Every finding on record at Avir at Park Bend

Based on observation, interviews and record review, the facility failed to ensure each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse and neglect. The facility failed to prevent CNA A from mistreating Resident #1. CNA A verbally abused Resident #1 while providing care for her on 06/21/2026 at 8:19 p.m. This failure could place all residents who received care from CNA A at risk of staff mistreatment.Findings included: Record Review of Resident #1's face sheet, dated 07/22/2026, reflected an 86-years-old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (loss of memory, thinking abilities, and behavioral changes that interfere with daily life), hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting left non-dominant side (damage to the right side of the brain-due to a blocked blood vessel [stroke]-causes paralysis (hemiplegia) or weakness (hemiparesis) on the left side of the body), and major depressive disorder (persistent sadness, loss of interest in activities, and low energy). Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 5 indicating, severe cognitive impairment. Record review of Resident #1's care plan, dated 04/15/2024, reflected the focus: Resident #1 is dependent on staff for emotional, intellectual, physical, and social needs related to disease process Dementia and a focus: Resident #1 has a behavior problem (screaming vocal sounds, ripping of colostomy bag, refusing incontinent care) related to dementia and cerebral infarction with interventions: Anticipate and meet the resident's needs. Caregivers provide opportunities for positive interaction, attention. Stop and talk with her as passing by. Record review of camera recording, dated 06/21/2026 at 8:19 p.m., revealed CNA A was changing Resident #1's incontinent brief and when Resident #1 started to tell her how she felt, CNA A told her I don't care, be quiet. Nothing is wrong with you. Do you think you have special privileges you, shit. I get you cleaned up and you will get some rest. During an observation and interview on 07/22/2026 at 11:20 a.m., Resident #1 appeared calm and not in distress. Resident #1 could not identify any situation or staff member in the facility who mistreated her or was not nice to her. During an interview on 07/22/2026 at 4:01 p.m., Resident #1's family member stated that Resident #1's care started declining a year ago and she was communicating verbally to DON who recently was let go by the facility. She stated that she had a video camera installed in Resident #1's room to monitor her care. She stated that she showed this video recording, dated 06/21/2026 at 8:19 p.m. to HN. During an interview with HN on 07/22/2026 at 2:21 p.m., she stated she was trying to assist Resident #1's family to move Resident #1 out of this facility after reviewing this video recording with evidence of CNA A verbal abuse. She stated that she brought this video to ADM's attention and CNA A was terminated along with the DON. She stated that facility put combative and aggressive behavior in Resident #1's medical chart but she was not like that unless she was mistreated. She stated that she was with Resident #1 for a very long time and she has never been that way with her. During an interview on 07/22/2026 at 4:10 p.m., the ADM stated they provide ANE in-services to all staff annually and monthly or after complaints or during incident investigation. He stated that he educated staff on different types of ANE and the requirement of reporting to him any signs of ANE immediately. His phone number as the ANE coordinator was posted in the building for all staff to call him any time. He stated that he received a complaint with allegation of abuse for Resident #1 on 07/15/2026 and immediately called CNA A to confirm allegation and suspended her and terminated her shortly after confirming an allegation. He stated that the facility initiated ANE investigation immediately, Resident #1 was monitored, and assessed promptly. He stated that per nursing assessment, Resident #1 was not in physical or psychological distress. He stated that CNA A was employed at this facility for a few months but came from another facility with no prior counseling or similar allegations. He stated that, per interviews with other staff members, no reports were made regarding similar interactions between CNA A and residents at this facility. He stated that according to the facility's investigation they determined that the care provided by CNA A did not meet the facility's standards of care. He stated that he provided an education of ANE immediately, continued monitoring of Resident #1's condition, and Resident #1's care plan was updated. During an interview on 07/24/2026 at 12:05 p.m., CNA A stated that she worked at this facility for a few months and she knew better than to use this kind of language with a resident. She stated that she had a training on abuse and neglect a few months ago and knew about treating elderly with respect and good bedside manners. She stated that she was caught on camera using disrespectful language toward Resident #1, but it was not an excuse for doing what she did as she should know better. She stated that it was crazy busy day, but she should still handle herself better with a resident. She stated that she did not see a distress in Resident #1 when she addressed her as she did, she provided the care and left her safely in bed. She stated that this situation never happened before, and she knows that she should provide care to any residents with dignity and respect towards residents. Record review of the facility's policy on ANE, dated 04/2021, reflected Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This include but is not limited to freedom from .verbal, mental, sexual or physical abuse. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation. by anyone including a. facility staff.3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 4 residents (Resident #2 and Resident#3) reviewed for respiratory care.The facility failed to ensure the nebulizer masks and tubing of Resident #2 and Resident #3 were stored safely in protective bags.This failure placed residents at risk for respiratory infections through contamination. Findings included:Record review of Resident #2's face sheet dated 04/29/26 reflected Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with heart failure, dementia, acute and chronic respiratory failure, abscess of lung without pneumonia, chronic kidney disease and obesity.Record review of Resident #2's annual MDS dated [DATE] reflected a BIMS score of 13 indicating his cognition was intact. Further review revealed he was on oxygen therapy for respiratory issues.Record review of Resident #2's care plan dated 11/26/25 reflected that he had altered respiratory status/difficulty breathing r/t hyper capnic (elevated CO2 level in blood) respiratory failure. The relevant intervention was administering medication/puffers as ordered and monitoring for effectiveness and side effects.Record review of Resident #2's physician's order reflected : Arformoterol Tartrate Inhalation Nebulization Solution 15 MCG/2ML (Arformoterol Tartrate): 1 vial inhale orally via nebulizer two times a day for COPD. -Start Date-04/09/2026Record review of Resident #3's face sheet, dated 04/29/26, reflected Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with COPD(difficulty in breathing), heart failure, dementia, acute kidney failure and adult failure to thrive.Record review of Resident #3's annual MDS dated [DATE] reflected a BIMS score of 14 indicating his cognition was intact. Further review revealed he was on oxygen therapy for respiratory issues. Record review of Resident #3's care plan dated 04/02/25 reflected that he had COPD and relevant intervention was administering aerosol or bronchodilators as ordered and monitoring/documenting any side effects and effectiveness.Record review of Resident #3's physician's order reflected : Plastic tubing must be kept in a plastic bag attached to the concentrator or nebulizer. Check every shift for infection control. -Start Date- 07/10/2025During an observation and interview with RN B on 04/29/26 at 1:35 PM, it was noted that the nebulizers for Resident #2 and Resident #3 were placed on their side tables. The tubes and masks of the nebulizers were laid openly on the tables, not stored in protective bags, exposing them to the open atmosphere. Specifically, the mask and tubing for Resident #2 were among the resident's other belongings, and a urine bottle containing urine was positioned beside Resident #3's nebulizer mask. RN B, immediately removed the unprotected masks and tubes, stating that they should have been stored in protective bags. She explained that if the equipment was not protected from external environmental factors, there was a risk of cross-contamination and microorganism colonization, which could lead to serious respiratory and other infections. RN B emphasized that it was the nurses' responsibility to ensure proper storage of respiratory equipment in protective bags. She stated , as the charge nurse on that day, she acknowledged that she should have identified this noncompliance and corrected it immediately.In an interview conducted on 04/29/26 at 3:30 p.m., the DON stated that nebulizer masks, tubing, and oxygen nasal cannulas should be cleaned and stored in a clean protective bag after use. He explained that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment. The DON further clarified that it was the nurses' responsibility to ensure this process was completed after medication administration. He noted that residents sometimes remove their equipment and forget to replace it in the protective bags, highlighting the importance of regular rounds by nursing staff to verify proper storage of respiratory devices.Record review of the in-service since [DATE] revealed there were no in services on safe handling of respiratory equipment.Review of the facility policies on 04/29/26 revealed there were no policies available on safe storage of nebulizer mask and tubes after medication administration.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #1) reviewed for privacy.The facility failed to ensure CNA A provided privacy by closing the door and drawing the privacy curtain during incontinent care for Resident #1.This failure could place residents at risk of lack of privacy and not having residents' rights acknowledged.The findings include:Record review of Resident #1's face sheet, dated 04/29/26, reflected Resident #1 was admitted on [DATE]. She was an [AGE] year-old female diagnosed with fracture of the right femur(thigh bone), dementia, adult failure to thrive and gastro-esophageal reflux .Record review of Resident #1's initial MDS dated [DATE] reflected a BIMS score of 03 indicating her cognition was severely impaired . Further review revealed she needed complete support with toilet hygiene.Record review of Resident #1's care plan dated 03/26/26 reflected that she had an ADL self-care performance deficit r/t Dementia, Impaired balance, Right femur fracture and failure to thrive. The relevant intervention was assistance by one staff member with personal hygiene.During an observation and interview on 04/29/26 at 1:50pm CNA A had provided incontinent care to Resident #1 in her room. CNA A did not close the door or draw the privacy curtain fully during the incontinent care. The incontinent care would have been fully visible to anyone who entered the room during the incontinent care.During an interview conducted on 04/29/26, at 2:00 p.m. Resident #1 said that she believed CNA A had performed the care satisfactorily and that she was pleased with the service. She further noted that she did not observe whether the privacy curtain was fully closed nor whether the door to her room was shut. Resident #1 was unable to comprehend and answer whether she will feel comfortable if an unidentified bystander observes her during personal care activities.In an interview on 04/29/26 at 2:20pm, CNA A reported having over one year of experience as a CNA. He said that incontinent care was a routine part of his responsibilities since the beginning of his career. CNA A stated that it was a mistake that the door and privacy curtain were not fully closed. He explained that he believed it was acceptable to keep the curtain partially closed since the peri care was not visible to Resident #1's roommate , but he recognized that leaving the door open was inappropriate. On further discussion, CNA A stated that the open door with the privacy curtain in partly opened position allow visibility of the peri care to anyone entering the room. He said that his neglect compromised Resident #1's right to privacy and dignity during the incontinent care.During an interview on 04/29/26, at 3:30p.m, the DON stated that it was mandatory to respect and uphold residents' privacy and dignity during nursing care, including incontinent care, by closing doors, windows, and privacy curtains. The DON stated that the door and privacy curtain of Resident #1 should have been fully closed prior to initiating care. He expressed the belief that Resident #1's privacy was not compromised since no unauthorized persons observed the procedure. He added, however, there was a possibility of violating privacy if anyone entered the room during the incontinent care. The DON also noted that resident rights were part of ongoing staff training and that all nursing staff were required to complete an annual evaluation to ensure their competence in respecting residents' rights and maintaining proper nursing practices.Record review facility policy Resident Rights revised in February 2021 reflected: Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:A) dignified existence.t) privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #1) of 29 residents on 300 Hall reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #1's personal health information was protected from being viewed by unauthorized person when the RN left Resident #1's personal information displayed on the computer screen located at the charting station on 300 Hall while unattended. This failure could place residents' personal information at risk of being exposed to unauthorized individuals. The findings included:Observation on 2/27/2026 at 10:12 a.m., revealed the computer screen on the RN's charting station on 300 Hall was open and unlocked, with Resident #1's personal clinical information displayed and visible to unauthorized individuals, including visitors or other residents. Other nursing staff members were observed walking on the 300 Hall near the charting station at the same time. Nobody was observed looking at the screen at that time, but other residents, unauthorized staff or visitors could be potentially walking by the charting station. The RN came to her charting computer at 10:15 a.m. from residents' room on 300 Hall.During an interview on 2/27/2026 at 10:14 a.m., RN stated that she was in-serviced on HIPAA five months ago. She stated the HIPAA in-service included instructions on not sharing residents' private clinical information with unauthorized individuals and to lock the computer screen when stepping away from the charting computer. She stated everybody who worked with charting computers were responsible for closing and locking the computer when not in attendance. She stated leaving the screen unlocked with Resident #1's clinical information displayed could be harmful for the residents because anybody could see it. She stated she was at fault for not locking the computer before going to answer the call light.During an interview on 2/27/2026 at 3:05 p.m., the ADM stated he received HIPAA training upon hire and a few months ago which covered the importance of maintaining the residents' private information. He stated whoever used the computer was responsible for shutting it down to ensure the residents' information was not visible. He stated the potential risk for not shutting down charting computers could be a breach of residents' privacy. He stated all staff completed HIPAA in-service upon hire and annually. He stated the last staff HIPAA in-service was conducted in September 2025 and on 02/27/2026, after the incident.During an interview on 2/27/2026 at 3:21 p.m., the DON stated the facility's HIPAA policy was to minimize the charting computers' screens when stepping away. He stated if the computer screens were not minimized, someone could have unauthorized access to private clinical information displayed on the screen. He stated HIPAA in-services were included employees at hire and annually through computer modules which included instructions on locking the computer screens. He stated the person who works with residents' private clinical information should lock the screen before walking away. He stated the potential negative effect was unauthorized disclosure of residents' private information and could affect residents' dignity.Record review revealed HIPAA in-services, dated 09/17/2026, indicated the RN completed and signed the in-service.Record review of facility's Privacy Notice policy, revised on 03/2014, revealed h. (1) the facility is required by law to maintain the privacy of patient health information.Record review of facility's Resident Rights policy, revised on 01/2021, revealed 3. Unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws, governing privacy of information issues.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control. Facility staff failed to recognize infection control protocol for EBP and Contact precautions for Resident #1. The facility failed to ensure CNA C disinfected the mechanical lift before taking it out of Resident #1's room. The facility failed to ensure CNA C put on a gown and conduct handwashing/hand hygiene between glove changes when providing peri-care to Resident #1 These failures could place the residents at risk of infection transmission, poor wound healing, and hospitalization.Findings included: Record review of Resident #1's undated face sheet dated 2/5/26 at 10:41 am reflected a [AGE] year-old male who admitted to the facility on [DATE] and was re-admitted on [DATE]. He had diagnoses of intracranial injury with loss of consciousness of unspecified duration (traumatic brain injury), abdominal hernia without obstruction or gangrene, chronic pain syndrome, presence of cardiac pacemaker, hemiplegia affecting left nondominant side, major depressive disorder, hypothyroidism, chronic kidney disease, dysphagia (difficulty swallowing), bacterial infection, and schizophreniform disorder. Record review of Resident #1's Quarterly MDS Assessment, dated 12/31/2025, reflected the resident had a BIMS Score of 11, which indicated the resident had a mild to moderate cognitive impairment. Resident #1 required two people to assist with all of his activities of daily living (ADLs), and he required transfer from bed to chair to bed with two people and a mechanical lift. Resident #1 had a diagnosis of bacterial infection. Resident #1's MDS further reflected he did had an open lesion other than ulcer, rashes or cuts. Record review of Resident #1's undated Care Plan reflected a focus area of actual impairment to skin integrity of the right breast related to cellulitis, infection of soft tissue. The goals reflected Resident #1 will have no further complications related to open wound of the right breast/axilla area through the review date. The interventions included:*Monitor for side effects of the antibiotics and over-the-counter pain medications such as gastric distress, rash, or allergic reactions which could exacerbate skin injury*Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD.Resident #1's Care Plan also reflected a focus area of ADL self-care performance deficit related to dementia, hemiplegia, impaired balance and traumatic brain injury. The goal reflected Resident #1 would maintain current level of function through the review date. The interventions reflected Resident #1 required total assistance of two people for all of his ADL care. Record review of wound culture order dated 08/27/2025 revealed a culture was ordered to wound but did not specify location of wound. Record review of wound culture resulted 09/02/2025 at 8:30 AM revealed report contains critical results site: right flank/ Organism Escherichia coli and methicillin resistant staphylococcus aureus. Record review of Resident #1's contact precaution order dated 09/02/2025-09/07/2025 revealed that all services including treatments, activities, showers, and meals, have been received in the resident's private room d/t strict isolation/contact precautions ordered by DR Record review of Resident #1's contact precaution order dated 10/28/2025 revealed contact isolation precautions due to MRSA infection to wound in right flank area. ordered by DR. Record review of Resident #1's EBP Order dated 10/28/2025 Order end date: Indefinite, revealed ENHANCED BARRIER PRECAUTIONS every shift. ordered by DR. Record review of Resident #1's EBP Order dated 11/11/2025 Order end date: Indefinite, revealed EBP: Staff must use gown and gloves during high- contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced barrier precautions are recommended for residents known to colonize or are infected with a MDRO as well as those who are not confirmed to have MDRO. ordered by DR Record review of Resident #1's physician order start date 11/11/2025 revealed EBP precautions to include gloves and gown during high-contact resident care with an end date of indefinite. ordered by DR Observation of video dated 08/18/2025 at 9:27 AM Staff member wiped Resident #1's fungal area (that was later diagnosed as MRSA) then used same wipe to clean the rest of Resident #1's body. Observation of video dated 09/03/2025 at 7:14 PM unidentified staff members applied cream to both sides of Resident #1's face. Wound to right side checked bandage intact. Staff were wearing gloves and masks, not a gown. Observation of video dated 09/04/2025 at 10:08 AM unidentified staff members wore gloves for Resident #1's incontinent care and applies patch without changing gloves. Observation of video dated 09/05/2025 at 3:31 PM an unidentified staff member took the trash can from floor and sat it on Resident #1's sheets during incontinence care. The same gloves were used to make bed after incontinence care. The mechanical lift was taken outside of the room without being cleaned. This staff member did not wear a gown and wore gloves outside of room after incontinence care provided. Observation of video dated 09/05/2025 at 8:43 AM No gowns during Resident #1's incontinence care. Observation of video dated 09/06/2025 at 9:18 AM revealed no gowns are worn while changing resident's clothes. Observation of video dated 09/06/2025 at 11:44 AM revealed unidentified staff wore no gowns during Resident #1's wound care to right side. Male nurse carried tray with wound care supplies out of room wearing same gloves used for wound care. Observation of video dated 09/10/2025, nurse provided wound care used marker from pants and replaced the marker back to pants after using on Resident #1's wound bandage without cleaning marker. He did not change gloves and walked out of room with trash in his hand from wound care and a tray. He did not change gloves, wipe down tray or the marker used. Observation of video dated 10/29/2025 at 9:33 AM nurse provided Resident #1's wound care on bedside table and does not wipe down table prior to leaving the room. DR touches remote to bed, bedside table, and drinking glass with gloves that she used to examine the wound. Observation of video dated 10/29/2025 at 7:48 AM revealed unidentified staff provided Resident #1's incontinence care without a gown. Observation of video dated 10/30/2025, at 3:53 PM revealed unidentified staff provided Resident #1's incontinence care provided with gloves only. Observation of video dated 10/31/2025 at10:08 AM revealed unidentified staff provided Resident #1's incontinence care with gloves then applies pain patch with same gloves. Observation of video dated 11/01 2025 at10:32 AM an unidentified staff member wore no gowns during Resident #1's wound care and did not take off gloves before leaving the room after wound care. She also did not clean down the bedside table used during wound care. In an observation on 02/05/2026 at 10:53 AM Resident #1's door and area next to door was without an EBP sign. An observation on 02/05/2026 at 2:25 of peri-care for Resident #1 revealed CNA C did not conduct handwashing/hand hygiene and did not put on a gown prior to providing peri-care. After cleansing the peri-area, CNA C removed soiled gloves and did not conduct hand hygiene before putting on clean gloves. She proceeded to cleanse Resident #1's bottom, removed the soiled brief and placed it in the trash can. CNA C removed soiled gloves and did not conduct hand hygiene before putting on clean gloves. She then applied skin barrier to Resident #1's bottom. CNA C removed soiled gloves and did not conduct hand hygiene before putting on clean gloves. She then put a clean brief on Resident #1, provided repositioning with pillows, reapplied his left foot/lower leg boot and put a clean blanket over him. Interview on 02/10/26 at 2:57 PM the DR stated Resident #1 had developed an abscess on his right flank that was treated with doxycycline until closed and healed. She stated on healing the wound had sealed on the outside, but there was some infection on the inside, so it had re-opened. The DR stated Resident #1 had been seen by wound care physician and was treated with Bactrim, and to date the wound has not returned or opened up. The DR stated there had not been any other wounds. The DR stated Resident #1 was not colonized with MRSA and did not require Enhanced Barrier Precautions at this time, since his wound had healed. The DR then gave the DON verbal orders to discontinue Enhanced Barrier Precaution orders, dated 02/10/26. An observation on 02/05/2026 at 3:01 PM of Resident #1's transfer to bed with a mechanical lift revealed CNA C did not disinfect the mechanical lift before taking it out of the room. An interview on 02/05/2026 at 3:14 PM CNA C revealed she knew she should have washed her hands and used sanitizer between glove changes, but she did not have hand sanitizer with her during the care. She stated she did not have the hand sanitizer because she had been trying to get Resident #1's weight when he was in the mechanical lift and stated LVN B was trying to leave after his shift. CNA C stated she had forgotten to disinfect the mechanical lift before removing it from Resident #1's room. CNA C stated she did not think she needed to put on a gown when providing care to Resident #1 at this time. She stated she had received training on Infection Control, wearing a gown with precautions, and handwashing/hand hygiene each month. CNA C stated not conducting hand hygiene when providing resident care and between glove changes and not wearing a gown when there were precautions could lead to the spread of infection between residents. An interview on 02/10/26 at 3:40 PM with ADON who stated when Resident #1 had first developed the wound to his right flank, it was treated as an abscess. We did not have contract with [company], so he went to outside wound care, which is when we received communication for MRSA. His PCP started him on an antibiotic and wound care. The wound re-opened and we started another ABT and isolations. Then we had [company], and once the wound healed he should have been taken off isolation. The ADON stated all staff should conduct handwashing/hand hygiene when gloves were changed. She stated the policy on Hand Hygiene was to always conduct handwashing/hand hygiene when providing care for residents, and when changing from soiled to clean gloves. She stated she had conducted an in-service on EBP and hand hygiene in January 2026. The ADON stated a consequence of staff not following all infection control precautions and handwashing/hand hygiene was transferring infection from one resident to another, resident to another staff member or to yourself. An interview on 02/11/2026 at 11:30 AM with the ADM revealed he had been trained on Infection Control. He stated the training included the importance of conducting hand hygiene/handwashing when providing care to residents, when changing gloves, and to strict handwashing when suspected Norovirus, as hand sanitizer did not kill this virus. The ADM stated he took this training in April 2025, the CDC Infection Preventionist training. He stated the policy for hand washing when providing care included when staff should wash their hands, such as when picking up food trays, when entering and leaving a resident room, high contact touch areas, and when changing their clothing. He stated all staff, residents, and visitors should be washing their hands to help prevent the spread of infection. He further stated a negative outcome of staff not doing proper hand hygiene could be an outbreak of an infection. He stated the DON and the ICPC nurse monitor to ensure all staff were washing their hands, along with monthly in-services on Infection Control and hand hygiene. A record review of policy Handwashing/Hand Hygiene dated 01/2025, revealed the following relevant information: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Administrative Practices to Promote Hand Hygiene1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.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.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand-hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility.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.2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations.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.5. The use of gloves does not replace hand washing/hand hygiene.A record review of the facility's policy titled Isolation - Initiating Transmission-Based Precautions dated 03/28/2025 reflected, Policy Statement - Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions.The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated 01/2025 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility.

