Every finding on record at Avir at Petal Hill

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 19 residents reviewed for accidents. (Resident #1). The facility failed to ensure adequate supervision and implementation of safety interventions for Resident #1 who resided on a secured unit and was assessed to be at risk for elopement. This resulted in Resident #1 exiting the building on 04/30/2026 without staff knowledge or supervision, placing the resident at risk for harm.The noncompliance was identified as PNC (past noncompliance). The IJ began on 04/30/2026 and ended on 05/06/2026. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of potential accidents, injuries, harm, or death.Findings included: A record review of a face sheet dated 04/30/2026 indicated Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia, psychotic disturbance (where a person loses touch with reality), anxiety, hypertension, trigeminal neuralgia (a sudden intense electric shock-like pain in the face), hyperlipidemia (high levels of lipids (fats) such as cholesterol in the blood), conversion disorder (a sudden weakness, paralysis , tremors or swallowing), with seizures or convulsions, major depressive disorder, type 2 diabetes mellitus, ischemic attack (TIA often called a mini-stroke, blockage of blood flow to the part of the brain), dysphagia (difficulty swallowing), cerebral infarction (ischemic stroke a blood vessel blocked or severely narrowed), chronic obstructive pulmonary disease (an irreversible lung disease that restricts airflow and makes breathing difficult) , and cognitive communication deficit ( impairment caused by disruptions in attention, memory, and function). Resident #1 was discharged on 05/7/2026 and transferred to a secured unit. A record review of Resident's #1 MDS dated [DATE] Section C0500: indicated Resident #1, had a BIMS score of 03 which indicated severe cognitive impairment. Section E0900: indicated wandering behavior was present and occurred with a frequency of one to three days.A record review of Resident #1's elopement risk assessment dated [DATE] indicated a score of 6 which was high risk for elopement.A record review of Resident's #1 care plans initiated on 11/6/2026, updated 4/30/2026 indicated Resident #1 resided in the secured/memory unit and was at risk for injury from wandering in an un- safe environment related to diagnosis of dementia and impaired safety awareness. The resident was at risk of injury from others while residing in secured/ memory unit due to altered cognition. On 4/30/2026, an actual elopement occurred without injury or emotional distress, and the resident was successfully returned to the facility. Intervention initiated on 4/30/2026 included the resident was placed on 1 on 1 observation. Staff were instructed to sit outside of exit door; resident room was moved closer to the nurse's station. Family and PCP in agreement with secured unit placement. Staff ensured residents safety.A record review of Resident #1's police report indicated the incident was reported on 4/30/2026 at 9:45 a.m. The resident was last known secured at 9:46 a.m. Officer responded to the area of two local streets regarding an elderly female, later identified as Resident #1, wandering in the neighborhood and entering a residential backyard. Dispatch contacted the facility and requested staff verify whether any residents were missing. Upon arrival, facility staff were present with Resident #1. The MDS RN arrived on scene and assisted Resident #1 back to the facility without incident. The MDS RN reported Resident #1 exited through a secured door that had not been properly closed, allowing the resident to leave the facility unsupervised.A record review of Medical Records/CNA B's typed and signed statement on 4/30/2026 at 9:49 a.m., indicated the police department contacted the facility regarding a white female with gray hair, located approximately one block away. Once CNA B received the call, she informed the Director of Nursing (DON) to conduct a resident count while she went to identify the individual. Upon arrival, she confirmed that the individual was one of the facility residents. After identification was verified, the DON, MDS nurse, and Administrator arrived on the scene, and the resident was safely escorted back to the facility. A record review of Resident #1's provider investigation report dated 4/30/2026 at 12:30 p.m. indicated Resident #1 was seen at activity at 9:45 a.m. Within a 4-minute time frame the resident walked out of the rear exit of the secured unit. The facility was notified by the police department about an older lady in a person's backyard. The police notified Resident #1 was located 4/30/2026 at 10:00 a.m. on a sidewalk of a local street. A record review of Resident #1's progress notes dated 4/30/2026 at 4:39 p.m. indicated the IDT met to discuss the PD notified staff that there was a resident outside of the premises on 4/302026 at 9:49 a.m. A facility head count and search of the immediate perimeter was initiated. The IDT care notes indicated, a member of the management found the resident walking on the sidewalk and immediately notified the DON, ADM, and MDS RN. ADM, DON, and MDS RN, drove to location where resident was with management staff and two PD officers. the IDT care notes indicated residents returned to the facility at 10:14am and the Nurse immediately completed a head-to-toe assessment with no Injuries. [Resident #1did not show any signs and symptoms of emotional distress. Resident #1 stated I just wanted to go for a walk. A record review of Resident #1's BIMS Evaluation on 4/30/2026 at 4:09 p.m. indicated Resident #1, had a BIMS score of 10 which indicated moderate impairment. A record review of Resident #1's elopement risk assessment dated [DATE] indicated a score of 5 which was high risk for elopement.A record review of Resident #1's nurse's note dated 5/1/2026 at 3:42 p.m. indicated the DON discussed with the resident's responsible party, a possible transfer to a secured unit for increased safety. The resident's responsible party agreed with the plan, and the social worker was to be notified. A record review of Resident #1's social service notes dated 5/1/2026 at 3:52 p.m. indicated the DON informed the social worker that she had spoken with resident's RP and advised that, per corporate direction, a referral was being sent to the sister facility's memory care unit to better support the safety and security needs of the resident. A record review of Resident #1's nurse's note dated 5/7/2026 at 12:16 p.m. indicated Resident #1 was discharged to the sister facility's memory care unit at 9:00 a.m. with medications and belongings. The resident was noted to be pleasant with no behaviors or complaints of pain or discomfort. During an observation on 5/12/2026 at 11:15 a.m., revealed Resident #1 was no longer residing on the secured unit. On the secured unit several residents were in the dining area. Observed three staff members in the hallway and in the dining area of the secured unit. Staffing patterns were compliant with facility postings. Observed all exit doors locked with keypad combination and the secured locked door at the end of the hallway alarms were in working order. During an interview on 5/12/2026 at 11:45 a.m., CN/LVN J said the last time she observed Resident #1 on the day of elopement was at approximately 8:30 a.m., when she administered the resident's medications and the resident was in her room in bed. She said the resident was highly functioning and frequently paced throughout the unit, in and out of her room. CN/LVN J said she returned to the unit approximately 9:55 a.m., due to the commotion heard on the unit. She said there were two CNAs and the Activity Assistant left on the unit while she observed the residents' smoke break. CN/LVN J said Resident # 1 reportedly exited through the secured locked door at the end of the hallway; however, staff were unable to determine how the secured locked door at the end of the hallway was opened and did not hear the alarm. She said staff denied using the door for entry or exit, and for breaks and reported the keypad code had been changed after the incident. She further said the hallway cameras were not functioning, preventing review of the incident. Following the elopement, she said staff received education regarding the secured door policy and Elopement Prevention and Response.During an interview on 5/12/2026 at 11:55 a.m., CNA (A) stated she last observed Resident #1 ambulating in the hallway at approximately 9:20 a.m. to 9:25 a.m. She said she was in another resident's room when she responded to the commotion on the unit. CNA (A) stated immediately a resident count was done but they were unable to locate Resident #1. She said Resident #1 frequently said she wanted to go home and often would pack her belongings. CNA (A) denied using the secured hallway door for breaks, entering and exiting, and stated staff were in-serviced not to use the back hallway secured door, only during a facility emergency. She said she had occasionally observed maintenance staff using the door. She said she was unable to determine how the resident got out the door and did not hear the alarm sound. During an interview on 5/12/2026 at 12:05 p.m., the Activity Director said she was in the secured unit the day of the incident and said she last observed Resident # 1 sitting at the table in the dining area eating and the time was approximately 9:00 a.m.; she remembered after breakfast trays were served. The Activity Director stated she was provided with in-service training on elopement prevention and the security door following the incident that occurred on 4/30/2026. During an interview on 5/12/2026 at 12:15 p.m. the ADM said the hallway camera was not functioning and had not worked since he was hired. He said the alarm was functioning at a low volume however the door was closed and locked when he arrived at the secured unit during the incident on 4/30/2026. He said he immediately questioned all staff, and the maintenance man denied entering and exiting the secured door however he was unable to determine how the resident exited the secured door. He said he immediately checked the alarm systems and turned the volume up. He said the secured door and the alarms systems were immediately checked and secured. During an interview on 5/12/2026 at 12:35 p.m., the MDS RN said the administration team was in a meeting when they were notified by the PD that a resident was missing, immediate resident count of the secured unit, and the facility was conducted. She said the alarms were not heard however the secured unit door was locked. She further stated there was a storm the day before, however, she said she was unable to determine how the resident got out the door. During an interview on 5/12/2026 at 12:45 p.m., the DON said after notification by the police department she immediately responded and went to the secured unit, an immediate conducted a count of the residents was conducted, the facility parameters were searched, however, she said there were no alarm sounds, and the secured door was locked. The DON said all staff that were interviewed denied entering and exiting the secured door. However, she said she was unable to determine how the resident got out the door. She said immediately after the resident returned to the secured unit; a head-to-toe assessment was completed. The DON said the resident was moved closer to the nurses' station for observation and placed on 1 to1 for short time, approximately two and half hours. The DON said a staff member was placed in the hallway to monitor door exits. She said the secured door and the alarms systems were immediately checked and secured. The DON said immediate steps were taken to make sure all residents' elopement assessments were completed. The DON said a head-to-toe assessment on Resident #1 and an emotional assessment were completed. The DON said the RP and MD were notified. The DON said a facility head count with emphasis on secured units was completed. The DON said an elopements drill was conducted on every shift (1st shift 6a-2p, 2nd shift 2p-10p, and 3rd shift 10p-6a), until all shifts were completed, and printed floor plans identifying the locations of all secured and alarmed doors were provided. The DON said in-services on the secured Exit Door, Elopement Prevention and Response, Secured unit and Safety Supervision of residents were completed.During an observation and interview on 5/12/2026 at 1:00 p.m., the ADM demonstrated functioning of the alarm systems on the secured locked door at the end of the hallway. The alarm systems were in working condition once the door was open with a combination keypad code. The ADM said he had changed the combination keypad code since the incident. He stated he currently did not have maintenance assistance, however on 05/07/2026, the Corporate Maintenance Technician came and checked all the door alarms at the facility. During an interview on 5/12/2026 at 1:35 p.m., the ADON said she had nothing further to add except she was on staff at the time of the elopement and verified immediately the secured unit was searched and counted. The ADON said Resident #1 was not located on the unit, and the security door was locked. She said the staff were in-serviced on elopements drill every shift (1st shift 6a-2p, 2nd shift 2p-10p, and 3rd shift 10p-6a) until all shifts were completed. She said staff were further educated on Education stat on ANE, Elopement/Missing Resident, Elopement prevention and response, and Secured unit and Safety Supervision of residents.During an interview and observation on 5/13/2026 at 9:54 a.m., with Medical Records/CNA (B) said that on 4/30/2026 at approximately 9:49 a.m., she received a call from the police department regarding concerns of a missing resident. She said she immediately notified the DON, and she was instructed to identify the resident, and the team immediately proceeded to the memory care unit and the facility units. CNA (B) stated that at approximately 9:50 a.m., she identified Resident #1 standing on the sidewalk with a community neighbor in front of the neighbor's home. She stated police arrived approximately two minutes later. CNA (B) said she notified the DON that the individual was a resident of the facility. The ADM, DON, and MDS Nurse subsequently arrived at the scene by vehicle. According to CNA (B) the community neighbor reported he observed the resident standing in front of his yard and contacted police to determine whether the resident belonged to one of the nearby facilities. Following the interview, a walk-through was conducted to the location where Resident #1 was identified. Observation revealed the resident was found approximately one block from the facility and estimated seven-minute walk or 0.3 miles away, standing on the sidewalk along a local street with a posted speed limit of 30 mph in a college district.During an interview on 5/13/2026 at 12:30 p.m., with CN/LVN (K), CNA (C), and CNA (D), all three staff said they performed rounds every two hours to account for and verify the location of each resident on their unit. All three staff stated they had received in-service training regarding emergency codes, missing resident procedures, and conducting routine rounds to ensure residents were accounted for. Staff further stated they had been in-serviced not to provide facility security codes to non-employees, including family members, residents, or contract workers. During an interview on 5/13/2026 at 12:45 p.m. with CN/LVN (L), and CNA (E), both said they conducted rounds every two hours to account for residents and communicated resident locations, including appointments, dialysis and physical therapy. Staff stated they had received in-service training on elopement prevention alarms, missing resident procedures, and immediately accounting for residents. Staff further stated only employees should have access to security codes, and to ensure doors were closed securely. CNA (E) said staff were to assist visitors, residents, or contractors by entering door codes for them. During an interview on 5/13/2026 at 12:50 p.m., the DON said all staff, including nurses, dietary, housekeeping, and therapy staff, received in-served training on elopement prevention, missing resident response, secured door systems, and resident safety supervision. The DON said security door codes were not to be shared with residents, visitors or contractors, and staff were required to enter codes for individuals needed access to secured areas. The DON further stated elopement assessments were completed quarterly or with increased exit-seeking behaviors, elopement drills were conducted quarterly, and additional in-services were provided following elopement incidents.During an interview on 5/13/2026 at 4:30 p.m., with RN (M), CNA (F), and CNA (G), they said they performed rounds every two hours. CNA (F) said if a resident could not be located on the unit, staff searched the bathrooms and outside perimeters before notifying 911. All three staff stated security door codes were not to be shared with residents, visitors, family members or contractors, and staff were required to enter the code themselves when assisting individuals into the secured areas. Staff further stated they received in-service training on quarterly elopement drills and were required to follow up with the ADON or DON if they missed scheduled training. During an interview on 5/13/2026 at 4:50 p.m. with RN (N), CNA (H), and CNA(O) located on the secured unit, all three staff said they conducted rounds and resident head counts every two hours, and staff reported they had been in-serviced that the back secured door was not to be used for entrance or exit unless there was an emergency. Staff further stated the security door codes were not to be shared with residents, family members, contractors, pharmacy staff, or delivery personnel. Staff stated they were responsible for assisting individuals needing access into the secured areas. Staff further stated they received monthly elopement training and or drills. Record review of facility Elopement Evaluation facility rating assessment Wandering and Elopements dated 3/2019 indicated Score value of 1 or higher indicated Risk of Elopement.Record reviews of electronic records indicated 19 residents located on the secured unit were assessed for elopement risk on 04/30/2026. Elopement risks were identified and updated, as necessary due to increased need for observation.Record review of care plans updated 5/13/2026 indicated 19 residents located on the secured unit were updated, as necessary with additional interventions related to elopement risk. Interventions included completing elopement risk assessments upon admission, readmission, quarterly, annually, with significant change, and as needed. Interventions also included informing the physician, responsible party, and residents of identified risk factors and any noted changes.Record review of facility Safety and Supervision of Residents Policy dated; Revision date July 2017, Med-pass 2001 indicated .2. Safety risk and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes: Quality Assurance and Performance Improvement reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Systems Approach to Safety indicated .2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Due to their complexity and scope, certain resident risk factors and environmental hazard are addressed. These risk factors included . e Unsafe Wandering.Record review of facility Routine Resident Checks Policy; Revision date July 2013, Med-pass 2001 indicated .2. Routine resident checks involve entering the resident's room and/ or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs, toileting assistance, etc. Review of facility Wandering and Elopements Policy; Revision March 2019, Med-pass 2001 indicated: Policy Statement: the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.3. Resident missing, initiate the elopement/missing resident emergency procedure; (a). Determine if the resident is out on authorized leave or pass; (b). initiate a search of the building(s) and premises; and (c). notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcements officials, and (as necessary) volunteer agencies. (rescue squads etc.).4. Resident returned to the facility DON or Charge nurse (a). examine the resident for injuries. (b). report finding and conditions of the resident. (e). complete and file an incident report, and (f). document relevant information. The facility took the following actions to correct the noncompliance prior to surveyor entrance:Record review of Resident #1's skin assessment completed by the DON, dated 4/30/2026 revealed no injuries noted.Record review of Resident #1's Head-to-toe assessment completed by the DON on 4/30/2026 revealed no injuries noted.Record review of Resident #1's Emotional assessment completed by the DON on 4/30/2026 revealed no signs and symptoms of emotional distress.Record review of Resident # 1's nurse's notes completed by the DON on 4/30/2026 revealed head-to-toe assessment was completed upon return to the secured unit at approximately 10:20 a.m. Skin was intact with no bruising, redness, or open areas noted. Resident denied pain, consumed 100% of snack and fluids, and was calm and cooperative. Resident remained alert and oriented x2 and currently on 1:1 observation due to elopement. Record review of facility's daily staffing assignments dated 4/30/2026 and 5/1/20206 indicated staff members' door duty assignments were scheduled for each shift, included first shift (6:00 a.m. to 2:00 p.m.), second shift (2:00 p.m. to 10:00 p.m.), and third shift (10:00 p.m. to 6:00 a.m.).Record review for Resident #1 revealed the responsible party and physician were appropriately notified of the incident that occurred on 4/30/2026. Documentation confirmed that notifications were completed on 4/30/2026 in accordance with facility policy. Record review of facility head count conducted on 4/30/2026 with emphasis on the secured unit, of the facility floor plan and resident roster dated 4/30/2026 revealed all 82 residents accounted for. Record review of the facility's elopement drills revealed drills were conducted for each shift (1st shift 6a-2p, 2nd shift 2p-10p, and 3rd shift 10p-6a) until all shifts were completed on 4/30/2026.Record review of the facility's Printed floor plans revealed they identified the locations of all secured and alarmed doors locations and were made available to staff. This information was incorporated into Frequent Rounding Training and education.Record review of the Logbook Documentation Emergency Preparedness Drills and Exercise revealed drills were conducted, elopement drill for missing Resident drill dated April 30th at 9:49am, April 30th at 4:15PM, April 30th at 10:20pm, May 2nd at 1:30pm, May 11 and May 12th, 2026.Record review of Door Locks and Alarm Checks dated 04/27/2026 to 05/1/2026, 5/11/2026 and 5/12/2026 revealed all doors, locks and alarms had been tested frequently since 04/30/2026Record review of the Quality Assessment and Performance Improvement (QAPI) Plan meeting revealed the meeting was conducted on 4/30/2026 at 3:43p.m. and attended by all required staff in accordance with Quality Assessment and Performance improvement regulatory guidelines.Record reviews of electronic records revealed all 19 residents located on the secured unit were assessed for elopement risk on 04/30/2026. Elopement risks were identified and updated, due to increased need for observation. Interventions included completing elopement risk assessments upon admission, readmission, quarterly, annually, with significant change, and as needed. Record review of care plans updated 5/13/2026 revealed 19 residents located on the secured unit were updated, as necessary with additional interventions related to elopement risk. Interventions included completing elopement risk assessments upon admission, readmission, quarterly, annually, with significant change, and as needed. Interventions also included informing the physician, responsible party, and residents of identified risk factors and any noted changes. Record review of the facility's local company billing information dated 05/06/2026 revealed that a back emergency exit (a commercial-grade device) was installed with an HD SM ([NAME]-Duty Surface Mounted) door closer. Record review of documentation of training of all staff conducted beginning 04/30/2026 after the elopement for Elopement Prevention, Elopement Response, Abuse and Neglect:Record review of in-service on Entrance and Exit codes dated 4/30/2026 indicated Do not give codes out to non-employees such as Family Member, the residents, and contracted workers. Assist with helping individuals in an out of building. The training was conducted by the DON.Record review of in-service on Education stat on ANE and Elopement/Missing Resident dated 4/30/2026 indicated to assure that all residents were properly attended to and appropriately monitored.Record review of in-service on Elopement risk dated 4/30/2026 indicated all residents in the secured unit were elopement risk residents. The training was conducted by the DON.Record review of in-service on Elopement, Prevention and Response dated 4/30/2026 indicated the need to ensure all staff prevented elopement through active supervision and environmental awareness. Recognize high-risk residents. Respond immediately and correctly, if a resident attempted to leave or goes missing. The training was conducted by the DON.Record reviewed of in-service on Frequent Rounding dated 04/30/2026 indicated staffs conducted Rounds on Residents every two hours. Nurses (even hour) and CNAs were (odd hour). The training was conducted by the DON.Record review of in-service on Secured Unit and Safety Supervision of residents 4/30/2026 indicated staff to make frequent rounds to ensure all residents are accounted for. Make sure doors are secured and alarm is set. The training was conducted by the DON.Record review of in-service on Abuse and Neglect dated 4/30/2026 indicated ensured that all residents are being properly attended to and were being monitored. The training was conducted by the DON.Record review of in-service on Abuse Neglect Exploitation and Misappropriation Prevention Program dated 4/30/2026 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Which included but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Record review of in-service on Frequent Rounding dated 4/30/2026 indicated Make frequent rounds to ensure all residents are accounted for. Make sure doors are secured and alarm is set. The training was conducted by the DON.Record review of in-service record door post Exit Door (DO NOT USE THE Back DOOR ON THE SECURE UNIT! THAT DOOR IS NOT AN ENTRANCE OR EXIT) Disciplinary action will be taken. The Secure unit is not a cut through, walk around. 4/30/2026. The training was conducted by the DON.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for one of one rooms (the primary therapy room) reviewed for environment. The facility failed to ensure residents were not exposed to mold growing in the air vents in the primary therapy room. This failure could place residents at risk for respiratory infections and allergic reactions. The findings included: During an observation on 04/01/2026 at 8:56 AM, revealed a black, spotty substance observed on four air vents and the surrounding ceiling area located in the primary therapy room. 1. A record review of Resident #3's face sheet, dated 04/01/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included spinal stenosis, cervical region (the narrowing of the spinal canal in the neck area), weakness, unsteadiness on feet, other abnormalities of gait and mobility, and hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side (paralysis and weakness following a stroke). Record review of Resident #3's most recent Quarterly MDS dated [DATE] indicated a BIMS of 15, which indicated normal cognitive function. Resident #3 received therapy services for at least 15 minutes a day on one or more days in the last 7 days. During an observation and interview on 04/01/2026 at 9:00 AM, Resident #3 was observed utilizing the SciFit machine in the primary therapy room directly underneath the vent and ceiling area that had the black, spotty substance. Resident #3 indicated he had a history of strokes and had been at the facility for about two and a half years. Resident #3 indicated he often utilized the primary therapy room and entered it at least once a day. Resident #3 indicated he had not noticed the substance on the air vents and surrounding ceiling as he did not often look up. Resident #3 indicated he had not experienced any adverse effects including respiratory illness or skin irritation. Resident #3 did not have any observable skin irritation or respiratory issues. 2. A record review of Resident #4's facesheet, dated 04/01/2026, indicated a [AGE] year-old male admitted [DATE]. Resident #4 had diagnoses which included other nontraumatic intracerebral hemorrhage (bleeding in the brain tissue), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side (paralysis and weakness following a stroke), muscle weakness, and unsteadiness on feet. Record review of Resident #4's most recent Quarterly MDS dated [DATE] indicated a BIMS of 13, which indicated normal cognitive function. Resident #4 received therapy services for at least 15 minutes a day on one or more days in the last 7 days. During an observation and interview on 04/01/2026 at 10:38 AM, Resident #4 was observed completing a puzzle at a table directly underneath a vent and ceiling area that had a black, spotty substance. Resident #4 indicated he entered the primary therapy room daily. Resident #4 indicated he never looked up to see the black substance. Resident #4 indicated he had not experienced any adverse effects including respiratory illness or skin irritation. Resident #4 did not have any observable skin irritation or respiratory issues. During a record review on 04/01/2026 at 10:24 AM, a list of residents who had pneumonia in the last 6 months was cross referenced with a roster of residents receiving therapy services. These records indicated no residents who had received therapy services in the front therapy room had been diagnosed with pneumonia. During an interview on 04/01/2026 at 10:41 AM, the Director of Rehab indicated he was not sure what specifically was on the vents and ceiling. The Director of Rehab indicated somebody had come to the facility about 3 or 4 months ago. The Director of Rehab indicated they were instructed not to use the air conditioning or heat in that room and to bring residents to a separate therapy area when it was too hot or too cold. The Director of Rehab indicated they now had a wall unit to regulate the temperature. The Director of Rehab indicated he felt it was safe as no air was going through the vents. During an interview on 04/01/2026 at 12:43 PM, the PT indicated she had worked at the facility part time for about a year and a half. The PT indicated they were using a separate therapy area and she was instructed not to bring residents to the primary therapy area when it was too hot or too cold as they could not use the vented air system. The PT indicated it was around Christmas time that she had been instructed this. The PT indicated she was it was okay to bring residents to the primary therapy area full time now that there was a wall unit to regulate the temperature even with the black substance on the vents and ceiling. During an interview on 04/01/2026 at 12:52 PM, the PTA indicated she had worked at the facility for about 7 months. The PTA indicated in December she was told not to use the main air system in the therapy room and that there had been a water leak in the ceiling. The PTA indicated they got a new window unit last week to regulate the temperature. The PTA indicated she thought the vents looked black, brown, and dusty and the appearance of the vents had not changed since December 2025. The PTA declined to answer if she felt it was safe to bring residents for therapy underneath these vents and ceiling areas. During an interview on 04/01/2026 at 12:57 PM, the ADON indicated she understood the air system was not working in the therapy area. The ADON indicated she was unaware of any further issues. During an interview on 04/01/2026 at 1:04 PM, the DON indicated the primary therapy area was supposed to receive updates soon. The DON indicated there was talk regarding mold so therapy was moved to a separate area. The DON indicated she believed the vents were recently cleaned. The DON indicated she was unsure if it was mold, but she thought it was suspected and that was why air flow was stopped in that room. During an interview on 04/01/2026 at 1:38 PM, the ADM indicated he was waiting on bids to be able to repair the primary therapy area. The ADM indicated they planned to remove and replace the venting system. The ADM indicated he did not have test results that showed what the substance was, but he knew it had been tested. The ADM indicated he was told to not use the central air in that room and it was safe as long as the system was not running. The ADM was unable to provide information on who stated it was safe for residents to utilize that room. The ADM did not answer when asked if he felt it was safe for residents to be using that room, instead he stated they could close it off and move the residents. The ADM indicated they attempted to move as much of the therapy services as possible to the separate therapy area that was not affected. During an interview on 04/01/2026 at 2:25 PM, the regional director of maintenance indicated he had a report regarding the issue in the vents and ceiling and would provide it. The regional director of maintenance indicated the testing sample indicated it was penicillin, aspergillus, and another fungus that he was unaware of. The regional director of maintenance indicated he would not want his family receiving therapy underneath the substance and it was not acceptable. During a telephone interview on 04/07/2026 at 10:35 AM, the mold assessment consultant indicated the majority of the typical mold spores throughout the area were low, with the air duct being the exception. The mold assessment consultant indicated he was contacted by 2 remediation companies for clarification on his report, which indicated the facility was getting quotes for the work to be done. The mold assessment consultant indicated if the facility followed the recommendation for use of the primary rehab room found in the report there was no significant health risk to anyone who used the area. A record review of the report provided by the regional director of maintenance titled Physical Therapy Room Mold Report & Protocol dated 12/17/2925 indicated the following: Project SummaryThis is an assisted living residence that requested a mold inspection with associated testing be done to determine the risk of mold exposure to residents. The physical therapy (PT) room had mold growth evident around the vents on the ceiling. The ductwork was also tested and showed heavy mold spore populations. Employees working in that room reported irritation to skin and other symptoms that may be caused by mold exposure. General Remediation Methods.Secure the work area(s) from access by building occupants, employees, other contractors, and other nonessential traffic prior to the start of remediation activities. Only Texas licensed, or registered mold contractor, consultant, and worker personnel are allowed to enter the remediation containment area(s) between the start date specified on the Texas notification and the date written clearance is achieved. Accomplish this, where possible, by locking doors, windows, or other means of access to the work area(s); by scheduling work for periods of time that the building is unoccupied or by constructing temporary wood stud and plywood barriers where necessary. Periodically re-inspect the perimeter for any breaches that may allow for work area entry. In addition, post signs advising that a mold remediation project is in progress at all accessible entrances to remediation area of the building in according with TDLR mold regulations. Special Considerations & Protocol Measures for Remediation of the Physical Therapy RoomThis Remediation Work Area is being conducted adjacent to a main entrance where heavy foot traffic is expected. To protect the guests, employees and residents, a sheet of 6-mil polyethylene film shall be draped and sealed across the main doorway to the PT Room with access from that doorway being completely blocked off while contaminated materials are being removed, demolished, or remediated and while any construction activities that generate dust are being performed in the PT room. This will protect the people entering and leaving the building from mold, construction debris, and other potentially harmful airborne particles. Lab Data The following lab data shows relatively low levels of spores in the PT Room's air, similar to the fungal diversity of the Outside Control Sample. Summary & Recommendations.The HVAC system should not be operated until the ductwork is cleaned and remediated. A record review of the facility's policy entitled Homelike Environment, dated February 2021 indicated the following: Policy Statement Residents are provided with a safe, clean, comfortable, and homelike environment.Policy Interpretation and Implementation.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for one of seven residents (Resident #1) reviewed for abuse. The facility failed to report an allegation of abuse to HHSC until approximately 5 hours after the incident occurred. This failure could place residents at risk of not receiving timely investigation into allegations of abuse. The findings included: 1. A record review of Resident #1's facesheet dated 04/01/2026 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included encephalopathy (a brain condition that can manifest as altered mental state, confusion, or memory loss) and dementia (a decline in cognitive abilities that interferes with memory, thinking, reasoning, and behavior). Resident #1's most recent Quarterly MDS dated [DATE] indicated Resident #1 had a BIMS of 3, which indicated severe cognitive impairment. Record review of progress notes for Resident #1 indicated the following:A nurse note dated 03/26/2026 at 4:30 PM indicated Resident #1 was sitting in the dining area when another resident walked by and hit her in the face with a sneaker that she was carrying in her hand. The note indicated Resident #1 showed no signs of physical or emotional distress and had no redness, pinkness, or bruising to her face or complaint of pain. Record review of a social services note dated 03/26/2026 at 6:44 PM indicated Resident #1 appeared without distress, was pleasant and calm, and unable to recall any event. The social services note indicated that the SW contacted Resident #1's family to inform them of the incident. A record review of neurological evaluation checklists dated 03/26/2026 at 4:00 PM, 4:30 PM, 5:15 PM, 5:30 PM, 6:00 PM, 6:30 PM, and 7:30 PM indicated Resident #1 was alert, was able to move all extremities, pupils were equal and reactive to light, and she had an appropriate response to pain. Record review of an IDT Care Conference note dated 03/27/2026 at 8:13 PM indicated neuro checks were initiated, psych NP was contacted for assessment, and nursing staff were to continue to monitor Resident #1 for signs and symptoms of delayed injury and physical/emotional distress. An observation of Resident #1 on 04/01/2026 at 9:16 AM indicated no bruising or redness to her face or other indicators of abuse. An attempt was made to interview Resident #1, but she was unable to answer questions appropriately. 2. A record review of Resident #2's facesheet dated 04/01/2026, indicated she was a [AGE] year-old female who was initially admitted on [DATE]. Resident #2 had diagnoses which included cerebral ischemia (a condition in which insufficient blood flow to the brain leads to reduced oxygen supply) and dementia (a decline in cognitive abilities that interferes with memory, thinking, reasoning, and behavior). Resident #2's discharge MDS dated [DATE] indicated a BIMS of 3, which indicated severe cognitive impairment. Record review of progress notes for Resident #2 indicated the following:A nurse noted dated 03/26/2026 at 4:30 PM indicated Resident #2 walked by another resident seated in the dining area and hit her in the face with a sneaker she was carrying in her hand, then sat at the table and put the sneaker on her foot. The note indicated Resident #2 had no anxiety or aggressive behavior and had nothing to say about the incident. The note indicated Resident #2 was immediately placed on one to one supervision and separated from the other resident. Record review of a social services behavior note dated 03/26/2026 at 5:50 PM indicated referrals were sent to multiple behavioral health hospitals for Resident #2 following the event. The social services note indicated the SW contacted Resident #2's family to inform them of the incident. Record review of an IDT Care Conference note dated 03/27/2026 at 11:07 AM indicated Resident #2 had no signs or symptoms of aggression that day, would continue to be on one-to-one monitoring, and a referral would be placed for the psych NP to assess Resident #2. Record review of a nurse note dated 03/27/2026 at 3:00 PM indicated Resident #2 was transferred to a behavioral health hospital. Record review of an encounter by the psych NP dated 03/27/2026 at 10:16 PM, with date of service 03/26/2026, indicated Resident #2 reported she moved her shoe to ward off Resident #1's hand that was out and that it was not an intentional provocation. Attempted observation and interview on 04/01/2026 at 9:20 AM revealed the resident was unavailable due to hospitalization. During an interview on 04/01/2026 at 9:32 AM, LVN A indicated she was not working when the event occurred, but she worked the following day. LVN A indicated Resident #2 often paced the halls. LVN A indicated she did not observe any redness or bruising to Resident #1 the following day. LVN A indicated she did not believe Resident #2 was acting intentionally to harm Resident #1. During an interview on 04/01/2026 at 9:36 AM, CNA A indicated she was a witness to the event. CNA A indicated Resident #1 was sitting with her hand extended and Resident #2 then walked by and hit Resident #1 with her shoe that she was holding. CNA A indicated she separated the residents, made sure Resident #1 was okay, and told the nurse. CNA A indicated the ADM was the abuse coordinator and staff were to inform him of allegations of abuse. During an interview on 04/01/2026 at 9:41 AM, CNA B indicated she was a witness to the event. CNA B indicated Resident #2 was walking the halls. Resident #1 had her hand extended in a comfortable position for her, and Resident #2 walked by Resident #1 and hit her with the shoe. CNA B denied Resident #1 had redness. CNA B denied this event could have been anticipated as Resident #2 liked to walk the halls and had been throughout the day. CNA B indicated the nurse was notified and completed assessments on both residents. CNA B indicated she was aware the abuse coordinator was the ADM and stated if she witnessed any abuse she was to tell the charge nurse. During a telephone interview on 04/01/2026 at 9:48 AM, RN A indicated she did not see the event occur but was notified by a CNA Resident #2 had hit Resident #1 in the face with a sneaker. RN A indicated Resident #1 had no redness and would not grimace when touched. RN A indicated they immediately separated the residents, placed Resident #2 on one-to-one supervision, and assessed Resident #1's skin, emotional state, and vital signs. RN A indicated she immediately notified the DON, ADON, physician, and family. During an interview on 04/01/2026 at 12:33 PM, the SW indicated she followed up with Resident #1 and Resident #2 that same day. The SW indicated Resident #2 denied being angry or upset. The SW indicated Resident #1 did not recall the event occurring. The SW indicated she was aware that the ADM was the abuse coordinator and stated the DON communicated to the ADM when there was an allegation of abuse. During an interview on 04/01/2026 at 12:57 PM, the ADON indicated she was at the facility in her office when the event occurred and immediately went to the secured unit to assist. The ADON indicated she was told Resident #1 was stretching out her arm when Resident #2 was passing by and was when Resident #1 was hit with the shoe. The ADON indicated Resident #2 had never been physically aggressive before. The ADON indicated she was on the secured unit and she contacted the DON by phone who gave instructions to the nursing staff. The ADON indicated she was aware the ADM was the abuse coordinator and she believed he was notified within an hour of the event occurring. During an interview on 04/01/2026 at 1:04 PM, the DON indicated she was contacted by the ADON and notified Resident #2 hit Resident #1 with her shoe. The DON indicated she had never known Resident #2 to be physically aggressive. The DON indicated she was aware the ADM was the abuse coordinator and she contacted him around 6:20 PM that evening. The DON indicated there was an estimated hour and a half to two hours between when she learned of the incident and when she contacted the ADM. The DON indicated she was not at the facility at the time of the event but returned after she contacted the ADM. The DON indicated she understood the policy on reporting suspected abuse to be within 24 hours if there was no bodily injury. The DON indicated she did not believe this to be an instance of abuse as Resident #2 did not know what she was doing. The DON indicated if she had not known the residents' cognitive status she would have considered the event abuse, but since she knew the residents she did not think Resident #2 would harm another resident willfully. The DON indicated if she could go back she would report the event earlier. During an interview on 04/01/2026 at 1:38 PM, the ADM indicated he did not feel the event should have been reported within 2 hours because he did not believe there was willful intent. The ADM indicated he understood the residents to be interviewed after the event and claimed they did not have knowledge of what happened. The ADM agreed abuse can occur regardless of cognitive status. The ADM indicated there was a delay reporting as he had to arrive at the facility and obtain information and indicated the TULIP system will often kick him out. The ADM indicated he was notified of the event at 6:51 PM on 03/26/2026. A record review of TULIP case details on 04/01/2026 at 8:50 AM indicated the report of alleged abuse was received by HHSC on 03/26/2026 at 9:16 PM. A record review indicated an in-service on abuse and neglect was held on 03/26/2026 and was instructed by the DON. A record review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation dated April 2021 indicated the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to.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 or misappropriation of property by anyone including but not necessarily limited to:.b. other residents A record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022 indicated the following: Reporting Allegations to the Administrator and AuthoritiesIf resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:The state licensing/certification agency responsible for surveying/licensing the facility;. Immediately is defined as:Within two hours of an allegation involving abuse.

