just did not think to report it. In an interview on 03/21/13 at 3:48 PM CNA B stated she had just started working at the facility in March 2013. She stated she was told by another aide that Resident #1 accuses people of things so be careful. When asked about the events on 3/16/13, CNA B stated Resident #1's front side was toward her and his back side toward CNA A. When asked about her involvement during the incontinent care, CNA B stated she had gloves on and did not want to touch him. CNA A told me to hold the resident so he would not lean against CNA A while he was cleaning the resident. CNA B then stated that Resident #1 ' s bottom was toward her when he began calling out rape and accusing her of sticking her finger in the resident's butt. CNA B stated she had heard rumors that Resident #1 was blamed for child molestation, but did not ask the resident about his past during care. CNA B stated she did not report the resident's allegation to the charge nurse because the resident is always saying "things." CNA B stated she was off Sunday (03/17/13), worked Monday (03/18/13), Tuesday (03/19/13), Wednesday (03/20/13) and today (03/21/13). CNA B stated she had not been told to not work the short hall where Resident #1 resides. Review of the Daily Sign-In Sheets and Card Punch Records for the past 30 days reflected that CNAs A and B did work Monday (03/18/13) through Thursday (03/21/13). In an interview on 03/22/13 at 8:50 AM MA C stated she did go into Resident #1 ' s room on the evening of 03/16/13 and the resident did tell her that they were poking him in the butt. She stated she told him she did not think they did it. MA C stated she did not report it to anyone as he is always saying they are coming to take him to jail and he has people in bed with him. She stated she did not remember saying anything else and does not remember saying, cut that out (used the name of Resident #1) they are helping you. MA C stated she only said " they would not do nothing like that." She restated she did not believe anyone around here would do something like that. During a confidential interview, the interviewee stated they were afraid the Administrator and DON would find out that the complaint was called in and they would lose their job but they felt it was their duty to report the incident with Resident #1 relating to the allegation of sexual abuse. They stated the facility was not calling the incident in. The interviewee stated that everyone was terrified to call the incident in. The interviewee stated Resident #1 was interviewed and he was very alert. They stated because of his Dementia the management wants to play down the allegation of sexual abuse. During another confidential, the interviewee stated CNA B was accused and they (CNA A and B) are still working on the floor. The interviewee stated the nurse aide was not suspended pending the completion of the investigation. During an additional confidential interview, the interviewee stated the facility was not reporting the incident with Resident #1 and they did not know if the person (CNA B) was guilty or not. The interviewee stated an incident report was written but the Director of Nurses (DON) did not want her incident report. The interviewee stated what was reported to the state in the intake is correct. In an interview on 03/21/13 at 4:00 PM the DON stated she was the abuse coordinator. The DON stated she did an investigation related to Resident #1, she stated she called the hotline today (03/21/13) with the report of the allegation of sexual abuse. When the DON was asked if a investigation report was faxed to the State Agency, she stated that she had not faxed anything yet. When asked why she had identified CNA A as the perpetrator when all of the documentation stated the allegation was against CNA B, the DON did not respond and made a facial expression toward the Investigator. The DON stated she did not send Resident #1 to the emergency room for an assessment as she and the nurses assessed him and there were no bruising or damage noted. She stated she did notify the physician today 03/21/13. On 03/22/13 at 11:52 AM the attending physician, who is the Medical Director, was unavailable for an interview until next week. Review of the Provider Investigation Report for Resident #1, provided by the DON, dated 03/21/13 reflected a checkmark next to Neglect under the Incident Category and identified the perpetrator as CNA A with CNA B as the witness. The investigation included that the resident was assessed and there were no signs of a reddened area to the face or rectum on 03/17/13. The Provider Action taken included that CNA A was not scheduled to work on the resident's hall (short hall), but did not address actions for CNA B. The Administrator was notified on 03/21/13 at 5:05 PM that an IJ had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 03/22/13 at 11:24 AM. The final Plan of Removal was accepted by the Investigator on 03/22/13 at 6:15 PM The Plan of Removal contained the following: Failure to Protect a resident after allegations of abuse. -The alleged employees were suspended of their duties on 03/21/13 and replaced with staff on the evening shift. -DON reviewed the policy and procedure of abuse/neglect regarding sexual, physical and verbal abuse with the alleged employees during the suspension process conference on 03/21/13. They were placed on suspension on 03/21/13 pending completion of investigation. -DON and Staff Coordinator (LVN) on 03/21/13 made rounds, interviewed and observed cognitive impaired residents for any signs of abuse. ie: Unknown bruises, other physical, mental, emotional or behavioral changes. -In-service for all employees on all types of abuse/neglect including sexual, physical and verbal abuse and the procedures for reporting abuse was conducted on 03/20/13 at staff meeting. The staff present on 03/21/13 6-2 shift and 2-10 and 10-6 shifts was in-service again on all forms of abuse and the procedure for reporting abuse. All other nursing staff members not present at the in-services held on 03/21/13 and 03/22/13 will be in-serviced prior to making contact with the residents. -Physical assessments for unknown bruises, other physical, mental, emotional or behavioral changes will be done and an interview (ie: " Are you being treated well? " and " Has anyone been mean to you? " ) of the cognitively impaired residents will be conducted and completed by Administrator or designee. This will be ongoing and with any allegations until the investigation is complete. -QA team consisting of Administrator, Medical director, Operations Manager, Activity Director, DON, Food Service Supervisor will monitor monthly for 90 days then quarterly thereafter. The next QA meeting will be Monday, March 25, 2013. -Administrator or designee will monitor ongoing the Policy for Abuse and Neglect to assure all residents are safe and free from abuse. - Failure to investigate allegations of abuse and report it to the consumer services. -Administrator initiated an investigation on 03/17/13. DON continued the investigation for the abuse allegation when she arrived at the facility on 03/17/13. -The DON notified the residents ' primary physician and responsible party on 03/21/13 of alleged abuse. -DON notified Consumer Services of any abuse allegations on 03/21/13. -In-service for all employees on all types of abuse/neglect including sexual, physical, and verbal abuse and the procedures for reporting abuse was conducted on 03/20 staff meeting. The staff present on 03/21 6-2 shift, 2-10 shift 10-6 shifts were in-serviced again on all forms of abuse and the procedure for reporting abuse. All other staff members not present at either in -service will be in-serviced by 03/25/13. -Physical assessments for unknown bruises, other physical, mental, emotional or behavioral changes and / or interviews (ie: " Are you being treated well? " and " Has anyone been mean to you? " ) of the cognitively impaired residents were conducted and completed by the DON and MD Coordinator on 03/21/13. -QA team consisting of Administrator, Medical director, Operations Manager, Activity Director, DON, Food Service Supervisor will monitor monthly for 90 days then quarterly thereafter. The next QA meeting will be Monday, March 25, 2013. -Administrator or designee will monitor ongoing. The investigator monitored the current plan of removal as follows: On 03/21/2013 at 5:20 PM the DON suspended CNA A and CNA B. They left the building. The two staff were replaced by two LVN ' s. Reviewed documentation provided by the DON revealed that she and the Staff Coordinator (LVN) on 03/21/13 made rounds, interviewed and observed cognitive impaired residents for any signs of abuse. ie: Unknown bruises, other physical, mental, emotional or behavioral changes. Reviewed in-service documentation provided by the DON for abuse/neglect including sexual, physical and verbal abuse and the procedures present on 03/21/13 6-2 shift and 2-10 and 10-6 shifts was in-service again on all forms of abuse and the procedure for reporting abuse. On 03/22/13 at 6:15 PM the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope as widespread that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The Administrator provided a census of 50 residents who have the potential for being abused.