Based on observations, interviews, and record review, the facility failed to ensure 1 (Resident #2) of 4 residents reviewed for Resident Rights was treated with respect and dignity. Resident #2 stated she felt that she was being labeled here for being bipolar. Resident #2 stated she had been getting high anxiety all over her body, had a lot of crying, and she had been picking at a place on her chin to [NAME] come and could not stop. Resident #2 said she felt as if it was her responsibility to speak in Spanish to MA E to show her respect since that was MA E's preferred language. These failures can lead to residents feeling like their rights were not being respected. Findings included: Record review of Resident #2's undated face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses of dementia, insomnia, anxiety disorder, hyperlipidemia (high blood fats), difficulty in walking, post-traumatic stress disorder, cognitive communication deficit, bipolar disorder, and hypertensive heart disease. Further review revealed Resident #2's primary language was English. Record review of Resident #2's Quarterly MDS Assessment, dated 11/26/2025, reflected a BIMS Score of 15, which indicated the resident had a mild cognitive impairment. Resident #2 required two people to assist with her activities of daily living (ADLs), and she required transfer from bed to chair to bed with one person assist and her mechanical wheelchair. An observation and interview on 02/05/26 at 12:13 PM of Resident #2 revealed her hands trembling while she was stating, I feel that I am being labeled here for being bipolar. Resident #2 stated she had been getting high anxiety all over her body, a lot of crying, and she had been picking at a place on her chin to [NAME] come and cannot stop. She stated she was peeling layers off the skin on her chin. Resident #2 stated her anxiety levels were high due to issues with her medication changes, and all the confrontation between her RP and the facility. Resident #2 stated MA E only spoke to her in Spanish. Resident #2 felt she had to speak in Spanish to MA E to get her medications. Resident #2 said she felt as if it was her responsibility to speak in Spanish to MA E to show her respect since that was MA E's preferred language. Resident #2 stated did not know that one of her resident rights was to be spoken to in her primary language. Resident #2 further stated she does not want to upset anyone and will continue to speak to MA E in her preferred language so that she can have her pain medications when she asked for them. Resident #2 stated she had spoken to the Administrator and the DON about her concerns, but she did not remember when she had talked to them. An interview on 02/05/2026 at 11:30 AM with MA E revealed the residents had a right to be spoken to in their preferred language. MA E further stated she would not talk to a resident in a language they were not comfortable speaking. An interview on 02/10/26 at 3:40 PM the ADON stated Resident #2 came to visit her often and to confide in her. The ADON stated she had not witnessed anyone in the facility yelling at or mistreating Resident #2. She stated the other day Resident #2 came to her and stated she thought nobody in the facility liked her. The ADON stated she told Resident #2 she had a right to her feelings and perceptions, and that she liked Resident #2. ADON stated the residents had the right to exercise their rights while they were in the facility, and that speaking to residents in their preferred language was one of their rights. A review of the facility's Policy and Procedure on Notice of Resident Rights and Responsibilities, dated 03/2017 reflected, Policy StatementOur facility shall inform the resident both orally and in writing of his or her rights as a resident, and the rules andregulations governing the resident's conduct and responsibilities during his or her stay in the facility.Policy Interpretation and Implementation5. Our facility will inform the resident of his or her rights and responsibilities in a language that is understandable to the resident. If the resident has limited English proficiency, his/her rights and responsibilities will be presented in the resident's primary language.6. For foreign languages commonly encountered in our community the facility will provide the resident with written translations of his or her rights and responsibilities. If the foreign language is not common to our community, such rights may be communicated orally through a competent interpreter.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring, receiving, dispensing and administering of medications to meet the needs for one resident (Resident #1) of 4 residents reviewed for pharmacy services, in that: MA failed to correctly administer a lidocaine patch medication to resident on 8/15/2025 at 11:03 AM. This failure placed residents at risk for medical errors, complications, decreased quality of life and hospitalization. Findings included:Review of Resident #1's face sheet dated 10/29/2025 reflected he was a [AGE] year-old-male admitted on [DATE] with diagnosis that included: Type 2 Diabetes Mellitus (characterized by high levels of sugar in the blood), Idiopathic Epilepsy (a brain disease which causes seizures.), Major Depressive Disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety Disorder (anxiety disorders, frequently have intense, excessive and persistent worry and fear about everyday situations).Review of Resident #1's admission MDS dated [DATE] reflected he had a BIMS of 05 indicates severe cognitive impairment. Review of Resident #1's MAR reflected an order start date of 11/12/2024: Lidocaine Pain Relief External Patch 4 %(Lidocaine). During an interview on 10/29/2025 at 3:44 pm, the DON stated on 10/9/25, at the care plan meeting she was made aware of a CNA was putting on the lidocaine patch on Resident #1. DON stated, the resident's sister told her that CNAs were applying patches. Asked who but sister couldn't identify. She started investigating but there was no date provided. She questioned all staff till someone cracked. Discovered it was Med aide CNA A. Both were educated on their scope of practice, 1/1 inservice and then all staff were in service. No disciplinary action. (They did 'verbal' warnings, and it was documented in their personnel files.) DON stated that facilities policy for medication administration is to be administer medication by licensed personnel only; Nurses and MA, not CNAs - she stated a CNA giving medications did not meet expectations. Potential outcomes of a CNA giving medication - severe reactions. Potentially death. They don't know what they are administering and if they're the right person because they don't have access to MAR. There could be allergic reactions, they could apply incorrectly or to the wrong area. Treatment isn't being achieved because med isn't administered properly. She stated this had not happened previously.During an interview with the ADM on 10/29/2025 at 3:52 PM he stated that he discovered that incident during the care plan meeting on10/09/2025. The ADM stated, the family described the video recording which includedCNA applying a lidocaine patch to Resident # 1. The ADM stated that facility policy only allows licensed professional to administer medication, even OTCDuring an interview on 10/29/2025 at 11:01 am CNA A stated she did put a lidocaine patch on Resident #1. She said she was told that she was not authorized to put a medication patch on a resident and was retrained.During an attempted interview on 10/29/2025 at 5:35 pm and 10/30/2025 at 10:03 am MA B was not at the facility and was not returning voicemails left on her personal phone.During an observation of a video dated 08/15/2025 at 11:03 AM, CNA A applied a lidocaine patch to Residents # 1 upper back. Record Review of undated policy 9.3. Medication Administration revealed, Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations Manual when administering medications. Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.

Based on observation, interview, and record review, the facility failed to ensure 1 (Resident #1) of 5 residents had the right to be treated with respect and dignity.CNA A did not provide Resident #1 with a shower when he asked to be assisted with a one.This failure placed the residents at risk of not receiving the care and services to meet their needs, and therefore not respecting their dignity. Findings included:Review of an undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included a nontraumatic cerebral hemorrhage in the cortical hemisphere ( bleeding in the brain without external injury), chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), heart failure, hyperlipidemia (elevated cholesterol in the blood) , atrial fibrillation (irregular heart rhythm), metabolic encephalopathy (brain's function that is affected by body's metabolism), convulsions, cerebral infarction (stroke), dysphagia (difficulty swallowing), presence of a cardiac pacemaker, presence of a prosthetic heart valve, dementia, and adjustment disorder with depressed mood.Record review of Resident #1's Quarterly Minimum Data Set Assessment, dated 09/05/25, reflected a BIMS score of 8, which indicated moderate cognitive impairment. Resident #1 used a manual wheelchair for mobility and was dependent on staff for all of his activities of daily living, including showers, incontinent care, and chair/bed-to-chair transfers (including a wheelchair). Record review of Resident #1's Care Plan, dated 08/07/25, reflected,Focus: Resident #1 has an ADL self-care performance deficit related to intracerebral hemorrhage, chronic obstructive pulmonary disease, hypertension, congestive heart failure, atrial fibrillation, encephalopathy, Transient ischemic attacks (stroke) and benign prostatic hypertrophy(enlarged prostate gland). Interventions: Resident #1 required limited to extensive assistance with one staff member with showers and provide a sponge bath when a full bath or shower cannot be tolerated.A telephone interview on 11/19/25 at 2:45 PM with Resident #1's RP revealed the facility was not providing his care, and Resident #1 smelled like urine when coming back from a doctor's appointment. The RP stated Resident #1 had not been taking showers which should be every other day or three times per week. She further stated Resident #1 told her facility staff did not shower him because he was too difficult to shower. The RP stated she did not have proof of this, but she had observed him being smelly. An observation on 11/20/25 at 10:30 AM of Resident #1 revealed him sitting up in his wheelchair in his room. Resident #1 was wearing a white T-shirt and blue shorts. There was a strong urine-type of odor near the resident and the bed. In an interview on 11/20/25 at 10:30 AM with Resident #1, he said the staff were not giving him a shower that day. He stated he had urine on the bed, and on his clothing. He stated they had changed the bed, but he had not been changed or showered. Resident #1 stated the lady in charge (couldn't recall her name) was mean and ugly as hell and treated other people the same way. Resident #1 stated he asked for a shower that morning, and CNA A told him it was not his day for a shower, and that he got showers on Mondays, Wednesdays, and Fridays. Resident #1 further stated CNA A told him he should have taken a shower on his scheduled day. Resident #1 stated he could not even go to the dining room without feeling dirty and smelling like urine. Resident #1 stated it made him feel like he was a nobody, and he felt neglected.Review of Resident #1's Shower Sheet dated 11/20/25, reflected he had received a shower on 11/16/25, 11/18/25, and 11/19/25.In an interview on 11/20/25 at 3:50 PM with the DON, she said Resident #1's shower should have been done, and that was unacceptable, especially since he had an odor. The DON said the policy for providing showers to the residents included three scheduled shower days, three times per week. She further stated if a resident was requesting a shower off cycle, they should be getting that done for the residents. The DON stated the CNAs, the charge nurse, and herself were responsible for ensuring residents were clean and groomed. She further stated it was important to assist the residents with getting their showers to keep their skin clean, for their dignity, hygiene, and health. She started the resident could feel uncared for, unworthy and unkempt, and these feelings could spark anger and depression. The DON stated she was ultimately responsible for monitoring to ensure that staff were providing ADL care to the residents, and stated she pulled reports and talked to the residents during rounds. She stated she did not know why a resident would have been left in dirty clothing and had an odor. She stated if a resident were asking for a shower off cycle, the staff should have brought it to her attention, and she could have provided the shower to Resident #1 herself. The DON stated that by the end of the day shift, CNA A had given Resident #1 a shower, but that should have been done in a timelier manner. Review of the facility's Policy & Procedure on Resident Rights, dated February 2021, which reflected, Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' rights to:a. A dignified existenceb. Be treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention.The facility failed to ensure enhanced Barrier Precautions (EBP) were implemented when CNA A & CNA B provided peri and colostomy care to Resident #1.This deficient practice could place the residents at risk for the spread of infection.Findings included:Record review of Resident #1s face sheet revealed she was a 85 year of female with and initial admission date of 9/27/2023 with readmission date of 9/21/2025 and with diagnosis which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hemiplegia (paralysis)and hemiparesis (partial weakness) following cerebral infarction affecting left non-dominant side (stroke to left side of the brain), type 2 diabetes mellitus with diabetic nephropathy (nerve damage), major depressive disorder (mental health condition characterized by persistent sadness, loss of interest in activities, and a range of emotional and physical problems.), hyperlipidemia (excessive fat in the blood), chronic pain syndrome, hypertension (high blood pressure), gastro-esophageal reflux disease (heartburn) without esophagitis (inflammation of the esophagus), colostomy status (surgical procedure that creates an opening in the abdomen to allow stool to exit to allow stool to exit the body when part of the colon is not functioning properly), acute gastritis (inflammation of the stomach)with bleeding, neuromuscular dysfunction of bladder (nerve damage impaired bladder control).Record review or Resident #1s MDS assessment dated [DATE] revealed a BIMS score of 06, indicating impaired cognition. Further review revealed Resident #1 had a colostomy (surgical opening in the abdominal wall to allow the colon to pass waste through the body into a bag that can be emptied and replaced as needed.) Review revealed resident wears a brief and needs assistance with ADL s.Record review of Resident #1s Care Plan dated 9/21/2025 revealed a Problem which included Enhanced barrier Precautions related to colostomy. This problem area included the following interventions: Post EBP signs on or beside door to make precautions clear to those who are entering the room. and Follow enhanced barrier precaution guidelines when providing close contact resident care and Ensure clean PPE is readily accessible near residents room. All interventions were initiated 3/12/2025.Observation on 11/5/2025 at 10:28 AM revealed there was a sign indicating Enhanced Barrier Precautions outside the door to Resident #1s room, and there was a supply of PPE available just inside the door. Sign stated, Enhanced Barrier Precautions everyone must: clean their hands, including before entering and when leaving the room. and Providers and staff must also: wear gloves and a gown for the following activities: dressing, bathing / showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care of central line, urinary catheter, feeding tube, tracheostomy, wound care. Further observation revealed that CNA A and CNA B donned gloves but did not wear a gown while performing peri care and emptying the stool from Resident #1s colostomy bag. In an interview on 11/5/2025 at 10:30 AM with CNA A, he stated he did not always where a gown when providing care to Resident #1. He stated he was unable to explain enhanced barrier precautions. In an Interview 11/5/2025 at 10:32 AM with CNA B, she stated that she sometimes wore a gown when performing peri care but not always. When Surveyor and CNA B exited the room and Surveyor asked what the sign on the door meant, CNA B stated she did not see the sign before providing care to Resident #1. She stated she should have worn a gown when emptying the colostomy bag and providing peri care.In observation and interview on 11/5/2025 at 10:51 AM with CMA A, she entered the room and put on a gown and gloves and obtained Resident#1s blood pressure. She removed the PPE sanitized her hands and prepared medication following physician's order. CMA A then placed another gown and set of gloves on and assisted Resident #1 in taking her medications and ensured all medication were swallowed. She stated she wore the gown and gloves to provide any care to Resident #1 as she was on Enhanced barrier precautions. In a telephone interview on 11/6/2025 at 12:50 PM, with DON, she stated that she frequently inserviced staff on abuse, neglect and enhanced barrier precautions. She stated that if a resident is on enhanced barrier precautions she expects the staff to wear gowns and gloves when providing care to the residents.In an interview on 11/6/2025 at 12:54 PM with ADON, she stated that she knows they have reviewed EBP in July. She stated that anyone with a chronic wound, g tube, trach, or surgically opened areas in the body would require the resident to be placed on enhanced barrier precautions. She stated she expects staff to wear a gown and gloves during direct patient care. She stated that the PPE for enhanced barrier precautions should be worn to prevent infection. She stated she would expect staff to wear a gown and gloves when providing incontinent care in a resident with a colostomy as well as when they are emptying the colostomy bag. She denied that there have been reports that staff have not been utilizing proper PPE on a patient labeled as EBP. She was unable to provide the signed in-service where EBP was covered recently. She stated that the documents must be locked up in the DONs office and she is currently out of state.In an interview on 11/6/2025 at 1:20 PM with the Administrator he stated he expected the staff to wear PPE when providing care to residents on enhanced barrier precautions. He stated that ADON, DON and himself have already established a plan to further educate the staff on enhanced barrier precautions.Record review on 11/5/2025 of facility policy titled Enhanced Barrier Precautions dated 2001 MED-PASS, Inc. stated: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reducetransmission of multidrug-resistant organisms that employs targeted gown and glove use during highcontact resident care activities. Related Policy Interpretations and Implementation excerpts include: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention toreduce the transmission of multi-drug-resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident.c. Face protection may be used if there is also a risk of splash or spray.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:a. dressing;b. bathing/showering;c. transferring;d. providing hygiene;e. changing linens;f. changing briefs or assisting with toileting;g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.);h. wound care (any skin opening requiring a dressing).5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/orindwelling medical devices regardless of MDRO colonization.a. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasisulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears.b. Examples of indwelling medical devices include, but are not limited to, central vascular catheters(including hemodialysis catheters, peripherally inserted central catheters (PICCs)), indwelling urinarycatheters, feeding tubes, and tracheostomy tubes. Peripheral IV catheters are not considered anindwelling medical device for purposes of EBPs.10. Staff are trained prior to caring for residents on EBPs. 11. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPErequired.12. PPE for EBP's is available outside or inside of the residents' rooms.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #19) of 5 residents and 3 (100 Hall MC 200 Hall MC and 300 Hall MC) of 8 medication carts reviewed for pharmaceutical services. A total of 29 loose pills were observed in 100 Hall MC 200 Hall MC and 300 Hall MC A total of 3 medications were observed as expired in 100 Hall MC 200 Hall MC and 300 Hall MC These failures could place residents at risk of not receiving all their prescribed medications, which could exacerbate their illness, and expired medications could have a decrease in effectiveness or make the resident sick. Findings included: Observation on 06/12/2025 at 10:03 am revealed 6 loose pills in the drawers of the 100 hall MC . Observation on 06/12/2025 at 10:17 am revealed 21 loose pills in the drawers of the 200 hall MC . Observation on 06/12/2025 at 11:25 am revealed 2 loose pills found in the drawers of the 300 hall MC . Observation on 06/12/2025 at 11:18 am revealed 2 bottles of nystatin powder in the drawers of 100 Hall MC for Resident #19 with expiration dates of 03/24/2025 and 06/03/2025 prescribed for fungal infection on the skin. Observation on 06/12/2025 at 11:18 am revealed a foil packet patch labeled Asper creme without a resident name with an expiration date of December 2024. Record review of Resident #19's face sheet dated 06/12/25 reflected she was admitted to the facility on [DATE]. Her diagnoses included dementia, iron deficiency anemia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction with right sided weakness, and a history of falling. Record review of Resident #19's Quarterly MDS dated [DATE] reflected a BIMS Score of 13, which indicated no cognitive impairment. Section GG functional abilities reflected Resident #19 required substantial/maximal assistance for chair/bed to chair transfer, bed mobility, sit to lying, lying to sitting on the bed, sit to stand, and shower, and she used a wheelchair for mobility. Record review of Resident #19's Care Plan, last revised on 03/26/25, reflected she had diabetes mellitus. The goal reflected Resident #19 would have no complications related to diabetes mellitus through the review date. Relevant interventions included check all of body for breaks in skin and treat promptly as ordered by doctor, and to monitor/document/report PRN any signs and symptoms of infection to any open areas: Redness, Pain, Heat, Swelling, or Pus formation. Interview with MA F on 06/12/2025 at 10:30 am revealed that she was unaware there were loose pills in the cart. She was unable to identify the pills or what resident they came from. She was supposed to be checking daily or weekly for loose pills and expired medication. She stated she was trained on medication administration when she started at the facility. They were required to do a skills check-off sheet that demonstrated they could accurately administer medications. She stated that if she found a loose pill she was to get another staff member, crush it, and place it in the sharp's container. She stated that sometimes the medications came accidentally get popped out because the drawer was very full. She was unable to say if any risks were present for the residents because they always had extra in the medication storage room. Interview with MA G on 06/12/2025 at 11:29 am revealed that he did not know there were loose pills in his cart. He had checked his cart within the last week for expired medications and loose pills. He was trained on medication administration and was required to demonstrate the administration while someone was watching. He stated that if a loose pill was found he was supposed to crush it and place it in the sharps container. He stated the residents had not run out of medication and that there were always extra medications in the storage room. In an interview with the ADON on 06/12/2025 at 11:52 am she stated that she had been working at the facility for 24 years. She revealed the LVNs and MAs were supposed to be checking for loose and expired medications at least daily and at every shift. It was unacceptable that there were loose pills in the cart. She stated that there were very few risks to the resident because they ordered the medication refills about a week ahead of time. She stated that she was not concerned for residents accidentally ingesting the medications because they were locked up. She revealed that keeping the carts clean and free from expired medications was a part of their job duties. She stated anyone who administered medication completed a medication check off sheet that was evaluated by another nurse or herself. She stated they have done in-services recently to reeducate the medication aides on how to keep carts clean. In an interview with the DON on 06/12/25 at 10:26 AM she revealed that the medication cart should have been clean and free from any loose pills. The MAs should have been completing a full cart audit weekly to ensure that everything was clean and organized. She stated that it was her and the ADON's responsibility to ensure the MAs had completed their job correctly. The pharmacist had come to the facility and completed a few cart audits as well. She stated that to her knowledge no loose pills had been given to residents, so there was no risk to residents. She stated that the facility kept backups of all medication in the medication bank in the medication storage room. According to her, there was no risk of residents running out of medication. Interview with the ADM on 06/12/2025 at 1:46 pm, revealed that it was unacceptable to have loose pills. She stated the DON and ADON audited the MCs 1 time per month. She stated they completed an in-service in the last 6 months for medication administration. She stated that anyone who passed medication was responsible to ensure that the cart was clean, free from loose pills, and expired medication. She stated that there was no risk to residents because they had intentionally kept back up medication in the storage tower in the medication storage room for that reason. Record review of medication storage policy, undated, titled Delivery, Receipt and Storage of Medication reflected it did not contain any language related to policies about storing non-refrigerated medications. Requested cart audit records from DON on 06/12/2025, but none were provided before exit. Record review of in-services on 06/12/2025 revealed no in-services were available on medication administration in the last 6 months