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two of two residents (Resident # 1 and Resident # 81), two of four medication carts ( LVN Cart #1 and RN Cart #2), and one of two mediation storage rooms reviewed for pharmacy services. LVN D failed to use the proper technique for administration of eye drops for Resident #1 on 3/4/2026. LVN B failed to use the proper technique for administration of eye drops for Resident #81 on 3/5/2026. RN A signed the controlled substance count sheets for the end of their shift at the beginning of their shift on RN Cart #2 on 3/5/2026. LVN B signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart #1 on 03/5/2026. The facility failed to ensure expired medications were removed from the medication storage room. These failures had the potential to place residents at risk for not receiving the intended therapeutic effect of prescribed medications, ineffective treatment, administration of medications that are no longer safe or effective, and inaccurate medication control practices, which could lead to potential resident harm.1. Observation on 3/4/2026 at 9:10 a.m., revealed during a medication pass observation, the surveyor observed LVN D administer eye drops to Resident #1. LVN D assembled the required equipment and followed general aseptic technique for medication administration. However, LVN D failed to use the proper technique for administration of eye drops. Specifically, LVN D did not gently pull the resident's lower eyelid down to create a conjunctival pocket (a small pocket) and did not instruct the resident to look upward during installation of the eye drops. Observation on 3/5/2026 at 10:00 a.m., revealed during a medication pass observation, the surveyor observed LVN B administer eye drops to Resident # 81. LVN B assembled the necessary equipment and supplies and followed general aseptic guidelines for medication administration. However, LVN B did not gently pull the resident's lower eyelid down to create a conjunctival sac (a small pocket) and instead instilled the eye drops directly onto the eyeball. During an interview on 3/5/2026 at 11:30 a.m., LVN B stated she had been trained in the proper administration and care of eye drops. LVN B stated the correct technique included maintaining aseptic technique and gently lowering the lower eyelid to create a conjunctival sac to ensure the eye drop is properly instilled. During an interview on 3/5/2025 at 11:40 a.m., the Director of Nursing (DON) stated that nursing staff were trained on the proper administration of eye drops, including the guidelines and procedural steps. After reviewing the facility policy and professional standards of practice, the DON acknowledged that steps #7 and # 8 of the procedure were not followed during the observed medication administrations. The DON stated that all nursing staff would be re-in-serviced on the proper technique for the administration of eye drops. Review of the facility policy on Instillation of Eye Drops (Dated 2001 Med Pass) revealed: Steps in the Procedure: # 7 Gently pull the lower eyelid down. Instruct the resident to look up. # 8 Drop the medication into the mid lower eyelid fornix (Conjunctival fornix is the loose, folded, pocket-like tissue joining the inner eyelid to the eyeball surface) 2. Observation on 3/5/2026 at 12:05 p.m., of the main medication storage room revealed three bottles of medication that were expired and had not been removed from active medication storage. The medications revealed: Magnesium oxide 400mg Expired 1/2026, Naprosyn 224mg Expired 1/2026, and CoQ10 100mg Expired 2/2026. During an interview on 3/5/2026 at 12:07 p.m., LVN B and LVN E confirmed that medications observed in the medication storge room were labeled with expiration dates 1/2026 and 2/2026. LVN E stated she primarily worked on weekends. Both nurses stated the main medication storage room was checked for expired medications; however, neither nurse was able to confirm how often the medication storage room was routinely checked to ensure expired medications are removed. Durning an interview on 3/5/2026 at 1:30 p.m., the DON stated that expired medications should be removed from the medication storage area and disposed of according to facility policy and guidelines and should not remain in active medication storage room. The DON stated the medication storage room was normally checked monthly for expired medications. The DON further stated nursing staff would be reminded to continue performing monthly checks of medication storage areas to ensure expired medications are identified and removed. Review of the policy for Medication Labeling and Storage dated Med-Line, revised February 2001 indicated: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. During an observation on 3/5/2026 at 11:30 AM, while doing observation of 2/2 med cart it was discovered that RN A and LVN B were signing on and off at the same time of signing on at shift count, the drug-controlled drugs on hand. During a record review on 3/5/2026 at 11:30 AM the sign on/off sheet read, signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication count is in agreement with the quantity stated on the controlled. 3. During an interview on 3/5/2026 at 11:45 AM with RN A, she said she was aware she could not to sign the day/off until she actually was going off shift. During an interview on 3/5/2026 at 11:45 AM with LVN B said she was aware that nurses should not sign the narcotic count sheet for the off-going shift until they were leaving their shift. Interview on 03/05/2026 12:00 PM with the DON and let he see the 8-hour shift-to shift Narcotic Count Sheet and she agreed that the nurses were not to sign the sheet only at the beginning and end of their shift Record review of a policy and procedure document titled Controlled Substances indicated the facility with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II -V of the comprehensive Drug Abuse Prevention and Control Act of 1976) revised November 2022. 4. Nursing staff coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services