This deficient practice was cited on 03/22/2013 and the facility remains out of compliance. Based on interview and record review, the facility failed to ensure A) an allegation of neglect and B) an allegation of resident to resident abuse was immediately reported to the State survey agency, thoroughly investigated, and interventions put in place to further prevent abuse for 2 of 7 residents reviewed for abuse and neglect. (Resident #4 and #3) A) Resident # 4 sustained fractures in three places on her ankle from an unknown source when the facility failed to thoroughly investigate and immediately report Resident #4's incident to the Department of Aging and Disability Services (DADS) for investigation; and. B) Resident # 3 kicked another resident in the buttocks when the facility failed to thoroughly investigate and immediately report the Resident's allegation of Resident to Resident Abuse to DADS. This deficient practice placed 45 Residents at risk for abuse and neglect, who were dependent on staff for some type of assistance. Findings Include: Review of the facility Abuse/Neglect policy, undated, reflected: D) Investigation The confidential investigation will be directed by the facility Administrator or designee, and will include: 1) An incident report form. 2) An interview of the reporting person. 3) Interviews of the resident(s)/witness(es) involved, if possible. 4) A review of statements or additional statement and/or interviews of all staff who may have knowledge regarding the incident. 5) Interview of other residents, if possible, who receive care from the accused individual. 6) A review of the medical record for the resident involved. F) Reporting The facility administrator (or designee in the administrator's absence) will immediately obtain basic information required for a telephonic report to the Texas Department of Human Services (TDHS) if indicated per regulations and make the report before further investigation. The facility administrator will ensure completion of the entire investigation and provide a comprehensive final written report to TDHS within 5 working days. The policy reflected no information regarding injuries of unknown origin. A) Review of Resident # 4's Admitting Record reflected a [AGE] year old female who entered the facility on 04/11/2013. Review of Resident # 4's undated Prior Level of Function Assessment reflected the Resident entered the facility with an [MEDICAL CONDITION] status [REDACTED]. Review of Resident # 4's Admission Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) and indicated she was cognitively intact. The assessment reflected Resident # 4 was at risk for falls having had falls in the last month prior to admission and the last two - six months prior to entry. Review of Resident # 4's Comprehensive Care Plan reflected a plan of care dated 05/14/2013 regarding the Resident "requires assistance/potential to restore function to maximum self-sufficiency for MOBILITY characterized by the following functions; positioning, locomotion/ambulation related to right ankle fracture." Interventions were MOBILITY - Independent with walker." Review of Resident # 4's Nurse's Notes dated 04/30/2013 reflected a late entry for 04/27/2013 and "Resident returned from oop (out on pass) with her boyfriend; being wheeled in by him in a wc (wheelchair). Resident was in good sports and said she had a good time; no c/o (complaints) voiced by resident to this nurse. She was taken to her room by her boyfriend. Around 9:30 PM she reported to CNA (Certified Nurse Aide) that she wanted someone to look at her foot and that was all she said. At 9:45 PM in report it was passed on. That she wanted someone to check her ankle." There was no other Nurse's Note until 05/09/2013 that reflected "pain med (medication) given for right ankle pain w/+ (with positive) results. resting quietly in bed w/eyes closed at this time. resp (respirations) even and unlabored. denies pain or discomfort at this time. temp (temperature) 97.2. conts abt/post (continues antibiotic therapy/post) surgery to right foot w/nar (with no adverse reaction). voices needs." Review of Resident # 4's Incident/Accident report dated 04/28/2013 at 11:45 AM. "On 04/28/2013 Resident returned from OOP, c/o right lower leg pain and swelling. Right leg noted with redness and warmth and tender to touch. Three + [MEDICAL CONDITION]. Offered pain rx (prescription)." Review of an X-ray report for Resident # 4 dated 04/28/2013 reflected three views of the right ankle were performed with findings of "Trimalleolar displaced ankle fracture with marked soft tissue swelling present. There is angulation of the fibular fracture. There is a displacement of the medial malleolar and posterior malleolar fractures. Additionally there appears to be a cortical [MEDICAL CONDITION] tibia. Medial malleolar fracture extends to the articular surface." Review of Resident # 4's Release of Responsibility for Leave of Absence form reflected the Resident left the faciity on [DATE] and returned on 04/27/2013. In an interview on 05/16/2013 at 3:00 PM the Social Worker (SW), who is responsible for investigating incidents, stated Resident # 4 was out on pass, came back on 04/28/2013 and complained her foot was hurt and swollen. The SW stated she questioned Resident # 4 regarding an abusive situation with her boyfriend and the Resident told her no, she was not in an abusive situation. The SW stated she questioned Resident # 4 if she had drank alcoholic beverages while out on pass and the Resident told her she had consumed a few beers. The SW stated she felt Resident # 4 sustained her fractures while out on pass. When advised the Release of Responsibility for Leave of Absence reflected Resident # 4 came back from out on pass on 04/27/2013 the SW stated "that is wrong, you can ask her." The SW stated the physician had told Resident # 4 the fracture was three (3) to four (4) weeks old. When questioned regarding the physician's [DIAGNOSES REDACTED]. Review of the Physician's Report dated 04/30/2013 the History/Physical Information reflected "Ankle pain noted. (Resident # 4's name) sustained an injury to the right ankle. The injury was 3 days ago. No precipitating event or injury is identified. She noticed painful deformity upon awakening Saturday morning 4/27/13...." In an interview on 05/16/2013 at 4:00 PM Resident # 4 stated she had come back from out on pass and spent one night at the facility prior to having her ankle and foot x-rayed (04/27/2013). Resident # 4 stated she did not know when or what happened to her foot, it started swelling and hurting and her boyfriend had told her she needed to get back to the nursing home. Resident # 4 stated she came back and advised the facility her foot was hurting and swelling on 04/27/2013. Review of the Provider Investigation Report dated 04/30/2013 reflected the report was made to DADS on 04/30/2013, 3 days after the incident occurred. The report reflected Resident # 4 sustained an "unknown injury while resident oop (out on pass)." The report reflected Resident # 4 required no special supervision with minimal functional ability and [DIAGNOSES REDACTED]. Description of the allegation was "Resident has an unknown origin of fracture to her rt (right) ankle." with Provider Response as "Resident denies any abuse occurred. While she was here at facility or while she was at home. She does admit to drinking while out on pass. Resident seen at emergency room . Resident admitted to hospital for surgery to repair fracture." Provider Action Taken Post-Investigation reflected the following: 1. Encourage resident to ask for assistance. 