Based on observation, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skill and techniques necessary to care for 1 of 10 resident's needs (Resident #44) related to PEG Tubes. The facility failed to ensure CNA C was appropriately trained on providing bed baths for residents with PEG tubes for Resident #44. This could lead to a risk of infection and medical complication, and a decreased quality of life. Findings included: Record review of face sheet dated 06/12/2025 reflected Resident #44 was a [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses of intractable epilepsy (uncontrollable seizures) , mild protein calorie malnutrition (a mild nutrient deficiency), aphasia (inability to speak), dysphasia (inability to swallow), gastronomy status (feeding via tube in the stomach), intellectual disability, anoxic brain damage (brain damage due to lack of oxygen). Record review of Resident #44's MDS dated [DATE] indicated Resident #44 had no BIMS score which indicated the BIMS was not attempted. Resident #44 is coded as a complete dependence on caregiver for all efforts related to bathing. Record review of Resident #44's care plan updated on 03/20/2025 reflected, Check for tube placement and gastric contents/residual volume. Nothing in the care plan related to providing bed baths. Record review of Resident #44's progress notes dated 12/18/2024 revealed resident was transferred to the hospital to replace PEG tube after CNA had accidentally removed PEG tube while changing resident. Observation of Resident #44 on 06/10/2025 at 1:30 pm revealed resident lying in bed. Resident #44 was able to make eye contact but was unable to answer any questions or communicate. In an interview with Resident #44's RP on 06/11/25 at 01:57 PM, she stated she had no issues or concerns for her care. They communicated well and always notified her if Resident #44 had to go to the hospital. She stated she knew there had been issues, but no complications had occurred this year. She stated she felt like Resident #44 was well taken care of. In an interview with CNA C on 06/11/2025 at 2:30 pm she stated that on 12/18/2024 she was giving the resident a bed bath when the PEG tube had become dislodged. Specifically, it was while she was putting Resident #44's shirt back on. She stated that when it happened, she ran to grab LVN A. LVN A tried to replace it, but they were instructed to send her out to the hospital. She stated that she had training on a bed bath at CNA school. She had not had any training on handling PEG tubes while working at the facility. She stated they did not provide any further education after the incident. She believed the resident was unharmed because the resident was smiling and made no noises or facial grimacing that could have been considered a painful response. In an interview with CNA B on 06/11/2025 at 1:45 pm she stated that she had been working there 3 years. She stated that she was not checked off on providing bed baths. She stated it was common sense just to be careful around providing care to a resident with a PEG tube. She stated if she ever had questions she would ask the nurse. She stated that they had in-services on tube feedings, but could not remember when they had occurred. Interview with LVN A on 06/11/2025 at 2:45 pm revealed that she was the nurse on the hall when Resident #44's PEG tube became dislodged. She stated CNA C had immediately notified her when the tube became dislodged. The CNA reported that while pulling Resident #44's top down after a bed bath the PEG tube became dislodged. She stated the tube had come out twice before. She stated during the incident there was no bleeding, no obvious signs of pain. She cleaned the area, covered it, and prepared Resident #44 to be transferred to the hospital She stated the only training CNAs got was communication between the LVN and CNAs to be careful around the tube. She stated she was responsible for ensuring that the CNAs were handling the tube correctly while giving a bed bath. In an interview with the MD on 06/12/25 at 09:40 AM she stated that she had no concerns for Resident #44's care at the facility. She stated that Resident #44's feeding tube can come out and that the stoma opening had significant scar tissue around the stoma. She said the risk of infection was very low especially if staff had put in a catheter to protect the opening and cover it. She stated it was acceptable to send the resident out to the hospital to replace the PEG tube. She expected the staff to be careful around the PEG tubes and know how to provide a bed bath around the PEG tube. In an interview with the DON on 06/12/2025 at 10:26 am she stated that she had been at the facility for two weeks and was not aware of the incident with Resident #44's PEG tube being dislodged during care. She stated that the CNAs should be aware of who had indwelling devices. She stated that any sort of change of condition that required hospitalization should have required a reeducation or a 1-1 education session. She stated that education was important, but the CNA should have asked for help if bathing became too difficult. She stated that she believed the risk to the resident was low because they had done the right thing. In an interview with the ADM on 06/12/2025 at 1:45 pm, she stated that the CNAs had reeducation on bed baths after that event, but CNAs were not assessed on providing bed baths for residents with PEG tubes. She stated that education was important. She stated that it was important to get education on specific topics for specific residents. She stated the previous DON did the initial check offs, but they could not find the initial check off for CNA C. She stated that residents needed trained caregivers for their specific medical conditions to improve their quality of life. Record review of CNA C's staff file on 06/12/2025 revealed there was no assessment of bed baths or PEG tubes. Record review of in-services on 06/12/2025 revealed no in-services related to bed baths or PEG tubes.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 10 (Resident #44) residents reviewed for care plans. The facility failed to update the care plan for Resident #44 to reflect how to meet the needs of the resident when a gastrointestinal tube becomes dislodged. This failure placed the resident at risk of complications with indwelling devices. Findings include: Record review of Resident #44's face sheet dated 06/12/2025 reflected Resident #44 was a [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses of intractable epilepsy (uncontrollable seizures) , mild protein calorie malnutrition (a mild nutrient deficiency), aphasia (inability to speak), dysphasia (inability to swallow), gastronomy status (feeding via tube in the stomach), intellectual disability, anoxic brain damage (brain damage due to lack of oxygen). Record review of Resident #44's MDS dated [DATE] indicated Resident #44 had no BIMS score which indicates the BIMS was not attempted. Resident #44 is coded as a complete dependence on caregiver for all efforts related to bathing. Record review of Resident #44's care plan updated on 03/20/2025 reflected, Check for tube placement and gastric contents/residual volume. No information was included on care planning for tube removal or replacement if necessary. Record review of Resident #44's progress notes dated 03/27/2023 revealed a physician visit due to PEG tube infection after PEG tube had become dislodged a week prior. Record Review of Resident #44's progress notes dated 03/20/2024 revealed a physician visit due to PEG tube replacement due to it becoming dislodged. Record review of Resident #44's progress notes dated 12/18/2024 revealed resident was transferred to the hospital to replace PEG tube after CNA had accidentally removed PEG tube while changing resident. Observation of Resident #44 on 06/10/2025 at 1:30 pm revealed resident lying in bed. Resident #44 was able to make eye contact but was unable to answer any questions or communicate. In an interview with the RDN on 06/11/2025 at 1:31 pm, he stated he had no concerns for Resident #44. He stated her weight was stable, she had tolerated her feeds well and was healthy. He stated he had no opinion about her tube becoming dislodged because that was outside of his area of expertise. He was unaware about care plans and refused to comment. In an interview with Resident #44's RP on 06/11/25 at 01:57 PM, she stated she had no issues or concerns for her care. They communicated well and always notified her if Resident #44 had to go to the hospital. She stated she knew there were issues, but no complications this year as far as she knew. She stated she felt like Resident #44 was well taken care of. In an interview with CNA C on 06/11/2025 at 2:30 pm she stated that on 12/18/2024 she was giving the resident a bed bath when the PEG tube had become dislodged. Specifically, it was while she was putting Resident #44's shirt back on. She stated that when it happened, she ran to grab LVN A. LVN A tried to replace it, but they were instructed to send her out to the hospital. She stated that she had training on a bed bath at CNA school. She had not had any training on handling PEG tubes while working at the facility. She stated they did not provide any further education after the incident. She believed the resident was unharmed because the resident was smiling and made no noises or facial grimacing that could have been considered a painful response. She stated she thought it was important to have training and action plans for bed baths on her care plan. Interview with LVN A on 06/11/2025 at 2:45 pm revealed that she was the nurse on the hall when Resident #44's PEG tube became dislodged. She stated CNA C had immediately notified her when the tube became dislodged. The CNA reported that while pulling Resident #44's top down after a bed bath the PEG tube became dislodged. She stated the tube had come out twice before. She stated during the incident there was no bleeding, no obvious signs of pain. She cleaned the area, covered it, and prepared Resident #44 to be transferred to the hospital. She stated it would be important to have the steps to take when a tube is dislodged on the care plan because it would help guide another nurse who was unfamiliar with Resident #44. She stated the only training CNAs got was communication between the LVN and CNAs to be careful around the tube. She stated she was responsible for ensuring that the CNAs were handling the tube correctly while giving a bed bath. In an interview with the MD on 06/12/25 at 09:40 AM she stated that she had no concerns for Resident #44's care at the facility. She stated that Resident #44's feeding tube can come out and that the stoma opening had significant scar tissue around the stoma. She said the risk of infection was very low especially if staff had put in a catheter to protect the opening and cover it. She stated it was acceptable to send the resident out to the hospital to replace the PEG tube. She stated that all things related to PEG tubes should have been care planned. In an interview with the DON on 06/12/2025 at 10:26 am she stated that she had been at the facility for two weeks and was not aware of the incident with Resident #44's PEG tube being dislodged during care. She stated that the CNAs should be aware of who had indwelling devices. She stated that any sort of change of condition that required hospitalization should be on the care plan. She stated that it would have helped nurses know what to do when that did happen. This would have ensured timely care without confusion. In an interview with the ADM on 06/12/2025 at 1:45 pm, she stated that care plans were individualized. She stated that anything they needed to provide excellent care should be on the care plan. She stated the care plans should have been updated after the morning meeting. The DON or MDS nurse was responsible for updating care plans. She stated there was very little risk to the resident because the nurse acted quickly without having to look at the care plan. Care plan policy was requested on 06/12/2025 from Adm but not provided before exit.

Based on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 1 (Resident #72) of 6 residents reviewed for PASRR. The facility failed to complete an accurate PASRR level one screening after Resident #72 was admitted with a negative PASRR Level 1 screening but had a mental illness. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Record review of Resident #72's quarterly MDS assessment, dated May 9, 2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of Paroxysmal Atrial Fibrillation (irregular heart rhythm episodes are intermittent and short-lived), Atherosclerotic Heart Disease (buildup of fats, cholesterol and other substances in and on the artery walls), Sick Sinus Syndrome (heart rhythm problems caused by a malfunctioning sinus node) and Major Depressive Disorder. Her BIMS score was a 09 which indicated moderate cognitive impairment. Record review of Resident #72's care plan dated last revised 08/13/2024 reflected resident was on an antidepressant medication due to depression. Record review of Resident #72's PASRR Level 1 screening, dated 05/20/2023 conducted by an acute care hospital, reflected Resident #72 was negative for mental illness, intellectual disability, and developmental disability. Interview on 06/12/25 at 11:15AM, with MDS Coordinator J revealed she had been the MDS coordinator for the facility for 1 year. MDSC J stated that a mental illness would result in a positive Level 1 PASRR screening. If a resident had a positive Level 1 PASRR screening, it would lead to a Level 2 PASRR screening. MDSC J stated that Resident #72's diagnosis of Major Depressive Disorder, should have resulted in a positive Level 1 PASRR. MDSC J stated this could negatively impact a resident by not being provided services that they qualify for. Interview on 06/12/25 at 11:33 AM, with MDS Coordinator K revealed she had been the MDS coordinator for the facility for 23 years. MDSC K stated that a mental illness, intellectual disability and developmental disability would result in a positive Level 1 PASRR screening. MDSC K stated a resident that had a positive Level 1 PASRR screening, would qualify for a Level 2 PASRR screening. MDSC K stated that Resident #72's diagnosis of Major Depressive Disorder should have resulted in a positive Level 1 PASRR screening. MDSC K stated this could negatively impact a resident by not being provided the services that were needed. Interview on 06/12/2025 at 12:00PM with the DON revealed that she had been the DON for the facility for 2 weeks. The DON stated that Resident #72 had a diagnosis of Major Depressive Disorder, which should indicate a Positive Level 1 PASRR screening. The DON stated Resident #72 did have a diagnosis of Dementia but it was not her primary diagnosis. The DON stated not having proper PASRR services could negatively impact residents by being at risk of rapid decline and not getting the services necessary for her diagnosis. Interview on 06/12/2025 at 1:00PM with the ADM revealed that he had been the ADM for the facility for 3 years. The ADM stated that a positive Level 1 PASRR could be from mental health issues and intellectual disabilities. The ADM stated if the Level 1 PASRR was positive, residents were to be screened for Level 2 PASRR. The ADM stated Resident #72 had a diagnosis of Major Depressive Disorder. The ADM stated this should have resulted in a positive Level 1 PASRR. The ADM stated this could negatively impact residents by missing out on the beneficial services that were available. Review of the facility's PASRR policy dated last revised 05/10/2021 revealed The intent of this guideline is to identify residents with Mental Illness, Intellectual Disability or Developmental Disability/Related Conditions and to ensure they are properly placed, whether in community or in a Nursing Facility and to ensure they receive the services they require for their MI, ID or DD. This document revealed the following: 1. In the event of a positive PL1 that indicate the individual may have ID/DD or MI. a. The MDS coordinator will review the PE , print the form and place in the medical record. 2. When it is determined that PL1 was filled out incorrectly, the MDS coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form. a. If the case worker is unwilling/unable to correct the PL1 that contains a potential error, they will complete and submit a form 1012 (MI) or new PL1 (ID/DD).

Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, comfortable and homelike environment, for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally threaten Resident #1 on 08/30/24. This failure placed resident at risk of abuse. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, major depressive disorder, generalized anxiety disorder, intracranial injury with loss of consciousness (brain injury affecting cognition and behavior), hemiplegia (paralysis on one side of the body), morbid obesity due to excess calories. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderately impaired cognition. It reflected he was completely dependent on staff for toileting hygiene. Record review of Resident #1's care plan, dated 03/13/24, reflected the following: [Resident #1] is/has potential to be verbally aggressive (calling out, use of profanity) secondary to diagnosis of TBI. I will demonstrate effective coping skills through the review date. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc . Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. Two staff care providers at all times. Record review of an automated electronic monitoring video recording , dated 08/30/24, reflected the following exchange while CNA A helped Resident #1 get dressed: CNA A: Let go to put your jeans up, please! You're being difficult today. It's too much! Resident #1: Y'all gonna put my jeans on. CNA A: Stop holding yourself like that now I can put your jeans on. Long time ago. Come on, hold your hands. Resident #1: Don't rock the jukebox! CNA A: Rock the juice box, what does that mean? Resident #1: Don't rock me! CNA A: No one is rocking you! What does rocking mean?! Resident #1: Quit pushing me CNA A: Nobody's pushing you. I'm turning you. Resident #1: Quit pulling me CNA A: Turning! It's turn! Tuuurning! Resident #1: Whatever CNA A: Why are you yelling? Resident #1: Stop it! CNA A:You stop it. Stop yelling. Resident #1: *balls up fist and points it at CNA A* CNA A: What are you gonna do with that? Hit me! Watch! Hit me if you want! You gonna see. I got a hand too I'm gonna push you back. I don't care! You don't get the right to push me or punch me. I'm not playing with you! Record review of a psych note, dated 09/03/24, reflected the following: Behavioral meeting done with staffs and visit conducted per protocol. Mood assessed and reports gotten. No depression, anxiety, insomnia, loss of appetite, psychosis mentioned or reported. There has also been no reports of suicidal ideations. Record review of a psych note, dated 01/07/25, reflected the following: Behavioral round done at facility. No changes would be made today. There are no reports of depression, loss or increased appetite, insomnia. There are still some behaviors. no changes for now. During observation and an interview on 02/05/25 at 10:07 AM, Resident #1 was lying in his bed and said he was comfortable and not in any pain. He stated everyone at the facility treated him well, but his FM was always saying things. He stated he felt safe in the facility. He stated he did not know anyone with CNA A's name. He stated he did not remember anyone being abusive to him. During an interview on 02/05/25 at 10:30 AM, A FM for Resident #1 stated they looked at the video camera back in September 2024 and saw the video of CNA A threatening Resident #1. The FM stated they had not provided the video to the ADM due to not trusting the facility to intervene, but did not think CNA A worked at the facility anymore, because the FM had complained about CNA A and was under the impression CNA A had been fired. The FM stated they saw CNA A working at the facility on 01/01/25 and was concerned that she might have access to Resident #1 . During an interview on 02/05/25 at 01:15 PM, the ADM stated she had not seen the video in which CNA A threatened Resident #1. She stated the FM for Resident #1 did show her another video in November 2024 that was poor customer service by CNA A but not threatening, intimidation, or abuse. The ADM stated they took CNA A off Resident #1's care after the video in November and in-serviced her about customer service, but the ADM was not aware of any previous or later incidents. She stated the threat in the video was not acceptable and would lead to CNA A's termination from employment. The ADM stated she wished the FM for Resident #1 had shown the video much sooner. The ADM stated Resident #1 did have a history of verbal and physical aggression toward staff, and many of her staff did not wish to work with him. The ADM stated she was the abuse coordinator and responsible for the abuse prevention program. She stated the potential negative outcome of a staff person speaking in a threatening manner to a resident was the resident might not feel safe in the community . She stated she had not seen a difference in Resident #1's behavior since the incident. During an interview on 02/05/25 at 03:07 PM, the DON stated if he had seen the video of CNA A threatening Resident #1, she would have been terminated immediately. He stated he had not seen the video and was not aware of anyone from the facility seeing the video. The DON stated the ADM was the abuse coordinator, and he (the DON) was her back up abuse coordinator. He stated the entire facility staff was responsible for preventing abuse. He stated they ensured compliance through routine in-servicing, auditing, and frequent rounding. The DON stated they also heard from the resident council to prevent abuse and neglect. The DON stated the potential negative outcome of the failure exhibited in the video was emotional harm and it could have escalated to physical harm. The DON stated he had not seen any changes or decline in Resident #1. He stated Resident #1 frequently refused care, but they could usually go back in and provide care. He stated the staff were trained to walk away if he was being aggressive with them and reapproach later or have someone else reapproach. He stated he called and terminated CNA A's employment moments before (02/05/25 prior to 03:07 PM) and took her off the schedule. An attempt was made to interview CNA A by telephone on 02/05/25 at 03:17 PM. A voicemail was left, and no contact was returned as of 02/12/25. Record review of the 2024-2025 training transcript for CNA A reflected undated trainings on Resident Abuse and Managing Behaviors in the Dementia Resident. Record review of the facility's policy, dated 08/15/22, and titled Abuse, Neglect and Exploitation reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations, in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs, and behavioral symptoms.

Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, or injuries of an unknown source were reported immediately but not later than 24 hours after the allegation was made for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to report to the State Survey agency of an injury of unknown origin when Resident #1 was diagnosed with a L1 transverse process fracture (a break in one of the bony projections on the sides of the vertebrae). This deficient practice could place residents at risk of abuse and neglect. 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 unspecified dementia, hemiplegia (paralysis on one side of the body), generalized anxiety disorder, and morbid obesity. Review of Resident #1's quarterly MDS assessment, dated 10/03/24, reflected a BIMS score of 6, indicating he had a severe cognitive impairment. Review of Resident #1's quarterly care plan, dated 10/07/24, reflected he presented with cognitive impairment secondary to diagnosis of TBI and dementia with an intervention of asking yes/no questions in order to determine his needs. It further reflected he had paint r/t chronic physical disability with an intervention of anticipating his need for pain relief and responding immediately to any complaint of pain. Review of Resident #1's hospital discharge paperwork, dated 09/27/24, reflected the following: Hospital course: [Resident #1] admitted for low back pain and knee pain. Found to have L1 transverse process fracture. Review of Resident #1's progress notes, dated 09/30/24 and documented by LVN A, reflected the following: Transferred from hospital . has fx L1 and L knee contusion . During an interview on 11/26/24 at 12:30 PM, the DON stated he did not believe Resident #1's fracture was a reportable incident because they did not know when it happened, how it happened, or how long it had been there. He stated the hospital, orthopedist, and MD could not confirm when it happened. He stated he (Resident #1) had not had any recent falls at the facility. He stated he did not see it as an injury of unknown origin but more so as an injury of unknown time. The ADM stated she had heard the fracture had not been confirmed, but if she had known he had an actual fracture, she would have reported it to HHSC . The ADM stated the importance was to ensure they were addressing his pain, care, and to ensure there had not been any instances of abuse or neglect. Review of the facility's Abuse Investigation and Reporting Policy, Revised July 2017, reflected the following: All reports of resident abuse, neglect . injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management .