Based on interviews and record review, the facility failed to provide a private space for resident group meetings for 6 of 6 confidential residents interviewed. The facility failed to ensure the resident group had a meeting space available that was private and uninvited staff were not present during the meetings. This failure could place residents at risk for reluctance to voice their concerns due to staff members being present.The findings included: During a confidential interview at an undisclosed date and time, 6 of 6 confidential residents indicated that they held resident group meetings in the facility dining room. The confidential residents indicated that they would prefer not to meet in the dining room as staff entered the dining room throughout their meetings. The confidential residents indicated that they had told staff not to enter during their meetings, but that they continue to do so. During an interview on 03/04/2026 at 10:30 AM, the AD indicated that staff had often entered the dining room during resident council meetings despite being asked not to and a sign on the door was placed to notify staff not to enter due to a resident group meeting in process. The AD indicated that she had asked the ADM to address the issue approximately 6 months prior and staff continued to enter the dining room during resident group meetings. During an interview on 03/05/2026 at 9:03 AM, CNA C indicated that she had worked at the facility for 3 years and was aware the resident group meetings were typically held in the dining room. CNA C indicated that CNAs were educated not to enter the dining room while resident group meetings were in process, but that some staff members did still enter the room as the vending machines and kitchen were located there. CNA C indicated that she was aware that signs were posted during resident group meetings to notify staff members not to enter. During an interview on 03/05/2026 at 9:16 AM, the DON indicated that she was unaware of staff entering the dining room during resident group meetings. The DON indicated that staff were told not to enter the dining room during resident group meetings. The DON indicated that there was an alternative meeting area, a common area where therapy occasionally provides treatment, that residents could use to hold resident group meetings that was private as staff would not have reason to enter. The DON indicated that the risk to residents for not having a private area to conduct resident group meetings would be that residents would not be able to feel as though they could voice their concerns due to staff presence. During an interview on 03/05/2026 at 9:50 AM, the ADM indicated that he was unaware of staff entering the dining room during resident group meetings and that he did not recall the AD mentioning it to him. The ADM indicated that the dining room also holds the staff breakroom, the kitchen, and the vending machines. The ADM indicated that there were alternative meeting areas including the conference room or the therapy room. The ADM indicated that the risk to residents for not having a private area to hold resident group meetings included not being able to communicate without staff hearing them and fear of retaliation. A record review of the sign posted during resident group meetings provided by the AD indicated the following: Do Not EnterResident Council Meeting in Session. A record review of an undated facility policy titled Resident Council indicated the following: 2. All residents are eligible to participate in the resident council. The facility staff encourages residents who are willing to participate. Staff, visitors, or other guests may attend resident council meetings if invited by the respective resident group.3. The resident council group is provided with space, privacy, and support to conduct meetings.

Based on observation, interview, and record review, the facility failed to coordinate the assessment of 1 of 6 residents (Resident #6) reviewed for the pre-admission screening and resident review (PASRR) program and PASRR assessments and evaluations. The facility failed to ensure Resident #6 had an accurate Level 1 PASRR screening that reflected an active mental illness diagnosis. This failure could place residents with mental illness diagnoses at risk of not being evaluated for and potentially not receiving PASRR services for care and treatment. Findings included: Record review of a face sheet dated 03/04/2026 indicated Resident #6 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest, and fatigue lasting at least 2 weeks, severely impacting daily life). Further review of the same face sheet indicated a diagnosis of schizoaffective disorder [a chronic mental health condition combining psychotic symptoms (hallucinations, delusions) with mood disorder symptoms (mania or depression) was added to Resident #6's list of diagnoses on 09/21/2023. Record review of an admission MDS: Section I dated 03/18/2023 indicated Resident #6 had a diagnosis of depression. Record review of a quarterly MDS: Section I dated 05/16/2024 indicated Resident #6 had a diagnosis of depression and schizophrenia. Record review of the physician's orders dated 03/04/2026 indicated Resident #6 had diagnoses of major depressive disorder and schizoaffective disorder. Record review of Resident #6's undated care plan indicated interventions to address concerns for major depressive disorder and the potential risk of hallucinations, delusions, and behaviors related to the diagnosis of schizoaffective disorder. Record review of the admission MDS: Section I dated 03/18/2023 indicated Resident #6 had a diagnosis of major depressive disorder. Record review of Resident #6's Level 1 PASRR screening dated 03/14/2023 indicated she did not have a mental illness diagnosis. Record review of Resident #6's Level 1 PASRR screening dated 04/01/2024 indicated she did not have a mental illness diagnosis. During an interview with the MDS Coordinator on 03/05/2026 at 11:10 AM, she said both of Resident #6's Level 1 PASRR screenings were incorrect. She said the LA should have been notified of the incorrect Level 1 PASRR and a new Level 1 PASRR should have been submitted. The MDS Coordinator said a corrected Level 1 PASRR would have led to a PASRR evaluation that would have determined if Resident #6 qualified for PASRR care and services. The MDS Coordinator said she was not the person responsible for the PASRR process during the time Resident #6's Level 1 PASRRs were completed and did not know why steps were not taken to correct them. During an interview with the DON on 03/05/2026 at 11:20 AM, she said the MDS Coordinator was responsible for the PASRR process. The DON said the accuracy of Level 1 PASRR screenings was important to ensure residents who were eligible for PASRR services received those services. During an interview with the MDS Coordinator on 03/05/2026 at 02:05 PM, she said the RAI manual was the source used for managing the PASRR process.

Based on interview and record review the facility failed to submit a complete and accurate request for NFSS in the LTC Online Portal for 1 of 3 residents reviewed for PASRR assessments (Resident #1). The facility did not ensure the required NFSS form for Resident #1 to receive an OT Assessment and OT Services was submitted within 20 business days (6/21/2024) of the IDT meeting held for Resident #1 on 5/22/24 to the PASRR department via the LTC Online Portal. This failure could place residents who are PASRR positive at risk of not receiving the necessary services that would enhance their quality of life.Findings included: Record review of the face sheet dated 12/5/2025 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities (clearly shows intellectual disability but the severity is unknown), anxiety disorder, unspecified (the person experiences anxiety, but the cause and type are unknown), major depressive disorder, recurrent, unspecified (the person experiences depression, but the cause and type are unknown. Record review of the MDS assessment dated [DATE] indicated that Resident #1 had medically complex conditions, anxiety disorder, depression, and received no special treatments, procedures or programs. The document indicated that a BIMS should not be conducted. Record review of the Care Plan for Resident #1 dated 11/17/2025 which does not include OT services. Record review of the PASRR Comprehensive Service Plan dated 11/19/2024 which indicated a new service needed for Resident #1 for a specialized occupational therapy assessment and specialized occupational therapy. Record review of the Habilitation Service Plan last updated 11/11/2025 which indicated that Resident #1 was receiving IDD Habilitative specialized services including habilitation coordination and independent living skills. The document indicated that Resident #1 received the following NF Specialized Services: occupational therapy and physical therapy. During an interview on 12/4/2025 at 8:30 a.m. The PASRR Unit Program Specialist stated that the facility failed to submit and complete an accurate request for NFSS in the LTC Online portal within 20 business days after the date of the interdisciplinary team meeting and that due to that the resident had not received a Medicaid service. The facility was notified and instructed to submit an NFSS request on 12/31/2024 regarding the services directed for PASRR on 5/22/2024. A follow-up call was made to the facility on 1/14/2025 and as a result of this, the service was denied. During an interview on 12/5/25 at 2:30 p.m. the MDS Coordinator indicated that she did not have an NFSS form for Resident #1 for OT Services. She stated that she was new to the MDS position and that before she took over, the social worker was handling PASRR. She stated that she had some training on PASRR but was not aware of the timelines related to submitting the NFSS form. She stated that the risk of not sending the NFSS form was that the PASRR positive resident did not get the identified services that they needed. During an interview on 12/5/2025 at 2:48 p.m. the Social Worker indicated that she started working for the facility in April of 2025 and anything that happened before that she was not aware of. She stated that she has been trained on PASRR and that if a resident was coming to the facility from the hospital she would receive their PASRR before their arrival and she would enter it into the system and that was all that she did. She stated that she had never completed or had to submit an NFSS form and believed the MDS Coordinator was responsible for that. She stated that the importance of entering all of the documentation timely was that it was crucial for ensuring that all residents receive all of the services that were available to them so that they could have the highest quality of care possible. During an interview on 12/5/2025 at 3:44 p.m. the DON stated that PASRR responsibilities have been split between the Social Worker and the MDS Coordinator. She stated that had a result of the investigation they would be moving all of the PASRR responsibilities to the MDS Coordinator so that there was no confusion on roles and responsibilities. Record review of the facility's PASRR Policy dated 7/29/2025 which indicated that preadmission for PASRR happens when a person is coming from the community. This includes anywhere other than a medical acute care hospital or another nursing facility. The person, coming from the community with a PASRR Level 1 that indicates a suspicion of IDD.must also have a completed PASRR Evaluation submitted before they can be admitted to a nursing facility. This process must be followed to ensure people coming from a community setting can receive education about other placement alternatives before nursing facility admission .The Level I screening process determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission.If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is performed by a qualified mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate. In regard to documentation facilities must maintain thorough documentation of the PASRR assessments, including the Level I and Level II evaluations, as well as recommendations made. Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Residents who are admitted under PASRR guidelines may undergo periodic reviews to ensure that their needs are being met and that they continue to require nursing home care. Nursing homes must comply with all federal and state regulations regarding PASRR. Failure to do so can result in penalties or loss of funding. The facility follows HHS PASRR For Nursing Facility guidelines.