2. Encourage resident to not drink alcohol. 3. Encourage resident to use crutches when walking with stall. 4. Follow doctors ' orders s/p (status/post) surgery. B) Review of Resident # 3 ' s face sheet reflected a [AGE] year old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #3 ' s Quarterly MDS assessment dated [DATE], reflected Resident #3 had a BIMS score of 6, indicating Resident #3 had moderate cognitive impairments. The MDS reflected that Resident # 3 exhibited disorganized thinking and inattention behavior that fluctuated. The MDS reflected a Mood Severity Score of 13, indicating Resident #3 exhibited depressive symptoms more than half to nearly every day of the previous two week evaluation period. The MDS reflected Resident #3 exhibited both verbal and physical behavioral symptoms directed towards others four to six days a week. The MDS reflected that Resident # was totally dependent on staff for most activities of daily living. Review of Resident #3 ' s Comprehensive Care Plan did not reflect any Problems, Goals or Interventions addressing Resident #3 ' s Mood or Behavior that were triggered on his MDS. Review of Resident #3 ' s Nurse Notes dated 4/30/13 reflected Resident # 3 was attempting to close the bathroom door in the short hall when another resident grabbed the door and held it open. Resident #3 " began to curse and threaten to kick the other resident ' s ass " . Resident #3 then proceeded to follow the other resident down the hallway and Resident #3 kicked the other resident on the " buttocks " . Review of Incident/Accident Report dated 04/30/13 reflected Resident #3 is " alert and can voice needs. " Resident #3 was attempting to close the bathroom door when another resident grabbed the door and held the door open. Resident #3 cursed the other resident and then proceeded to kick him on his buttocks. Review of Incident Investigation dated 04/30/13 reflected the incident happened around 10:10 AM on the " short hall " . The Investigation Report reflected that Resident #3 " becomes aggressive when others bother him. " The report reflected that a " behavioral program " care plan was in place and to prevent another incident, the facility would begin " monitoring behaviors. " During an interview on 5/16/13 at 6:59 PM the SW stated that she did not exactly remember what happened and that she was not going to answer any questions until after she has spoken with the staff that witnessed the incident and wrote the report. The SW stated she did not believe that the incident happened due to Resident # 3 ' s health conditions and she did not believe that Resident # 3 was physically capable of performing the act. During an interview on 5/16/13 at 7:25 PM the SW stated that she had spoken to the housekeeper that witnessed the incident and stated that Resident #3 " did it " . The Social Worker stated that she was not aware of the incident report, therefore, it was not investigated or reported to DADS for further investigation. The facility provided a list of 45 residents who require assistance of some type.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit abuse for 1 of 13 residents reviewed for abuse (Resident #1). The facility failed to immediately report Resident #1's allegation of sexual abuse to the Administrator and/or designee, to the Department of Aging and Disability Services (DADS), nor thoroughly investigated the allegation. The facility failed to protect Resident #1 by allowing the alleged perpetrator, certified nurse aide (CNA B), to remain working with the resident and other residents from the date of the incident, 03/16/13 through 03/21/13. This failure resulted in an Immediate Jeopardy (IJ) on 03/21/13. While the IJ was removed on 03/22/13, the facility remained out of compliance at no actual harm with potential for more than minimal harm with a scope identified as widespread. This deficient practice placed all 50 residents at risk for abuse, who were dependent on staff for some type of assistance. Findings Include: Review of the facility ' s undated policy and procedure for abuse reflects the following: On page 3 under (E) Protection it stated the Administration will assess the situation to determine what protections is needed for the resident (s) involved during the investigation. Employees accused of resident abuse will be suspended from work and prohibited form (the facility) until the administrator completes the investigation and the Quality Assurance Committee meets to review the results of the investigation. The Quality Assurance Committee will meet within 5 days of the report of the incident. Under (F) Reporting it states the facility administrator or designee in the administrator ' s absence will immediately obtain basic information required for a telephonic report to the Texas Department of Human Services if indicated per regulations and make the report before further investigation. The facility administrator will ensure completion of the entire investigation and provide a comprehensive final written report to TDHS with 5 working days. Review of Resident #1's Facesheet reflected an admission date of [DATE], a date of birth of 12/13/52 and the following Diagnoses: [REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected the following: Resident #1 needs extensive assist with transfers, dressing, eating, and hygiene. He as limited range of motion and none ambulatory. The MDS also reflected Resident #1 is severely cognitively impaired and was coded a 3 (behavior of this type occurred daily) for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. Review of the Comprehensive Care Plan, last reviewed 10/10/12 reflected the following: Resident #1 is a full code, has memory deficits, max assist with activities of daily living, at risk for falls, receives bolus tube feeding via gastrostomy tube, care deficit for oral care, the use of medications may cause side effects, potential for [MEDICAL CONDITION], potential for contractors, head of bed up at least 45 degrees, anxiety at times, delusions (says the police are coming to arrest him and take him to jail). The Care Plan included an additional problem area added on 03/17/13 that included "Resident made statement that staff trying to put finger in rectum...." In an interview on 03/21/13 at 10:27 AM Resident #1 stated he did not want the facility to get into trouble as this was the only home the resident has. Resident #1 stated a new, black female aide, a big girl, (CNA B) came in about 10:30 at night and asked him if he had been charged with anything. Resident #1 told CNA B that he was charged with murder. CNA B then asked him if there was anything else he was charged with and he told her child molestation. Resident #1 stated that CNA A was also in the room. Resident #1 stated, " She (CNA B) hit me in the jaw (he showed the hit to the left jaw line) and then stuck her finger in my butt hole." He stated, "It embarrassed me but it did not hurt me." Resident #1 stated, "This is my home and I don ' t want to be labeled as a snitch. There was no mark left on my jaw and I don ' t want to have to leave here as this is the only home I have." The resident stated CNA A was cleaning him up when CNA B hit him and stuck her finger in his rectum. The resident could not remember the date of the incident, but it was a few days before. Observation on 3/21/13 at 10:27 AM revealed Resident #1 in bed, clean, and without any bruises or reddened areas to his jaw. During