49097 Based on observation, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five of 20 residents (Residents #9, Resident #69, Resident #71, Resident #352, and Resident #6) reviewed for accommodation of needs. The facility failed to ensure Residents #9, #69, #71, #352 and #6's call-lights were within reach. This failure placed residents at risk of not being able to call for needed care and services which could result in not having their needs met or being unable to call for help in an emergency. Findings included: Review of Resident #69's Face Sheet dated 05/01/2024 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnoses included dementia, overactive bladder, heart disease, weakness, urinary tract infection, toxic brain disease, and blood clots in the veins. Review of Resident #69's Quarterly MDS assessment dated [DATE] revealed his BIMS score was zero, which means resident is severely cognitively impaired. The MDS also revealed that Resident #69 was totally dependent on staff assistance with transfers, toileting, and bed mobility. Record review of Resident #69's care plan dated 03/14/2024 revealed in part (Resident #69) is high risk for falls related to: dementia, overactive bladder and high blood pressure. Further review of above plan revealed Be sure to keep residents call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request of assistance. Observation and interview on 04/30/2024 at 11:25 AM, observation of CNA A walked out the Resident #69's room with a bag in her hand . Resident was lying in bed and his call light was on the floor. Resident #69 stated that he had just been changed and that he usually has his call light and that he uses the call light. In an observation and interview on 04/29/2024 at 11:36 AM RN A stated Resident #69 used his call light sometimes. RN A went into Resident #69's room and observed the call light on the floor. RN A picked up the call light and put it in the resident's reach. In an interview on 04/29/2024 at 11:41 AM CNA A stated Resident #69 liked to put his call light on the floor. She stated that she had just finished changing Resident #69. When asked if she forgot to put the call light back in reach of the resident she did not answer. Review of Resident #9's Face Sheet dated 05/02/2024 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses included diabetes, swelling in the legs, asthma, morbid obesity, cancer of pituitary gland, insomnia, sleep apnea, depression, reflux, glaucoma, heart disease, and abnormal bone growth. Review of Resident #9's Quarterly MDS assessment dated [DATE] reflected her BIMS score was fifteen, which means resident has no cognitive impairment. The MDS also revealed that Resident #9 needs maximal assistance with transfers, toileting, and bed mobility. Record review of Resident #9's care plan dated 04/07/2024 reflected in part (Resident #9) is high risk for falls related to: obesity, sleep apnea, depression, glaucoma. Further review of above plan revealed Be sure to keep residents call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request of assistance. Review of Resident #71's Face Sheet dated 05/02/2024 reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnoses included dementia, lung disease, retention of water, kidney disease, anemia, absence of right leg, urine retention, reflux, heart failure, prostatic cancer, blocked arteries, and irregular heart rate. Review of Resident #71's Quarterly MDS assessment dated [DATE] reflected her BIMS score was eleven, which means resident is moderately cognitively impaired. The MDS also revealed that Resident #71 needs extensive assistance with toileting, and bed mobility. Resident #71 was totally dependent for transfers. Record review of Resident #71's care plan dated 02/29/2024 reflected in part (Resident #71) is at risk for falls related to: dementia, chronic obstructive pulmonary disease, chronic kidney disease, and congestive heart failure. Further review of above plan revealed Be sure to keep residents call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request of assistance. Observation and interview on 05/01/2024 at 9:29 AM, Resident #9 sitting in wheelchair, dressed and well groomed. Resident was sitting approximately three feet away from her bed, along the side of her bed. Resident's call-light was wrapped around the bed rail that was farthest away from the resident. Resident #9 stated she used her stick to get the call light or would wheel herself out to the hall for assistance. Observation and interview on 05/02/2024 at 8:28 AM with Resident #71 revealed Resident #71 was sitting up on the edge of his bed, in the middle of the bed. Resident was groomed and in a hospital gown. Resident #71's call light was hanging straight down from the wall on the floor in between his bed and the wall. The call light was not in the resident's reach. Resident #71 stated that staff do not answer his call light and that he did not know where it was. Record review of Resident #352's undated Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory failure with Hypoxia (condition where there is not enough oxygen in body tissues), Hemiplegia (paralysis affecting one side of body) and Hemiparesis (partial weakness) following Cerebral Infarction (brain stroke) affecting left non-dominant side and Major Depressive Disorder (mood disorder causing persistent feeling of sadness and loss of interest). Record review of Resident #352's initial MDS assessment dated [DATE] reflected a BIMS score of 14 indicating intact cognitive status. Functional abilities and goals reflected he was dependent for repositioning in bed, transferring from bed to chair and for toileting hygiene. Record review of Resident #352's Care Plan dated 05/01/2024 reflected he had a moderate risk for falls r/t weakness. Intervention: be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation on 04/30/2024 at 10:44 AM revealed Resident # 352's call light was on the floor and under his bed. He was sleeping and not responsive to any questions. In an observation and interview on 04/30/2024 at 10:50 AM the DON stated Resident #352's call light should not have been on the floor and was not in reach if the resident needed something. The DON placed the call light back on Resident #352's bed. Record Review of Resident #6's face sheet dated 05/02/2024 revealed an admitted [DATE] with diagnoses of unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hemiplegia (paralysis on one side of body), unspecified intracranial injury (injury to the brain), major depressive disorder, conversion disorder with seizures (condition where mental health issue disrupts how your brain works), cirrhosis of liver (liver damage leading to scarring and liver failure), morbid obesity (when weight is significantly more than ideal body weight), chronic kidney disease (condition in which the kidney are damaged and cannot filter blood as well as they should), and chronic pain syndrome (persistent pain that lasts weeks to years). Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 which indicated the resident has moderate cognitve impairment. Further review revealed Resident #6 is dependent for chair/bed-to-chair transfers. Observation on 4/30/2024 at 9:47 AM revealed Resident #6's call button was on the ground and not in reach of Resident #6. During an interview on 04/30/2024 at 9:47 AM, Resident #6 stated he was not sure where his call button was. In an interview on 05/02/2024 at 11:27 AM LVN A stated that the policy was the call light should be within the resident's reach. He also stated there were several types of call lights for residents with different needs. He stated that the call lights should be answered within five minutes. He stated all care staff were responsible for answering the call lights. LVN A stated care staff and CNAs were responsible for placement of the call lights. He stated it was important the call lights were in reach of the residents so that they can call staff if they need something or in an emergency. He stated the call light should never be out of the resident's reach. He stated he was not aware of the call lights not being in reach of the residents. He stated they may have fallen but if staff noticed it should have been put back in the resident's reach. In an interview on 05/02/2024 at 11:39 AM the ADM stated the policy on the call lights were to be always in reach of the resident. She stated all staff in the facility were responsible for ensuring the call lights were in the resident's reach. She stated it was important to make sure the call light was in reach so the staff can accommodate the resident's needs or in case of an emergency. She stated Resident #71's light may have fallen. She stated that Resident #9's light was missed by staff because they may have gotten busy and were not thinking about the light. She stated they did not have a written policy. In an interview on 05/02/2024 at 11:52 AM CNA B stated everyone was responsible for answering call lights. She stated CNAs are responsible for placing the call light in the resident's reach. She stated it was important to place the call light in the resident's reach so, when the resident needs something, or needed to go to the bathroom they can call a staff member. CNA B stated the call light should be always in the resident's reach. She did not know why Resident #9's and Resident #71's call lights were not in their reach. In an interview on 05/02/2024 at 12:02 PM CNA C stated the policy was the call light needed to be next to the resident. She stated if the resident is in the chair the call light should be next to them. She also stated if the resident was in bed the call light should be on the bed with the resident. She stated any staff can answer the call light but CNAs, ma's and nurses are responsible for ensuring the call light was in the resident's reach. She stated it was important for the resident to be able to call for help when they need something. CNA C stated that the call light should be anywhere the resident is at in the room. She stated she did not know why Resident #9 and Resident #71's call lights were not within their reach. In an interview on 05/02/2024 at 12:11 PM the Director of Clinical Services stated call lights should be in reach of the resident so they can get the assistance they need. She stated if the resident's call light was not in reach, they wouldn't be able to get help and that could potentially lead to them falling. In an interview on 05/02/2024 at 1:51 PM the DON stated the policy on the call lights should be in the resident's reach and answered. He stated anyone who walks past the light or up and down the hall is responsible for answering the call light or checking the call light placement. He stated that the call light should always be in the resident's reach when the resident is in their room. He stated it is important to have it within the resident's reach so that the resident's need can be met. He stated that Resident #9 and Resident #71's call lights were not in reach of the resident because someone did not do what they were supposed to do. Record Review of Daily Care: Assigned Rounds for Excellence not dated reflected call light in reach of resident (check function). Bathroom call light functional were on the checklist.

Based on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 3 of 5 residents (Resident #52, Resident #62, and Resident #99) reviewed for advanced directives: The facility failed to ensure Resident #52's MPOA included all pages and was signed, dated, and witnessed or notarized to confirm it was valid. The facility failed to ensure Resident #62's OOH-DNR form has the physician's license number, date of signature and printed name in the physician's statement section which made the document invalid. The facility failed to ensure Resident #99's OOH-DNR was signed and dated by a legal guardian, agent, proxy or qualified relative and witnessed or notarized or executed by two physicians which made the document invalid. These failures could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention due to confusion regarding authority to make medical decisions on behalf of the resident. The findings include: Record review of Resident #52's face sheet dated [DATE] revealed an admitted [DATE] with diagnoses of: Encephalopathy (brain disease that alters brain function) unspecified dementia, alcohol dependence, and major depressive disorder. Further review revealed Resident #52's family member was listed as responsible party and POA of care. Record review of partial MPOA for Resident #52 reflected this document only included two pages and did not include any signatures or dates therefore rendering it incomplete and invalid. The signature pages should include Resident #52's dated signature and the dated signatures of two individuals who were witnesses or a dated notary signature Record review of Resident #52's undated care plan reflected interventions to ensure resident wishes were followed as desired and to follow advance directives. Record Review of neuropsychological report dated [DATE] revealed Resident #52 had increased cognitive impairment. Record Review of letter from MD dated [DATE] reflected that Resident #52's MD suggested her MPOA make all decisions regarding health care, finances, and legal matters. Record review of The St. Louis University Mental Status (SLUMS) examination dated [DATE] indicated Resident #52 scored in the dementia range. Record review of Resident #62's face sheet dated [DATE] reflected an admitted [DATE] and diagnoses of unspecified dementia, type 2 diabetes, unspecified glaucoma (eye disease that can cause vision loss), overactive bladder, restless legs syndrome, depression, and heart disease. Record review of Resident #62's clinical records revealed an OOH-DNR order form reflected an MD signature in section F and no signature in the physician's statement section. The physician's statement section lacked an MD's license number, date signed, printed name and signature in the physician's statement section. Record review of Resident #62's undated care plan reflected resident chose DO NOT RESUSCITATE status with intervention to ensure that Resident had a completed Texas OOH-DNR in the medical chart. Record review of Resident #62's quarterly MDS assessment dated [DATE] reflected a BIMS score of 1 and indicated severe cognitive impairment. Record review of Resident #99's face sheet dated [DATE] revealed a readmitted [DATE] with diagnoses of acute respiratory failure with hypoxia (when oxygen is not available in sufficient amounts), schizoaffective disorder (a mental health condition which includes symptoms of schizophrenia and mood disorder), anemia (a condition when a lower amount of red blood cells are produced), type 2 diabetes, metabolic encephalopathy (an imbalance in the brain), essential hypertension (high blood pressure), pressure ulcer of sacral region (skin injury in the lower region of body near back and spine), and colostomy status (opening of large intestine through the abdomen). Record review of Resident #99's clinical record revealed an OOH-DNR order form dated [DATE] lacked both required physician's dated signatures, printed name and license numbers under section F as required for an OOH-DNR order form executed by a physician. Record review of undated care plan for Resident #99 reflected resident chose DNR status. Record review of Resident #99's MDS dated [DATE] reflected that Resident #99 expired. Record review of Resident #99's clinical records indicated he was admitted to hospice on [DATE]. In an interview on [DATE] at 12:34 PM, RN B stated when a new resident was admitted the facility received a report from the hospital and were notified of code status (resident's preferred resuscitation procedures) for the resident. RN B stated the resident was asked what their code status was when they were admitted . RN B stated that if a Resident was unable to answer what their code status was then their documents were reviewed and family members were called. RN B stated code status can be discussed during care plan meetings. RN B stated if the resident did not have DNR paperwork they were considered full code until the facility obtained paperwork. RN B stated that she was able to check if a DNR was filled out correctly and then confirmed with the social worker and updated the order in the system. RN B stated that the DNR for Resident #99 was filled out correctly. During an interview on [DATE] at 12:41 PM, LVN A stated that they determined code status by looking it up in the computer and looked to verify if there was an actual document and if the document was filled out correctly. LVN A stated that the DNR must be filled out correctly to be valid and that he was able to determine if it was filled out correctly when he reviewed it. LVN A stated that if it was found that the OOH-DNR was incorrect he would let someone know in management so it could be corrected. LVN A stated that social worker was responsible to ensure the OOH-DNR was filled out correctly. During an interview on [DATE] at 12:48 PM, the DON stated that the social worker initiated advanced directives and the physician signs and executed them. The DON stated that the social worker and family were responsible to ensure it was filled out completely and accurately and then it was reviewed by medical staff. The DON stated he should ensure that advanced directives were in PCC (point click care, the facility's electronic health record) and ensure they were filled out correctly. The DON stated if it is filled out incorrectly staff may have to initiate CPR which may not meet the residents' wishes. The DON reviewed Resident #62's OOH-DNR and stated that it was not filled out correctly. The DON reviewed Resident #52's MPOA and stated it was not considered a full MPOA and there were no signatures. The DON stated that he believes it is the social worker who reviewed the advanced directives. During an interview on [DATE] at 2:00 PM, the ADM stated that first the social worker checked advanced directives upon admission to see if the resident had any. Then, the social worker reviewed code status and what the resident wishes were and what the resident had in place. The ADM stated it is the expectation that all advanced directives are filled out accurately and complete. Record review of the facility's advance directives policy dated [DATE], titled Advance Directive revealed The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Record review of Texas DSHS Instructions for Issuing an OOH-DNR Order dated [DATE] reflected the attending physician may execute the OOH-DNR Order by signing and dating it in Section F with concurrence of a second physician (signing it in Section F) who is not involved in the treatment of the person or who is a representative of the ethics or medical committee of the health care facility in which the person is a patient. Record review of health and safety code 166.151 dated [DATE] revealed the medical power of attorney must be signed by the principal in the presence of two witnesses or have the signature acknowledged by a notary public; witnesses must also sign the document.

Based on observation and, and interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for two of two shower rooms (100-200 Hall and 300-400 Hall) in the facility used by the residents. The facility failed to ensure the shower curtains would close for privacy in both shower rooms used by the residents. This failure could place all residents at risk for lack of privacy, dignity, and a diminished quality of life. Findings included: In a confidential interview, an interviewee stated the shower curtains did not close all the way in the 100 and 200 hall shower room, and she did not have privacy during her showers. Observation on 05/01/2024 at 2:04 PM of the shower curtains in shower room for the 100-200 halls revealed the curtains in three shower stalls were missing hooks and did not close all of the way. Observation on 05/01/2024 at 2:10 PM of the shower curtains in the shower room for 300-400 halls revealed hooks were missing on the middle shower stall curtain and it did not close all of the way. The shower curtain closest to the 300 hall was missing hooks and did not close completely. In an interview on 05/02/2024 at 10:45 AM the Maintenance Director stated he made rounds in shower rooms but did not notice anything wrong with the curtains. He could not say when he last made rounds in the shower rooms but stated he was informed on 05/01/2024 that the curtains needed repair and he fixed them. He stated the staff were supposed to put maintenance requests into a computer application for maintenance. In an interview on 05/02/2024 at 10:49 AM CNA F stated she had worked at the facility since 2017 but did not know how to access the computer application for maintenance. She stated if she saw an issue that required maintenance she notified the nurse, and they would enter it into the computer. In an interview on 05/02/24 at 10:52 AM CNA A stated she had worked at the facility for 6 months. She stated she did not know how to enter a maintenance request. She further stated she would just tell the Maintenance Director because he spoke Spanish. Observation on 05/02/2024 at 11:00 AM revealed a posting on the wall next to a desk on 100 hall that was used by the CNAs. The posting stated, How to make a Maintenance Request. It stated the computer application was how the Maintenance Director managed his work orders and there were step by step instructions on how to enter a work order into the computer. In an interview on 05/02/2024 at 1:20 PM the ADM stated she expected the Maintenance Director to check the shower rooms weekly and to make sure everything was functioning correctly. She stated if the shower curtains did not close all the way it could affect the resident's dignity. In an interview on 05/02/2024 at 1:53 PM the Director of Clinical Services stated her expectation was to provide privacy for residents. She stated the shower curtains not closing all of the way could affect the residents' dignity. She further stated the staff made rounds daily, and shower curtains might need to be added to the checklist. In an interview on 05/02/2024 at 1:25 PM the DON stated his expectation was that bathroom doors would be closed during showers and ensure the shower curtains were in working order to preserve the resident's dignity. Record review of an undated checklist titled Daily Care: Assigned Rounds for Excellence reflected shower curtains were not listed. Record review of a facility policy and procedure titled Homelike Environment dated 2001 and revised February 2021 reflected, Residents are provided with a safe, clean, comfortable homelike environment.

Based on observation, interview, and record review the facility failed to ensure residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents which resulted in a mechanical lift lift falling on 1 resident for 1 of 3 (Resident #6) residents reviewed for safe transfers. The facility failed to ensure the legs of the mechanical lift lift were widened during a transfer for Resident #6. This failure could place residents who require mechanical lift lift transfers at risk for falls and/or injury. The findings include: Record Review of Resident #6's face sheet dated 05/02/2024 revealed an admitted [DATE] with diagnoses of unspecified dementia, hemiplegia (paralysis on one side of body), unspecified intracranial injury (injury to the brain), major depressive disorder, conversion disorder with seizures (condition where mental health issue disrupts how your brain works), cirrhosis of liver (liver damage leading to scarring and liver failure), morbid obesity (when weight is significantly more than ideal body weight), chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), and chronic pain syndrome (persistent pain that lasts weeks to years). Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 which reflects moderate cognitive impairment. Further review of MDS revealed Resident #6 was dependent for chair/bed-to-chair transfers. Record review of undated care plan reflected Resident #6 has an ADL self-care deficit and required total dependence with mechanical lift lift transfer. Record review of nurse progress note from RN A dated 02/24/2024 at 1:37 PM revealed nurse and CNA (unnamed) helped Resident #6 to transfer in wheelchair with mechanical lift lift. Record review revealed mechanical lift tilted on Resident #6 during transfer. The progress note reflected Resident #6 was assessed for injury and reflected no injury was found. Record review of nurse progress note dated 02/24/2024 at 9:46 PM reflected no change in condition related to mechanical lift lift accident for Resident #6. Review of video footage dated 02/24/2024 at 12:52 PM revealed mechanical lift fell on Resident #6 during transfer from bed to wheelchair. Further review revealed a leg of the mechanical lift lift was under the wheels of the wheelchair with the other leg of the mechanical lift lift in the front of the wheelchair and did not appear to be widened. Record review revealed in-service dated 02/24/2024 was completed with facility staff regarding mechanical lift lift use. Record review of facility's undated Mechanical Lift Skill Assessment reflected staff should open the legs of the lift to their widest position. Observation on 04/30/2024 at 9:45 AM revealed electronic monitoring posting outside of Resident #6's room. Further observation revealed electronic monitoring device in Resident #6's room. Observation on 05/01/2024 at 9:21 AM displayed CNA D and CNA E transfer Resident #24 with mechanical lift lift out of bed to wheelchair. Observation showed mechanical lift lift legs widened and placed around front of wheelchair and Resident #24 lowered into wheelchair. Observation on 05/01/2024 at 10:02 AM displayed CNA H and CNA F utilized mechanical lift lift to weigh Resident #27. Observation showed CNA H and CNA F widened mechanical lift lift legs during this lift. Observation on 05/01/2024 at 10:12 AM displayed CNA E, CNA G and ADON transfer Resident #6 with mechanical lift lift. Observation showed staff widened mechanical lift lift legs and placed them around the wheelchair to lower Resident #6. During an interview on 05/01/2024 at 11:09 AM, CNA A stated that the legs of the mechanical lift lift were always supposed to be widened during transfers. During an interview on 05/01/2024 at 11:11 AM, CNA D stated the legs of the mechanical lift lift were supposed to be opened and the wheelchair was supposed to go between the legs of the mechanical lift lift and from the front of the wheelchair. CNA D stated she could not recall the last time she received an in-service regarding mechanical lift lift transfers. During an interview on 05/01/2024 at 11:15 AM, LVN A stated the placement of the mechanical lift lift legs depended on the size of the chair. LVN A stated if it was a larger chair you may need to go through the wheelchair, but if able the legs should go around the wheelchair and were widened. During an interview on 05/01/2024 at 11:24 AM, CNA C stated that during a mechanical lift transfer legs were supposed to go around the wheels of the wheelchair and transfers were supposed to be done from the front of the wheelchair with the mechanical lift lift legs widened. During an interview on 05/02/2024 at 11:04 AM: CNA F stated the legs of the mechanical lift were supposed to be opened and go around the wheelchair so it does not tip over. During an interview on 05/01/2024 at 1:46 PM, RN A stated there was an incident (on 2/24/2024) with Resident #6 and a mechanical lift tipping over. She stated there was a CNA present during this transfer but she was unable to recall who the CNA was. RN A stated the CNA was leading the transfer and the CNA forgot to widen the mechanical lift lift legs during the transfer. When RN A was asked why she did not ask the CNA to widen the legs prior to lifting Resident #6, RN A stated she did not notice the legs of the mechanical lift lift were not opened all the way until after the mechanical lift lift tipped. RN A stated that Resident #6 was in the chair and then the mechanical lift fell over. RN A stated the mechanical lift lift did not hit Resident #6. RN A stated that initially Resident #6 was scared but Resident #6 was assessed and was not injured. RN A stated that she completed an incident report and notified the on-call NP and ADM. RN A stated that Resident #6 was assessed for 72 hours after the incident to ensure there was not injury or bruising. During an interview on 05/02/2024 at 12:54 PM, DON stated during a mechanical lift transfer two people should be present and the legs of the mechanical lift should be opened wide. The DON stated if the legs of the mechanical lift lift are not opened wide this could cause the resident to be dropped or the mechanical lift may tip over. The DON stated it is the expectation that employees should have the legs of the mechanical lift lift widened for every mechanical lift lift transfer. The DON stated the mechanical lift lift legs should go around the entire wheelchair from the front of the wheelchair. Record Review of facility policy titled Safe Lifting and Movement of Residents dated July 2017 reflected in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to provide a system of medication records that enabled periodic accurate reconciliation and accounting for all controlled medications for 2 (300 Hall and 400 Hall) of 2 medication carts that were reviewed for pharmacy services. The facility failed to remove narcotic medications from medication carts once the order was discontinued. This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift. The findings included : During an observation and record review on [DATE] at 12:29 pm, an inspection of the medication cart for 300 Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), was missing signatures for [DATE]. On the aforementioned sheet, there was no signature present for the off-going night shift staff, nor the staff coming on for the morning shift. Further review revealed a form titled Shift Change Controlled Substance Inventory Log which revealed no signatures were present for [DATE]. The form was blank for the off-going night shift staff, and the staff coming on for the morning shift. Further review of the binder revealed that no signatures were present on the narcotic sheets for residents who had scheduled narcotics that should have been administered already on [DATE]. Resident #1 had a sheet that reflected she should get 3 hydrocodone per day, one every 8 hours, and none were documented on the sheet as administered [DATE] . Resident #2 had a sheet that reflected she should get pregabalin at 8 am and it was not signed as administered on [DATE]. In addition, she should have been given tramadol according to the sheet and it was not signed as administered either. Further review revealed that Resident #3 had a sheet for hydrocodone reflected to take 1 tab every 4 hours as needed for pain for 10 days and was written [DATE]. The sheet was still in the binder . On the same medication cart was the binder labeled 400 Hall and review of that binder revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), was missing signatures for [DATE]. There was no signature present for the off-going night shift staff, nor the staff coming on for the morning shift. Further review revealed a form titled Shift Change Controlled Substance Inventory Log and no signatures were present for [DATE]. The form was blank for the off-going night shift staff, and the staff coming on for the morning shift. During an interview on [DATE] at 12:37 pm with MA A, she stated that she had given the medications to Resident #1, Resident #2, and Resident #3, but she does not fill out the log (she does not fill out the count sheet for any specific controlled medication at the time she retrieves the medication) or do any paperwork until the end of her shift. She said that she hadn't got to the books yet. She further stated that when she hands off the keys to the medication cart at the beginning and end of shift, she counted all blister packets and not individual pills . She then pulled the hydrocodone and narcotic sheet for Resident #3 that was expired and pulled a morphine and the narcotic sheet for Resident #3 because it was an old prescription and no longer used. The medications and corresponding narcotic sheets were given to the DON. During an observation on [DATE] starting at 1:10 pm with MA A on the 400 Hall revealed she administered 1 alprazolam (an anxiety medication) .25 mg tablet to Resident #4 without documenting the administration in the narcotic logbook. During the same observation, MA A administered 15 mg of morphine, ordered every 8 hours, to Resident #5 without documenting the administration in the narcotic administration logbook. During an observation and record review on [DATE] at 12:45 pm of the 300 Hall Medication Cart and logbook revealed there was a narcotic sheet for Resident #6 that reflected Oxycodone 5 mg tablets, take ,d+[DATE] by mouth as needed and dated [DATE]. During an interview on [DATE] at 12:50 pm with RN B, she stated that Resident #6 no longer took oxycodone 5 mg. The medication and narcotic count sheet were removed from the medication cart. Record review of Resident #6's active orders list revealed no active order for oxycodone. During an interview on [DATE] at 3:00 pm with the ADM and DON they stated that the expectation was that staff would fill out the sheets in the narcotic logbook at each shift change with the out-going and on-coming staff counting the narcotics together and signing the sheets. They further stated that staff should fill out the narcotic count sheet at the time the medication was administered. Record review of the facility's policy titled, Controlled Substances, revised in ,d+[DATE], revealed, .3. nursing staff count controlled medication inventory at the end of each shift . 4. Nurse coming on duty and nurse going off duty make the count together . 13. Controlled substances remaining in the facility after the order has been discontinued are securely locked in an area with restricted access until destroyed.