Based on interview, observation, and record review the facility failed to ensure residents were free from physical abuse for 2 of 8 residents reviewed for abuse. (Resident #s 1 and 2) The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 threw Resident #2 against the wall in the hallway of the secured unit causing Resident #2 to hit her head on the corner of the wall and fall onto the floor resulting in a closed head injury and a fractured lumbar vertebra on 5/13/25. The noncompliance was identified as past noncompliance (PNC). The IJ began on 5/13/25 and ended on 5/14/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm. Findings included: 1. Record review of an admission record dated 11/8/25 indicated Resident #1 was an [AGE] year-old female who initially admitted to the facility on [DATE] onto the secured unit and readmitted on [DATE] and was discharged on 5/13/25 with diagnoses including Cerebral palsy (caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture), paranoid schizophrenia (a severe mental health condition characterized by persistent delusions and hallucinations), mood disorder (a mental health condition that primarily affects your emotional state. It can cause persistent and intense sadness, elation and/or anger), major depressive disorder (Clinical depression causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy.), and TBI (an injury to the brain caused by an external force. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.) Record review of annual MDS assessment dated [DATE] indicated Resident #1 was considered by the state to have a level II PASRR condition due to her serious mental illness diagnosis and other related conditions. Section A indicated Resident #1's most recent 3/12/25 admission was from an inpatient psychiatric hospital. She had clear speech but had difficulty communicating some words or finishing thought but was able if prompted or given time; and comprehend most conversations. She was independent with most ADLs and no DME required. She had BIMS score of 6 out of 15 indicating she had severe cognitive impairment with thinking and memory. Section E - Behaviors was marked none of the above indicating no hallucinations nor delusions and no physical, no verbal and no other behavioral symptoms directed towards other; Section E1100 indicated Resident #1 behavior status remained the same when compared with the prior MDS Section E assessment. Record review of Resident #1's undated revised care plan indicated the following:-Focus: Problematic manner in which [Resident #1] acted characterized by ineffective coping; verbal/ physical Aggression related to: Cognitive impairment/phys.-Goal: For [Resident #1] to cope with the current situation; [Resident #1] will not strike others; [Resident #1] will not verbally abuse others; Staff will recognize and avoid behaviors that provoke aggressive [Resident #1]; to minimize disruptive behavior during recreation programs; to reduce incidents of aggression and angry outbursts.-Interventions: Allow [Resident #1] time to respond to directions or requests (due to dementia more time is required to absorb instructions); approach [Resident #1] slowly and from the front; be cognizant of not invading [Resident #1's] personal space; Do not argue or condemn resident; do not express [facility employee] anger or impatience verbally or with physical movements (i.e shaking head, pointing finger). These responses are likely to increase confusion and agitation; Document summary of each episode. Note cause & successful interventions, include frequency and duration; Give [Resident #1clear, concise explanation of anything about to occur; avoid information overload since the angry aggressive resident cannot assimilate many details; Help [Resident #1] identify activities that tend to decrease angry behavior and encourage their utilization; If aggressive, try and remove from recreational program, and provide individualized program; Initiate behavior charting to identify why the [Resident #1] became angry or agitated( note time of day, who was present, & what proceeded the incident).Record review of Resident #1's Progress notes indicated the following:-On 5/13/25 at 10:02pm (Late Entry); completed by MDS RN: [The local] PD was called to facility due to assault. [Two] officers arrived and interviewed [Resident #1] and witnesses. [Resident#1] was arrested for assault/injury of the elderly and walked out of facility with [the two] officers to patrol vehicle.-On 5/13/25 at 7:50pm; completed by LVN B: [Resident #1] came out of her room walking down the hallway. [LVN B] called out to [Resident#1] asking her to come back. [Resident #1] continued to walk down the hallway. The resident then stopped and grabbed both arms of [Resident #2] standing in the hallway and threw her into the wall. [Resident #1] was redirected back to her room at that time. Dr. notified, RN/DON notified, and Resident's [family member] notified. Record review of a psychiatric subsequent assessment completed on 5/13/25 by psych services indicated Resident #1 had an in-person visit at facility for an exacerbation of chronic problem requiring prescription management due to increased auditory and visual hallucinations, delusional thinking, forgetfulness, confusion, and difficulty completing tasks. Resident #1 reported trouble sleeping, including delayed sleep onset and frequent awakening. Recommended medication changes: effective 5/13/25; the Seroquel dose was increased from 25 mg BID to 50 mg BID due to continued hallucinations, delusional behavior, and worsening disorganization, indicating the previous dose was not effective. Record review of Resident #1's physical aggression initiated incident report dated 5/13/25 indicated the incident happened in the hallway on the secured unit. Incident Description: Nursing Description - [Resident #1] came out of her room walking down the hallway. [LVN B] called out to [Resident#1] asking her to come back. [Resident #1] continued to walk down the hallway. The resident then stopped and grabbed both arms of [Resident #2] standing in the hallway and threw her into the wall. [Resident #1] was redirected back to her room at that time. Resident Description: [Resident #1] did not respond at that time as to why she grabbed [Resident #2]. Immediate Action Taken: [Resident #1] was redirected back to her room to separate from peers, CNA assigned to stay with [Resident #1] as all times. Safety of all residents was ensured immediately. First aid was provided for [Resident #2] that was affected. EMS called for transport to hospital. Other information: [Resident #1] with schizophrenia and active delusions and upset about not having cigarettes. Agencies/People Notified: DON, physician, [Resident #1's] family member, administrator, local and police department. 2. Record review of an admission record dated 11/10/25 indicated Resident #2 was an [AGE] year-old female who initially admitted on [DATE] and readmitted on [DATE] to the secured unit with diagnoses including Dementia without behavioral disturbances (a general term for a group of conditions that cause a decline in cognitive function, memory, and thinking skills severe enough to interfere with daily life.), anxiety (an emotion characterized by feelings of worry, dread, and fear of future events) and cognitive communication deficit (a communication challenge caused by problems with thinking abilities like attention, memory). Record review of Resident #2's physical aggression received incident report dated 5/13/25 indicated the incident happened on the hallway on the secured unit. Incident Description: Nursing Description - [Resident #2] was standing at the end of the hallway when [Resident #1] walked up to [Resident #2 ], grabbed both of [Resident #2's] arms and threw her into the wall.[Resident #2 ] hit the back of her head on the corner of the wall and fell to the floor. [Resident #2] noted to have laceration to the back of her head. [LVN E] held pressure to area and another nurse called 911. [Resident #1] complained of back pain, [LVN E] instructed [Resident #2] not to move and held pressure to laceration until EMS arrived.[Resident #2] was placed in a neck brace then [Resident #2 was transferred onto the stretcher x4 persons. [Resident #2 was awake and alert at time of transfer to ER. Resident Description- [Resident #2] unable to give description. Immediate Action Taken: Description- [Resident #1 and #2] were separated and safety was ensured for residents on the secured unit. [Resident #1] who pushed [Resident #2] went to her room and sat calmly on her bed with staff outside of the door to monitor. First aid was provided by a nurse to [Resident #2] to laceration on head with firm pressure applied to control bleeding, [Resident #2] complained of back pain and was moved until EMS arrived and applied c-collar and was transferred to stretcher. [Resident #2's] family member was notified by nurse of incident. Injuries Observed at Time of incident: Injury Type- Laceration; Injury Location - Top of Scalp. Level of pain - 6. Other information: [Resident #2] was pushed down by [Resident #1] in the hallway. Record review of Resident #2's hospital physician progress notes dated 5/14/25 indicated the following: [Resident #2] was a [AGE] year-old female who had a primary diagnosis of a closed head injury. Length of Stay: 1 Day. admitted overnight for a closed head injury, and a 4cm laceration to a posterior scalp closed with staples. On 5/13/25 a CT Reconstruction of the Lumbar Spine (a special type of CT scan that focused on the lower back region or the spine) conducted at the hospital revealed there was an L1 compression fracture (break) which is one of the bones in the lower part of Resident #2 spine. 24 Hour Events: Scalp Wound stable - hemostatic (anything that stops or slows bleeding). Reviewed and Discussed L1 Endplate Fx with Neurosurgery, non op Fx, with LSO support brace. [Resident #2] to follow up Neurosurgery clinic in 4-6 weeks. Plan: Mobilized with use of LSO-to be used for OOB activity/ambulation. Okay to leave off when sitting up in chair and/or short distance ambulation, such as going to bathroom. [Resident #2] cleared to return to SNF . Record review of 76-hour neuro checks report dated effective 5/14/25 indicated Resident #2 had no change in neuro status. Resident #2's neuro remained at baseline, and she voiced no pain complaints. Record review of quarterly MDS assessment dated [DATE] indicated Resident #2 had clear speech, was able to make her self-understood by expressing ideas and wants; had clear comprehension. She had BIMS score of 9 out of 15 indicating she had moderate cognitive impairment with thinking and memory. Section E - Behaviors was marked none of the above indicating no hallucinations nor delusions and no physical, no verbal and no other behavioral symptoms directed towards others; She was independent with most ADLs and no DME required. Resident #2 was incontinent of bladder and bowel. The MDS assessment indicated Resident #2 had no fractures and/or other multiple traumas, and no skin condition, no skin injury/wound or treatment, and no recent falls since admission. Record review of Resident #2's undated revised care plan indicated the following:-Focus: [Resident #2] care planned for a potential psychosocial well-being problem due to receiving physical aggression from [Resident #1]. -Goal: [Resident #2] will have no indications of psychosocial well-being problem.-Intervention: Monitor/document [Resident #2] usual response to problems; Monitor/document [Resident #2] feelings relative to receiving aggression; When conflict arises, remove [Resident #2] to a calm safe environment and allow to vent/share feelings. Record review of Resident #2's Progress notes indicated the following:-On 5/13/25 at 7:50pm; completed by LVN B: [Resident #3 ]was standing at the end of the hallway when [Resident #1] walked up to [Resident #2], grabbed both [Resident #2] arms and [Resident #1] threw [Resident #2] into the wall.[Resident #2] hit the back of her head on the corner of the wall and fell to the floor. [Resident #2] noted to have laceration to the back of her head. [LVN B] held pressure to area while another nurse called 911. [Resident #2] c/o back pain. [LVN B] instructed [Resident #2] not to move. [LVN B] held pressure to [Resident #2] head laceration until EMS arrived.[Resident #2] was placed in a neck brace then [Resident #2] was transferred onto the stretcher x4 persons. [Resident #2] is awake and alert at time of transfer to ER. Dr. was notified, RN/DON notified, and Resident's family member was notified.-On 5/14/25 at 8:42pm; completed by LVN B:[Resident #2] returned to the facility from the hospital via facility transportation. [Resident #2] vitals were taken, skin assessment completed, [Resident #2] family was notified, Dr. was notified and was DON notified.-On 6/2/25 at 2:02pm; completed by LVN D: [Resident #2] allowed the ADON and DON to take her [11] staples out [located back of head].-On 7/31/25 at 1:08pm; completed by LVN D: [Resident #2] went to her [follow up Neurologist] appointment via facility van.-On 7/31/25 at 2:47pm; completed by LVN B: [Resident #2] returned from her appointment with new orders for PT to evaluate and treat 3x/wk x4 weeks for chronic low back pain, DDD L5-S1, bilateral trochanteric bursitis inflammation of the bursa on both sides of the hips, causing pain, tenderness, and swelling on the outer hips that may radiate down the thighs). Record review of facility's typed post investigation submission report dated 5/20/25 Incident Type: Abuse and Neglect/ Resident to Resident Altercation. Agency Immediate Response to prevent recurrence/protect individuals: Agency contacted the local police department and self-reported the incident to HHS. Notified RP, the MD, Ombudsman and Administrator. Investigation Summary: On 05/13/2025 2p-10p shift [Resident #1] (Alleged Perp) was advised that she could not go out the side patio door of the secured memory care unit to smoke. [Resident #1] became angry and verbally aggressive while ambulating away from the entry door. In Passing [Resident #1] came into contact with [Resident #2] (Alleged Victim). During the interaction there was a verbal altercation between the two which escalated to [Resident #1] physically assaulting [Resident #2] before staff could intervene between the two. [Resident #1] grabbed [Resident #2] by her shoulders and pushed [Resident #2], causing [Resident #2] to fall backwards and sustain a head injury. Staff present in the area were able to redirect other residents from the scene of the incident while the assigned nurse provided first aide to [Resident #2] (Alleged Victim). [Resident #2] sustained a noticeable laceration to the head which was bleeding while the nurse applied pressure EMS was notified while comfort and safety continued to be provided to the injured resident. The alleged perpetrator [Resident #1] was placed on one-to-one supervision. [Resident #1] remained very agitated and returned to her room cursing and making obscenities at nearby staff. EMS arrived shortly thereafter triaged the[Resident #2] onsite and transported her to the ER for further evaluation. Due to the level of aggression and agitation the local police department were notified who arrived to the facility to address the safety risk of [Resident #1] and due to [Resident #1] current state and active behaviors she was removed by law enforcement and transferred to the ER for a psych hold. Upon further follow up from the facility to accepting hospital the facility was advised that [Resident #2] was admitted due to her acute injuries. The alleged perpetrator [Resident #1] was being detained and pending transferred to jail due to new charges and of assault on elderly and prior criminal convictions prior to [Resident #1] initial admission. Investigation Findings: Confirmed. Agency Actions Post Investigations: Notifications Provided to RP, MD, DON, Administrator and Regulatory Agency. Facility had In-serviced and trained staff on the following areas. Abuse and Neglect and Resident Rights, De-Escalation and Effective Communication Methods, Safe Surveys throughout the facility. Resident Plan of Care Reviews and Increased monitoring for patients who may be at risk. IDT team members reviewed the incident and reported findings to QAPI committee for recommendations. The committee reviewed the findings and provided recommendations and ongoing monitoring to reduce the risk patient needs not being met. Record review of handwritten statement dated 5/13/25 at 7:50pm provided by the facility completed by: LVN B indicated the following: [LVN B] was standing at the med cart on the secured unit, dispensing bedtime medications, when [Resident #1] was walking out of her room down the hallway. [LVN B] called out to [Resident #1] to return back so [LVN B] could check her blood sugar, but [Resident #1] had ignored her and continued to down the hallway. [LVN B] called out again but [Resident #1] continued to ignore [LVN B} because [Resident #1] was upset about not getting to go outside to smoke; LVN B] yelled out Nooo and [Resident #2's name] and she then threw [Resident #2] into the wall causing [Resident #2] to his her head on the corner of the wall and fell to the floor. During an observation and attempted interview on 11/7/25 at 6:00pm, Resident #2 was in the tv room with the other resident on secured memory care unit, she introduced herself and said that she was getting ready to have a meeting and started talking about life. Resident #2 was clean, well-groomed with no unpleasant odor and there were no visible bruising, skin tears or marks. During an interview on 11/10/25 at 11:59am, CNA K said that she was the CNA for the secured memory care unit during the 2pm-10pm shift and worked there since March 2025. She said she did work the day of the incident between Resident #1 and Resident #2 but she did not witness the actual resident to resident altercation because she was on the other end of the hall assisting another resident on the secured memory care unit finishing up with patient care at that time and she heard a loud BOOM like sound and at that time she stepped into the hall to find out what the loud sound had come from and that was when she witnessed Resident #2 laying on her left side in fetal like position making moaning like sounds and Resident #1 was standing up over Resident #2. CNA K said learned the BOOM sound was the sound of Resident #2 head hitting/bouncing off wall. CNA K said then several staff started running from all over, and after she had already been with Resident #2 for about 5 or 10 minutes, she got out the way so the nurses could have room, she said LVN B had been there the entire time with Resident #2 and applying pressure because Resident #2 head was bleeding. CNA K said Resident #1 at that time was in her room, and CNA K said she was with the other resident on the secured memory care unit and making sure that they were okay. CNA K said on the day of incident around 7:00pm or not too long afterwards she had just assisted Resident #1 with getting her clothes laid out for bed, and Resident #1 did not appear to be aggressive or to have had been in a bad mood alarming her that in less than an hour later Resident #1 would have a physical resident to resident aggressive altercation with another resident. CNA K described Resident #1 as a resident who stayed to herself and said she was very surprised by what had happened. During an interview on 11/10/25 at 12:22pm, CNA L said that she was a CNA for the secured memory care unit during the 2pm-10pm shift and worked there since March 2025. She said she did work the day of the incident between Resident #1 and Resident #2, but she did not witness the actual resident to resident altercation because she had taken another resident outside to smoke. CNA L said Resident #1 did not give her any problems but did get the feeling if Resident #1 did not get what she wanted then Resident #1 would probably become angry, aggressive, and would become scary to be around. She described Resident #1 with having childlike behaviors, if Resident #1 got everything she wanted, she was good, if Resident #1 did not, then that's when the aggressive behaviors were initiated. CNA L said since working there she had only seen Resident #1 get triggered maybe 1 time it was not frequent and could not remember about what or what happened. CNA L said during the smoke break the day of the incident she heard a loud noise, described Big BOOM, she said she did not know what happened, but she knew immediately Resident #1 had did something, and assumed it was because it was because Resident #1 did not get her way about something. CNA L said brought the other resident back inside facility to find out what had happened and where the sound had come from, later found out the Big Boom sound was Resident #2's head hitting wall. CNA L witnessed Resident #1 standing next to Resident #2 and Resident #2 was on the floor screaming and Resident #2 head was bleeding. LVN B was on the floor next to Resident #2 holding bandages to Resident #2 head. CNA L said she saw Resident #1 walking and pacing the hallway outside of Resident #1's room back and forth at the moment and appeared to be talking to herself loudly, she was cursing, and staff could not get Resident #1 to calm down. CNA L said Resident #2 targeting anyone particularly, but at that point no one did not know what she may do, and she could potentially harm another resident, staff or herself and at that time, they determined it was best to call the local police for everyone's safety, since Resident #1 would not calm down, CNA L said she was the assigned staff who did one-on-one monitoring until the police arrived and during that time, Resident #1 was back her room and sitting on her bed. Resident #1 behavior did appear to change after she was notified the police were called.During an interview on 11/10/25 at 5:46pm, LVN B said that she was the charge nurse for the secured memory care unit during the 2pm-10pm shift and worked there since May 2022. LVN B said the incident between [Resident #1 and Resident #2] happened a while back and she could not recall all the details. LVN B said she provided a witness statement and the information on her statement was accurate. LVN B said that it was herself, CNA K, and CNA L who were working that day and she remembered it was after dinner, so they [CNA K and CNA L] were busy CNA K was doing patient care at one end of the hall, CNA L was assisting another unknown resident outside. LVN B said she remembered she was doing her evening meds pass and was standing right outside of Resident #1's room door, possibly just had given her some meds she could not remember. LVN B said Resident #2 had been standing at the exit door near the end of the hall that had led into the main part of the building with bags of her own belongings, LVN B explained of Resident #2's dementia diagnosis Resident #2 will forget and think she's waiting to get picked up. LVN B said from the hallway when she was standing by her med cart she remembered looking up and Resident #1's room door was open and seeing Resident #1 with Resident #2's bags of personal belongings inside Resident #1's room. LVN B said at some point Resident #1 took Resident #2's items because Resident #2 is forgetful and will walk away often leaving the items unattended near the door, LVN B explained Resident #1 had a habit of taking the other resident items. LVN B said she entered Resident #1's room and explained to Resident #1 how the bag of items belonged to Resident #2 and needed to be returned, LVN B said Resident #1 told her the bag of items was hers [Resident #1] and not Resident #2, LVN B said she waited until Resident #1 released the bag and appeared to be okay and she [LVN B] received the bags of items from Resident #1 and left Resident #1 room. LVN B said whenever she stepped back onto the hallway Resident #2 happened to been standing and she [LVN B] handed Resident #2 her bag of items back and with direct eye contact instructed for Resident #2 to take the bag of items straight to her [Resident #2's] room, LVN B said Resident #2 replied okay, as if she understood and then immediately took off walking the opposite direction of her [Resident #2] room and went right back towards the directions of the exit door where Resident #2 had been standing originally with the bag of items. LVN B said since Resident #1 was in her room at that time and did not appear to be coming back out she did not believe there would be any concerns or issues. LVN B said she was in the process of getting ready to start doing her med pass and was at her med cart and she remembered Resident #1 left her [Resident #1's] room, she [LVN B] looked up from her med cart and seen Resident #1 was walking fast paced like and was headed straight towards in Resident #2 direction, LVN B said she immediately started screaming/yelling Resident #1's name repeatedly, in hopes to prevent whatever from happening, but she before she knew it, it was too late Resident #2 flying in the air, landed against the wall, bounced off the wall and finally landed onto the floor. LVN B said it was the most horrific thing she ever witnessed or imagined and was still in shock about the incident. LVN B described Resident #1 as being strong and the amount of strength Resident #1 had Resident #2 did not have a chance. LVN B said Resident #1 and Resident #2 did not have word exchange, did not have an incident or anything, LVN B said Resident #1 just walked up to Resident #2 and picked her up by both arms in one second and by the next second Resident #2 was in the air literally. LVN B said she was the only staff who witnessed the resident-to-resident physical abuse, the other staff assisted after the incident had happened. LVN B said Resident #1 had a history of being physical in 2024 with residents nothing physical she could recall in 2025 against another resident. LVN B said normally staff were able to redirect Resident #1, but Resident #1 had never done anything like that before. LVN B said post incident Resident #2, did not appear fearful of the other residents or staff. She said Resident did not stay in room or appear fearful other than Resident #2 went from long hair to shoulder length hair and possibly if asked may not recall but never brought it back up out of respect for Resident #2 and did not want to trigger anything. LVN B said after the incident she was retrained on abuse and neglect prevention, resident rights, early identification of escalating behaviors, and proper use of de-escalation techniques. She was instructed to intervene immediately, maintain resident dignity, notify supervisory staff and the physician without delay, follow the care plan, and accurately document all actions taken. During an interview on 11/07/25 at 5:50pm, The Administrator said he was the abuse coordinator and followed their abuse policy. The Administrator said following their investigation it was confirmed the abuse incident did occur and they had not had any similar issues since. He said he was the Administrator at the time of the incident. It was determined these failures resulted in Resident #2's closed head injury and a fractured lumbar vertebra on 5/13/25.Facility took the following actions to correct the noncompliance: -On 5/13/25 the morning of the altercation Resident #1 was seen by psych services and new orders were given to increase medication to control the increased behaviors and delusions. -Resident #1 the alleged perpetrator was placed on one-on-one supervision with staff place outside of her door to monitor, until the police arrived. -On 5/13/25 Local police were notified and arrived at the facility, detained and arrested Resident #1 at 9:08pm. - Resident #2's Neurological evaluation assessment was completed from 5/14/25 to 5/19/25. -On 5/14/25 Facility had in-serviced and trained staff in the following areas: Abuse and Neglect, Resident Rights, De- Escalation, and Effective Communication Methods. In-Services addressed immediate recognition and reporting of any behaviors or incidents that may place a resident at risk. Staff were in-serviced on Effective de-escalation methods, including calm verbal responses, allowing personal space, avoiding confrontation, and using redirection techniques. Resident rights, ensuring residents are treated with dignity, and staff do not use any form of intimidation or retaliation. Staff were educated on accurate and timely documentation of resident behavior, attempted interventions, and escalation to supervisory personnel. In-service emphasized following individualized care plans, including implementing interventions for residents with behavioral risks and increasing monitoring when indicated. This was verified by record review of staff in-services signature sheets and staff interviews. The in-service rosters indicated 46 employees were provided education on the topics. -On 5/14/25 Safe surveys throughout the facility were completed. The residents reported that staff were courteous, respectful, and kind, and stated they felt comfortable and safe with the care provided. The residents indicated that staff were careful when assisting or transferring them and confirmed that they were receiving the care they needed. This was verified by record review of safe survey sheets. --On 6/2/25 Resident #2 had an appointment at the trauma clinic for staples removal and refused treatment. Interviews and record reviews were conducted from 11/9/25 through 11/11/25 from 8:00 a.m. to 6:00 p.m. and included 5 LVNs, 4 CNAs, ADON, DON, and MDS Coordinator. Staff were able to explain abuse and neglect prevention, resident rights, and the facility's expectations for immediate intervention and reporting. Staff were able to explain how to identify early signs of behavioral escalation and proper use of effective and calm communication techniques and apply de-escalation strategies. Staff had knowledge to intervene immediately, maintain resident dignity, notify supervisory staff and the physician without delay, follow the care plan, and accurately document all actions taken. During observations from 11/9/25 through 11/11/25 at various times from 8:00 a.m. to 6:00 p.m. on the secured memory care unit, residents were noted to engage in calm and non-confrontational interactions. Residents appeared generally quiet, with limited verbal engagement, and interactions were primarily passive or casual in nature. Some residents were observed walking in common areas or sitting near one another without signs of agitation or distress. No instances of verbal or physical aggression were observed. Residents did not demonstrate behaviors that suggested intimidation or fear. Staff were present in the area, providing routine supervision and re-direction as needed, and were observed promptly intervening if any residents began to appear anxious or confused. Residents appeared to be appropriately monitored, and no residents displayed behaviors that posed a risk to others during the period of observation. Interactions were consistent with the cognitive and functional levels of the residents on the memory care unit. Interview with RN MDS who was the DON at the time of the incident, verified the QAPI committee implemented the following steps as part of the Post Investigation follow up, the secure unit policy and procedure was reviewed and during care plan review, IDT determined other residents with independent ambulatory ability on the secure unit may be at risk for similar behaviors of initiating or receiving physical aggression. The facility will monitor staff to ensure appropriate and care planned interventions were implemented: Department heads agreed to assist in providing increased rounding on secure unit - for 4 weeks department heads (Med Records, Staffing, Admin, DON, ADON, Housekeeping, BOM) intentionally made hourly walking rounds on the secure unit to enhance observation of ambulatory residents and provide assistance with any noted needs (snacks, hydration, distraction, re-direction is needed), QAPI Committee reviewed the incident and findings at June 2025 and July