an interview on 03/21/13 at 9:55 AM, when asked about the allegation of sexual abuse to Resident #1, the Administrator stated she is not the abuse coordinator and referred the investigator to the DON. In an interview on 03/21/13 at 2:35 PM the DON stated the allegation of sexual abuse of Resident #1 occurred on 03/16/13 after supper. She stated the allegation was reported on 03/17/13 by CNA C, who reported the allegation to the charge nurse. The allegation was reported that CNA A and CNA B were involved. The DON stated she had not reported the allegation of sexual abuse to the state and she did not suspend the CNA ' s pending an investigation. When the DON was asked about the investigation, the DON stated the investigation was started on 3/17/13 and that "this is my investigation " and provided the investigator with a packet of written staff statements. The DON stated she told CNA A that he was not supposed to be working on the short hall with Resident #1. The DON stated CNA A was off until the 20th which was his regular days offs and they (CNAs A and B) both worked the long hall (opposite hall) from Resident #1 on 03/20/13. The DON stated CNA A did not work the 17th, 18th or 19th. Review of three of six written staff statements provided by the DON reflected Resident #1 identified CNA B as the perpetrator. The written statements also includes those by CNAs A and B. In an interview on 03/21/13 at 1:20 PM CNA C stated she reported Resident #1 ' s accusation on 03/17/13 to the charge nurse on duty. She stated Resident #1 told her "The new black girl did it; she stuck her finger in my butt and put a sheet over his face and hit him in the jaw." Resident #1 stated that CNA A was also in the room when CNA B stuck her finger in the resident's butt. CNA C stated she called the DON after she notified the charge nurse. The DON, who is the abuse coordinator, told CNA C to write out a statement and put it under her door on Sunday, 03/17/13. In an interview on 03/21/13 at 2:50 PM CNA A stated Resident #1 was facing him during incontinent care, at which time Resident #1 accused CNA B of sticking her finger in his butt and started yelling "rape. CNA A stated that Resident #1 was turned with his bottom to CNA B, but he did not see anything. He told Resident #1 he would not let anyone do that to him. CNA A stated he was not paying attention as he was too busy cleaning the resident up. Medication Aide (MA) C came into the room after Resident #1 made his allegation and told Resident #1 to, "Cut that out, they are her to help." CNA A stated Resident #1 had told his past before, but did not recall CNA B asking the resident about his past or recall her saying anything to him. CNA A stated he was off Sunday, 03/17/13, and he worked the next day Monday (3/18/13), Tuesday (3/19/13), Wednesday (3/20/13) and today (03/21/13). CNA A stated he was not told to not work with Resident #1 until this afternoon when he came on his shift (03/21/13). He stated he and CNA B had been assigned to the long hall and not the short hall where Resident #1 resided. Then CNA A stated he made a mistake and he was off on Monday and worked Tuesday, Wednesday and today (03/21/13). CNA A added that he did assist another unidentified aide on Wednesday that included the short hall. CNA A stated he did not report the allegation because Resident #1 says so much stuff and he just did not think to report it. In an interview on 03/21/13 at 3:48 PM CNA B stated she had just started working at the facility in March 2013. She stated she was told by another aide that Resident #1 accuses people of things so be careful. When asked about the events on 3/16/13, CNA B stated Resident #1's front side was toward her and his back side toward CNA A. When asked about her involvement during the incontinent care, CNA B stated she had gloves on and did not want to touch him. CNA A told me to hold the resident so he would not lean against CNA A while he was cleaning the resident. CNA B then stated that Resident #1 ' s bottom was toward her when he began calling out rape and accusing her of sticking her finger in the resident's butt. CNA B stated she had heard rumors that Resident #1 was blamed for child molestation, but did not ask the resident about his past during care. CNA B stated she did not report the resident's allegation to the charge nurse because the resident is always saying "things." CNA B stated she was off Sunday (03/17/13), worked Monday (03/18/13), Tuesday (03/19/13), Wednesday (03/20/13) and today (03/21/13). CNA B stated she had not been told to not work the short hall where Resident #1 resides. Review of the Daily Sign-In Sheets and Card Punch Records for the past 30 days reflected that CNAs A and B did work Monday (03/18/13) through Thursday (03/21/13). In an interview on 03/22/13 at 8:50 AM MA C stated she did go into Resident #1 ' s room on the evening of 03/16/13 and the resident did tell her that they were poking him in the butt. She stated she told him she did not think they did it. MA C stated she did not report it to anyone as he is always saying they are coming to take him to jail and he has people in bed with him. She stated she did not remember saying anything else and does not remember saying, cut that out (used the name of Resident #1) they are helping you. MA C stated she only said " they would not do nothing like that." She restated she did not believe anyone around here would do something like that. During a confidential interview, the interviewee stated they were afraid the Administrator and DON would find out that the complaint was called in and they would lose their job but they felt it was their duty to report the incident with Resident #1 relating to the allegation of sexual abuse. They stated the facility was not calling the incident in. The interviewee stated that everyone was terrified to call the incident in. The interviewee stated Resident #1 was interviewed and he was very alert. They stated because of his Dementia the management wants to play down the allegation of sexual abuse. During another confidential, the interviewee stated CNA B was accused and they (CNA A and B) are still working on the floor. The interviewee stated the nurse aide was not suspended pending the completion of the investigation. During an additional confidential interview, the interviewee stated the facility was not reporting the incident with Resident #1 and they did not know if the person (CNA B) was guilty or not. The interviewee stated an incident report was written but the Director of Nurses (DON) did not want her incident report. The interviewee stated what was reported to the state in the intake is correct. In an interview on 03/21/13 at 4:00 PM the DON stated she was the abuse coordinator. The DON stated she did an investigation related to Resident #1, she stated she called the hotline today (03/21/13) with the report of the allegation of sexual abuse. When the DON was asked if a investigation report was faxed to the State Agency, she stated that she had not faxed anything yet. When asked why she had identified CNA A as the perpetrator when all of the documentation stated the allegation was against CNA B, the DON did not respond and made a facial expression toward the Investigator. The DON stated she did not send Resident #1 to the emergency room for an assessment as she and the nurses assessed him and there were no bruising or damage noted. She stated she did notify the physician today 03/21/13. On 03/22/13 at 11:52 AM the attending physician, who is the Medical Director, was unavailable for an interview until next week. Review of the Provider Investigation Report for Resident #1, provided by the DON, dated 03/21/13 reflected a checkmark next to Neglect under the Incident Category and identified the perpetrator as CNA A with CNA B as the witness. The investigation included that the resident was assessed and there were no signs of a reddened area to the face or rectum on 03/17/13. The Provider Action taken included that CNA A was not scheduled to work on the resident's hall (short hall), but did not address actions for CNA B. The Administrator