Based on observation, interview, and record review, the facility failed to ensure staff did not use physical or psychological abuse on a resident for 1 of 5 residents (Resident #1) reviewed for abuse in that: The facility failed to ensure CNA A did not raised a fist at Resident #1 stating, stop touching me and pointed her finger while stating, stop it while providing peri-care to Resident #1. This failure could place residents at risk of fear and physical/psychosocial injury. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Dementia with agitation, Hemiplegia affecting non-dominant side, unspecified intracranial injury, muscle wasting and atrophy, hypothyroidism, anemia, chronic kidney disease, schizophreniform disorder, depression, anxiety, and cognitive communication deficit. Review of the quarterly MDS assessment for Resident #1 dated [DATE] reflected a BIMS Score of ,d+[DATE], which reflected moderate impairment in mental status, and indicated no physical or verbal behavioral symptoms directed toward others. MDS assessment for Resident #1 dated [DATE] also reflected substantial/maximal assistance was needed to roll from lying on back to left and right side, and returning to lying on back on the bed, and transfer from bed to chair with a mechanical lift. Review of the care plan for Resident #1 dated [DATE] reflected the following: Resident #1 has an ADL self-care performance deficit r/t Dementia, Hemiplegia, Impaired balance and TBI (all aides should provide care with 2 aides) and Special Instructions: Resident #1 has a diagnosis of TBI- this makes him have inappropriate behavior- female aides please take 2 people in with care and redirect as needed. During an interview on [DATE] at 10:45 AM the complainant revealed while viewing videos for Resident #1 she watched CNA A draw back her fist like she wanted to punch Resident #1, which happened after CNA A grabbed Resident #1 very tender and paralyzed arm as he removed her hand from the arm. While CNA A did not make contact, complainant felt the inappropriate and abusive behavior could escalate very quickly. Review of a video attachment on [DATE] per intake for Resident #1 reflected the following. CNA A and Resident #1 were alone in the room and CNA A struggled to turn Resident #1 toward his right side to secure brief on left side while pulling his left arm toward his body. Resident #1 stated, Leave my left arm alone while he grabbed CNA A left arm. CNA A pulled her left arm back with a fist and stated, Stop. Resident #1 again stated, Leave my left arm alone and grabbed CNA A left arm again, who again pulled her arm away and angrily stated, Stop touching me as she raised her right index finger in Resident #1 face. Observation conducted on [DATE] at 12:05 PM of Resident #1 sitting up in his wheelchair in room. Resident #1 was calm and appeared clean and well-groomed. During an interview on [DATE] at 12:05 PM Resident #1 revealed he had no concerns about his care, and he felt safe in facility. Resident #1 did not recall any incidents of staff mistreating him, and he stated the only thing he needed was 12 tacos, a car, and a camper to live in, and to go hog hunting and deer hunting. A telephone interview was attempted on [DATE] at 2:05 PM with CNA A . She did not answer, and no return contact had been initiated as of [DATE]. During an interview on [DATE] at 2:21 PM CNA B revealed she had been in-serviced monthly on abuse/neglect/incident reporting and providing care for residents with dementia and identified abuse/neglect/reporting protocols and strategies to assist residents with dementia who were being resistant or combative. CNA B stated when she comes on, they do report/rounds and check PCC under patient Information. CNA B also revealed she had not been aware of any altercations on 300 Hall. During an interview on [DATE] at 2:32 PM CNA C revealed she had been in-serviced monthly on abuse/neglect/incident reporting and providing care for residents with dementia and identified abuse/neglect/reporting protocols and strategies to assist residents with dementia who were being resistant or combative. CNA C stated when she comes on, they do report/rounds, ask the charge nurse and also check PCC under patient Information. CNA C also revealed she had not been aware of any altercations on 300 Hall. During an interview on [DATE] at 2:45 PM CNA D revealed she had been in-serviced monthly on abuse/neglect/incident reporting and providing care for residents with dementia and identified abuse/neglect/reporting protocols and strategies to assist residents with dementia who were being resistant or combative. CNA D stated if first time working with resident ask the nurse and look in PCC at the care plan. During an interview on [DATE] at 2:55 PM CAN E revealed she had been in-serviced through Care Agency on abuse/neglect/incident reporting and providing care for residents with dementia. CNA E stated she had been coming here for a couple of years. CNA E further stated when a resident requires more help, she will pull the call light. CNA that worked before me will tell me if a resident is one or two people. CNA E stated she checked residents at beginning of the shift after getting shift report. During an interview on [DATE] at 11:30 AM ADM stated she was not aware of any abuse allegations occurring on the date of [DATE] and would have initiated an investigation immediately. ADM further stated her expectation was for the residents to not have any kind of ANE occur, and for any allegations of ANE to be reported immediately. ADM revealed the facility utilized Care staffing agency, and they are responsible for registering background checks, expired licenses, registry concerns, and they will remove those staff from shifts. CNA A had customer service concerns Our facility chose to not have CNA A come back due to customer service issues regarding communication. Review of in-services from [DATE] through [DATE] reflected an in-service on abuse and neglect conducted on [DATE]. Review of facility policy dated [DATE] and titled Abuse, Neglect and Exploitation reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations, in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs, and behavioral symptoms.