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 17 or 25 rooms (Room #'s A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, B10, B11, C12, C14, C15, C16, C17, C18, C19, C19, C20, C21, and C22) reviewed for environmental concerns. Rooms A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10 had black spots around the air vents in the showers, holes in the walls, missing baseboards non-working lights, and showers not working properly. Rooms B10 had mold identified in the room and B11 was used for storage. Rooms C12, C14, C15, C16, C17, C18, C19, C19, C20, C21, and C22 had black spots in, no light in bathrooms or light covers, holes in the wall, missing tiles on the floor, holes in the walls, black buildup in showers, and baseboards missing. The facility failure could cause residents to have safety concerns. Findings included: Observation and interview were conducted of the locked Unit Hall 200 on 2/26/25 between 12:51 p.m. and 1:30 p.m. with the Administrator. He said the census on the unit was 19 female residents. During an observation on 2/26/25 at 12:51 p.m. Room A1 had a lock on the door, but the lock was not secured to the door. The door was blocked, and the Administrator pushed the door open. The room was used as storage room. There were things in the room like a popcorn machine, a dresser that was behind the door, boxes, trash bags, clothes littered the floor around the bed. There was a bulletin board propped on the bathroom door. The closet in the room had dark spots on the wall at the top of the closet. It looked like a spray of black dots on the wall. The bathroom ceiling had paint peeling and the spackle hanging down for about 1/3 of the ceiling. The bathroom was also used as storage area and the toilet had some feces in it that looked like it had not been flushed in a while, the water in the commode was brown. The Administrator said the room was not occupied. During an observation on 2/26/25 at 12:56 p.m. Room A2 the ceiling in the bathroom had paint peeling about 8-inch circumference around the light. The shower in the bathroom had black stuff protruding out of the cracks on the side of the wall and the corner. The baseboard under the sink was loose and hanging from the wall. There was black buildup around the base of the commode. The base board under the toilet paper holder in front of the commode was loose from the wall about an inch and present a tip hazard. There was rust around the door posts, the rust was on the floor and up the side of the post that appeared to be metal. This room was occupied by two residents. During an observation on 2/26/25 at 1:01 p.m. Room A3 the vent in the ceiling of the bedroom had a large spot about 12 inches wide and 12 inches long with white paint that was a brighter color than the rest of the ceiling. The paint did not cover up the back spots in the ceiling. There were residents residing in the room. During an interview on 2/26/25 at 1:04 p.m. the Administrator said he had only been at the facility since 1/27/25. He said he knew they had some pipes bust during the freeze last year. He said he knew they had the roof was replaced but the paint did not appear to be covering up a water stain in room A3. He said he could not say what it was under the paint. The Administrator said he could only say it was dark or black and not covered up well. He said when he began work at the facility there were 5 or 6 rooms that had locks on the doors. He said he was told last week by the RDO that they could take the padlocks off the doors the rooms were fine. The Administrator said he was not a carpenter and did not have any knowledge of the events that happened before his arrival. He said when he arrived there were locks on 6 rooms in the facility; Rooms 212, 217, 115, 111, 109, and 105. He said he had heard rumors from some staff about black mold, but he did not know any definite information. He said the corporate office had not informed him of any issues regarding mold. He said he only knew that some of the rooms had black particles around the air vents. He said two of the rooms Room C14 and Room C15 had to be repaired because the walls were missing. The Administrator said some of the rooms were being renovated but he did not know exactly what the rooms needed. He said the RDO had been the administrator before him and had not informed him of what was needed as of the current time. He said he had just hired a new Maintenance Director and the Maintenance Director had been at the facility for about a week. During an observation on 2/26/25 at 1:12 p.m. Room A4 the baseboard hanging from the wall beside the commode, and under the toilet paper holder. The baseboard was loose and hanging for about 4 to five feet. It was also loose and hanging behind the commode about 12 to 18 inches. During an observation on 2/26/25 at 1:15 p.m. Room A5 the bathroom had a 3-drawer cabinet with about a three-inch space on the floor where the base board was hanging off the wall with brown and black debris protruding from the sides, over the top, and under the cabinet. The baseboard on the right side of the commode was hanging from the wall about an inch out. The wall behind the commode had wrinkled paint with holes in it and dark spots. There were dark spots on the floor around the commode, a hole in the wall to the right side of the commode about an inch wide. The baseboard in front of the commode on the left side was loose and hanging off the wall. During an observation on 2/26/25 at 1:17 p.m. Room A6 the bathroom showed down the wall on the right side of the commode about 3 to 4 feet of missing base board and behind the commode about 12 inches of missing base board. The spacing between the wall and the floor was visible with debris, paint and parts of sheet rock hanging out. The space in the corner where the baseboard was missing was broken and had a hole in the wall about 3 inches long. During an observation on 2/26/25 at 1:18 p.m. of the common area bathroom on the locked unit, off the dining room area appeared to be used as a storage area. There were clothes on a tall rolling hanger, stored in the shower, and a shower chair. There was missing baseboard along the wall up to the commode on the left side of the wall. The floor had debris and brown particles on the floor. The shower in the common area had black buildup in the corners on both sides of the shower. Staff said they use the shower and the bathroom for residents. During an observation on 2/26/25 at 1:21 p.m. room [ROOM NUMBER] in the bathroom a large area by the paper towel dispenser with pealed pain. A towel rack may have once held the spot or a soap dispenser it was about 7 inched high and 4 inches wide. During an observation and interview on 2/26/25 at 1:22 p.m. Room A7 in the bedroom it has black substance around the air vent in the ceiling. The black substance was in spots some about an inch wide and some just specks but it was mostly in the front of the vent with some black areas all around the vent. Observation of the bathroom the left side of the commode baseboard was hanging off the wall for about 3 feet. The Administrator said he did not know what it was the substance was in the ceiling, but it was black. During an observation on 2/26/25 at 1:27 p.m. Room A9 had some dark spot around the air vent. A base board was coming off the wall in the bathroom. During an interview on 2/26/25 at 1:31 p.m. RN A said that she had no complaints about any residents with respiratory issues. During and observation of 2/26/25 at 1:35 p.m. Observation of Room B11 showed a lock hanging from the door, but the door was not locked. The room had 4 beds and mattresses and odds and ins. I was just enough space to walk into the room. Observation of the bedroom showed there was some black areas around the air vent in the ceiling. During an interview on 2/26/25 at 1:37 p.m. Ombudsman said she had complaints from residents and families about concerns with black mold before Thanksgiving 2024. She said it was a different Administrator at that time. She said that Administrator told her that the corporate office had a plan to ensure the wellbeing of the residents. She said she had asked what those plans were but was never given an answer. She said there continued to be reported concerns from some staff, residents, and family members about maintenance issues and the black substance that is suspected to be mold throughout the facility. She said she was unable to close her concerns until the matter was resolved. During an observation on 2/26/25 at 1:40 p.m. Room C16 had an orange sign of the door that said, Please excuse this area currently under renovation. There was a place for a lock on the door but there was no lock. The closet in the room had exposed pipes and insulation hanging out of the wall. The area in the closet had holes on two sides about a 12 to 18 inches high. There was debris all over the floor in the closet. During an observation on 2/26/25 at 1:42 p.m. of Room C15 had an orange sign on the door and it had a lock but was not locked. It had a hole cut in the wall in the closet and wall along the bathroom wall about 2 and half feet high, the sink was propped against the wall and behind the commode the wall was out all along the wall. During an observation on 2/26/25 at 1:50 p.m. there was a sign on the door of Room C14 that said the room was under construction. There was a lock on the door, but it was not locked. The wall in that room was also missing about 2 feet high. That room connected to Room C15. During an interview on 2/26/25 at 1:56 p.m. LVN B said she worked on the unit and Resident #2 had gone to the hospital with a cough, but they said she had COPD. She said Resident #3 had frequent falls, but she was on the unit and was very confused. She said there were no resident on the unit had really been sick. She said that they did have a water damage and there were some damages in Room A1. During an interview on 2/26/25 at 2:00 p.m. CNA C said there was some black stuff in several of the rooms on the lock unit and that they had some in the hallway at one time. She said the roof had been repaired a while back. She said she was not aware of any Resident that had respiratory issues. She said that she had asthma, but that she has not had any problems. During an interview on 2/26/25 at 2:05 PM CNA D said it had been several months since Room A9 was locked. She said she heard that it had something to do with mold, but she was not sure. She said she was not aware of any residents on the locked unit complaining of respiratory issues. During an interview on 2/26/25 at 2:10 p.m. CNA E said she noticed the black stuff in several of the rooms on the locked unit. She said that there were no residents had coughs or respiratory issues that she was aware of on the locked unit. She said she had allergies, but she did not have any more problems at the facility than she did at home. During an observation on 2/26/25 at 2:30 p.m. the former DON's office showed a dark spot on the ceiling, and one in the hallway outside her office around the vents. However, they appeared to be painted over. During an interview on 2/26/25 at 2:36 p.m. the RDO said he oversaw the facility as the acting administrator for 3 weeks in January. He said the old administrator left on the first of January 2025; he worked between administrators. He said the current administrator came the last week in January. He said the Ombudsman brought some concerns about Room A5 missing toilet tank cover, and an emergency light in the bathroom. He said she had some concerns about Rooms C14 and C15 with some black mold looking areas in the bathroom. He said those two rooms connect. He said they had called a plumber and when Plumber came in to repair the area mold was identified. The RDO said there were residents in those rooms, and they were moved. He said there are no residents in those rooms now. He said Rooms C14 and C15 shared a wall, and both of those rooms were mediated. He said remediating was when the cleanup company came out and removed the contaminated areas. The RDO said they had called an environmental services company that identified the black stuff as mold, they then had to contact a different company to complete the cleanup. He said after the cleanup they had to have the environmental services company come back and say it was clear. He said they had done those things with those two rooms only. He said mold was also identified in Room B10 and they were getting ready to start remediating that room. He said they started the process in November 2024 but did not know the exact dates. The Director said the dark stuff on the ceiling in the facility rooms was lint like in any homes where the vent blows. He said they were trying to get the rooms in order, it was not something they could not do overnight. He said they required a different company to come in and test the air quality and then they had to have different company to come in clean up the area. He said once the room it cleaned then the other company comes back to do the air testing again. The RDO said he was not aware of the areas on the locked unit that had suspected mold. He said they only had specific areas of the facility tested . He said he did not know why the locks were on two doors on the locked unit and several doors throughout the facility. He said they had a former employee that said she had mold toxicity and they had the area where her office was tested also. He said the only identified areas of mold concern was Rooms B14, B15, and B10. The RDO said they had gotten the air ducts cleaned back in December 2024. During an observation on 2/26/24 at 3:29 p.m. of Room B17 showed that room was used as an office. There were curtains on the window, chairs and tables set up along with a coffee pot and refrigerator. RN A said they turned Room B17 into a work area. Observation of the room showed the door had a place for a lock but there was no lock present. RN A said she was told by someone up front (she did not specify who) that the room was fine to use. She would not have just opened the room on her own. She said she got the key from up front. During an observation and interview on 2/26/25 at 3:31p.m. the RDO said he did not know why there was a hole in the closet of room C16. He said that in Room C14 and C 15 the environmental cleanup crew came in and cleaned those rooms and that was why they were missing walls. However, they should still be locked until they were repaired. During an observation and interview on 2/26/25 at 3:40 p.m. with RDO Room A 7 had black stuff in the ceiling around the air vent. The RDO said that he did not know what the black substance was. He said it was not lint. The RDO said it was black substance and they would need to get it tested . During an interview on 2/26/25 at 4:24 p.m. Administrator said last week came the environmental company that did cleanup work came to the facility. He said they looked at to look at one room, and only communicated about one room. He said the RDO said told him he did not know why the locks was on some of the doors. The Administrator said on last week 2/19/25 the family member of Resident #6 was upset because they felt there was mold her room, RoomC18. He said he informed the RDO because the family was upset and taking pictures of the area. He said he had not gotten a response from the RDO but had written a grievance regarding the family concerns. He said he had removed Resident #6 and her roommate to another room. During an observation and interview on 2/26/25 at 5:19 p.m. Maintenance Director said that he was a new maintenance man. He had only been there a week. He was observed putting a lock on the door of Room C12. He said that he was told to make sure that room A1 had a lock and he had already placed that one. He said he was instructed by RDO to put locks on C12, C14 C15, B10 and B11. He said 6 rooms total had locks on them. He said he knew some of the rooms required some work, but he did not know about the other rooms. Doing an observation and interview on 2/26/25at 5:20 p.m. showed room B10 was basically empty. RNA had the key, and the door was locked. During an interview on 2/27/25 at 10:08 a.m. the RDO said for rooms C14 and C15 they had received an all clear on 1/5/25. He said on room B 10 they are waiting on permit from the city. He said they had just gotten an update this morning. Could not say why put locks on the other rooms need work to be done. Not saying it is not suspected mold. but could not say that it is not had the rooms tested . He said he was not aware of Room C18 having any issues. He said the Administrator said he sent an email, but did he did not see it. He said he was going to get the rooms tested . During an observation and interview on 2/27/25 at 10:30 a.m. Room A8 with the RDO showed that the vent in the bathroom had been painted over and there was also a vent that was in the bedroom and there was also been in the bathroom that had black stuff on the vent and around the vent also in Room A7 it had been painted over but you could see over the paint and it still had black stuff on the outer surface During observation and interview on 2/27/25at 10:40 a.m. Room C19 was not locked. It had dirty black stains on the floor. The room appeared to be used for storage. It had three beds two wheelchair as a trap bar stand in the potty chair and a wheelchair in the bathroom and that door was not locked. Record review of an invoice from a restoration cleaning company dated 12/3/24 commercial duct cleaning was performed at the facility on vents and HVAC systems. Record review Remediation Clearance report number CS24688 dated 1/10/25 indicated remediation work was completed on 1/2/25. The report indicated Room C14 and Room C15 were clear of fungal spores. Record review Remediation Clearance report number CS5040 dated 1/24/25. indicated there was water damage and potential fungal growth found in Room B10 Recommendation indicated no airborne spore levels of concern. Recommended mold protocol be completed for Room B10, and the bathroom enclosed all material to be disturbed by remediation activities. The back wall of Room B10 should include the repair or replacement of window flashing to ensure against future water intrusion. Other areas tested conference room, DON office and Hallway by DON office. No notable concerns listed. During an interview on 2/27/25 at 12:13 p.m. the environmental services company director said regarding Job SS24688 the rooms looked when where at the facility was C 14 and C 15 and they only looked at those two rooms. He said they were first contacted on 11/21/24. He said they did the initial assessment on 11/26/24. They did a written protocol a work procedure that needed to be followed to get the work completed. He said the cleanup is complete by a different company and once they finish the cleanup then his company came back to retest the air quality and determined on 1/2/25 they had some additional items to take care of. The facility corrected that issue and they came back on 1/5/25 and gave them an all clear for Rooms C14 and C15. He said Job CS25040 was a different cite area. He said they were initially called on 1/15/25 regarding room B10 and they came out on 1/21/25. He said they determined mold in that room also. He said that the mold that was discovered was common mold penicillium spores. It was not black mold. He said if they had determined anything toxic with their testing they would have had the residents evacuated, and notified the city and the proper authorities. He said the State of Texas is not equipped to handle black mold. What they do when they come out is take a swab of the area that looked suspicious. They then test the air quality outside and inside the area to determine the concentration of mold in the area. He said the testing they conducted indicated some high levels of mold but not to a toxic level. They assessed the mold and made recommendations that it be cleaned by environmental specialist. He said Room B10 had some water damage and they needed to remove the wall panels. He said if an area had black substance sometimes it could just be cleaned but they needed to determine the root of the problem that was causing the damage. If there was water in the walls or if the area was left damp for an excessive amount of time. He said just because something looked suspicious did not mean it was mold, but it could be. During an interview on 2/27/25 at 2:33 p.m. the Medical Director said he was aware the facility had a problem with mold, but he was informed it was not toxic mold. He said he worked at the hospital and had not seen anything that suggested respiratory issues. He said if it was something going on with the mold it would have been something that have shown up at the hospital since it had been several months. He said the owners standpoint was that it was mold but not toxic. He said he had heard rumors about black mold. However, it had not shown up in residents UTIs and there had been no respiratory that indicated any fungal infections. He said different people have allergies to multiple things, but he did not see any issues with mold.