was notified on 03/21/13 at 5:05 PM that an IJ had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 03/22/13 at 11:24 AM. The final Plan of Removal was accepted by the Investigator on 03/22/13 at 6:15 PM The Plan of Removal contained the following: Failure to Protect a resident after allegations of abuse. -The alleged employees were suspended of their duties on 03/21/13 and replaced with staff on the evening shift. -DON reviewed the policy and procedure of abuse/neglect regarding sexual, physical and verbal abuse with the alleged employees during the suspension process conference on 03/21/13. They were placed on suspension on 03/21/13 pending completion of investigation. -DON and Staff Coordinator (LVN) on 03/21/13 made rounds, interviewed and observed cognitive impaired residents for any signs of abuse. ie: Unknown bruises, other physical, mental, emotional or behavioral changes. -In-service for all employees on all types of abuse/neglect including sexual, physical and verbal abuse and the procedures for reporting abuse was conducted on 03/20/13 at staff meeting. The staff present on 03/21/13 6-2 shift and 2-10 and 10-6 shifts was in-service again on all forms of abuse and the procedure for reporting abuse. All other nursing staff members not present at the in-services held on 03/21/13 and 03/22/13 will be in-serviced prior to making contact with the residents. -Physical assessments for unknown bruises, other physical, mental, emotional or behavioral changes will be done and an interview (ie: " Are you being treated well? " and " Has anyone been mean to you? " ) of the cognitively impaired residents will be conducted and completed by Administrator or designee. This will be ongoing and with any allegations until the investigation is complete. -QA team consisting of Administrator, Medical director, Operations Manager, Activity Director, DON, Food Service Supervisor will monitor monthly for 90 days then quarterly thereafter. The next QA meeting will be Monday, March 25, 2013. -Administrator or designee will monitor ongoing the Policy for Abuse and Neglect to assure all residents are safe and free from abuse. - Failure to investigate allegations of abuse and report it to the consumer services. -Administrator initiated an investigation on 03/17/13. DON continued the investigation for the abuse allegation when she arrived at the facility on 03/17/13. -The DON notified the residents ' primary physician and responsible party on 03/21/13 of alleged abuse. -DON notified Consumer Services of any abuse allegations on 03/21/13. -In-service for all employees on all types of abuse/neglect including sexual, physical, and verbal abuse and the procedures for reporting abuse was conducted on 03/20 staff meeting. The staff present on 03/21 6-2 shift, 2-10 shift 10-6 shifts were in-serviced again on all forms of abuse and the procedure for reporting abuse. All other staff members not present at either in -service will be in-serviced by 03/25/13. -Physical assessments for unknown bruises, other physical, mental, emotional or behavioral changes and / or interviews (ie: " Are you being treated well? " and " Has anyone been mean to you? " ) of the cognitively impaired residents were conducted and completed by the DON and MD Coordinator on 03/21/13. -QA team consisting of Administrator, Medical director, Operations Manager, Activity Director, DON, Food Service Supervisor will monitor monthly for 90 days then quarterly thereafter. The next QA meeting will be Monday, March 25, 2013. -Administrator or designee will monitor ongoing. The investigator monitored the current plan of removal as follows: On 03/21/2013 at 5:20 PM the DON suspended CNA A and CNA B. They left the building. The two staff were replaced by two LVN ' s. Reviewed documentation provided by the DON revealed that she and the Staff Coordinator (LVN) on 03/21/13 made rounds, interviewed and observed cognitive impaired residents for any signs of abuse. ie: Unknown bruises, other physical, mental, emotional or behavioral changes. Reviewed in-service documentation provided by the DON for abuse/neglect including sexual, physical and verbal abuse and the procedures present on 03/21/13 6-2 shift and 2-10 and 10-6 shifts was in-service again on all forms of abuse and the procedure for reporting abuse. On 03/22/13 at 6:15 PM the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope as widespread that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The Administrator provided a census of 50 residents who have the potential for being abused.

Based on interview and record review, the facility failed to ensure A) an allegation of neglect and B) an allegation of resident to resident abuse was immediately reported to the State survey agency, thoroughly investigated, and interventions put in place to further prevent abuse for 2 of 7 residents reviewed for abuse and neglect. (Resident #4 and #3) A) Resident # 4 sustained fractures in three places on her ankle from an unknown source when the facility failed to thoroughly investigate and immediately report Resident #4's incident to the Department of Aging and Disability Services (DADS) for investigation; and. B) Resident # 3 kicked another resident in the buttocks when the facility failed to thoroughly investigate and immediately report the Resident's allegation of Resident to Resident Abuse to DADS. This deficient practice placed 45 Residents at risk for abuse and neglect, who were dependent on staff for some type of assistance. Findings Include: A) Review of Resident # 4's Admitting Record reflected a [AGE] year old female who entered the facility on 04/11/2013. Review of Resident # 4's undated Prior Level of Function Assessment reflected the Resident entered the facility with an [MEDICAL CONDITION] status [REDACTED]. Review of Resident # 4's Admission Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) and indicated she was cognitively intact. The assessment reflected Resident # 4 was at risk for falls having had falls in the last month prior to admission and the last two - six months prior to entry. Review of Resident # 4's Comprehensive Care Plan reflected a plan of care dated 05/14/2013 regarding the Resident "requires assistance/potential to restore function to maximum self-sufficiency for MOBILITY characterized by the following functions; positioning, locomotion/ambulation related to right ankle fracture." Interventions were MOBILITY - Independent with walker." Review of Resident # 4's Nurse's Notes dated 04/30/2013 reflected a late entry for 04/27/2013 and "Resident returned from oop (out on pass) with her boyfriend; being wheeled in by him in a wc (wheelchair). Resident was in good sports and said she had a good time; no c/o (complaints) voiced by resident to this nurse. She was taken to her room by her boyfriend. Around 9:30 PM she reported to CNA (Certified Nurse Aide) that she wanted someone to look at her foot and that was all she said. At 9:45 PM in report it was passed on. That she wanted someone to check her ankle." There was no other Nurse's Note until 05/09/2013 that reflected "pain med (medication) given for right ankle pain w/+ (with positive) results. resting quietly in bed w/eyes closed at this time. resp (respirations) even and unlabored. denies pain or discomfort at this time. temp (temperature) 97.2. conts abt/post (continues antibiotic therapy/post) surgery to right foot w/nar (with no adverse reaction). voices needs." Review of Resident # 4's Incident/Accident report dated 04/28/2013 at 11:45 AM. "On 04/28/2013 Resident returned from OOP, c/o right lower leg pain and swelling. Right leg noted with redness and warmth and tender to touch. Three + [MEDICAL CONDITION]. Offered pain rx (prescription)." Review of an X-ray report for Resident # 4 dated 04/28/2013 reflected three views of the right ankle were performed with findings of "Trimalleolar displaced ankle fracture with marked soft tissue swelling present. There is angulation of the fibular fracture. There is a displacement of the medial malleolar and posterior malleolar fractures. Additionally there appears to be a cortical [MEDICAL CONDITION] tibia. Medial malleolar fracture extends to the articular surface." Review of Resident # 4's Release of Responsibility for Leave of Absence form reflected the Resident left the faciity on [DATE] and returned on 04/27/2013. In an interview on 05/16/2013 at 3:00 PM the Social Worker (SW), who is responsible for investigating incidents, stated Resident # 4 was out on pass, came back on 04/28/2013 and complained her foot was hurt and swollen. The SW stated she questioned Resident # 4 regarding an abusive situation with her boyfriend and the Resident told her no, she was not in an abusive situation. The SW stated she questioned Resident # 4 if she had drank alcoholic beverages while out on pass and the Resident told her she had consumed a few beers. The SW stated she felt Resident # 4 sustained her fractures while out on pass. When advised the Release of Responsibility for Leave of Absence reflected Resident # 4 came back from out on pass on 04/27/2013 the SW stated "that is wrong, you can ask her." The SW stated the physician had told Resident # 4 the fracture was three (3) to four (4) weeks old. When questioned regarding the physician's [DIAGNOSES REDACTED]. Review of the Physician's Report dated 04/30/2013 the History/Physical Information reflected "Ankle pain noted. (Resident # 4's name) sustained an injury to the right ankle. The injury was 3 days ago. No precipitating event or injury is identified. She noticed painful deformity upon awakening Saturday morning 4/27/13...." In an interview on 05/16/2013 at 4:00 PM Resident # 4 stated she had come back from out on pass and spent one night at the facility prior to having her ankle and foot x-rayed (04/27/2013). Resident # 4 stated she did not know when or what happened to her foot, it started swelling and hurting and her boyfriend had told her she needed to get back to the nursing home. Resident # 4 stated she came back and advised the facility her foot was hurting and swelling on 04/27/2013. Review of the Provider Investigation Report dated 04/30/2013 reflected the report was made to DADS on 04/30/2013, 3 days after the incident occurred. The report reflected Resident # 4 sustained an "unknown injury while resident oop (out on pass)." The report reflected Resident # 4 required no special supervision with minimal functional ability and [DIAGNOSES REDACTED]. Description of the allegation was "Resident has an unknown origin of fracture to her rt (right) ankle." with Provider Response as "Resident denies any abuse occurred. While she was here at facility or while she was at home. She does admit to drinking while out on pass. Resident seen at emergency room . Resident admitted to hospital for surgery to repair fracture." Provider Action Taken Post-Investigation reflected the following: 1. Encourage resident to ask for assistance. 2. Encourage resident to not drink alcohol. 3. Encourage resident to use crutches when walking with stall. 4. Follow doctors ' orders s/p (status/post) surgery. B) Review of Resident # 3 ' s face sheet reflected a [AGE] year old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #3 ' s Quarterly MDS assessment dated [DATE], reflected Resident #3 had a BIMS score of 6, indicating Resident #3 had moderate cognitive impairments. The MDS reflected that Resident # 3 exhibited disorganized thinking and inattention behavior that fluctuated. The MDS reflected a Mood Severity Score of 13, indicating Resident #3 exhibited depressive symptoms more than half to nearly every day of the previous two week evaluation period. The MDS reflected Resident #3 exhibited both verbal and physical behavioral symptoms directed towards others four to six days a week. The MDS reflected that Resident # was totally dependent on staff for most activities of daily living. Review of Resident #3 ' s Comprehensive Care Plan did not reflect any Problems, Goals or Interventions addressing Resident #3 ' s Mood or Behavior that were triggered on his MDS. Review of Resident #3 ' s Nurse Notes dated 4/30/13 reflected Resident # 3 was attempting to close the bathroom door in the short hall when another resident grabbed the door and held it open. Resident #3 " began to curse and threaten to kick the other resident ' s ass " . Resident #3 then proceeded to follow the other resident down the hallway and Resident #3 kicked the other resident on the " buttocks " . Review of Incident/Accident Report dated 04/30/13 reflected Resident #3 is " alert and can voice needs. " Resident #3 was attempting to close the bathroom door when another resident grabbed the door and held the door open. Resident #3 cursed the other resident and then proceeded to kick him on his buttocks. Review of Incident Investigation dated 04/30/13 reflected the incident happened around 10:10 AM on the " short hall " . The Investigation Report reflected that Resident #3 " becomes aggressive when others bother him. " The report reflected that a " behavioral program " care plan was in place and to prevent another incident, the facility would begin " monitoring behaviors. " During an interview on 5/16/13 at 6:59 PM the SW stated that she did not exactly remember what happened and that she was not going to answer any questions until after she has spoken with the staff that witnessed the incident and wrote the report. The SW stated she did not believe that the incident happened due to Resident # 3 ' s health conditions and she did not believe that Resident # 3 was physically capable of performing the act. During an interview on 5/16/13 at 7:25 PM the SW stated that she had spoken to the housekeeper that witnessed the incident and stated that Resident #3 " did it " . The Social Worker stated that she was not aware of the incident report, therefore, it was not investigated or reported to DADS for further investigation. Review of the facility Abuse/Neglect policy, undated, reflected: D) Investigation The confidential investigation will be directed by the facility Administrator or designee, and will include: 1) An incident report form. 2) An interview of the reporting person. 3) Interviews of the resident(s)/witness(es) involved, if possible. 4) A review of statements or additional statement and/or interviews of all staff who may have knowledge regarding the incident. 5) Interview of other residents, if possible, who receive care from the accused individual. 6) A review of the medical record for the resident involved. F) Reporting The facility administrator (or designee in the administrator's absence) will immediately obtain basic information required for a telephonic report to the Texas Department of Human Services (TDHS) if indicated per regulations and make the report before further investigation. The facility administrator will ensure completion of the entire investigation and provide a comprehensive final written report to TDHS within 5 working days. The facility policy did not refer to injuries of unknown origin. The facility provided a list of 45 residents who require assistance of some type. This deficient practice was cited on 03/22/2013 and the facility remains out of compliance.