Based on observation and interview the facility failed to ensure 1 of (Resident #1) 4 resident was free from abuse. The facility failed to keep a resident free from verbal and physical abuse as staff were observed committing physical and verbal abuse to a resident. These failures could place residents at risk of injury, intimidation, punishment resulting in physical harm, pain, and mental anguish. An IJ (Immediate Jeopardy) was identified on 08/18/2023. While the IJ was removed on 08/21/2023 the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Review of Resident #1's face sheet, dated 08/18/2023, revealed a [AGE] year-old-male, with diagnosis of dementia (a range of conditions that affect the brain's ability to think, remember and function normally), Intracranial injury, chronic kidney disease, presence of cardiac pacemaker, and cognitive communication deficit. Review of Resident #1's MDS, dated [DATE], revealed a BIMS of 07 indicating a severe cognitive impairment. Further review revealed bed mobility at extensive assistance with two plus person physical assist, transfers as total dependence with two plus person physical assist, and personal hygiene at extensive assistance with two plus person physical assist, and bathing total dependence. Review of Resident #1's specified dates of assessments: Review of Resident #1's assessments page, undated, revealed no head-to-toe assessments completed on 07/12/2023, 07/13/2023, and 08/15/2023. Observation on 08/18/2023 of Resident #1's electronic monitoring video in his assigned room that was supplied by family, revealed on 07/12/2023 at 07:44 p.m., CNA A assisting Resident #1 with Hoyer transfer: At the 01:55 mark CNA A initiated the Hoyer transfer by himself, at the 4:21 mark the CNA A place the resident down on his bed by himself with the Hoyer lift. At the 2:35 mark of the video, CNA started tapping Resident #1 in the stomach area stating that Resident #1 was his best friend, Resident #1 responded, keep your hands off of me., CNA A continued to perform the tapping motion on Resident #1's stomach area. At the 9:46 mark of the video, Resident #1 asks Where's the table?, CNA A responds in a loud tone, I Don't know!, Resident #1 stated, Well, go get it!, CNA A responds, No, I say No!. At the 9:57 mark of the video, Resident #1 stated, You're going to jail., CNA A responded, Even you., Further observations revealed Resident #1 stated to CNA A, they are going to fuck you in the ass., CNA A asked Resident #1, Who?, Resident #1 states, The inmates, CNA A responded back, They are going to fuck you too. Resident #1 states, They are going to fuck you., CNA A responded back, They are going to fuck you too., Resident #1 responded, Not me, CNA A responded, You, you're lying down, you're ready, you're ready, yah you're ready to be fucked. Observation on 08/18/2023 of Resident #1's electronic monitoring video in his assigned room that was supplied by family, revealed on 07/13/2023 at 08:56 p.m., CNA B and CNA C assisting Resident #1 with ADL care: At the 0:03 mark of the video, CNA C touched Resident #1's pants, Resident #1 yells, Don't touch me., CNA C then touched Resident #1 on his left hand. CNA C danced and clapped her hands while music played in the background. CNA B was observed with a white towel coming out of Resident #1's bathroom with a white towel. At the 2:23 mark of the video, CNA B wiped Resident #1's right leg with the white towel, then observed wiping Resident #1's right leg, CNA B was observed swinging the white towel to Resident #1, Resident #1 catches the white towel with this right hand, CNA B was observed tugging the white towel back, and was observed in a forcible motion with her right hand, grabs the white towel and proceeds to wipe Resident #1's upper portion of his body, staff are heard laughing. At the 2:34 mark of the video, Resident #1 was heard saying, Stop it lady. At the 2:49 mark of the video, CNA C was observed using intimidating language, stating We are the boss here, cooperate. At the 3:27 mark of the video, CNA B is observed wiping Resident #1's gluteal cleft (groove between the buttocks) with the white towel and then proceeds to wipe Resident #1 on his right leg with the same white towel. At the 3:36 mark of the video, CNA B is observed hitting Resident #1 in the gluteal area with the white towel, with a noticeable impact sound, CNA C is observed laughing. At the 3:43 mark of the video, CNA B is observed again hitting Resident #1 with the white towel in gluteal cleft, with a noticeable impact sound, CNA C is observed laughing. At the 4:11 mark of the video, CNA B stated, I love you (Resident #1's name)., CNA B further stated, I love you many fucker.,with Resident #1 while CNA C proceeds to laugh. At the 4:57 mark, CNA C is on the left side of Resident #1, CNA B is on the right side of Resident #1, CNAs perform turning of resident while, CNA C is fastening Resident #1's brief, while CNA B is holding Resident #1 on his side, CNA B proceeds in a forcible motion to lay Resident #1 down, Resident #1 screams, What are you doing?. At the 5:06 mark, CNA B is observed explaining that she will put Resident #1's t-shirt on, Resident #1 stated, You're a nigger you're lying., CNA A responded back, I'm a liar, nigger liar, liar nigger., CNA C is observed laughing and dancing. At the 5:37 mark of the video, CNA C is observed dancing next to Resident #1, on his right side, CNA B states, look at her bootie., while CNA C continued to dance, and perform a dancing motion with her buttocks, staff continued to laugh. CNA B is heard asking, you don't like the bootie?, staff continued to laugh. Interview on 08/19/2023 at 11:24 a.m., CNA A revealed knowledge of what abuse is, and confirmed he works the 2:00 p.m. to 10 p.m. shift. CNA A stated the last day he was at the facility was on 8/15/2023, as the ADM informed him there was an allegation for one resident related to a video related to Resident #1. CNA A stated, He swears to God, he did not curse., and added Resident #1 refuses care and curses at staff, and him. Interview on 08/19/2023 at 02:16 p.m., ADM revealed knowledge of abuse, and stated all allegations are to be reported to HHSC within two hours, any alleged perpetrators will be pulled off the halls immediately to assure resident's safety. Social worker will check on resident. ADM stated that the family did not inform her of the video until 08/15/2023, ADM stated that she was not informed of any allegation of abuse, the family brought concerns related to requesting medical records and that she explained the process. ADM stated she was informed by the family that they wanted to discuss the videos related to Resident #1. ADM stated Resident #1's family showed her the videos, although they would not supply to her fully, ADM saw it that day only. ADM confirmed the use of derogatory language, racial language, demeaning behavior, and verbal abuse used on Resident #1, reported the incident to HHSC within two hours, and suspended the alleged perpetrators. ADM reiterated, she reported the incident to HHSC on 08/15/2023, alleged perpetrators were pulled from the facility shift, safe surveys we completed, Resident #1 was seen by psych services, and ADM revealed during the meeting the family left the facility at approximately 04:00 p.m., she cannot recall the exact time she saw the video as she was emotionally affected by viewing the video, ADM stated she saw the video one hour before the family left the faciity on [DATE] at 04:00 p.m., ADM confirmed the identities of the staff in video as CNA A, CNA B, and CNA C. Interview on 08/19/2023 at 03:00 p.m., DON revealed knowledge of abuse, verbal abuse and physical abuse should not occur as it is mistreating residents. DON stated all allegations need to be reported immediately, assure resident safety. DON added that background checks are completed to check for outstanding behaviors in that certain charges are not accepted for hire. DON stated she watched the video for Resident #1 on 08/15/2023, and the incident was reported to HHSC. Interview on 08/19/2023 at 03:51 p.m., NP psychiatry revealed she visited Resident #1 on 08/15/2023 approximately at 05:30 p.m., as the social worker alleged that Resident #1 was abused. she stated Resident #1 can speak for himself, he knows a lot of things, and that she is able to converse with Resident #1. Resident #1 denied the facts of the incidents. NP psychiatry described types of abuse to Resident #1 and he denied it and stated no one is hurting him. NP psychiatry revealed that Resident #1 should be able to say if he was abused. NP psychiatry revealed when she saw Resident #1, he was calm and not in distress. Interview on 08/19/2023 at 04:13 p.m., CNA B revealed the last time she worked was on 08/15/2023, and stated Resident #1 can be aggressive to staff. CNA B stated she is aware Resident #1 has an electronic monitoring device in his rom. CNA B stated she did not mean to hit Resident #1 with the brief, as they were just playing, I just flicked him. CNA B stated she never abused Resident #1, and that Resident #1 uses racial language with staff. CNA B stated she has taken in-services related to abuse. Interview on 08/19/2023 at 04:55 p.m., DON stated that head-toe-assessments completed after allegations are made, DON stated that I did not get to do an assessment on Resident #1 after the allegation was made and brought to her attention, she just did not. Interview on 08/19/2023 at 04:55 p.m., ADM stated procedure for allegations of abuse are to investigate and report the allegations to HHSC, start in-services, social services will monitor, report it to local law enforcement. ADM stated she instructed LVN A to do an assessment on Resident #1 after the allegation was made. Interview on 08/19/2023 at 05:06 p.m., LVN A stated she does not remember that she was instructed to do a head-to-toe assessment for Resident #1 on 08/15/2023, she confirmed she did not do it. She stated that assessments are completed because we need to document anything going on with residents. LVN A stated that when nursing does an assessment, she is notified, what she recalls on Resident #1 in the past was treatment on his foot, swelling, some sloth, redness. LVN A stated that nursing is supposed to notify family about orders, and if family is not notified there is a problem because they are supposed to be informed. LVN A stated to her knowledge they did inform Resident #1's family for all orders and changes. Record review of HHSC's complaint website revealed a facility reported incident, control date 08/15/2023 at 05:01 p.m. and date received at 08/15/2023 at 05:00 p.m. Record review of the facility's daily nursing sign-in: Schedule for date 07/12/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/13/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts, and CNA C worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/14/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/15/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/16/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/17/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift., and CNA B worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/18/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/19/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/20/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/21/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift., and CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/22/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/23/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift., and CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/24/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/25/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/26/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 07/27/2023, revealed CNA B worked the 10:00 p.m. to 6:00 a.m. shift. Schedule for date 07/28/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/29/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/30/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 07/31/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 08/01/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 08/02/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 08/03/2023, revealed CNA B 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 08/06/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B worked the 2:00 p.m. to 10:00 p.m. shift. Schedule for date 08/07/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 08/08/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 08/09/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 08/11/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 08/12/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m. Schedule for date 08/13/2023, revealed CNA A worked the 2:00 p.m. to 10:00 p.m. shift, and CNA B worked the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts. Schedule for date 08/14/2023, revealed CNA B worked the 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. shifts. Record review subsequent evaluation/management visit, encounter date 08/15/2023, revealed Resident #1 stated, I'm fine, no one hursts me or abuses me Staff report Meeting done with family, they complain that he is being abused. No significant finds. Record review of facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restrain not required to treat the resident's symptoms. Policy interpretation and implementation The resident abuse, neglect, and exploration prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. 7. Implement measures to address factors that may lead to abusive situation, for example: a. adequately prepare staff for caregiving responsibilities. b. provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation. c. Instruct staff regarding appropriate ways to address interpersonal conflicts; and d. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. The plan of Removal was accepted on 08/21/2023 at 09:24 a.m., and included: Plan of Removal: Immediate Jeopardy On 08/18/2023 an abbreviated survey was initiated on 08/18/2023 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. Date Initiated: 08/18/2023 The notification of Immediate Threat states as follows: F600 The facility failed to ensure that the resident # 1 was free from Abuse. Statement of Deficient Practice: All residents could be at risk for potential negative affects to psychological well-being, emotional distress and fear due to abuse. Corrective Action: Upon learning of allegation Administrator immediately suspended alleged perpetrators, Reported, allegation in TULIP and began investigation. Responsible Party: Administrator Target Date/Date of Completion:08/18/2023 Follow-Up: Five-day report, 3613-A will be submitted no later than 8/22/23. Correction Action: Administrator and designee conducted resident safe surveys with residents cared for by the alleged perpetrators. Safe surveys are interviews with residents where residents are asked about abuse and neglect, if they ever experienced it in the facility and if they know who to report abuse and neglect to. Head to toe skin assessments were conducted on residents who were non-interviewable. Responsible Party: Administrator or Designee Target Date/Date of Completion:08/18/2023 Follow-Up: Safe surveys were reviewed by the Administrator and no additional concerns were voiced by residents. Department managers will interview 3 residents per week during assigned rounds for excellence to rule out abuse and neglect. Results of interviews will be reported to QAPI for 3 months and prn thereafter. Correction Action: Regional Director of Operations in-serviced Administrator on abuse and neglect. Administrator will provide in-service education for all staff, including agency, on abuse and neglect prior to next shift worked. Responsible Party: Regional Director of Operations/Administrator Target Date/Date of Completion: 08/18/2023 Follow-Up: All newly hired staff to include agency staff will be educated on abuse and neglect upon hire. The facility will provide annual and as needed abuse and neglect training to all staff. Administrator verified completion of training on 8/18/23. New hire in-services will be reviewed in QAPI for 3 months and prn thereafter. Corrective Action: Immediately upon being informed of the allegation on 8/15/23, the allegation was reported to the [NAME] Police Department. Case# 23-00386179 Responsible Party: Administrator Target Date/Date of Completion:08/18/2023 Follow-Up: Will follow up with [NAME] Police Department to obtain a copy of the report. Corrective Action: Psychiatric Nurse Practitioner met with Resident #1 to evaluate emotional well-being after incident on 8/15/23. Responsible Party: Social Worker Target Date/Date of Completion:08/18/2023 Follow-Up: Psychiatric NP will follow up with resident to re-evaluate emotional well-being on 8/21/23. Social Worker to meet with resident weekly for the next 6 weeks to evaluate emotional well-being. Social Worker to report any concerns identified during weekly evaluation, immediately to Psychiatric NP for additional follow up. Corrective Action: Social Worker met with resident # 1 to evaluate emotional well-being every day for 4 days after incident was reported. Ongoing, the facility Social Worker will conduct daily evaluation of emotional well-being for 3 days for any resident with an abuse or neglect allegation. Responsible Party: Administrator Target Date/Date of Completion:08/18/2023 Follow-Up: Social Worker to meet with resident # 1 weekly for the next 6 weeks to evaluate emotional well-being. Social Worker will report results of meeting to Administrator every week. Ongoing, Social Worker will complete emotional well-being evaluation daily for 3 days for any residents with Abuse or Neglect allegations. Corrective Action: Inservice education by [NAME] President of Clinical Services provided to Director of Nursing, Assistant Director of Nursing, Treatment Nurse and MDS Coordinator on proper assessment of residents on 8/18/23. Training of facility charge nurses, to include PRN and Agency will be conducted by DON or Designee. Education includes Use of the weekly skin observation tool, accident and incident investigation and reporting and initial and follow up assessments. Responsible Party: [NAME] President of Clinical Services Target Date/Date of Completion:08/18/2023 Follow-Up: Regional Nurse Consultant will review 5% of skin assessments and 5% of incident accidents weekly for 6 weeks and prn thereafter to monitor compliance. Corrective Action: Administrator reviewed staffing sign in sheets and assignments to determine what resident perpetrators worked with from 7/12/23 to 8/15/23. Responsible Party: Administrator Target Date/Date of Completion:08/18/2023 Follow-Up: No follow up required, item completed. This task was to identify residents who required head to toe skin assessments and interviews to rule out abuse, no additional abuse allegations were identified from skin assessments or interviews. Corrective Action: Head to toe skin assessments were completed on all residents that the perpetrators worked with from 7/12/23 to 8/15/23. Responsible Party: DON, Nurse Managers, Corporate DON and designee Target Date/Date of Completion:08/18/2023 Follow-Up: DON and designee will review skin assessments during morning meeting, 5 days a week, to assure completion. Nurse manager on call will review skin assessments on weekend and holidays to assure completion. Any issues identified with completion of skin assessments will be reviewed by the QAPI committee for 3 months and prn thereafter. Corrective Action: Inservice education provided to all licensed nurses to include agency and PRN on proper assessment of residents after an incident prior to next shift worked. Education includes Use of the weekly skin observation tool, accident and incident investigation and reporting and initial and follow up assessments. Responsible Party: DON and designee DON and all Nurse managers were provided training on 8/18/23 by the [NAME] President of Clinical Services. Target Date/Date of Completion:08/19/2023 Follow-Up: The administrator will review in-service records and compare them to nurse schedule 7 days per week to assure compliance for 100% nurses. All new hires will be educated upon hire. Results of in-service education will be reviewed by the QAPI committee for 3 months and PRN thereafter. The Survey team monitored the Plan of Removal from 08/19/2023 to 08/21/2023 as followed: Interviews on 08/19/2023 from 11:25 a.m. to 1:20 p.m., revealed four CNA , one MA, one housekeeping staff and two RN were in-serviced on abuse. Interviews on 08/19/2023 from 11:25 a.m. to 1:20 p.m., revealed two RN were in-serviced on resident assessments after an incident, to use weekly skin observation too, and follow up assessments. Interviews on 08/19/2023 from 11:25 a.m. to 1:20 p.m., four residents interviewed with no significant findings related to allegations of abuse. Record review on 08/19/2023, revealed Resident #1 skin assessment completed on 08/18/2023. Further record review revealed social service note on 08/15/2023, SW informed of situation with resident and was able to arrange psychiatry NP visit with resident. On 08/16/2023 SW checked in with resident who was attending an activity event in the dining room. Resident was smiling and denied feeling down, depressed, or scared. On 08/18/2023 SW checked in with resident who reported feeling fine. SW reminded resident of birthday event this afternoon and resident voiced wanting to attend event. Record review on 08/19/2023, revealed in-services competed on 08/15/2023 to 08/18/2023 on abuse, neglect, exploitation and misappropriation of property, resident with difficult behaviors and how to intervene with different types of behaviors, hot to protect yourself when residents have behaviors, how to deal with verbal aggression, notify charge nurse of behaviors immediately, and In-services for nurses on assessments. Interview on 08/20/2023 at 10:42 a.m., ADM revealed Regional Director of Operations in-serviced all RN case managers yesterday on resident assessments. DON in-serviced nurses on assessments yesterday and then were here at 6:00 a.m. to in-serviced the nurses coming for their shift. No nurses will work the floor until in-serviced. All staff were in-serviced on abuse and difficult residents on 8/15 and it will be on-going. Record review and observations on 08/20/2023, revealed in-services conducted. All nurses in-serviced 08/19/2023. DON got here at 6:00 a.m. to in-service nurses before they worked the floor. No nurses will work the floor until in-serviced. All staff were in-serviced on 8/15/23. Record review on 08/20/2023, revealed skin assessments for Resident #1 and other residents on his hall to ensure they were completed yesterday. Record review on 08/20/2023, revealed on 08/19/23 12:30 p.m. - Ad Hoc QAPI meeting held with ADM, DON, Regional Director, of Operations, and MD (via phone). Interviews on 08/20/2023 from 12:46 p.m. to 01:18 p.m., revealed two nurses, two CNA, one MA, and medical records were able to describe different types of abuse, report all allegations to ADM immediately. Two nurses were able to describe when to do skin assessments. Interview on 08/21/2023 from 11:32 a.m. to 1:18 p.m., revealed three nurses, to CNA, and one transportation aide were knowledgeable of different types of abuse, and to report all allegations to ADM immediately. Interview on 08/21/2023 on 12:55 p.m., ADM stated in-services are pending, they are waiting for the 2:00 p.m. to 10:00 p.m. shift to arrive, in-services are ongoing for all PRN staff and agency, nursing staff is almost completed. Record review and observations on 08/21/2023, revealed in-services conducted. All nurses in-serviced 08/19/2023. Observation at 2:10 p.m. revealed ADM in-servicing staff. Record review on 08/21/2023, revealed on 08/19/23 12:30 p.m. - Ad Hoc (when necessary or needed) QAPI meeting held with ADM, DON, Regional Director, of Operations, and MD (via phone). Record review on 08/21/2023, revealed ADM contacted local law enforcement, and was pending retrieval of report. The ADM was notified on 08/21/2023 at 02:24 p.m., that the Immediate Jeopardy was lowered, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new pressure ulcers from developing for 1 (Resident #1) of 6 residents reviewed for pressure injuries, in that: The facility failed to: 1. Ensure newly admitted residents were assessed, monitored and documented for significant risk factors for developing pressure ulcers. 2. Describe and document/report the location, stage, measurements (length, width and depth) and conditions of pressure ulcers. 3. Properly clean the resident and inspect for the development pressure ulcers. 4. Obtain orders from medical doctor for the management of pressure ulcers. An Immediate Jeopardy (IJ) existed from 07/11/2023 until 07/27/2023. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. On 07/31/2023 at 4:30 pm an IJ template was given to the administrator when notifying the facility of the past noncompliance IJ. This deficient practice placed residents at risk for skin break down, multiple pressure ulcers, and a decline in quality of life. Findings included: Record review of Resident #1's face sheet dated 07/30/2023 revealed a [AGE] years-old-female with an admitted [DATE]. Diagnoses included encounter for surgical aftercare following surgery on the nervous system (spinal cord), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well), unspecified, type 2 diabetes mellitus with diabetic polyneuropathy, and muscle (affects multiple peripheral sensory and motor nerves that branch out from the spinal cord into the arms, hands, legs and feet), and muscle weakness. Record review of Resident #1's most recent MDS assessment dated [DATE] revealed Resident #1 was admitted to the facility from an acute hospital stay. Observation of MDS was 07/27/2023, the date of Resident #1's discharge from the facility to the hospital, functional status revealed Resident #1 was Spanish speaking and required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility (bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). MDS revealed that evaluation of Resident #1's ability to walk in room and walk in corridor did not occur, Resident #1 had an Indwelling Foley catheter, Resident #1 was frequently incontinent, Resident #1 had malnutrition. MDS did not contain BIMS score or skin/pressure ulcer assessment. Review of hospital admission records dated 07/27/2023 revealed Resident #1 had four wounds: 1. Date discovered 07/27/2023 sacrum (shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) unstageable eschar/slough (advanced wound). Measurement - length 12 cm and width 9 cm depth not revealed. 2. Lumbar surgical wound would appearance yellow slough. Measurement length 11 cm, width 1.3 cm, and depth 2.3 cm. 3. Left heel unstageable (full thickness tissue loss in which actual. depth of the ulcer was completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) length 4 cm, width 3.8 cm, depth 0.2 cm. 4. Right heel Stage 1 (injuries are not open wounds). Review of hospital admission records dated 07/27/2023 revealed Resident #1 was discharged from the hospital and transferred to the facility and at the facility developed sacral wound with pain and foul smelling and oozing pus from a surgical wound. Physical Exam notes reflected the lower lumbar surgical wound had some dehiscence (splitting or bursting), pus, tenderness to palpation. Resident #1 did not walk at nursing facility. Review of hospital records by the plastic surgeon dated 07/27/2023 revealed Resident #1's general appearance was chronically ill appearing, frail with a wound in the lumbar area and an acute pressure ulcer in the sacral region (located below the lumbar spine and above the tailbone) unstageable (the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black and the doctor cannot see the base of the wound to determine the stage). Resident #1 not on proper support surface at the facility and would benefit from surgical debridement (when a doctor removes dead or unhealthy tissue from a wound to help a wound heal because dead tissue gives bacteria a place to grow and can cause infection). Record reflected photographic documentation that revealed extensive necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply). Requested plastic surgery consult for wound care evaluation as wounds were extensive. Sacrum (shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) was covered with eschar (a dry, dark scab or falling away of dead skin) with tissue is mushy to palpation indicating liquifying necrosis of underlying tissues. Due to proximity of wound to the anus fecal contamination was an issue for wound healing potentially. Record review of facility's Admission Evaluation dated 07/11/2023 revealed Resident #1 had a skin impairment (wounds, bruises, skin tears, etc.) listed as other - surgical incision lower back. No length, width, depth, stage indicated. Record review of Weekly Skin Observation Tool - (Licensed Nurse) dated 07/12/2023 revealed pressure ulcer heals stage N/A surgical incision midline of back. No length, width, depth indicated. Record review of Weekly Skin Observation Tool - (Licensed Nurse) dated 07/15/23 revealed pressure ulcer on the heel, stage I (observable, pressure-related alteration of intact skin with non-blanchable (no loss of skin color) redness of a localized area usually over a bony prominence (where bones are close to the surface) and other, surgical incision. No length, width, depth, or stage indicated. Record review of Weekly Skin Observation Tool - (Licensed Nurse) dated 07/22/2023 revealed right heal pressure ulcer stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.), left heal pressure ulcer stage II (partial-thickness skin loss involving the epidermis (the skin) and dermis (living tissue), bottom pressure ulcer stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.), surgical incision stage N/A. No length, width and depth of the pressure ulcers indicated. Record review of Weekly Skin Observation Tool - (Licensed Nurse) dated 07/27/2023 revealed right and left heal pressure ulcers stage II (partial-thickness skin loss involving the epidermis (the skin) and dermis (living tissue), bottom pressure ulcer unstageable ( Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and surgical incision stage N/A. No length, width and depth of the pressure ulcers indicated. Record review of the July 2023 MAR revealed there were no physician's orders for the management of the pressure ulcers on the right and left heels and the pressure ulcer at the bottom Record Review of Facility's Progress Note of in-person face-to-face visit at facility from APRN dated 07/27/2023 revealed Resident #1 was admitted to the facility 06/26/23 with current level of functioning toilet hygiene/shower/lower body dressing maximum assist, upper body dressing moderate assist, bed mobility maximum assist, transfers maximum assist and two person Hoyer lift with no ambulation, wheelchair mobility dependent, TLSO brace (brace used to limit motion in the back, not your neck) when up and out of bed. Progress notes revealed unstageable wound to left heel with heel protectors on BLE. Unstageable eschar to her sacrum/coccyx today. Resident #1 needed to be evaluated by Neurosurgeon for further work-up and General Surgery for possible wound debridement. Record review of Resident #1's Progress notes from 07/12/23 to 07/27/23 did not indicate that the MD was informed of the pressure ulcers on the heels and Resident # 1's bottom when these were identified respectively on 7/12/2023, 7/15/2023 and 7/22/2023. Record Review of Resident #1's point of care bathing record dated 07/30/2023 revealed Resident #1's shower schedule was Monday, Wednesday, and Friday. Her bathing record revealed: Date admitted - 07/11/2023, a Tuesday, no shower 07/12/2023 - Wednesday shower marked N/A but the ADON revealed that the Medical Administration Record access reflects staff gave Resident #1 a bed bath. 07/13/2023 - Thursday shower marked N/A 07/14/2023 - Friday agency staff marked Resident #1 had a bed bath 07/17/2023 - Monday agency staff marked Resident #1 had a bed bath 07/19/2023 - Wednesday agency staff marked Resident #1 had a bed bath 07/21/2023 - Friday shower marked NA by agency no shower or bed bath. 07/26/2023 - Wednesday shower marked NA by agency no shower or bed bath. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], 16 days, and received 4 bed baths. Interview on 07/30/2023 with ADON, at 12:00 PM revealed Resident #1's shower schedule was Monday, Wednesday, and Friday and she was admitted to the facility on [DATE] and discharged [DATE]. The ADON confirmed received a total of four bed baths during her seventeen days at the facility. Interview on 07/29/2023 at 12:15 PM with hospital RN Charge Nurse revealed that for Resident #1's sacral pressure ulcer to have gotten that large, the resident must have been left without care. Interview on 07/29/2023 12:30 PM with Resident #1's hospital MD who assessed her sacral wound revealed the wound was impressive and the facility did not do what needed to be done for the patient to prevent the wound from occurring. MD stated that the facility should have been more aggressive with procedures, like bathing and repositioning the resident, to prevent pressure ulcers. He revealed that the size of her sacral wound is huge and covers the whole area of her sacrum. When asked what stage it was, he said he was unable to tell because there was so much black stuff on the wound it made the wound unstageable. Interview on 07/29/2023 with the hospital surgeon at 12: 40 PM revealed Resident #1 was obviously not turned regularly and because the wound is so large it points to neglect. The surgeon revealed he was very sure he will have to debride down to the bone and Resident #1 was not a good candidate for surgery because of her diabetes and her protein levels. Interview on 07/29/2023 with Resident #1 at 1:55 PM revealed, through a Spanish interpreter, she received 1 bed bath an no other baths when at the facility. She said described her mattress as regular and hard, she said she was never turned or repositioned. Resident said it did not matter if she used the call light, she said she would push it 50 times and no one would come. She always ate in her room, and they cleaned her body with wipes only. When asked how they changed her adult briefs, she said they would remove the two side tabs and pull the brief down and away from her, no turning her. An interview on 07/31/2023 at 10AM, RN A stated since there was no designated wound care nurse, the skin assessment was done by all the four nurses at the facility. When the investigator asked what she was looked for during the assessment she stated, she observed the wound site and at what stage the wound was and documented them in the weekly skin observation tool. RN A said the nurses were not allowed to measure the wound and document them and the measurement was done either by the wound nurse or wound doctor, who visited the facility every week. RN A stated Resident #1 was not assessed by the wound doctor until 07/25/2023. The wound doctor attend only the residents who were referred to him. When investigator asked, without knowing the measurement of the wounds every week, how the nurses decide the progress of the wound, RN A stated she decided it from the memory. RN A stated since she worked at the facility for more than 1.5 years, she was able to remember what was size, shape and condition of the wounds of all the residents she attended. RN A did not answer the question what if there was another nurse who assessed a resident in her absence. RN A stated she attended a training at the facility on 7/28/23 teaching how to measure and document wounds. An interview on 07/31/2023 at 11:00 AM NP, she stated she had assessed Resident #1 next day after the admission and there was no wound at the sacral area of Resident #1 at that time. NP stated, she observed and documented the surgical wound at the lumbar region. Resident # 1 had staged ulcers on the heels on admission. NP said on 07/25/2023 she saw a moderately large discoloration of skin at her back below the surgical incision. NP stated Resident #1 appeared malnourished and was one of the causative factors for developing skin ulcers in general. She stated there were no referrals of Resident #1 to the nutritionist until 07/27/2023 and the wound doctor saw her only on 07/25/23. NP stated the facility had issues with wound care because of the lack of wound care coordination. A telephone interview on 07/31/2023 at 12:00 PM, RD stated she received the referral on 07/27/2023. RD stated if she had received the referral earlier than 07/27/23 it would have been beneficial to the resident since she could recommend a diet that was therapeutic to Resident #1. RD stated she made the diet recommendation appropriate to Resident #1 and her condition, however the resident did not benefit from it as she was admitted to hospital by that time. A telephone interview on 07/31/2023 at 12:30 PM, MD stated he heard about the ongoing investigation related to the allegation of wound care neglect. He stated there was some element of truth in this allegation. MD said he had identified two main issues with wound care at the facility and those were, lack of proper communication among the healthcare providers and the absence of a permanent full time wound care nurse for managing, coordinating, and intervening wound care at the facility. He said the immobility of the resident and her low motivation with compliance with nursing interventions like consistent turning to alleviate pressure was also contributory to worsening the wound. An interview on 07/31/2023 at 1:00 PM ADON stated, she has worked at the facility about a year. ADON said, apart from ADON role, she did weekly skin assessment and accompanied the wound doctor during his weekly visits. When the investigator asked what she was looking for while assessing a wound, she stated, she looked for information like the location of the wound, the size, edge, drainage, and appearance. ADON stated she took measurements as well but that typically was not allowed for other nurses until the incident with Resident #1 occurred. When asked what went wrong with the wound care of Resident #1, ADON stated, it was messed up by everyone. When asked to elaborate she stated there was a failure in reporting about the wound, documentation and follow ups. An interview on 07/31/2023 at 2:30 PM the DON stated she began working at the facility in April 2023. She stated facility needed some changes with immediate effect. She said since she had identified substandard wound assessment and documentation, she was going to appoint a regular full time wound nurse and streamline the communication and documentation for effective wound care. DON said during her investigation after the incident, it was revealed that some of the wounds were not reported on time by the nursing staff including the NP. She said after this incident, the facility initiated and completed checking every resident's skin and noted findings if any issues. DON said Resident #1's physical condition also was contributory to her skin break down. She was a sick and under nourished lady who came with a surgical wound. DON stated the nutritionist did not provide her service on time. DON stated one of the CNAs noticed the wound and reported to the charge nurse however, this information was not passed on to DON, ADON or MD by that nurse, thus a communication deficit also contributed to this incident. DON stated now the facility has a system in place for correct documentation, communication, and timely intervention. She stated she makes rounds and follows up every day with nurses to ensure appropriate actions were taken place. An interview on 07/31/2023 at 4:00 PM ADM stated, there were a few ongoing issues related to wound care at the facility. She said the facility identified those issues immediately after Resident# 1 was sent to the hospital and started remedial actions. The facility had no full-time wound nurse at the facility. She said from 7/31/23 to 8/7/23 the facility had an interim full time treatment nurse and from 8/7/23 a regular permanent fulltime wound care nurse will take over the role of wound care nurse from the interim wound nurse. She said there was ineffective communication and lack of coordination among the staff regarding wound care and this issue was addressed with in-service trainings. ADM stated all staff members were trained and instructed to report any issues or concerns as soon as possible to DON, ADON, or charge nurse. She said, training on proper documentation also was included in the Inservice. Prior to the incident, the staff who did the skin/wound assessment were not allowed to size (measure) the wound however currently they were trained properly and started documenting the measurement and the wound nurse confirms the accuracy of every measurement. ADM stated, the DON and ADON supervise the activities by staff daily and ensure all the interventions were done correctly in a timely manner. An interview on 07/31/2023 at 10:30AM CNA A stated she has worked at the facility more than a year and had attended the in-services conducted at the facility on 07/28/23. When the investigator asked what she leaned, CNA A stated the facility taught them the importance of reporting any wound, including discoloration of the skin immediately to the charge nurse. If charge nurse was not available, they had to let ADON, DON, ADM, or MD available at that time. She said she learned from the training that documenting the finding also was important. An interview on 07/31/2023 at 11:30 AM MA A stated she has worked at the facility for more than 3 years and mostly works in the night. MA A stated she came into the facility on [DATE] in the daytime on request, to complete the in-service. She stated they taught her about the importance of reporting and documenting any finding related to skin, like redness, discoloration of skin or wounds. When the investigator asked who she should report, MA A stated the reporting should be done to the wound care nurse if possible. If Wound Nurse was not available charge nurse, DON or ADON should be informed. An interview on 07/31/2023 at 1:30P M LVN A stated she has worked at the facility for about two years in the afternoon shift as charge nurse. LVN A stated she attended the in-service on 07/27/2023. LVN A stated the in-service was about head-to-toe assessment, skin issues observed while showering or during weekly assessment. When investigator asked LVN A to elaborate what she had learned, she stated it was important to do weekly head to toe skin assessment and reporting to wound nurse, ADON or DON as soon as any issues found. The observations during the assessment should be documented properly as well. The resource for any questions or concerns would be treatment nurse, ADON or DON. A review of facility Pressure Ulcers/Skin Breakdown Clinical Protocol dated April 2018 revealed: Assessment and Recognition 1. The nursing team member and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or, overall medical instability 2. The physician will clarify the status of relevant medical issues; for example, the impact of comorbid conditions on healing an existing wound. Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 2. The physician will help identify medical interventions related to wound management; for example, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. a. Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcers. b. Beyond trying to maintain a stable weight there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer. 3. The physician will help team member characterize the likelihood of wound healing, based on a review of pertinent factors; for example: Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. A review of facility policy Activities of Daily Living (ADLs), Supporting dated April 2018 revealed: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. Review of facility policy Perineal Care dated February 2018 revealed: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess for any special needs of the resident. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. Ask the resident to turn on her side with her top leg slightly bent, if able. An Immediate Jeopardy (IJ) existed from 07/11/2023 until 07/27/2023. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents reviewed (Resident #1) for pain management. The facility failed to ensure Resident #1 received [MEDICATION(S)] for pain according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk of facility staff not recognizing resident pain symptoms resulting in worsening pain. Findings included: Review of the face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge orders for Resident #1 dated 5/16/2022 reflected the following: -[MEDICATION(S)] 4 mg every six hours as needed; Indication pain scale 7-10 -[MEDICATION(S)] 10 mg at bedtime Review of MDS assessments for Resident #1 reflected that he had no completed assessments. Review of care plans for Resident #1 reflected there was no completed baseline care plan. A care plan template had been entered into the EMR and contained only information related to code status. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCl tablet 4 mg every six hours as needed for pain, dated 5/16/2022. Review of the May 2022 MAR for Resident #1 reflected the following: [MEDICATION(S)] HCl 4 mg not administered on 5/16/2022 and first administered at 1:05 p.m. on 5/17/2022. Pain scale for this administration was rated at a 9/10. Review of the Emergency Kit narcotics log sheet reflected that no narcotic pain medication was marked as administered from 5/16/2022 to 5/17/2022. Observation on 5/18/2022 at 1:18 p.m. revealed that no narcotic medication had been removed from the emergency kit. All cards were full with all pills accounted for. Review of nursing notes for Resident #1 reflected the following: 5/16/2022 at 8:14 p.m. - Note Text: Resident transferred from hospital to facility via EMS and introduces himself with a smile. Resident is a bilateral [CONDITION(S)] of the lower extremities and paralyzed from the umbilicus (belly button) down. Resident also has a [CONDITION(S)] (surgical port through which feces is eliminated) but resident mentioned that he still has bowel movements through his rectum. Resident has a suprapubic catheter (catheter surgically inserted between the urinary bladder and the skin) with an output of 500ml. There is a dressing on the RLQ, resident stated it was a scab and the hospital dressed it. Dressing is clean and intact. Resident also has a dressing on his sacral/buttock area which is clean, dry, and intact. Resident is comfortable in bed with call light in reach and bed at the lowest position. Written by LVN C. -5/17/2022 at 5:28 a.m. - Called pharmacy about resident [MEDICATION(S)], but no one has accesses in the building for Omnicell. written by LVN D. -5/17/2022 at 10:35 a.m.- Note Text: Call placed to Omnicare pharmacy to request [MEDICATION(S)] ([MEDICATION(S)]) to be sent stat. Spoke with (pharmacist), who stated medication would be sent stat. written by ADON A Review of administration note for Resident #1 dated 5/17/2022 at 1:05 p.m. reflected the following: Note Text: [MEDICATION(S)] HCl Tablet 4 MG Give 1 tablet by mouth every 6 hours as needed for Pain 7/10. During an interview and observation on 5/18/2022 at 9:40 a.m., Resident #1 stated he got his pain medications five hours prior and could ask for more in an hour. He stated his pain was primarily on and around his buttocks where he had two open wounds and an infection in the bone. He stated his pain medication did not arrive at the facility until the day after he arrived, which was 5/16/2022. He stated they did not offer him anything stronger than an aspirin prior to the [MEDICATION(S)] arriving on 5/17/2022, which he did not accept, because it would not have helped at all. He stated his last administration of pain meds at the hospital was at 3:00 p.m. on 5/16/2022 and then he was transferred to the facility and arrived around sunset that evening. He stated his pain got to an 8 or 9 out of ten by the morning of 5/17/2022. He stated his pain was now controlled. He stated he did not sleep at all the first night in the building because he did not have pain medication and also because his [MEDICATION(S)] had still not arrived to the facility. Observation revealed he was lying in his bed with the light off and looking at his cell phone. He did not demonstrate any outward, nonverbal signs of pain. During an interview on 5/18/2022 at 1:32 p.m., LVN C stated he worked for a staffing agency and acted as the hall nurse for Resident #1's hall on 5/16/2022. He stated the facility gave him some orientation related to the admission process, and he completed three admissions on that shift. He stated his process was to assess the resident: lungs, heart, vitals, affect, mood, and what services they were there for. He stated he remembered Resident #1, because a lot stood out- [CONDITION(S)], suprapubic catheter, amputated legs, pressure wounds on sacrum- but the thing he was really working on that night was getting the medications to the facility. He stated that, when the resident was admitted , LVN C called ADON A to notify her that the medications were not there. He stated he called the on call nurse practitioner at around 9:00 p.m., and he told LVN C to call the pharmacy to get a code to get into the emergency kit and administer pain medications from the kit. He stated it was an hour later, the pharmacy had not called back, and he was ending his shift. He stated he handed the issue over to the oncoming nurse, LVN D. He stated he did not know what the outcome was. He stated the process was the on call NP called the pharmacy and requested the code from the pharmacy, and he should have heard back directly from the pharmacy. He stated he did not know if there was a dedicated phone for the pharmacy to call back but his assumption was they would call the main phone number. He stated the resident told him there was high degree of pain, but based on the nonverbal signs of pain, LVN C was seeing a three or four out of ten. He stated, as soon as the resident told him about the pain, he went straight to get on the phone with the nurse practitioner. An attempt was made on 5/18/2022 at 2:08 p.m. and 6:15 p.m. to interview LVN D by telephone. As of 5/20/2022, contact was not returned. During an interview on 5/18/2022 at 2:43 p.m. ADON A stated she is the ADON for the hall where Resident #1 lives and has been the ADON since 4/1/2022. She stated from 8:00 a.m. to 5:00 p.m., they had an admitting nurse who put in the orders, verified the orders, and followed up with the pharmacy. After she finished with that, she went on the hall and helped the charge nurse get weights and heights. She stated the charge nurse usually did the admission head to toe assessments. ADON A stated for after-hours admissions, the on-call manager for the facility was notified, the nurses put orders in the system and should call the pharmacy to confirm the orders were received. From her understanding, they did call the pharmacy every time, but the pharmacy often took a long time to call back. When the pharmacy called back, they verified the orders with the facility, and the pharmacy said they could or could not send the medications. She stated that the last delivery time from the pharmacy was 11:00 p.m., so they would need to start the whole process by early evening to get the medications delivered that night. She stated what should have happened was the hospital should have sent the orders to the pharmacy as soon as they knew they were sending the resident over, but the hospital had not been doing that lately. She stated they did not know why, but her understanding from what her management told her was the hospital was having a hard time completing many of the preparation tasks they used to do for the facility prior to admission. She stated that they sometimes had to administer medications from the emergency kit, which they could do as long as the pharmacy had a triplicate order from the on-call physician/nurse practitioner. She stated most of the time, the residents had their daily medications by the time they admitted after-hours, so all they needed were PRN pain medications or sleeping medications. She stated that Resident #1's [MEDICATION(S)] was requested STAT on the morning of 5/17/2022, so she thought it came that morning. She stated he was not administered anything from the emergency kit in between arriving at the facility at 8:14 p.m. on 5/16/2022 and the first administration on 5/17/2022 at 1:05 p.m . after his [MEDICATION(S)] arrived. She stated she could not answer why nothing else was administered for pain. She stated she had not personally spoken to any of her management team about the issue and had not made her DON or ADM aware that there was a problem getting medications for after-hours admissions. She stated she did not understand why the nurses caring for resident #1 did not follow up with her or report to her the concerns. During an interview on 5/18/2022 at 3:20 p.m., the NP stated she was aware that Resident #1's pain meds took a while to come in. She stated she was a brand new practitioner to the facility and had only met with Resident #1 once, but he was paralyzed from the waist down, has a chronic wound and [CONDITION(S)] and chronic pain issues, so he has several conditions that would likely cause pain. She stated, as far as comfort levels, not having pain medication for 24 hours could definitely have an impact: diminished quality of life, being able to tolerate therapy, being able to reposition himself, high blood pressure, possible cardiac issues. During an interview on 5/18/2022 at 4:15 p.m., the RNC stated the ADM and DON were both at an important training meeting and would not be in the facility during the investigation. She stated the facility had a standardized admission checklist policy and process. The process was, when they had a new admission coming, they obtained orders from the discharge entity (most of the time hospital), verified the orders with the facility physician, entered the orders into the EMR, and activated the orders when the new resident arrived. At that point, the active orders were automatically sent to the pharmacy. She stated they had an admission nurse who did all of these steps during the day as well as helped new residents get settled in. She stated, in the event of an after-hours admission, the admission nurse often stayed late and entered the orders and verified with the physician, but if she was gone already, it was the responsibility of the charge nurse for the resident. She stated that she was not certain what went wrong that the communication of Resident #1's medications not arriving did not make it to someone who could intervene, but she stated that it seemed likely that Resident #1 would have spent some time in pain, given that his pain medications were not available, and he was offered nothing else. She stated that a resident would have a very bad first night at a facility if he were in pain all night. She stated that it is the goal of the facility to ensure that no one had to be in pain. She stated she could not locate and did not think the company had a policy on pain management. Review of facility policy dated 1/1/2013 and titled LTC Facilities Receiving Pharmacy Products and Services from Pharmacy reflected the following: 3. After the normal business hours set forth in the facility specific information sheet, facility staff should contact pharmacy by dialing the telephone number provided in the facility specific information sheet to page the on-call pharmacist. 4. If orders for medications are received from physician/prescriber when a pharmacy is closed, facility staff should take the following steps 4.1 Remind physician/prescriber that pharmacy is closed and that a delay in medication therapy can be prevented by using a medication that is included in facilities emergency medication supply as permitted by state regulation. 4.2 If a medication cannot be substituted ask physicians/prescriber if the medication therapy can be initiated the next morning. If it is possible to initiate the medication therapy the next morning, facility staff should document the conversation with the prescriber and include the start time in the order. 4.3 If a medication is considered essential and cannot be substituted or delayed, contact the emergency number provided by pharmacy. The emergency number should either page the on-call pharmacist or contact an answering service. Orders should be received directly from a facility nurse or a licensed physician/prescriber, and cannot be faxed, emailed or provided to answering service personnel.