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe clean comfortable and homelike environment for 5 of 10 residents (Resident #5, #6, #7, #8, #9, and #10) reviewed for environmental concerns. Resident #5 And Resident #6 had a black substance in their rooms that the families felt were suspicious of being mold. Resident #6, # 7, #8, #9, and #10's rooms had broken lights, holes in their walls, broken showers and maintenance issues that were not addressed. The facility failure could cause residents to have safety concerns. Findings included: Record Review of a nursing note dated 11/22/24 at 2:40 p.m. indicated Resident #5's family member wanted the nurse to look at Resident #5's room. The family member pointed to the air vent and stated, that is black mold. The family member was directed to the administrator's office at that time. The note was signed by LVN H and had a strike out on 11/25/24 at 8:18 a.m. The note said the reason for the strike out was entry error, but it was readable. A note at 4:30 p.m. indicated Resident #5 was discharged to another facility. During an observation on 2/26/25 at 1:24 p.m. Room A8 had a sign on the door that said, room was out of order and was being remodeled. It had a pad lock on the door that was locked. After the administrator got the key and he opened the door. The room had a strong pervasive odor of being closed for some time. The vent in the bedroom had a large area that looked like it had been painted over at one time but around the vent was areas with black substance. The vent in the bathroom appeared to be white but was covered in black particles. During an interview on 2/26/25 at 4:29 p.m. the ADON said the former DON said she got mold toxicity poisoning from the facility. She said the facility had someone to come out and test, but she did not know the results. She said there had been some family complaints and one family member moved Resident #5 to another facility from the looked unit. She said Resident #5 resided in Room A8. She said at that time the administrative staff had placed a lock on that door but did not know anything else. The ADON said she thought it was in November some time. During an interview on 2/27/25 at 9:58 a.m. LVN H said she remembered the day with Resident #5's family member complained about Room A8. She reviewed the note and she had written the note. She said she did not do the strike through on the note and as far as she knew that was what had happened. She said they moved the resident the same day. She said Resident #5 resided in room A8. She said she did not know what happed but there had been a lock on the door ever since. During an interview on 2/26/25 at 5:15 p.m. CNA F they were black stuff in some of the rooms on the lock unit. She said they put a lock on Room A8 when Resident #5 moved out. The family member came and moved her out. The family said they did carpenter work and knew what black mold looked like. She said Resident #5 was discharged to another facility. Record review of a Grievance Repot dated 2/19/25 indicated Resident #6's responsible party said there was black mold in the shower and shower tiles were missing. The report indicated the resident was moved to another room and the room was closed for repair. During an observation and interview on 2/27/25 at 9:50 a.m. Resident #6 said she was moved from Room C18 because they were doing remodeling in her room. She said that she really did not know why. During an interview on 2/27/25 at 11:53 a.m. a family member of Resident #6 said back in November 2024 Resident #6 was in a room that had mold. The family member said they had moved Resident #6 to another room and the same thing had occurred. The family member said they wanted answers and the facility to fix their problems. During an interview on 2/27/25 at 11:57 a.m. with Resident #6's responsible party. The responsible party said they had problems with mold in Resident #6's room back in November 2024. They moved her to a room on a different hall and now it was the same problem. The responsible party said she was very concerned when she saw what looked like mold in Resident #6's bathroom. She said then they moved her to Room C17, and the shower did not work in that room. During an observation on 2/26/25 at 4:03 p.m. of Room C18 showed in the bathroom the shower it was missing tile for about 8 inched across and 4 to 6 inches high. The board was showing in the wall was black with a little brown showing. The board was buckled and bumpy. There was large hole about 4 to f inches wide and 12 to 18 inches long. There was a pipe exposed behind the toilet with stuff sticking out that looked like someone had stuffed rag in the hole. The room still had the residents' personal belongings and there was a lock on the door, but it was not locked. During an interview on 2/26/25 at 5:15 p.m. CNA F said that they were not aware that there was anything going on in the room with C18. They were just told to move the residents out of the room. During observation and interview on 2/27/25 at 10:35 a.m. at 10:35 a.m. the shower in Room C18 showed the waferboard inside the shower had been removed, but the black debris and partials were still in the gap between the floors. There was a black substance on the exposed wall and on the remaining insulation. There were new tiles stacked in the doorway and some on the floor of the shower. The RDO said it appeared they had torn the damaged material out of the shower and was replacing the tile in the shower. He could not say if that was going to fix the problem of the black particles inside. During an observation and interview on 2/27/25 at 11:30 a.m. with CNA G she said the showerhead in Room C17 was broken and have been broke for a couple of months. She said that the residents were not able to get a shower. CNA F said they did not have a shower room. She said each room had their own shower, and she had let maintenance know on several occasions the shower was not working properly. Resident #9 resided in the room and said she had not had a shower in a while, she was only able to take bird baths. CNA G said when they have an empty room, they have taken Resident #9 to get a shower. Resident #6 said she had had been in the room about a week and she had not had a shower since she moved. Observation of the shower showed it had a pipe that came out of the wall but no shower head. During an observation and interview on 2/27/25 at 11:20 a.m. observation of the bathroom in Room C20 showed the light in the bathroom did not work and there was little light. The heat light was tuned on for extra light. The shower had black buildup in the corners of the shower and some of the tile had been replaced and there was black buildup in-between the spaced cracks in the wall. There were back spots in between some of the tiles on the floor in the shower. There was missing tile on the wall close to the 3-drawer cabinet about 4 feet off the floor. On the floor was missing tile and about two inches was filled with brown substance and brown debris was protruding out onto the floor. Under the cabinet the baseboard was missing, and it was brown with black and brown stains in the crack and onto the floor. The sink had the facing on the side missing showing exposed waferboard. There was a hole in the wall to the left side of the shower along the base board with a crack of about 1/4 inch with black substance along the wall for about 6 inches. There was a shower curtain on the rod rolled up and stuck in the corner on the left side of the commode. There was no shower curtain on the shower. The baseboard along the wall had dirty buildup between the top of the baseboard and the wall on the left side of the door for about 2 feet. The door posts on both sides of the door on the inside of the bathroom had dirt buildup around the base with holes and missing gaps. On the left side of the door above the base board was a brown stain or hole in the wall. The right side of the door going out of the bathroom was scared with several layers of paint showing. The area around the door was about 12 inches long and 12 inches wide. Resident #7 said the shower curtain had been down for quite some time. The Housekeeping Supervisor came in to clean the room. She said that there needed to be a light over the sink because that light did not work in the bathroom. She tried to clean his shower with bleach wipes and the black stains did not move. During observation and interview on 2/27/25 at 11: 27 a.m. Room C21 Resident #8 was laying in the bed. She said that her light in her bathroom did not work. She said sometimes it came on but most times not. An observation of the light show that the cover was missing, and the light was dim in the bathroom. There were baseboard missing under the sink for about 3 inches that showed the brown wall. Resident #8 said the staff were aware, she had requested the light be fixed several times. There was also missing tile at the threshold of the floor making the floor uneven and a trip hazard. In some places the missing tile was about 2 inches wide and 6 to 8 inches long and two others one-inch spots in the doorway. During an observation and interview 2/27/25 at 2:57 p.m. of Room C22 there was a large hole in the wall that was about 2 feet long and 4 inches high. The hole reached form the closet door to the bathroom door. The baseboard was propped against the wall and the wall was crumbled. There was an area above the hole that was about 12 inches high that was discolored. The wall that was crumbled did not appear to be wet at the current time. The sheet rock had basically disintegrated. Resident #10 said he had complained and been complaining ever since he had been in the room for about 3 months. Observation of the bathroom, the three-drawer cabinet the top drawer was missing. The wall along the side of the commode had been replaced at one time and appeared warped and buckled. Resident #10 said the commode was often stopped up, and he had complained several times. Record review of a Maintenance Request form dated 1/15/25 indicated Resident #10 said his toilet does not work and there is a hole in the wall. With no completion date or signature.

Based on record review and interview, the facility, with a capacity of more than 120 beds or more less, failed to employ a qualified social worker for the facility reviewed for administration in that: The facility did not have a qualified social worker since [DATE]. This failure could affect any residents in need of social services and place them at risk of psycho-social decline and poor-quality of life. Findings included: Record review of the Facility Summary Report from Tulip dated [DATE] revealed the facility had a maximum capacity of 120. Record review of facility's personnel file accessed on date [DATE], completed by HR indicated there was full time Social Worker on staff but the name listed did not reflect the current social worker that was in place. Record Review [DATE] from the Texas State Board of Social Worker Examiners did not list the facility current Social Worker as a license Social Worker name did not appear on the registry. In an interview with the HR director, on [DATE] at 10:30 AM, she said, the licensed Social Worker's last day at the facility was [DATE] and the Social worker they hired on [DATE] license had expired on [DATE] and his license are in the process of reinstatement. In an interview with the Regional Director of Clinical Operation on [DATE] at 12:00PM, she said they are sharing the Social Worker from a sister facility. In an interview with Administrator on [DATE] at 1:00 pm, he said they do not have a full time Licensed Social Worker. He said he just started work here [DATE] and had no idea that the current Social Worker was not licensed. He didn't know there had to be a full time Social Worker if your building was not at full capacity. He said he thought it was ok to share with the sister facility who has a building of 170. In an interview with facility's non licensed Social Worker on [DATE]@11:00 am he stated that his license was expired, and he had not planned to renew his license then he decided to come back to Social Work., he said he has completed his CEU's to reinstate his license he looked up his license and found license number 21994 was expired and no evidence of reinstatement. Record review of facility's policy Social Services dated 2024 revealed the following: Policy: The facility, regardless of size, will provide medically related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A facility with more than 120 beds will employ a qualified social worker on a full-time basis. A facility, regardless of size, will provide medically related social services to each resident, to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Making referrals and obtaining needed services from outside the facility Assisting residents with financial and legal matters Transitions of care services The facility should provide social services or obtain services from outside entities during situation where there is a lack of an effective family or community support system or legal representative.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to 1 of 3 rooms (DON's office) used for storage of drugs and biologicals. The facility failed to ensure the DON's office door and the metal filing cabinet where discontinued narcotics were stored, was at all times secured under double lock, and unable to be accessed by unauthorized personnel. This failure could place residents at risk for misuse of medication and overdose, drug diversions, and adverse reactions to medications. Findings included: During observation and interview on 12/10/2024 at 11:20 AM, the DON's office door was noted to be unlocked and slightly ajar. The DON, and the ADON joint office were easily push open, upon entering the office it was noted no one was inside. Observed, and noted behind the DON desk in the corner, the metal filing cabinet where discontinued narcotics were stored, the locked device hanging on the metal cabinet were unlocked. A second surveyor coming down the hallway, was asked to come inside the office before opening the drawer to the metal cabinet where the discontinued narcotics were stored. 11:30 AM, the DON, and the ADON entered the office and was informed the office door was left open slightly ajar, and the discontinued narcotics drugs were not secured and were available to anyone who walked into the DON's office. The DON said, the medications were to be processed for destruction, she was called to the front desk, and she did not know why she left the secured cabinet unlocked. The DON did not offer a rationale for not securing the drugs. The ADON did not offer any additional comments. During an interview on 12/10/2024 at 4:05 PM, the DON said, she locked her door when she left her office earlier today, she added the ADON shared the office with her and they both had keys, the ADON had returned and failed to lock the office door. The DON said, she had the only key to the secure metal cabinet and failed to re-lock the secured discontinued narcotics cabinet. Record review of the facility's policy dated 07/2022 and titled Medication Storage indicated the following: Narcotics and Controlled Substances: Scheduled II drugs and back-up stock of Schedule III, IV, and V medications are stored under double-lock and key. When a medication has passed its expiration date or is otherwise deteriorated, or has been discontinued, or for a resident no longer residing at the home, it should be removed from the medication cart as soon as possible, accounted for and kept under double lock and key until time of destruction.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #72) reviewed for care plans. The facility failed to ensure Resident #72's comprehensive care plan reflected her positive PASRR Evaluation and the recommended services. The facility failed to ensure Resident #72's comprehensive care plan addressed her smoking status. These failures could place residents at risk for not receiving needed care and services, including care and services to prevent injury. The findings included: A record review of a face sheet dated 12/11/2024 indicated Resident #72 was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay. She had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure (a long-term condition that occurs when the lungs cannot exchange oxygen and carbon dioxide properly), mood disorder, anxiety (intense, excessive, and permanent worry and fear about everyday situations), and depression (a serious mental health condition that can impact how a person feels, thinks, and acts). A record review of the admission MDS dated [DATE] reflected Resident #72 had a BIMS score of 15 indicating her cognition was intact and was independently ambulatory, continent of bowel and bladder, and able to voice concerns and needs. The MDS reflected Resident #72 was determined as positive for mental illness according to the PASRR Evaluation process. During observations of the designated smoking area on 12/09/2024 at 11:00 AM and on 12/10/2024 at 01:00 PM and 03:00 PM, Resident #72 was noted sitting in a chair in the area and smoking a cigarette. She was observed to hold the cigarettes safely and use the ashtray appropriately. Facility staff were noted present in the area and controlled the dispensing of cigarettes and use of lighters. A record review of the Admission assessment dated [DATE] indicated Resident #72 smoked cigarettes. A record review of a PCSP Form dated 08/30/2024 indicated Resident #72 was receiving specialized mental illness services which included Routine Case Management and Individual Skills Training. A record review of Resident #72's undated comprehensive care plan did not include any indication of Resident #72's positive PASRR status nor the specialized services to address the needs identified during the PASRR Evaluation. The care plan did not address Resident #72's smoking status nor did it identify any safety actions to prevent injury. During an interview on 12/09/2024 at 11:25 AM, RN A said she had worked at the facility about 3 years. She said Resident #72 was a smoker when she admitted to the facility. She said residents who smoked were assessed for smoking safety upon admission and their care plans would reflect their smoking status with interventions to prevent injury. RN A said the care plan would tell staff how much supervision was needed and if any special devices such as a smoking apron was required. RN A said if the care plan did not address smoking, the staff would not know if the resident required a smoking apron or how much supervision was needed. During an interview on 12/10/2024 at 10:15 AM, the Regional DCO said residents who smoked were assessed for safe smoking on admission and their care plans should reflect their smoking status. She said Resident #72 had not been assessed for safe smoking and her care plan did not address her smoking status. She said she did not know why Resident #72 had not been assessed nor why her care plan did not address it. The DCO said Resident #72 would be assessed immediately. During an interview on 12/10/2024 at 10:20 AM, the MDS Coordinator said she had been at the facility about a week. She said Resident #72's comprehensive care plan should have addressed smoking and PASRR related services to be provided. A record review of the facility's policy dated 06/2023 and titled Resident Smoking indicated the following: Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Policy Explanation and Compliance Guidelines: 9. All safe smoking measures will be documented on each resident's care plan, and communicated to all staff, visitors, and volunteers who will be responsible for supervising while smoking. Supervision will be provided as indicated on each resident's care plan. A record review of the facility's policy dated 07/2022 and titled Comprehensive Care Plans indicated the following: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Any specialized services or special rehabilitation services the nursing facility will provide as a result of PASRR recommendations.

Based on observations, interviews, and record reviews, the facility failed to provide maintenance and housekeeping services for 2 (Resident #13 and #54) of 10 resident rooms observed for safe, homelike and sanitary environment. The facility failed to ensure missing and damaged laminate flooring panels were replaced in Resident #13's room (216-B). The facility failed to ensure missing baseboards were replaced in Resident #54's bedroom (#207-B) and bathroom; repair the vanity drawer in the bathroom; clean the toilet and remove trash from the floor of bathroom. These failures could place residents at risk for psychosocial harm and a diminished quality of life and an unsanitary environment. Findings included: 1.A record review of a face sheet dated 12/11/2024 indicated Resident #13 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included dementia (a group of social and thinking symptoms that interferes with daily functioning), mood disorder (a serious mental illness that primarily affects a person's emotional status) , major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment of daily life), and history of falling. A record review of a MDS dated [DATE] indicated Resident #13 had a BIMS score of 9 indicating his cognition to be moderately impaired and required assistance with most ADLs. During an observation on 12/09/2024 at 10:32 AM, Resident #13 was noted to not be in his room. Three (3) approximately 3-3.5 feet long laminate flooring panels were noted be missing from the flooring in the area extending from outside the head of the bed and continuing under the bed. Two (2) more laminate flooring panels underneath the foot of the bed and extending outward into the room were noted to be loose, buckled, and almost completely unattached from the floor beneath them. Another panel of laminate flooring was noted in the same area at the foot of the bed to have a tear in it with the torn area slightly raised and not attached to the floor. A review of the undated Maintenance Work Log Book at the nurses' desk indicated there were no records of needed repairs in the book. The book contained only blank Maintenance Request Forms. During an interview on 12/09/2024 at 11:01 AM, CNA B said she did not know exactly how long the floor strips at the head and foot of Resident #13's bed had been missing or damaged. She said the staff were supposed to tell the Maintenance Supervisor if something needed to be fixed. She said she had not told anyone about the missing and damaged flooring panels. She said she forgot. During an observation and interview on 12/09/2024 at 11:20 AM in Resident #13's room, the Maintenance Supervisor said the unattached and damaged flooring panels at the foot of the bed were new. He said the staff didn't take time to unlock the bed's wheels and drag the bed over which caused the flooring panels to be pulled away from the floor and damaged. He said he was not made aware of the floor panels at the foot of the bed. The Maintenance Supervisor said the flooring panels at the head of the bed had been missing a while. He said staff were supposed to fill out a Maintenance Request Form and place it in the Maintenance Work Log Book when they saw needed repairs but they didn't. He collected the torn and unattached flooring panels from the floor and said he would see if he had some matching panels and replace them. He said he was going to in-service the staff on communicating repair needs. During an interview on 12/09/2024 at 01:25 PM, Resident #13 said he did not know how long the floor panels had been missing or damaged. He said his room would look better if they were replaced. During an interview with the Administrator on 12/11/2024 at 02:15 PM, he said he was new to the facility and was not aware of the missing and damaged flooring panels in Resident #13's room and would follow up with maintenance. During an interview on 12/11/2024 at 04:00 PM, the Maintenance Supervisor said he did not have any flooring panels, had ordered some, and would replace them when they came in. A record review of a face sheet dated 12/11/2024, indicated Resident #54 was a 41year-old female who admitted to the facility on [DATE]. She had diagnoses which included paranoid schizophrenia (a chronic condition that cause people to lose touch with reality), mood disorder (a serious mental illness that affects a person's emotional state), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). During an observation of Resident #54's bedroom and bathroom, on 12/09/24 at 11:27AM, a section of the baseboard in the bedroom and two sections of baseboard in the bathroom were missing. The toilet was dirty with brown water stain rings around the bowl of the toilet, brown particles that appeared to be fecal matter was around the inside of the bowl of the toilet and yellow water was in the bowl of the toilet. A separate square piece of sheetrock was in a corner, behind the toilet. Behind the sheetrock was a pile of trash. The middle drawer to vanity was broken. The drawer front was separated from the drawer box, making it inoperable. During an observation of Resident #54's bedroom and bathroom, on 12/09/24 at 12:59PM, a section of the baseboard in the bedroom and two sections of baseboard in the bathroom were missing. The toilet was dirty with brown water stain rings around the bowl of the toilet, brown particles that appeared to be fecal matter was around the inside of the bowl of the toilet and yellow water was in the bowl of the toilet. A separate square piece of sheetrock was in a corner, behind the toilet. A pile of trash was behind the separate square piece of sheetrock. Behind the sheetrock was a pile of trash. The middle drawer to vanity was broken. The drawer front was separated from the drawer box, making it inoperable. During an observation of Resident #54's bedroom and bathroom, on 12/10/24 at 8:11AM, a section of the baseboard in the bedroom and two sections of baseboard in the bathroom were missing. The toilet was dirty with brown water stain rings around the bowl of the toilet, brown particles that appeared to be fecal matter was around the bowl of the toilet and yellow water was standing in the bowl of the toilet. A separate square piece of sheetrock was in a corner, behind the toilet. Behind the sheetrock was a pile of trash. The middle drawer to vanity was broken. The drawer front was separated from the drawer box, making it inoperable. During an interview and record review on 12/10/24 at 9:05AM, the Director of Maintenance said he was not aware of the missing baseboards, in Resident #54's bedroom or bathroom. He said he was not aware that the vanity drawer was broken and inoperable. He said the sheetrock must have been left in the bathroom, from a previous repair to the sheetrock wall behind the toilet. The pile of trash was revealed when he removed the piece of sheetrock. He said he has asked the staff to use the maintenance logbook to make him aware of repairs that need to be done, but they will not do it. Record review of the maintenance logbook for the December 2024, revealed no documented maintenance request. During an interview, on 12/10/24 at 11:30AM, the Housekeeping Supervisor said she was not aware of the missing baseboards in Resident #54's bedroom or bathroom. She said she was not aware of the broken drawer of the vanity in the bathroom. She said when the housekeeping staff see something that needs repair, they should write down a maintenance request in the maintenance logbook, for the Maintenance Director. She said she was not sure why these things were not written in the maintenance logbook. A record review of the facility's policy dated 07/2022 and titled Work Order Request indicated the following: Policy: It is the policy of this company that all maintenance support requests must be made in writing and submitted into the Maintenance Work Log Book. Policy Explanation and Compliance Guidelines 1.Write your maintenance request and fill out all fields necessary in the Maintenance Work Log book so that the request is easily understood and able to be prioritized. 4. Maintenance will review work log book throughout the day for new work orders. 5. When orders are completed, maintenance personnel will complete the assignment on the work log in the maintenance book.