Based on interview and record review, the facility failed to ensure an allegation of sexual abuse was immediately reported to the State survey agency, thoroughly investigated the allegation, and prevented further potential abuse while an investigation was in progress for 1 of 13 residents reviewed for abuse (Resident #1). The facility failed to immediately report Resident #1's allegation of sexual abuse to the Administrator and/or designee, to the Department of Aging and Disability Services (DADS), nor thoroughly investigated the allegation. The facility failed to protect Resident #1 by allowing the alleged perpetrator, certified nurse aide (CNA B), to remain working with the resident and other residents from the date of the incident, 03/16/13 through 03/21/13. This failure resulted in an Immediate Jeopardy (IJ) on 03/21/13. While the IJ was removed on 03/22/13, the facility remained out of compliance at no actual harm potential for more than minimal harm with a scope identified as widespread. This deficient practice placed all 50 residents at risk for abuse, who were dependent on staff for some type of assistance. Findings Include: Review of Resident #1's Facesheet reflected an admission date of [DATE], a date of birth of 12/13/52 and the following Diagnoses: [REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected the following: Resident #1 needs extensive assist with transfers, dressing, eating, and hygiene. He as limited range of motion and none ambulatory. The MDS also reflected Resident #1 is severely cognitively impaired and was coded a 3 (behavior of this type occurred daily) for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. Review of the Comprehensive Care Plan, last reviewed 10/10/12 reflected the following: Resident #1 is a full code, has memory deficits, max assist with activities of daily living, at risk for falls, receives bolus tube feeding via gastrostomy tube, care deficit for oral care, the use of medications may cause side effects, potential for [MEDICAL CONDITION], potential for contractors, head of bed up at least 45 degrees, anxiety at times, delusions (says the police are coming to arrest him and take him to jail). The Care Plan included an additional problem area added on 03/17/13 that included "Resident made statement that staff trying to put finger in rectum...." In an interview on 03/21/13 at 10:27 AM Resident #1 stated he did not want the facility to get into trouble as this was the only home the resident has. Resident #1 stated a new, black female aide, a big girl, (CNA B) came in about 10:30 at night and asked him if he had been charged with anything. Resident #1 told CNA B that he was charged with murder. CNA B then asked him if there was anything else he was charged with and he told her child molestation. Resident #1 stated that CNA A was also in the room. Resident #1 stated, " She (CNA B) hit me in the jaw (he showed the hit to the left jaw line) and then stuck her finger in my butt hole." He stated, "It embarrassed me but it did not hurt me." Resident #1 stated, "This is my home and I don ' t want to be labeled as a snitch. There was no mark left on my jaw and I don ' t want to have to leave here as this is the only home I have." The resident stated CNA A was cleaning him up when CNA B hit him and stuck her finger in his rectum. The resident could not remember the date of the incident, but it was a few days before. Observation on 3/21/13 at 10:27 AM revealed Resident #1 in bed, clean, and without any bruises or reddened areas to his jaw. During an interview on 03/21/13 at 9:55 AM, when asked about the allegation of sexual abuse to Resident #1, the Administrator stated she is not the abuse coordinator and referred the investigator to the DON. In an interview on 03/21/13 at 2:35 PM the DON stated the allegation of sexual abuse of Resident #1 occurred on 03/16/13 after supper. She stated the allegation was reported on 03/17/13 by CNA C, who reported the allegation to the charge nurse. The allegation was reported that CNA A and CNA B were involved. The DON stated she had not reported the allegation of sexual abuse to the state and she did not suspend the CNA ' s pending an investigation. When the DON was asked about the investigation, the DON stated the investigation was started on 3/17/13 and that "this is my investigation " and provided the investigator with a packet of written staff statements. The DON stated she told CNA A that he was not supposed to be working on the short hall with Resident #1. The DON stated CNA A was off until the 20th which was his regular days offs and they (CNAs A and B) both worked the long hall (opposite hall) from Resident #1 on 03/20/13. The DON stated CNA A did not work the 17th, 18th or 19th. Review of three of six written staff statements provided by the DON reflected Resident #1 identified CNA B as the perpetrator. The written statements also includes those by CNAs A and B. In an interview on 03/21/13 at 1:20 PM CNA C stated she reported Resident #1 ' s accusation on 03/17/13 to the charge nurse on duty. She stated Resident #1 told her "The new black girl did it; she stuck her finger in my butt and put a sheet over his face and hit him in the jaw." Resident #1 stated that CNA A was also in the room when CNA B stuck her finger in the resident's butt. CNA C stated she called the DON after she notified the charge nurse. The DON, who is the abuse coordinator, told CNA C to write out a statement and put it under her door on Sunday, 03/17/13. In an interview on 03/21/13 at 2:50 PM CNA A stated Resident #1 was facing him during incontinent care, at which time Resident #1 accused CNA B of sticking her finger in his butt and started yelling "rape. CNA A stated that Resident #1 was turned with his bottom to CNA B, but he did not see anything. He told Resident #1 he would not let anyone do that to him. CNA A stated he was not paying attention as he was too busy cleaning the resident up. Medication Aide (MA) C came into the room after Resident #1 made his allegation and told Resident #1 to, "Cut that out, they are her to help." CNA A stated Resident #1 had told his past before, but did not recall CNA B asking the resident about his past or recall her saying anything to him. CNA A stated he was off Sunday, 03/17/13, and he worked the next day Monday (3/18/13), Tuesday (3/19/13), Wednesday (3/20/13) and today (03/21/13). CNA A stated he was not told to not work with Resident #1 until this afternoon when he came on his shift (03/21/13). He stated he and CNA B had been assigned to the long hall and not the short hall where Resident #1 resided. Then CNA A stated he made a mistake and he was off on Monday and worked Tuesday, Wednesday and today (03/21/13). CNA A added that he did assist another unidentified aide on Wednesday that included the short hall. CNA A stated he did not report the allegation because Resident #1 says so much stuff and he just did not think to report it. In an interview on 03/21/13 at 3:48 PM CNA B stated she had just started working at the facility in March 2013. She stated she was told by another aide that Resident #1 accuses people of things so be careful. When asked about the events on 3/16/13, CNA B stated Resident #1's front side was toward her and his back side toward CNA A. When asked about her involvement during the incontinent care, CNA B stated she had gloves on and did not want to touch him. CNA A told me to hold the resident so he would not lean against CNA A while he was cleaning the resident. CNA B then stated that Resident #1 ' s bottom was toward her when he began calling out rape and accusing her of sticking her finger in the resident's butt. CNA B stated she had heard rumors that Resident #1 was blamed for child molestation, but did not ask the resident about his past during care. CNA B stated she did not report the resident's allegation to the charge nurse because the resident is always saying "things." CNA B stated she was off Sunday (03/17/13), worked Monday (03/18/13), Tuesday (03/19/13), Wednesday (03/20/13) and today (03/21/13). CNA B stated she had not been told to not work the short hall where Resident #1 resides. Review of the Daily Sign-In Sheets and Card Punch Records for the past 30 days reflected that CNAs A and B did work Monday (03/18/13) through Thursday (03/21/13). In an interview on 03/22/13 at 8:50 AM MA C stated she did go into Resident #1 ' s room on the evening of 03/16/13 and the resident did tell her that they were poking him in the butt. She stated she told him she did not think they did it. MA C stated she did not report it to anyone as he is always saying they are coming to take him to jail and he has people in bed with him. She stated she did not remember saying anything else and does not remember saying, cut that out (used the name of Resident #1) they are helping you. MA C stated she only said " they would not do nothing like that." She restated she did not believe anyone around here would do something like that. During a confidential interview, the interviewee stated they were afraid the Administrator and DON would find out that the complaint was called in and