Based on interview and record review, the facility failed to implement its policies for preventing, identifying, and reporting abuse for two of seven residents reviewed for abuse (Residents #1 and #2), in that 1. The ADM (abuse coordinator) was verbally abusive to Resident #1 on an undetermined date, and the facility policies and procedures for preventing, identifying, and reporting abuse were not followed. 2. The ADM (abuse coordinator) was verbally abusive to Resident #2 on 8/10/2018 (closed record) and the facility policies and procedures for preventing, identifying, and reporting abuse were not followed. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/3/2018. While the IJ was removed on 10/5/2015, the facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as pattern. This failure could most likely place residents at risk of fear, depression, intimidation, and a diminished quality of life due to verbal abuse. Findings included: Review of face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly minimum data set (MDS) for Resident #1 conducted on 8/14/2018 reflected a brief interview for mental status (BIMS) score of 15, indicating little or no cognitive impairment. Review of care plan for Resident #1 dated 3/20/2018 reflected the following: History of depression. Observe for change in mental status. Approach resident warmly and positively. Evaluate effectiveness of medications and side effects. Encourage resident to perform at least two activities by self daily. Actively listen to resident and acknowledge the reality of concerns. Reassure resident during interactions. During a confidential interview a staff member stated he has worked for the facility for seven years and he works 300 and 200 Halls. When asked if he has ever witnessed the ADM verbally abuse residents, he stated that the ADM was loud and yelled at Resident #1 related to her diet. He then stated this happens all the time, that she yells at staff or residents. He stated that she is very demeaning and condescending to residents and staff. He stated that she has also treated family members the same way. He stated he was afraid to report the abuse he has witnessed and heard about because the facility administration always finds out who told on them, and retaliation begins. He was asked to elaborate on what retaliation entailed but refused to talk anymore about it. During an interview on 10/3/2018 at 11:44 a.m., Resident #1 stated that the ADM has been verbally abusive to her. Resident #1 stated that she is a diabetic and has been one for many years, and she always made sure she ate what she was supposed to eat to control her diabetes well. She stated that the kitchen wasn't giving her things that were good for a diabetic. She stated that, during meal times, she sits next to the kitchen and went to the kitchen door to ask why they give her so many things she shouldn't be eating. She stated that the ADM was in the kitchen at the time, and she yelled (Name) you don't know what you are talking about! and gave her an angry, demeaning look. Resident #1 stated that ever since this incident, she feels the ADM has something against her. She stated that there have been a couple of things that made her feel targeted by the ADM. She stated that one of these is that she was blamed when the ADM stated she could no longer have her dog in the building. Resident #1 stated that she does not know why the dog was no longer allowed in the building, but there was gossip among other residents that Resident #1 was the person responsible for the dog's banishment. The other thing that makes her feel as if the ADM holds something against her is that every time the ADM sees her, she will make a point to say hello to everyone around her by name except her. Resident #1 stated that the incident in the dining room with the ADM was a while ago, maybe two months ago, but the effects are ongoing. She stated that when the ADM yelled at her in that way, it made her feel like a nobody, and she has been scared since. Resident #1 stated that she has been especially scared due to unfriendly treatment by the ADM and some of the residents. Review of face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged to a group home on 9/5/2018. His [DIAGNOSES REDACTED]. Review of initial MDS for Resident #2 conducted on 7/9/2018 reflected a BIMS score of 15, indicating little or no cognitive disability. Review of care plan for Resident #2 dated 7/2/2018 reflected the following: Resident has dx of [MEDICAL CONDITION] as evidenced by: history, +PL1, PE per Rep. Monitor Resident for increased agitation, anger, verbal, and physical aggression. Document episodes of behavior. Remove Resident from increased stimuli during behavioral episodes. Resident has dx of [MEDICAL CONDITION] (bi-polar) and can have mood swings from euphoria to depression. Monitor Resident for s/s or mania, document finding in the clinical record. Monitor resident for s/s of depression and document in the clinical record. Attempts were made on 10/3/2018 at two different personal phone numbers and one number for the group home to which Resident #2 was discharged in an effort to interview Resident #2. These attempts were unsuccessful. During an interview on 10/3/2018 at 4:30 p.m., CNA D she stated the ADM verbally abused Resident #2 in front of several residents and staff. She stated that the ADM was yelling at him to get out, pointing her finger in his face, and threatening him that she was going to call the cops. She stated that the ADM was screaming at the resident because he wanted a sandwich, and that he wasn't doing anything wrong. She stated that she was scared to address this with the ADM, because she is the abuse coordinator. CNA D stated that more of the verbal abuse by the ADM is towards the staff, and they don't wish to add more by making her angry. She stated that today, 10/3/18, the ADM had yelled at a resident that he smelled like pee, and told him that everything around him was starting to stink. CNA D stated the resident resists showers and is incontinent of bladder and bowl. She stated the resident is nonverbal. She stated the resident got visibly upset and began to shake when this happened. She identified the resident by his first name and room number. She stated she was the only one in the room. During an interview on 10/3/2018 at 9:43 a.m., the ADM stated that abuse is any time a resident either feels unsafe, could be unsafe, receives aggressive verbal talk from a staff member or another resident, or any sort of physical, mental, verbal, sexual abuse or seclusion. She stated that she is the abuse coordinator. She stated that her role as abuse coordinator for the facility is to investigate any time someone reports abuse and to always be available for someone to report abuse concerns whether it's residents, family, or staff. She stated she also determines and reports within two hours of finding out about an allegation of abuse. She stated she investigates by interviewing the resident who is the alleged victim, interviewing staff, doing rounds with other residents to ensure nobody else feels the same way, and the social worker does a mini mental health evaluation. She stated she interviews the alleged perpetrator and assesses the resident for injuries. She stated she ensures the alleged victim is out of harm's way. She stated she calls corporate for guidance. The ADM stated that retaliation is to be negative or to treat someone differently because you knew that they reported abuse. She stated that for a resident, this might mean staff treating them differently, gossiping, not inviting them to activities, or other isolation. She stated the same goes for staff: supervisor treating them differently or changing their assignments without explanation. She stated that she would you say that yelling or raising the voice is abuse. She stated she would say that calling names, swearing, or belittling residents is abuse. She stated that yelling or raising the voice to staff in front of residents is abuse. She stated that yelling or raising the voice around residents could scare them, make them anxious, raise their blood pressure, or cause depression. She stated that her expectation is that no direct care staff or supervisors should raise their voices around residents. During a confidential interview a staff member stated that the ADM yells at the staff all the time. She stated that she knows about the ADM yelling at a resident. She stated that some of the staff saw and heard the ADM yelling at Resident #2, and she knows that someone reported this to the State Agency. The staff member stated that she is afraid to lose her job or have the ADM be angry at her and yelling, so she requested that the interview be kept confidential. She stated that all the staff is afraid. She stated that ADM becomes angry often and yells. During a confidential interview a staff member stated that the ADM has yelled at her for over-ordering supplies and all sorts of other things. She stated that the ADM yells at her and the other staff in front of residents all the time. She stated she has not witnessed her yell at the residents but does know about that. During a confidential interview a staff member stated that the ADM does yell at the staff and speaks rudely to the residents. She stated that this affects the residents and the staff, because they want ADM to treat them like humans, and she doesn't always do that. She stated that the ADM also treats the family members badly if they don't like her dog. She stated that there is ongoing trouble related to the ADM's dog. She stated that she is afraid of being treated worse if she speaks about what is going on in the facility and asked that the interview be confidential. During a confidential interview a staff member stated he has heard the ADM yell a little bit. He stated she talks badly to people. He stated it happened (she yelled at someone) Monday and sometimes other days. During an interview on 10/3/2018, family member (FM) stated the ADM has made racial comments and often treats family members, staff, and residents in the same demeaning, condescending way. She stated the ADM will talk down to them and be demeaning and condescending. She stated that the ADM sometimes yells at residents and family members. She stated she cannot remember any details or specific examples, but her mother has been in the facility for three years, and she has experienced the morale of the entire facility go down since the current ADM was hired. Review of undated facility policy titled Resident Behavior and Facility Practices Policy reflected the following: Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, and reasonable confinement, intimidation, neglect, psychological harm related to unauthorized photos or willful infliction of injury or punishment with resulting physical or emotional harm, mental anguish or pain to a resident. The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, exploitation, involuntary seclusion and misappropriation of resident property. Through the facility's mission statement each employee is expected to act in such a manner as to reflect the mission statement of this corporation. Each employee receives the employee standards of conduct which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. All staff in the nursing facility and all residents, responsible parties, and or legal representatives have all been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what type of incidents reported, will be investigated fully. All employees who suspect abuse at any time are to report it to their immediate supervisor. If the supervisor is not the charge nurse then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, he will then report to the allegation to the director of nursing, or the assistant director of nursing, the director of nursing, and/or the administrator. The administrator or his/her designee will report this allegation of abuse immediately to the state agency and to the proper local authorities. The facility delegates the administrator as the abuse coordinator and posts the name and phone number of the abuse coordinator in the facility. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator. The abuse coordinator will ensure that facility completes the appropriate investigated (sic) forms and forwards a copy of the investigation to DADS within five working days. It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Although abuse comes in different types, the facility has one common goal and that is to protect each and every resident. Upon notification of suspected abuse the director of nursing or designee will take two courses of action when an abuse identifies a perpetrator that is identified by an eyewitness, (1) the facility will immediately remove the perpetrator from the facility, pending outcome of the investigation. The RVP was notified on 10/3/2018 at 4:30 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the RVP on 10/3/2018 at 7:10 p.m. and accepted by the Survey Team at 7:15 p.m. a. Alleged perpetrator was immediately suspended pending investigation until further notice/investigation completion. Alleged perpetrator to be interviewed regarding statement of allegation by Divisional Director of People Strategy. b. Facility Vice President and Director of Clinical Operations to begin the investigation and implementation of remediation. The Director of Clinical Operations and the Assistant Director of Nursing Will begin education for facility staff to include RNs, LVNs, CNAs, CMAs, department heads, dietary, therapy and housekeeping staff on the definition of abuse and neglect and the different types of abuse. The education will also include the reporting of any allegation of abuse or neglect to the abuse coordinator immediately. If the abuse coordinator/administrator is not immediately available the notification will be made to the director of nursing or the next available in charge. c. Facility staff will be educated on policy against retaliation for fear of reporting abuse or neglect. Should the witness/individual reporting the allegation not feel comfortable reporting to abuse coordinator, education will be provided to direct concerns to the compliance hotline and/or HHSC abuse hotline. d. Resident representatives/residents will be educated on how to report allegations of abuse or neglect. e. Facility Director of Social Services Will initiate safe survey interviews on interview a ball residents to identify any other grievances or areas of concern which could be construed as an abuse or neglect allegation. f. If any potential abuse or neglect allegations are identified during the interviews and assessments the facility abuse Cordinator will immediately ensure the resident safety, suspend or remove the alleged perpetrator from the facility grounds (if applicable or identified), and initiate an investigation into the allegation. Appropriate notifications will be made to the resident representative, the physician, health and human services department, and the local authorities, if indicated. g. Those residents identified as alleged victims will be interviewed, assessed, and monitored for mental duress until it is deemed unnecessary by the interdisciplinary team as applicable. h. Director of Clinical Operations educate the facility director of nursing and assistant directors of nursing to include: the definition of abuse and neglect, including the different types of abuse; the process on what to do when an allegation of abuse or neglect is made starting with ensuring resident safety immediately and removing the alleged perpetrator, if applicable, from facility grounds; reporting guidelines from Health and Human Services department. i. An Ad Hoc QAPI meeting will be held with the Medical Director, just a lady administrator, director of nursing, social services director, vice president, and director of clinical operations to review plan of removal, as well as ongoing process improvements to ensure resident safety. Education will begin on 10/3/18 and continue each shift until 100% of the stuff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. To be completed by 10/5/18. The survey team monitored the plan of removal as follows: Observation and interview on 10/3/2018 at 4:35 p.m. revealed that the ADM had left the premises. During interviews on 10/4/2018 between 1:25 p.m. and 1:50 p.m., one RN, three LVNs, three CNAs, three HKs, one dietary aide, one CMA, the admissions coordinator, and the business office manager all verified their participation in and signatures on in-servicing to do with abuse and reporting. During interviews on 10/4/2018 at 10:15 p.m., several staff members verified their knowledge of abuse reporting procedures and verified their participation in and signatures on in-servicing on the topic. During interviews on 10/5/2018 at 2:30 p.m., several staff members verified their knowledge of abuse reporting procedures and verified their participation in and signatures on in-servicing on the topic. The RVP was informed at 2:40 p.m. on 10/5/2018 that the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of potential for more than minimal harm and a scope identified as pattern.

Based on interview and record review, the facility failed to ensure all allegations of abuse were reported immediately or within two hours for two (Residents #1 and #2) of seven residents reviewed for abuse, in that 1. The ADM (abuse coordinator) was verbally abusive to Resident #1 on an undetermined date. The resident had a history of [REDACTED]. 2. The ADM (abuse coordinator) was verbally abusive to Resident #2 on 8/10/2018 (closed record) The resident had a history of [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/3/2018. While the IJ was removed on 10/5/2015, the facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as pattern. This failure could most likely place residents at risk of fear, depression, intimidation, and a diminished quality of life due to verbal abuse. Findings included: Review of face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly minimum data set (MDS) for Resident #1 conducted on 8/14/2018 reflected a brief interview for mental status (BIMS) score of 15, indicating little or no cognitive impairment. Review of care plan for Resident #1 dated 3/20/2018 reflected the following: History of depression. Observe for change in mental status. Approach resident warmly and positively. Evaluate effectiveness of medications and side effects. Encourage resident to perform at least two activities by self daily. Actively listen to resident and acknowledge the reality of concerns. Reassure resident during interactions. During a confidential interview a staff member stated he has worked for the facility for seven years and he works 300 and 200 Halls. When asked if he has ever witnessed the ADM verbally abuse residents, he stated that the ADM was loud and yelled at Resident #1 related to her diet. He then stated this happens all the time, that she yells at staff or residents. He stated that she is very demeaning and condescending to residents and staff. He stated that she has also treated family members the same way. He stated he was afraid to report the abuse he has witnessed and heard about because the facility administration always finds out who told on them, and retaliation begins. He was asked to elaborate on what retaliation entailed but refused to talk anymore about it. During an interview on 10/3/2018 at 11:44 a.m., Resident #1 stated that the ADM has been verbally abusive to her. Resident #1 stated that she is a diabetic and has been one for many years, and she always made sure she ate what she was supposed to eat to control her diabetes well. She stated that the kitchen wasn't giving her things that were good for a diabetic. She stated that, during meal times, she sits next to the kitchen and went to the kitchen door to ask why they give her so many things she shouldn't be eating. She stated that the ADM was in the kitchen at the time, and she yelled (Name) you don't know what you are talking about! and gave her an angry, demeaning look. Resident #1 stated that ever since this incident, she feels the ADM has something against her. She stated that there have been a couple of things that made her feel targeted by the ADM. She stated that one of these is that she was blamed when the ADM stated she could no longer have her dog in the building. Resident #1 stated that she does not know why the dog was no longer allowed in the building, but there was gossip among other residents that Resident #1 was the person responsible for the dog's banishment. The other thing that makes her feel as if the ADM holds something against her is that every time the ADM sees her, she will make a point to say hello to everyone around her by name except her. Resident #1 stated that the incident in the dining room with the ADM was a while ago, maybe two months ago, but the effects are ongoing. She stated that when the ADM yelled at her in that way, it made her feel like a nobody, and she has been scared since. Resident #1 stated that she has been especially scared due to unfriendly treatment by the ADM and some of the residents. Review of face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged to a group home on 9/5/2018. His [DIAGNOSES REDACTED]. Review of initial MDS for Resident #2 conducted on 7/9/2018 reflected a BIMS score of 15, indicating little or no cognitive disability. Review of care plan for Resident #2 dated 7/2/2018 reflected the following: Resident has dx of [MEDICAL CONDITION] as evidenced by: history, +PL1, PE per Rep. Monitor Resident for increased agitation, anger, verbal, and physical aggression. Document episodes of behavior. Remove Resident from increased stimuli during behavioral episodes. Resident has dx of [MEDICAL CONDITION] (bi-polar) and can have mood swings from euphoria to depression. Monitor Resident for s/s or mania, document finding in the clinical record. Monitor resident for s/s of depression and document in the clinical record. Attempts were made on 10/3/2018 at two different personal phone numbers and one number for the group home to which Resident #2 was discharged in an effort to interview Resident #2. These attempts were unsuccessful. During an interview on 10/3/2018 at 4:30 p.m., CNA D she stated the ADM verbally abused Resident #2 in front of several residents and staff. She stated that the ADM was yelling at him to get out, pointing her finger in his face, and threatening him that she was going to call the cops. She stated that the ADM was screaming at the resident because he wanted a sandwich, and that he wasn't doing anything wrong. She stated that she was scared to address this with the ADM, because she is the abuse coordinator. CNA D stated that more of the verbal abuse by the ADM is towards the staff, and they don't wish to add more by making her angry. She stated that today, 10/3/18, the ADM had yelled at a resident that he smelled like pee, and told him that everything around him was starting to stink. CNA D stated the resident resists showers and is incontinent of bladder and bowl. She stated the resident is nonverbal. She stated the resident got visibly upset and began to shake when this happened. She identified the resident by his first name and room number. She stated she was the only one in the room. During an interview on 10/3/2018 at 9:43 a.m., the ADM stated that abuse is any time a resident either feels unsafe, could be unsafe, receives aggressive verbal talk from a staff member or another resident, or any sort of physical, mental, verbal, sexual abuse or seclusion. She stated that she is the abuse coordinator. She stated that her role as abuse coordinator for the facility is to investigate any time someone reports abuse and to always be available for someone to report abuse concerns whether it's residents, family, or staff. She stated she also determines and reports within two hours of finding out about an allegation of abuse. She stated she investigates by interviewing the resident who is the alleged victim, interviewing staff, doing rounds with other residents to ensure nobody else feels the same way, and the social worker does a mini mental health evaluation. She stated she interviews the alleged perpetrator and assesses the resident for injuries. She stated she ensures the alleged victim is out of harm's way. She stated she calls corporate for guidance. The ADM stated that retaliation is to be negative or to treat someone differently because you knew that they reported abuse. She stated that for a resident, this might mean staff treating them differently, gossiping, not inviting them to activities, or other isolation. She stated the same goes for staff: supervisor treating them differently or changing their assignments without explanation. She stated that she would you say that yelling or raising the voice is abuse. She stated she would say that calling names, swearing, or belittling residents is abuse. She stated that yelling or raising the voice to staff in front of residents is abuse. She stated that yelling or raising the voice around residents could scare them, make them anxious, raise their blood pressure, or cause depression. She stated that her expectation is that no direct care staff or supervisors should raise their voices around residents. During a confidential interview a staff member stated that the ADM yells at the staff all the time. She stated that she knows about the ADM yelling at a resident. She stated that some of the staff saw and heard the ADM yelling at Resident #2, and she knows that someone reported this to the State Agency. The staff member stated that she is afraid to lose her job or have the ADM be angry at her and yelling, so she requested that the interview be kept confidential. She stated that all the staff is afraid. She stated that ADM becomes angry often and yells. During a confidential interview a staff member stated that the ADM has yelled at her for over-ordering supplies and all sorts of other things. She stated that the ADM yells at her and the other staff in front of residents all the time. She stated she has not witnessed her yell at the residents but does know about that. During a confidential interview a staff member stated that the ADM does yell at the staff and speaks rudely to the residents. She stated that this affects the residents and the staff, because they want ADM to treat them like humans, and she doesn't always do that. She stated that the ADM also treats the family members badly if they don't like her dog. She stated that there is ongoing trouble related to the ADM's dog. She stated that she is afraid of being treated worse if she speaks about what is going on in the facility and asked that the interview be confidential. During a confidential interview a staff member stated he has heard the ADM yell a little bit. He stated she talks badly to people. He stated it happened (she yelled at someone) Monday and sometimes other days. During an interview on 10/3/2018, family member (FM) stated the ADM has made racial comments and often treats family members, staff, and residents in the same demeaning, condescending way. She stated the ADM will talk down to them and be demeaning and condescending. She stated that the ADM sometimes yells at residents and family members. She stated she cannot remember any details or specific examples, but her mother has been in the facility for three years, and she has experienced the morale of the entire facility go down since the current ADM was hired. Review of undated facility policy titled Resident Behavior and Facility Practices Policy reflected the following: Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, and reasonable confinement, intimidation, neglect, psychological harm related to unauthorized photos or willful infliction of injury or punishment with resulting physical or emotional harm, mental anguish or pain to a resident. The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, exploitation, involuntary seclusion and misappropriation of resident property. Through the facility's mission statement each employee is expected to act in such a manner as to reflect the mission statement of this corporation. Each employee receives the employee standards of conduct which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. All staff in the nursing facility and all residents, responsible parties, and or legal representatives have all been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what type of incidents reported, will be investigated fully. All employees who suspect abuse at any time are to report it to their immediate supervisor. If the supervisor is not the charge nurse then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, he will then report to the allegation to the director of nursing, or the assistant director of nursing, the director of nursing, and/or the administrator. The administrator or his/her designee will report this allegation of abuse immediately to the state agency and to the proper local authorities. The facility delegates the administrator as the abuse coordinator and posts the name and phone number of the abuse coordinator in the facility. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator. The abuse coordinator will ensure that facility completes the appropriate investigated (sic) forms and forwards a copy of the investigation to DADS within five working days. It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Although abuse comes in different types, the facility has one common goal and that is to protect each and every resident. Upon notification of suspected abuse the director of nursing or designee will take two courses of action when an abuse identifies a perpetrator that is identified by an eyewitness, (1) the facility will immediately remove the perpetrator from the facility, pending outcome of the investigation. The RVP was notified on 10/3/2018 at 4:30 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the RVP on 10/3/2018 at 7:10 p.m. and accepted by the Survey Team at 7:15 p.m. a. Alleged perpetrator was immediately suspended pending investigation until further notice/investigation completion. Alleged perpetrator to be interviewed regarding statement of allegation by Divisional Director of People Strategy. b. Facility Vice President and Director of Clinical Operations to begin the investigation and implementation of remediation. The Director of Clinical Operations and the Assistant Director of Nursing Will begin education for facility staff to include RNs, LVNs, CNAs, CMAs, department heads, dietary, therapy and housekeeping staff on the definition of abuse and neglect and the different types of abuse. The education will also include the reporting of any allegation of abuse or neglect to the abuse coordinator immediately. If the abuse coordinator/administrator is not immediately available the notification will be made to the director of nursing or the next available in charge. c. Facility staff will be educated on policy against retaliation for fear of reporting abuse or neglect. Should the witness/individual reporting the allegation not feel comfortable reporting to abuse coordinator, education will be provided to direct concerns to the compliance hotline and/or HHSC abuse hotline. d. Resident representatives/residents will be educated on how to report allegations of abuse or neglect. e. Facility Director of Social Services Will initiate safe survey interviews on interview a ball residents to identify any other grievances or areas of concern which could be construed as an abuse or neglect allegation. f. If any potential abuse or neglect allegations are identified during the interviews and assessments the facility abuse Cordinator will immediately ensure the resident safety, suspend or remove the alleged perpetrator from the facility grounds (if applicable or identified), and initiate an investigation into the allegation. Appropriate notifications will be made to the resident representative, the physician, health and human services department, and the local authorities, if indicated. g. Those residents identified as alleged victims will be interviewed, assessed, and monitored for mental duress until it is deemed unnecessary by the interdisciplinary team as applicable. h. Director of Clinical Operations educate the facility director of nursing and assistant directors of nursing to include: the definition of abuse and neglect, including the different types of abuse; the process on what to do when an allegation of abuse or neglect is made starting with ensuring resident safety immediately and removing the alleged perpetrator, if applicable, from facility grounds; reporting guidelines from Health and Human Services department. i. An Ad Hoc QAPI meeting will be held with the Medical Director, just a lady administrator, director of nursing, social services director, vice president, and director of clinical operations to review plan of removal, as well as ongoing process improvements to ensure resident safety. Education will begin on 10/3/18 and continue each shift until 100% of the stuff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. To be completed by 10/5/18. The survey team monitored the plan of removal as follows: Observation and interview on 10/3/2018 at 4:35 p.m. revealed that the ADM had left the premises. During interviews on 10/4/2018 between 1:25 p.m. and 1:50 p.m., one RN, three LVNs, three CNAs, three HKs, one dietary aide, one CMA, the admissions coordinator, and the business office manager all verified their participation in and signatures on in-servicing to do with abuse and reporting. During interviews on 10/4/2018 at 10:15 p.m., several staff members verified their knowledge of abuse reporting procedures and verified their participation in and signatures on in-servicing on the topic. During interviews on 10/5/2018 at 2:30 p.m., several staff members verified their knowledge of abuse reporting procedures and verified their participation in and signatures on in-servicing on the topic. The RVP was informed at 2:40 p.m. on 10/5/2018 that the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of potential for more than minimal harm and a scope identified as pattern.

Based on interview and record review, the facility failed to protect two (Residents #1 and #2) residents, of seven reviewed, from verbal abuse, in that 1. The ADM (abuse coordinator) was verbally abusive to Resident #1 on an undetermined date. The resident had a history of [REDACTED]. 2. The ADM (abuse coordinator) was verbally abusive to Resident #2 on 8/10/2018 (closed record) The resident had a history of [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/3/2018. While the IJ was removed on 10/5/2015, the facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as pattern. This failure could most likely place residents at risk of fear, depression, intimidation, and a diminished quality of life due to verbal abuse. Findings included: Review of face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly minimum data set (MDS) for Resident #1 conducted on 8/14/2018 reflected a brief interview for mental status (BIMS) score of 15, indicating little or no cognitive impairment. Review of care plan for Resident #1 dated 3/20/2018 reflected the following: History of depression. Observe for change in mental status. Approach resident warmly and positively. Evaluate effectiveness of medications and side effects. Encourage resident to perform at least two activities by self daily. Actively listen to resident and acknowledge the reality of concerns. Reassure resident during interactions. During a confidential interview a staff member stated he has worked for the facility for seven years and he works 300 and 200 Halls. When asked if he has ever witnessed the ADM verbally abuse residents, he stated that the ADM was loud and yelled at Resident #1 related to her diet. He then stated this happens all the time, that she yells at staff or residents. He stated that she is very demeaning and condescending to residents and staff. He stated that she has also treated family members the same way. He stated he was afraid to report the abuse he has witnessed and heard about because the facility administration always finds out who told on them, and retaliation begins. He was asked to elaborate on what retaliation entailed but refused to talk anymore about it. During an interview on 10/3/2018 at 11:44 a.m., Resident #1 stated that the ADM has been verbally abusive to her. Resident #1 stated that she is a diabetic and has been one for many years, and she always made sure she ate what she was supposed to eat to control her diabetes well. She stated that the kitchen wasn't giving her things that were good for a diabetic. She stated that, during meal times, she sits next to the kitchen and went to the kitchen door to ask why they give her so many things she shouldn't be eating. She stated that the ADM was in the kitchen at the time, and she yelled (Name) you don't know what you are talking about! and gave her an angry, demeaning look. Resident #1 stated that ever since this incident, she feels the ADM has something against her. She stated that there have been a couple of things that made her feel targeted by the ADM. She stated that one of these is that she was blamed when the ADM stated she could no longer have her dog in the building. Resident #1 stated that she does not know why the dog was no longer allowed in the building, but there was gossip among other residents that Resident #1 was the person responsible for the dog's banishment. The other thing that makes her feel as if the ADM holds something against her is that every time the ADM sees her, she will make a point to say hello to everyone around her by name except her. Resident #1 stated that the incident in the dining room with the ADM was a while ago, maybe two months ago, but the effects are ongoing. She stated that when the ADM yelled at her in that way, it made her feel like a nobody, and she has been scared since. Resident #1 stated that she has been especially scared due to unfriendly treatment by the ADM and some of the residents. Review of face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged to a group home on 9/5/2018. His [DIAGNOSES REDACTED]. Review of initial MDS for Resident #2 conducted on 7/9/2018 reflected a BIMS score of 15, indicating little or no cognitive disability. Review of care plan for Resident #2 dated 7/2/2018 reflected the following: Resident has dx of [MEDICAL CONDITION] as evidenced by: history, +PL1, PE per Rep. Monitor Resident for increased agitation, anger, verbal, and physical aggression. Document episodes of behavior. Remove Resident from increased stimuli during behavioral episodes. Resident has dx of [MEDICAL CONDITION] (bi-polar) and can have mood swings from euphoria to depression. Monitor Resident for s/s or mania, document finding in the clinical record. Monitor resident for s/s of depression and document in the clinical record. Attempts were made on 10/3/2018 at two different personal phone numbers and one number for the group home to which Resident #2 was discharged in an effort to interview Resident #2. These attempts were unsuccessful. During an interview on 10/3/2018 at 4:30 p.m., CNA D she stated the ADM verbally abused Resident #2 in front of several residents and staff. She stated that the ADM was yelling at him to get out, pointing her finger in his face, and threatening him that she was going to call the cops. She stated that the ADM was screaming at the resident because he wanted a sandwich, and that he wasn't doing anything wrong. She stated that she was scared to address this with the ADM, because she is the abuse coordinator. CNA D stated that more of the verbal abuse by the ADM is towards the staff, and they don't wish to add more by making her angry. She stated that today, 10/3/18, the ADM had yelled at a resident that he smelled like pee, and told him that everything around him was starting to stink. CNA D stated the resident resists showers and is incontinent of bladder and bowl. She stated the resident is nonverbal. She stated the resident got visibly upset and began to shake when this happened. She identified the resident by his first name and room number. She stated she was the only one in the room. During an interview on 10/3/2018 at 9:43 a.m., the ADM stated that abuse is any time a resident either feels unsafe, could be unsafe, receives aggressive verbal talk from a staff member or another resident, or any sort of physical, mental, verbal, sexual abuse or seclusion. She stated that she is the abuse coordinator. She stated that her role as abuse coordinator for the facility is to investigate any time someone reports abuse and to always be available for someone to report abuse concerns whether it's residents, family, or staff. She stated she also determines and reports within two hours of finding out about an allegation of abuse. She stated she investigates by interviewing the resident who is the alleged victim, interviewing staff, doing rounds with other residents to ensure nobody else feels the same way, and the social worker does a mini mental health evaluation. She stated she interviews the alleged perpetrator and assesses the resident for injuries. She stated she ensures the alleged victim is out of harm's way. She stated she calls corporate for guidance. The ADM stated that retaliation is to be negative or to treat someone differently because you knew that they reported abuse. She stated that for a resident, this might mean staff treating them differently, gossiping, not inviting them to activities, or other isolation. She stated the same goes for staff: supervisor treating them differently or changing their assignments without explanation. She stated that she would you say that yelling or raising the voice is abuse. She stated she would say that calling names, swearing, or belittling residents is abuse. She stated that yelling or raising the voice to staff in front of residents is abuse. She stated that yelling or raising the voice around residents could scare them, make them anxious, raise their blood pressure, or cause depression. She stated that her expectation is that no direct care staff or supervisors should raise their voices around residents. During a confidential interview a staff member stated that the ADM yells at the staff all the time. She stated that she knows about the ADM yelling at a resident. She stated that some of the staff saw and heard the ADM yelling at Resident #2, and she knows that someone reported this to the State Agency. The staff member stated that she is afraid to lose her job or have the ADM be angry at her and yelling, so she requested that the interview be kept confidential. She stated that all the staff is afraid. She stated that ADM becomes angry often and yells. During a confidential interview a staff member stated that the ADM has yelled at her for over-ordering supplies and all sorts of other things. She stated that the ADM yells at her and the other staff in front of residents all the time. She stated she has not witnessed her yell at the residents but does know about that. During a confidential interview a staff member stated that the ADM does yell at the staff and speaks rudely to the residents. She stated that this affects the residents and the staff, because they want ADM to treat them like humans, and she doesn't always do that. She stated that the ADM also treats the family members badly if they don't like her dog. She stated that there is ongoing trouble related to the ADM's dog. She stated that she is afraid of being treated worse if she speaks about what is going on in the facility and asked that the interview be confidential. During a confidential interview a staff member stated he has heard the ADM yell a little bit. He stated she talks badly to people. He stated it happened (she yelled at someone) Monday and sometimes other days. During an interview on 10/3/2018, family member (FM) stated the ADM has made racial comments and often treats family members, staff, and residents in the same demeaning, condescending way. She stated the ADM will talk down to them and be demeaning and condescending. She stated that the ADM sometimes yells at residents and family members. She stated she cannot remember any details or specific examples, but her mother has been in the facility for three years, and she has experienced the morale of the entire facility go down since the current ADM was hired. Review of undated facility policy titled Resident Behavior and Facility Practices Policy reflected the following: Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, and reasonable confinement, intimidation, neglect, psychological harm related to unauthorized photos or willful infliction of injury or punishment with resulting physical or emotional harm, mental anguish or pain to a resident. The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, exploitation, involuntary seclusion and misappropriation of resident property. Through the facility's mission statement each employee is expected to act in such a manner as to reflect the mission statement of this corporation. Each employee receives the employee standards of conduct which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. All staff in the nursing facility and all residents, responsible parties, and or legal representatives have all been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what type of incidents reported, will be investigated fully. All employees who suspect abuse at any time are to report it to their immediate supervisor. If the supervisor is not the charge nurse then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, he will then report to the allegation to the director of nursing, or the assistant director of nursing, the director of nursing, and/or the administrator. The administrator or his/her designee will report this allegation of abuse immediately to the state agency and to the proper local authorities. The facility delegates the administrator as the abuse coordinator and posts the name and phone number of the abuse coordinator in the facility. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator. The abuse coordinator will ensure that facility completes the appropriate investigated (sic) forms and forwards a copy of the investigation to DADS within five working days. It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Although abuse comes in different types, the facility has one common goal and that is to protect each and every resident. Upon notification of suspected abuse the director of nursing or designee will take two courses of action when an abuse identifies a perpetrator that is identified by an eyewitness, (1) the facility will immediately remove the perpetrator from the facility, pending outcome of the investigation. The RVP was notified on 10/3/2018 at 4:30 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the RVP on 10/3/2018 at 7:10 p.m. and accepted by the Survey Team at 7:15 p.m. a. Alleged perpetrator was immediately suspended pending investigation until further notice/investigation completion. Alleged perpetrator to be interviewed regarding statement of allegation by Divisional Director of People Strategy. b. Facility Vice President and Director of Clinical Operations to begin the investigation and implementation of remediation. The Director of Clinical Operations and the Assistant Director of Nursing Will begin education for facility staff to include RNs, LVNs, CNAs, CMAs, department heads, dietary, therapy and housekeeping staff on the definition of abuse and neglect and the different types of abuse. The education will also include the reporting of any allegation of abuse or neglect to the abuse coordinator immediately. If the abuse coordinator/administrator is not immediately available the notification will be made to the director of nursing or the next available in charge. c. Facility staff will be educated on policy against retaliation for fear of reporting abuse or neglect. Should the witness/individual reporting the allegation not feel comfortable reporting to abuse coordinator, education will be provided to direct concerns to the compliance hotline and/or HHSC abuse hotline. d. Resident representatives/residents will be educated on how to report allegations of abuse or neglect. e. Facility Director of Social Services Will initiate safe survey interviews on interview a ball residents to identify any other grievances or areas of concern which could be construed as an abuse or neglect allegation. f. If any potential abuse or neglect allegations are identified during the interviews and assessments the facility abuse Cordinator will immediately ensure the resident safety, suspend or remove the alleged perpetrator from the facility grounds (if applicable or identified), and initiate an investigation into the allegation. Appropriate notifications will be made to the resident representative, the physician, health and human services department, and the local authorities, if indicated. g. Those residents identified as alleged victims will be interviewed, assessed, and monitored for mental duress until it is deemed unnecessary by the interdisciplinary team as applicable. h. Director of Clinical Operations educate the facility director of nursing and assistant directors of nursing to include: the definition of abuse and neglect, including the different types of abuse; the process on what to do when an allegation of abuse or neglect is made starting with ensuring resident safety immediately and removing the alleged perpetrator, if applicable, from facility grounds; reporting guidelines from Health and Human Services department. i. An Ad Hoc QAPI meeting will be held with the Medical Director, just a lady administrator, director of nursing, social services director, vice president, and director of clinical operations to review plan of removal, as well as ongoing process improvements to ensure resident safety. Education will begin on 10/3/18 and continue each shift until 100% of the stuff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. To be completed by 10/5/18. The survey team monitored the plan of removal as follows: Observation and interview on 10/3/2018 at 4:35 p.m. revealed that the ADM had left the premises. During interviews on 10/4/2018 between 1:25 p.m. and 1:50 p.m., one RN, three LVNs, three CNAs, three HKs, one dietary aide, one CMA, the admissions coordinator, and the business office manager all verified their participation in and signatures on in-servicing to do with abuse and reporting. During interviews on 10/4/2018 at 10:15 p.m., several staff members verified their knowledge of abuse reporting procedures and verified their participation in and signatures on in-servicing on the topic. During interviews on 10/5/2018 at 2:30 p.m., several staff members verified their knowledge of abuse reporting procedures and verified their participation in and signatures on in-servicing on the topic. The RVP was informed at 2:40 p.m. on 10/5/2018 that the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of potential for more than minimal harm and a scope identified as pattern.