they would lose their job but they felt it was their duty to report the incident with Resident #1 relating to the allegation of sexual abuse. They stated the facility was not calling the incident in. The interviewee stated that everyone was terrified to call the incident in. The interviewee stated Resident #1 was interviewed and he was very alert. They stated because of his Dementia the management wants to play down the allegation of sexual abuse. During another confidential, the interviewee stated CNA B was accused and they (CNA A and B) are still working on the floor. The interviewee stated the nurse aide was not suspended pending the completion of the investigation. During an additional confidential interview, the interviewee stated the facility was not reporting the incident with Resident #1 and they did not know if the person (CNA B) was guilty or not. The interviewee stated an incident report was written but the Director of Nurses (DON) did not want her incident report. The interviewee stated what was reported to the state in the intake is correct. In an interview on 03/21/13 at 4:00 PM the DON stated she was the abuse coordinator. The DON stated she did an investigation related to Resident #1, she stated she called the hotline today (03/21/13) with the report of the allegation of sexual abuse. When the DON was asked if a investigation report was faxed to the State Agency, she stated that she had not faxed anything yet. When asked why she had identified CNA A as the perpetrator when all of the documentation stated the allegation was against CNA B, the DON did not respond and made a facial expression toward the Investigator. The DON stated she did not send Resident #1 to the emergency room for an assessment as she and the nurses assessed him and there were no bruising or damage noted. She stated she did notify the physician today 03/21/13. On 03/22/13 at 11:52 AM the attending physician, who is the Medical Director, was unavailable for an interview until next week. Review of the Provider Investigation Report for Resident #1, provided by the DON, dated 03/21/13 reflected a checkmark next to Neglect under the Incident Category and identified the perpetrator as CNA A with CNA B as the witness. The investigation included that the resident was assessed and there were no signs of a reddened area to the face or rectum on 03/17/13. The Provider Action taken included that CNA A was not scheduled to work on the resident's hall (short hall), but did not address actions for CNA B. Review of the facility ' s undated policy and procedure for abuse reflects the following: On page 3 under (E) Protection it stated the Administration will assess the situation to determine what protections is needed for the resident (s) involved during the investigation. Employees accused of resident abuse will be suspended from work and prohibited form (the facility) until the administrator completes the investigation and the Quality Assurance Committee meets to review the results of the investigation. The Quality Assurance Committee will meet within 5 days of the report of the incident. Under (F) Reporting it states the facility administrator or designee in the administrator ' s absence will immediately obtain basic information required for a telephonic report to the Texas Department of Human Services if indicated per regulations and make the report before further investigation. The facility administrator will ensure completion of the entire investigation and provide a comprehensive final written report to TDHS with 5 working days. The Administrator was notified on 03/21/13 at 5:05 PM that an IJ had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 03/22/13 at 11:24 AM. The final Plan of Removal was accepted by the Investigator on 03/22/13 at 6:15 PM The Plan of Removal contained the following: Failure to Protect a resident after allegations of abuse. -The alleged employees were suspended of their duties on 03/21/13 and replaced with staff on the evening shift. -DON reviewed the policy and procedure of abuse/neglect regarding sexual, physical and verbal abuse with the alleged employees during the suspension process conference on 03/21/13. They were placed on suspension on 03/21/13 pending completion of investigation. -DON and Staff Coordinator (LVN) on 03/21/13 made rounds, interviewed and observed cognitive impaired residents for any signs of abuse. ie: Unknown bruises, other physical, mental, emotional or behavioral changes. -In-service for all employees on all types of abuse/neglect including sexual, physical and verbal abuse and the procedures for reporting abuse was conducted on 03/20/13 at staff meeting. The staff present on 03/21/13 6-2 shift and 2-10 and 10-6 shifts was in-service again on all forms of abuse and the procedure for reporting abuse. All other nursing staff members not present at the in-services held on 03/21/13 and 03/22/13 will be in-serviced prior to making contact with the residents. -Physical assessments for unknown bruises, other physical, mental, emotional or behavioral changes will be done and an interview (ie: " Are you being treated well? " and " Has anyone been mean to you? " ) of the cognitively impaired residents will be conducted and completed by Administrator or designee. This will be ongoing and with any allegations until the investigation is complete. -QA team consisting of Administrator, Medical director, Operations Manager, Activity Director, DON, Food Service Supervisor will monitor monthly for 90 days then quarterly thereafter. The next QA meeting will be Monday, March 25, 2013. -Administrator or designee will monitor ongoing the Policy for Abuse and Neglect to assure all residents are safe and free from abuse. - Failure to investigate allegations of abuse and report it to the consumer services. -Administrator initiated an investigation on 03/17/13. DON continued the investigation for the abuse allegation when she arrived at the facility on 03/17/13. -The DON notified the residents ' primary physician and responsible party on 03/21/13 of alleged abuse. -DON notified Consumer Services of any abuse allegations on 03/21/13. -In-service for all employees on all types of abuse/neglect including sexual, physical, and verbal abuse and the procedures for reporting abuse was conducted on 03/20 staff meeting. The staff present on 03/21 6-2 shift, 2-10 shift 10-6 shifts were in-serviced again on all forms of abuse and the procedure for reporting abuse. All other staff members not present at either in -service will be in-serviced by 03/25/13. -Physical assessments for unknown bruises, other physical, mental, emotional or behavioral changes and / or interviews (ie: " Are you being treated well? " and " Has anyone been mean to you? " ) of the cognitively impaired residents were conducted and completed by the DON and MD Coordinator on 03/21/13. -QA team consisting of Administrator, Medical director, Operations Manager, Activity Director, DON, Food Service Supervisor will monitor monthly for 90 days then quarterly thereafter. The next QA meeting will be Monday, March 25, 2013. -Administrator or designee will monitor ongoing. The investigator monitored the current plan of removal as follows: On 03/21/2013 at 5:20 PM the DON suspended CNA A and CNA B. They left the building. The two staff were replaced by two LVN ' s. Reviewed documentation provided by the DON revealed that she and the Staff Coordinator (LVN) on 03/21/13 made rounds, interviewed and observed cognitive impaired residents for any signs of abuse. ie: Unknown bruises, other physical, mental, emotional or behavioral changes. Reviewed in-service documentation provided by the DON for abuse/neglect including sexual, physical and verbal abuse and the procedures present on 03/21/13 6-2 shift and 2-10 and 10-6 shifts was in-service again on all forms of abuse and the procedure for reporting abuse. On 03/22/13 at 6:15 PM the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope as widespread that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The Administrator provided a census of 50 residents who have the potential for being abused.