Based on observation, interview, and record review the facility failed to ensure each resident was provided adequate supervision and preventative measure to prevent injuries for 1 of 4 residents (Resident #72) reviewed for accident hazards. The facility failed to follow the facility's policy to assess Resident #72 for safety when smoking. This failure could place residents at risk for accidents and injuries due to failure to evaluate for risk. Findings included: A record review of a face sheet dated 12/11/2024 indicated Resident #72 was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay. She had diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure, mood disorder, anxiety, and depression. A record review of the admission MDS dated [DATE] reflected Resident #72 had a BIMS score of 15 indicating her cognition was intact. She was noted as independently ambulatory and able to voice concerns and needs. A record review of the Admission assessment dated [DATE] indicated Resident #72 smoked cigarettes. A record review of physician orders dated 12/11/2024 indicated Resident #72 did not have any orders related to smoking. A record review of Resident #72's undated comprehensive care plan did not address Resident #72's smoking status nor did it identify any safety needs to prevent injury. A record review of Resident #72's medical records did not reflect Resident #72 had been assessed for safe smoking. During observations of the designated smoking area on 12/09/2024 at 11:00 AM and on 12/10/2024 at 01:00 PM and 03:00 PM, Resident #72 was noted sitting in a chair and smoking a cigarette. She was observed to hold the cigarettes safely and use the ashtray appropriately. Facility staff were noted present in the area and controlled the dispensing of cigarettes and use of lighters. During an interview on 12/09/2024 at 11:20 AM, Resident #72 said she had smoked a long time and had never burned herself. She said she was going inside and could not talk anymore. During an interview on 12/09/2024 at 11:25 AM, RN A said she had worked at the facility about 3 years. She said Resident #72 was a smoker when she admitted to the facility. She said residents who smoked were assessed for smoking safety upon admission and their care plans would reflect their smoking status with interventions to prevent injury. RN A said the care plan would tell staff how much supervision was needed and if any special devices such as a smoking apron was required. RN A said if a resident who smoked was not assessed for safe smoking, the staff would not know if the resident required a smoking apron or how much supervision was needed. She said failing to assess a smoker for safe smoking could place residents at risk for burns. During an interview on 12/11/12 at 10:50 AM, CNA-E said the nurse would tell whoever came to get the smoking supplies if a resident needed special supervision or a smoking apron. During an interview on 12/11/2024 at 02:15 PM, DS-C said residents who needed anything, like a smoking apron, brought it with them when they were brought out to smoke. She said if a resident was brought out to smoke who needed a smoking apron but did not have it with them, she had no way of knowing they needed it. During an interview with HKS-D at 03:00 PM, she said the aides made sure residents who needed a smoking apron had it with them when they brought them out to smoke. During an interview on 12/10/2024 at 10:15 AM, the Regional DCO said residents who smoked were assessed for safe smoking on admission and their care plans should reflect their smoking status. She said Resident #72 had not been assessed for safe smoking and her care plan did not address her smoking status. She said she did not know why Resident #72 had not been assessed nor why her care plan did not address it. The DCO said Resident #72 would be assessed and her care plan would be updated immediately. A record review of the facility's policy dated 06/2023 and titled Resident Smoking indicated the following: Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Policy Explanation and Compliance Guidelines: 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive assessment process. 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment . 9. All safe smoking measures will be documented on each resident's care plan, and communicated to all staff, visitors, and volunteers who will be responsible for supervising while smoking. Supervision will be provided as indicated on each resident's care plan.

Based on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 1 building reviewed for pest control. The facility did not have an effective pest control program to eradicate the cockroaches in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns. Findings included: 1. Record review of the Pest Control Report dated 8/8/23 indicated American cockroaches we found in room [ROOM NUMBER] and in the rest rooms and German cockroaches were found in room [ROOM NUMBER]. Record review of the Pest Control Report dated 9/14/23 indicated the facility was treated for cockroaches. The Pest Control Report indicated resident room [ROOM NUMBER] was treated for American Cockroaches in the room and inside bathroom drawer. The Pest control report indicated resident room [ROOM NUMBER] had a follow-up for cockroaches. Record review of a grievance dated 10/16/23 indicated resident room [ROOM NUMBER] filed a grievance regarding the facility having a bad problem with water bugs. The grievance indicated maintenance sprayed bug killer around the room and outside area and placed the issues in the pest control book. Record review of the Pest Control Report dated 10/20/23 indicated the facility was treated for cockroaches. The Pest Control Report indicated it was reported that the secondary nurse's station had an issue with cockroaches. The Pest Control Report indicated resident room [ROOM NUMBER] was treated for bed bugs. Record review of a grievance dated 10/30/23 indicated all residents in resident rooms 128-136 complained of a roach problem. The grievance indicated maintenance had sprayed over the counter treatment and notified pest control. Record review of the Pest Control Report dated 11/14/23 indicated the facility was treated for cockroaches. The Pest Control Report indicated The Pest Control Report indicated it was reported that the secondary nurse's station had an issue with cockroaches. Record review of the Pest Control Report dated 12/15/23 did not indicated the facility was treated for cockroaches. Record review of the Pest Control Report dated 12/15/23 did not indicated the facility was treated for cockroaches. Record review of the Pest Control Report dated 2/28/2024 cockroaches were reported in resident rooms 127-133. The pest control report indicated resident rooms 127, 128, 129, 130, 131, 132, and 133 were treated for cockroaches. Record review of the Pest Control Report dated 3/26/24 indicated resident rooms [ROOM NUMBER] were treated for cockroaches. Record review of the Pest Control Report dated 4/17/24 did not indicated the facility was treated for cockroaches. During an observation on 4/16/24 at 12:08 p.m. when the light was turned on in a resident's bathroom [ROOM NUMBER] large cockroaches roaches scurried to the hole in the wall where tiles had come off. During an interview on 4/17/24 at 10:10 a.m. Resident #4 said she had seen roaches in her room a few days ago. Resident #4 said they really did not bother her too much and if one got close, she would kill it with her shoe. During an interview on 4/17/24 at 11:06 a.m. The Pest Control Company said they had someone on-site at the facility today (4/17/24) performing monthly routine service. The Pest Control Company said the last time they had been at the facility was 3/26/24 for monthly routine service. The Pest Control Company said they did call outs if a facility if they needed additional services beyond their monthly services. During an interview on 4/17/24 at 11:42 a.m. the Maintenance Director said he does daily walkthroughs of resident rooms and inspects 5-6 rooms per day. said he had complaints regarding roaches from residents. The Maintenance Director said when he received a roach or insect complaint, he logged it in the pest control book. The Maintenance Director said when there was a complaint regarding insects, he had the resident leave their room for a couple hours and treated the room with household chemicals. The Maintenance Director said the pest control company comes out monthly and as needed. During an interview on 4/17/24 at 1:41 p.m. Resident #5 said she had seen a roach in her room on 4/16/24. During an interview on 4/18/24 at 10:10 a.m. The DON said she had seen large cockroaches at the exit doors. The DON said she does not deal with pest control, but the facility had pest control out monthly and if there was an issue between the monthly visit, they just had the Maintenance Director take care of the issue. During an interview on 4/18/24 at 1:05 pm the Administrator said he expected to maintain a professional service that could reasonably maintain pest control. The Administrator said they had called the pest control company out between routine visits. The Administrator said he did not know if they gave him a service report for visits made outside the monthly routine visits. The Administrator said the importance of pest control was to protect the residents. Record review of the facility's Pest Control Program policy dated 1/2024 indicated, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats) .

Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 4 (Resident #2) residents reviewed for pharmacy services. The facility failed to ensure Resident #2 was administered his Ambien (a medication to treat insomnia) for 3 days while he was admitted to the facility for respite care. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: 1. Record review of the face sheet dated 4/18/24 indicated Resident #2 was admitted to the facility on [DATE] with diagnoses including weakness, hemiplegia and hemiparesis (one-sided weakness or paralysis) following a stroke affecting the left side, insomnia, and anxiety. Record review of the physician orders dated 4/18/24 indicated Resident #2 was admitted to the facility for respite care on 3/22/24. The physician orders indicated Resident #2 had an order for Ambien 12.5mg at bedtime for insomnia starting 3/23/24. Record review of the MAR dated March 2024 indicated Resident #2 did not receive his Ambien on 3/23/24, 3/24/34, 3/25/24, or 3/26/24. Record review of the MDS dated [DATE] indicated Resident #2 admitted to the facility on [DATE] and discharged on [DATE]. The MDS indicated Resident #2 understood others and was understood by others. The MDS indicated Resident #2 had a BIMS of 12 and was moderately cognitively impaired. Record review of the Pharmacy Manifest dated 3/23/24 indicated Resident #2's amlodipine 80mg (medication for elevated blood pressure), aripiprazole 2mg (medication to treat depression and bipolar disorder), atorvastatin 80 mg (medication to treat elevated cholesterol), buspirone 5mg (medication to treat anxiety), desvenlafaxine 100mg (medication to treat depression), Eliquis 5mg (medication to treat and prevent blood clots and prevent stroke), Jardiance 10mg (medication to treat elevated blood sugar), levetiracetam (medication to treat seizures), methocarbamol 500mg (medication to treat muscle spasms and pain), metoprolol 50mg (medication to treat elevated blood pressure), and mirtazapine 30mg (medication to treat depression), phenytoin 100mg (medication to prevent seizures) were delivered to the facility. Record review of the pharmacy manifest dated 3/24/24 indicated Resident #2's Lantus (medication to treat elevated blood sugar) was delivered to the facility. During an interview on 4/12/24 at 1:24 p.m. Resident #2's family said he was admitted to the facility for respite care on 3/22/24. Resident #2's family said when they arrived at the facility to visit Resident #2 on 3/22/24 at approximately 9:40 a.m. his medications from home had been left on the nightstand. Resident #2's family said the went and asked nurse about medications. Resident #2's family said when the asked the nurse they were told Resident #2's home medications would be administered to him. Resident #2's family said his meds were past due and they had to administer the resident's medications on 3/22/24. Resident #2's family said he only received his medications from the facility twice. During an interview on 4/16/24 at 2:20 p.m. the DON said the facility did not have any Ambien for Resident #2 while he was admitted for respite. The DON said Resident #2 was admitted under insurance respite care and not hospice respite care. The DON said this was the first time she had a resident under insurance respite care. The DON said the insurance case manager sends medical records to the facility and then the facility and the family coordinate medications, transportation, etc. The DON said the facility's transportation picked up Resident #2 from home with his medications. The DON said the family had sent his medications. The DON said the medical records they received indicated Resident #2 had an order for Ambien 10mg at bedtime. The DON said the facility did not receive Resident #2's Ambien from his family The DON said she did not follow-up with the family or insurance regarding Resident #2's Ambien. During an interview on 4/17/24 at 11:10 a.m. the DON said the facility did not have a policy for respite care. During an interview on 4/17/24 at 11:53 a.m. the DON said the facility had received Resident #2's clinical information and list of current medication from his insurance company. The DON said the list of current medications provided was how the facility knew what Resident #2's medication orders were. The DON said it was the family's responsibility to supply all Resident #2's medications. The DON said their doctor was not going to order medication for a respite care resident especially if the medication was a narcotic. The DON said there was no documentation of the admitting nurse contacting the family or physician regarding Resident #2's order for Ambien. The DON said without documentation she did not know how it could be proven the nurse contacted anyone regarding the Ambien and its order. The DON said the Medical Director would take responsibility for a respite resident and their care needs while they were in the facility. During an interview on 4/17/24 at 1:44 p.m. Resident #2's family said Resident #2 took Ambien at bedtime to help him sleep. Resident #2's family said the facility did not reach out to her regarding any medication. Resident #2's family said they told her they were going to use Resident #2's home medications while he was in the facility. During an interview on 4/17/24 at 2:16 p.m. the DON said the facility's pharmacy delivered all medications for Resident #2 except Ambien. The DON said when orders were put in the facility's electronic medical records for a resident if a box was not checked saying, medications on hand, the order went to the pharmacy. The DON said a designated agent would have needed to call in the Ambien into the pharmacy as it was a narcotic. During an interview on 4/18/24 at 8:58 a.m. RN E said the admitting nurse was responsible for ordering a new resident's medication from the pharmacy. RN E said if a medication did not come (including a narcotic) they should pull it from the electronic dispensing system the facility had for emergencies and when a medication was not yet received from the pharmacy if available. RN E said if a resident admitted for respite care and [NAME] medications from home but did not bring a medication they had an order for the nurse should order it from the pharmacy. RN E said it was important to ensure residents received all their ordered medication was for them to get the therapeutic benefit of the medications. During an interview on 4/18/24 at 10:03 am LVN H said the admitting nurse was responsible for ensuring a newly admitted resident's medications were ordered. LVN H said if a medication did not come in from the pharmacy, then the nurse should reach out to the provider. LVN H said if a newly admitted resident was at the facility for respite and the family was providing their medications and the family did not bring a medication the resident had an order for the nurse should reach out to the family and then the provider if the family cannot supply the medication. LVN H said it was important for residents to receive their ordered medications because of the diagnoses they have. During an interview on 4/18/24 at 10:10 am the DON said if a newly admitted resident's medication did not come from the pharmacy, she expected the nurses to obtain it from the emergency kit if it was available. The DON said if it was a respite care resident, and the family or hospice company did not provide all the medication that were ordered for the resident she expected the nurses to reach out to the family or hospice company. The DON said after reaching out to the family or hospice company for medication if they could not provide the medication, she expected the nurses to reach out to the pharmacy to get the medication. The DON said the importance for a respite care resident continuing to receive all the medications they had orders for and were receiving at home was for continuity of care. Record review of the facility's Medication Reordering policy dated 4/2024 indicated, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident .

Based on interview and record review the facility failed to ensure laboratory services were obtained to meet the needs for 1 of 5 (Resident #1) residents reviewed for laboratory services. The facility did not ensure Resident #1 had a CBC (complete blood count-used to look at overall health and find a wide range of conditions including anemia (condition in which the blood does not have enough healthy red blood cells) and infection) and CMP (complete metabolic panel-test that checks the body's fluid balance and levels of electrolytes) lab tests every 6 months as ordered. This failure could place the residents at risk of not receiving lab services as ordered and suffering from an undetected infection, decreased electrolyte balances, dehydration, and decreased kidney function. Findings included: 1. Record review of the face sheet dated 4/18/24 indicated Resident #1 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including vitamin deficiency, protein-calorie malnutrition (the state of inadequate intake of food occurring in the absence of inflammation, injury, or another condition that elicits a systemic inflammatory response), adult failure to thrive (when an older adult has loss of appetite, eats less than usual, loses weight, and is less active than normal), and anemia (lack of blood). Record review of the physician orders dated 4/18/24 indicated Resident #1 had an order for a CBC and CMP every 6 months in March and September starting 9/14/22. The physician orders indicated Resident #1 had an order for a valproic acid level (measures the amount of valproic acid in the blood) every three months starting 1/9/24. The physician orders indicated Resident #1 had an order for a thyroid stimulating hormone (TSH) level (a blood test that measure the amount of thyroid stimulating hormone) yearly in March starting 3/14/23. Record review of the MDS dated [DATE] did not indicate if Resident #1 was understood by other or understood others. The MDS did not indicate if Resident #1 had a BIMS assessment. Record review of the care plan revised on 2/8/24 indicated Resident #1 was resistive to care and would refuse lab draws, medications, and baths/showers. The care plan indicated Resident #1 had a nutritional problem or potential nutritional problem related to dementia and swallowing. Record review of the lab results dated 4/13/23 indicated Resident #1 had a TSH level drawn. Record review of the lab results dated 5/16/23 indicated Resident #1 had a valproic acid level drawn. Record review of the lab results dated 5/22/23 indicated Resident #1 had a TSH level drawn. Record review of the lab results dated 5/30/23 indicated Resident #1 had a valproic acid level drawn. Record review of the lab results dated 1/11/24 indicated Resident #1 had a valproic acid level drawn. Record review of the lab results dated 3/14/24 indicated Resident #1 had CBC, TSH, CMP levels drawn. Record review of all lab results for 2023 and 2024 indicated Resident #1 only had a CBS and CMP drawn on 3/14/24. During an interview on 4/16/24 at 9:30 a.m. the DON said Resident #1 sometimes refused labs. The DON said she was reaching out to the lab to obtain their records for Resident #1. During an interview on 4/17/24 at 1:53 p.m. the DON said she had talked to the lab and was informed by the lab they did not have an order for Resident #1's CBC and CMP to be drawn in March and September of 2023. The DON said the lab told her they had requested from the previous DON a lab orders audit of routine labs for 2023 at the end of 2022 and beginning of 2023. The DON said the lab told her they never received the audit, so they did not draw the labs or have an order to draw the labs on Resident #1 in 2023. During an interview on 4/18/24 at 10:03 a.m. LVN H said it was the nurse's responsibility to ensure routine labs were drawn. LVN H said the importance of routine labs was to monitor for certain medication levels, infection, and dehydration. During an interview on 4/18/23 at 10:10 a.m. the DON said every morning in morning meeting they reviewed to ensure labs that were supposed to have been drawn the previous day had been drawn. The DON said if they find a lab was not drawn, they reach out to the lab to find out the reason why and get the lab scheduled to be drawn. The DON said the importance of ensuring routine labs were drawn was because if they had an order for a lab there must be a reason for it. Record review of the facility's Laboratory Services and Reporting policy dated 11/2023 indicated, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical specialist according with state law .The facility is responsible for the timeliness of the services .

Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 3 (Resident #3) residents reviewed for diets. The facility failed to ensure Resident #3 received his health shake or double meat portion at lunch on 4/16/24. This failure could place resident at risk for weight loss, altered nutritional status and diminished quality of life. Findings included: 1. Record review of a face sheet dated 4/18/24 indicated Resident #3 was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), diabetes, hypertension (elevated blood pressure), and pneumonia. Record review of the physician orders dated 4/18/24 indicated Resident #1 had an order med pass (supplement) four times a day and have nurse thicken to honey starting 3/12/24. The physician orders did not indicate what Resident #3's diet was. Record review of the MDS dated [DATE] indicated Resident #3 understood others and was understood by others. The MDS indicated Resident #3 had a BIMS of 14 and was cognitively intact. The MDS indicated Resident #3 required setup or clean-up assistance with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident). The MDS indicated Resident #3 required a mechanically altered diet (require change in texture of food or liquids (e.g., pureed food, thickened liquids). Record review of the care plan last revised on 2/16/24 indicated Resident #3 was at risk for complications due to non-compliance with physician orders-mechanical soft food with honey thickened liquids. The care plan indicated Resident #3 had a potential nutritional problem related to diet restrictions of mechanical soft food with honey thickened liquids. The care plan indicated Resident #3 was non-compliant with his diet and liquids and would have other residents give him thin liquids and regular textured foods. Record review of the diet type report dated 4/17/24 indicated Resident #3 was on a mechanical soft diet with honey thickened liquids and fortified foods. Record review of a meal ticket dated 4/17/24 indicated Resident #3 was to receive a mechanical soft diet with honey thickened liquids. The meal ticket indicated Resident #3 had special needs including fortified foods, shake with all three meals, and double portions of meat. During an observation and interview on 4/16/24 at 12:19 p.m. Resident #3's meal card indicated he was to receive a health shake with each meal and double portions of meat. Resident #3's lunch tray did not have a health shake or double portion of meat on it. Resident #3 said he drank the health shakes when they put them on his tray, and he liked the extra meat. Resident #3 said he did not always receive health shakes or extra meat. During an interview on 4/18/24 at 8:58 a.m. RN E said the nurses were responsible for checking the meal trays. RN E said nurses checked the meal trays against the meal ticket and were ensuring the residents received the ordered diet, correct consistency of food and drink, any supplements (health shake), and any double portions. RN E said if the meal tray was incorrect, it should be taken back to the kitchen to get the correct meal. During an interview on 4/18/24 at 9:23 a.m. CNA F said it was the nurse's responsibility to check the meal trays to ensure residents were receiving the correct diet, texture, portions, and supplements. CNA F said it was important to ensure resident received the correct texture of food to prevent choking. CNA F said it was important to ensure residents received the correct portion because it was their right to have extra food if requested or to aide in meeting nutritional needs. During an interview on 4/18/24 at 9:25 a.m. CNA G said nurses were responsible for checking meal trays and fluid consistency. CNA G said if a resident received the wrong diet or fluid consistency it could cause them to choke. During an interview on 4/18/24 at 10:03 a.m. LVN H said the nurses were responsible for checking the meal trays for diet consistency. LVN H said meal trays were checked against the meal ticket. LVN H said it was important to check the meal trays to ensure residents were not getting something they were allergic to and to prevent aspiration. During an interview on 4/18/24 at 10:10 a.m. the DON said it was the nurse's responsibility to check the meal trays. The DON said nurses checked the meal trays against the meal ticket for diet and fluid consistency. The DON said the importance of ensuring the residents' meal trays matched their meal tickets was in case a mistake was made because they cannot serve a meal that does not match the ticket. During an interview on 4/18/24 at 1:05 p.m. the Administrator said he expected the dietary staff while preparing the trays and the nursing staff while passing out the trays to ensure residents were receiving the appropriate diets and fluids including consistencies. The Administrator said it was important to ensure residents received the correct diet and fluids for their well-being. Record review of the facility's Nutritional and Dietary Supplements policy dated 4/9/24 indicated, It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being . Nutritional Supplements refers to products that are used to complement a resident's dietary needs such as calorie or nutrient dense drinks, total parenteral products, enteral products and meal replacement products (e.g., Ensure, Glucerna, Promote) . The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs . Record review of the facility's Liberalized Diets policy dated 4/9/34 indicated, It is the policy of this facility to incorporate individualized, liberalized diets for residents in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' specific goals, needs and preferences . Diet consideration is determined with the resident and in accordance with their informed choices, goals and preferences, rather than exclusively by diagnosis. The facility will work with the resident's practitioner and other members of the IDT team (dietitian, dietary manager, nursing, speech therapists, etc.) to determine the best plan for the resident and accommodate the resident's needs, preferences, and goals and update the care plan accordingly. Unless a medical condition warrants a restricted diet, consider beginning with a regular diet and monitor how the resident and their condition related to their goals regarding nutritional status and their physical, mental and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure honey thickened liquids were prepared in a form designed to meet individual needs for 1 of 3 residents (Resident #3) reviewed for food form and preparation. The facility failed to ensure Resident #3 received honey thickened liquids with his lunch meal on 4/16/24 and 4/17/24. This failure could place residents who received thickened liquids at risk of consuming liquids that could cause choking and aspiration (when something you swallow goes down the wrong way and enters your airway). Findings included: Record review of a face sheet dated 4/18/24 indicated Resident #3 was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), diabetes, hypertension (elevated blood pressure), and pneumonia. Record review of the physician orders dated 4/18/24 indicated Resident #1 had an order med pass (supplement) four times a day and have nurse thicken to honey starting 3/12/24. The physician orders did not indicate what Resident #3's diet was. Record review of the MDS dated [DATE] indicated Resident #3 understood others and was understood by others. The MDS indicated Resident #3 had a BIMS of 14 and was cognitively intact. The MDS indicated Resident #3 required setup or clean-up assistance with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident). The MDS indicated Resident #3 required a mechanically altered diet (require change in texture of food or liquids (e.g., pureed food, thickened liquids). Record review of the care plan last revised on 2/16/24 indicated Resident #3 was at risk for complications due to non-compliance with physician orders-mechanical soft food with honey thickened liquids. The care plan indicated Resident #3 had a potential nutritional problem related to diet restrictions of mechanical soft food with honey thickened liquids. The care plan indicated Resident #3 was non-compliant with his diet and liquids and would have other residents give him thin liquids and regular textured foods. Record review of the diet type report dated 4/17/24 indicated Resident #3 was on a mechanical soft diet with honey thickened liquids and fortified foods. Record review of a meal ticket dated 4/17/24 indicated Resident #3 was to receive a mechanical soft diet with honey thickened liquids. The meal ticket indicated Resident #3 had special needs including fortified foods, shake with all three meals, and double portions of meat. Record review of the swallow screen progress note dated 12/10/23 indicated Resident #3 had a current diet of pureed and honey thick liquids-no straws. The swallow screen progress note indicated the ST had educated Resident #3 on his diet and importance of complying to prevent choking. The swallow screen progress note indicated Resident #3 was educated on aspiration precautions. Record review of a nursing progress note dated 12/10/23 at 1:39 p.m. indicated, While passing [Resident #3's] room another resident was in room giving [Resident #3] a can of peanuts. [Resident #3] was educated on the importance of sticking to his pureed diet. [Resident #3] refused to give me his peanuts . Record review of a nursing progress note dated 12/31/23 at 1:10 p.m. indicated Resident #3 was educated during lunch regarding eating pureed goods and thickened liquids. The progress note indicated the nurse educated Resident #3 on choking precautions and keeping his head elevated. Record review of a nursing progress note dated 12/31/23 at 1:17 p.m. indicated the nurse provided Resident #3 with a cup of honey thickened cranberry juice. The progress note indicated Resident #3 tolerated the first cup well and started coughing while drinking the second cup. The progress note indicated Resident #3's oxygen level was 84% (normal range is 90-100%). The progress note indicated Resident #3 said he would not go to the hospital. The progress note indicated the nurse put oxygen on Resident #3 via nasal cannula (a device that delivers oxygen through a tube and into the nose). The progress note indicated Resident #3 remained non-compliant with keeping the nasal cannula on. Record review of a nursing progress note dated 12/31/23 at 7:22 p.m. indicated the charge nurse was called to Resident #3's room due to him having a whole can of chicken noodle soup in his mouth. The progress note indicated a CNA reported to the nurse Resident #3 was choking and throwing up the contents. Record review of a nursing progress note dated 1/3/24 at 8:30 p.m. indicated Resident #3's roommate went to the vending machine and purchased chips and a honey bun for Resident #3. The progress note indicated Resident #3 became upset with the nurse when she took the items from him and re-educated him regarding his diet. Record review of a nursing progress note dated 1/3/24 at 9:50 p.m. indicated the nurse was notified by a CNA that Resident #3 had a can of chicken noodle soup and was drinking it. The progress note indicated when the nurse enter the room Resident #3 was holding a chicken noodle soup can and had drunk all the liquid out of it. The progress notes indicated the nurse took the can of chicken noodle soup and re-educated Resident #3 regarding his diet and the risk of aspiration. Record review of a nursing progress note dated 1/21/24 at 2:43 p.m. indicated when Resident #3 was transferred by a CNA the CNA found chocolate Butterfinger on his mouth and body. The progress note indicated the nurse advised Resident #3 of his diet. Record review of a nursing progress note dated 2/15/24 at 9:10 p.m. indicated Resident #3 received a new order to upgrade his diet to mechanical soft. The progress note indicated Resident #3 was served a mechanical soft diet for supper and did not have any coughing or choking. Record review of a nursing progress note dated 3/2/24 at 10:38 a.m. indicated Resident #3 had drank coffee without thickening in it and without notifying the nurse. The progress note indicated Resident #3 was able to drink the coffee without thickening without incident. The progress note indicated when Resident #3's hospice nurse arrived he asked he if he could drink coffee without thickening moving forward. The progress note indicated the hospice nurse told Resident #3 she would check with his weekday nurse. During an observation on 4/16/24 at 12:20 p.m. CNA B obtained thickened liquid from the nurse and took to Resident #3. During an observation and interview with LVN C on 4/16/24 at 12:22 pm revealed the thickened liquid in nurse cart provided to CNA B for Resident #3 was nectar thickened and not honey thickened. LVN C said the nectar thickened liquid in her nurse cart was what was provided to CNA B for Resident #3. LVN C said she was unaware of what Resident #3's liquid order was for as she was not his nurse. LVN C said CNA B did not ask for a specific thickness for Resident #3. LVN C said she did not ask CNA B what specific thickness of liquid Resident #3 had ordered. LVN C said a resident who was given the incorrect thickness of liquid could aspirate. During an interview on 4/16/24 at 12:24 p.m. CNA B said she did not know what thickness of liquid she got for Resident #3. CNA B said the liquid in Resident #3's cup was what the nurse gave her. CNA B said she did not ask for a specific thickness of liquid when she asked the nurse for thickened liquid for Resident #3. CNA B said if a resident received the incorrect thickness of liquid, it could cause them to cough and choke. During an observation 4/16/24 at 12:26 p.m. LVN C came in Resident #3's room and took the nectar thickened liquid away. During an observation on 4/17/24 at 12:00 p.m. Cook D gave Resident #3 thin liquids. During an interview and observation on 4/17/24 at 12:01 p.m. Cook D said she was not checking the resident's meal tickets before providing them with a beverage to know if they required thickened liquids or not. Cook D said she usually prepares the trays and the only reason she was passing them was she did not have anyone in the dining room to pass trays. Cook D said Resident #3 was supposed to get thickened liquids. Cook D was observed taking the thin liquid tea from Resident #3 and giving him honey thickened water. During an interview on 4/18/24 at 8:58 a.m. RN E said the nurses were responsible for ensuring resident received the proper consistency of fluids (thin, nectar thick, honey thick, etc.). RN E said the importance of resident receiving the appropriate fluid consistency was to prevent aspiration. During an interview on 4/18/24 at 9:23 a.m. CNA F said nurses were responsible for checking fluid consistency and ensuring resident were receiving the correct fluid consistency. CNA F said it was important to ensure resident received the correct fluid consistency to prevent aspiration. During an interview on 4/18/24 at 9:25 a.m. CNA G said nurses were responsible for checking meal trays and fluid consistency. CNA G said if a resident received the wrong diet or fluid consistency it could cause them to choke. During an interview on 4/18/24 at 10:03 am LVN H said nurses were responsible for checking fluid consistency. LVN H said the importance of checking the resident had the correct fluid consistency was to prevent aspiration. During an interview on 4/18/24 at 10:10 a.m. the DON said it was the nurse's responsibility to check the meal trays. The DON said nurses checked the meal trays against the meal ticket for diet and fluid consistency. The DON said the importance of ensuring the residents' meal trays matched their meal tickets was in case a mistake was made because they cannot serve a meal that does not match the ticket. During an interview on 4/18/24 at 1:05 p.m. the Administrator said he expected the dietary staff while preparing the trays and the nursing staff while passing out the trays to ensure residents were receiving the appropriate diets and fluids including consistencies. The Administrator said it was important to ensure residents received the correct diet and fluids for their well-being. Record review of the facility's Thickened Liquid policy dated 4/9/24 indicated, The facility provides commercially prepared thickened liquids, as prescribed, to residents who require them. Thickened Liquids refer to liquids in which the consistency has been altered to facilitate safe, oral intake .The use of thickened liquids will be based on the resident's individual needs as determined by the resident's assessment, and will be in accordance with the resident's goals and preferences .Residents with swallowing difficulties or orders for thickened liquids are to be referred to speech-language pathologist for screening and evaluated as indicated .Nursing staff are responsible for notifying dietary staff of the need for thickened liquids, including category/consistency. The consistency shall be added to the resident's tray card and medication administration record .

Based on interview and record review the facility failed to ensure residents received care consistent with professional standards of practice to promote healing and prevent infection and new pressure sores from developing for 2 of 5 residents reviewed for pressure sores. (Resident #1 and Resident #2) The facility failed to provide nutritional interventions to promote wound healing for Resident #1. The facility failed to ensure Resident #1 received wound treatment as prescribed. The facility failed to identify signs and symptoms of infection for Resident #1 and she was admitted to the hospital due to septic shock. The facility failed to identify and treat wounds on Resident #2. They failed to educate Resident #2 on the consequences of wearing a shoe on a foot that had a pressure sore. An Immediate Jeopardy (IJ) situation was identified on 07/12/23 at 2:07 p.m. While the IJ was removed on 07/13/23 at 5:55 p.m., the facility remained out of compliance at actual harm that is not immediate with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems These failures placed residents at risk for pain, worsening of wounds, wound infection, emotional distress, harm, and death. Findings included: Record review of Resident #1's Admission Record indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses were encephalopathy (broad term used to describe a brain disease or disorder), pressure ulcer of the sacral region, stage 3, pressure ulcer of the right heel unstageable, pressure ulcer of the left heel unstageable, pressure ulcer unspecified site, unstageable, type 2 diabetes, and end stage renal disease. Resident # 1 was dependent of two people assistance with bed mobility, dressing, and transfers. The resident was not ambulatory and required the assistance of one person for toilet use and personal hygiene. Record review of Resident # 1's hospital Healthcare After Visit Summary dated 6/16/23 indicated there was no infection history in the last 12 months. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was moderately impaired. Resident #1 was dependent of two people assistance with bed mobility, dressing, and transfers. The resident was not ambulatory and required the assistance of one person for toilet use and personal hygiene. Record review of Resident #1's Care Plan dated 6/27/23 indicated a focused area of Abdomen (site 1) stage 3, L Buttock (site 2 resolved 7/3/13- stage 4 of Sacrum (site 3) Unstageable of right heel (site 4) Unstageable of left heel (site 5) stage 3 to lower back (site 6) related to immobility. Some of the interventions were monitor nutritional status, monitor changes in skin status such as appearance, color, wound healing, and signs and symptoms of infection. Obtain lab and monitor lab diagnostic work as ordered. Report results to the MD and follow up as needed. The care plan also indicated a focused area of ADL self care performance deficit related to wound and ESRD. The interventions were provide finger foods when the resident had difficulty using utensils, provide milkshakes or liquid food supplements when the resident refused or had difficulty with solid food or provide nutritious foods that can be taken from a cup or mug where appropriate. Review of Resident # 1's Diet Order and Communication form dated 6/19/23 indicated she was to receive a mechanical soft diet with regular liquids. Another Diet Order and Communication form dated 6/25/23 indicated Resident #1 was to receive a regular mechanical soft diet with chopped meats and regular liquids. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 6/16/23 indicated she had no impairment for sensory perception, rarely moist skin, walks frequently, mobility was slightly limited, nutrition was adequate, and no apparent problem with friction and shearing. The score was 21 indicting the resident was not at risk for pressure sores. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 6/23/23 indicated the resident's sensory perception was completely limited. Moister was constantly moist skin. The activity was listed as bedfast. Mobility was completely immobile. Nutrition was probably inadequate. Friction and shearing were problems. The resident's score was a 7 which was a very high risk for pressure sores. Record review of Resident #1's Initial Wound Evaluation and Management Summary dated 6/19/23 completed by the Wound Care Doctor. The evaluation indicated Resident #1 presented with wounds on her sacrum (shield shaped bony structure that is located at the base of the lumbar vertebrae that is connected to the pelvis.), left abdomen, lower back, left buttock, right heel and left heel. The medication affecting wound healing was lisinopril oral tablet 40 mg once daily. Her appetite was fair, and she was not on any supplements. Musculoskeletal system deconditioning. Her BMI was 22.59. (Site 1) Unstageable (due to necrosis- the death of most of the cells of tissue due to disease) of left abdomen, full thickness- etiology pressure- 9 x2.4x0.1 cm, surface area 21.60 cm. exudate- light serous (a clean liquid that leaks out of a wound), slough( a nonviable tissue that occurs as a byproduct of inflammatory process [NAME] in chronic wounds and presents as yellowish, moist, stingy substance. It can delay wound healing and increase the risk of infection) 30 percent and skin 70 percent. Dressing plan Leptospermum honey( a natural antimicrobial agent used for burns and surgical wounds) apply once daily. Gauze island dressing. Recommendations limit sitting to 60 minutes, off load wound, reposition per facility protocol and turn side to side in bed every 1-2 hours. (Site 2) Pressure wound of the left buttock full thickness, etiology pressure stage 3, 4x3x0.1 cm- surface area 12.00 cm exudated moderate serous drainage, slough 40 percent, skin 60 percent. Dressing treatment plan apply alginate to wound bed and cover with gauze island dressing (Site 3) Unstageable due to necrosis Sacrum full thickness- etiology pressure, 8x8x 0.1 cm surface area 64.00 cm moderate serous exudate slough 30 percent skin 70 percent. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 4) Unstageable due to necrosis of the right heel full thickness- etiology pressure, 3x3x 0.1 cm surface area 9.00 cm moderate serous exudate- black necrotic tissue eschar 100 percent. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 5) Unstageable due to necrosis of the right heel full thickness- etiology pressure, 2x2x 0.1 cm surface area 4.00 cm moderate serous exudate- black necrotic tissue eschar 100 percent. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 6) Unstageable due to necrosis of the left lower back full thickness- etiology pressure, 4x4x 0.1 cm surface area 16.00 cm moderate serous exudate- black necrotic tissue eschar 100 percent. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. Record review of Resident #1's computerized physician's orders dated 7/11/23 indicated: Registered dietitian to evaluate and treat. Skin assessment completed weekly and PRN, Weekly weights for 4 weeks. Initiated on 6/16/23 Resident #1 received dialysis three times a week on Monday, Wednesday, and Fridays. She was a Feeder. Pressure relieving mattress to bed. Initiated on 6/19/23. (Site 1) Cleanse wound to L Abdomen with normal saline, apply medi-honey to wound bed and cover with gauze island dressing with borders as needed for loosening/dislodgement- one time daily. Order initiated on 6/19/23. (Site 3) Cleanse wound to Sacrum normal saline pat dry with gauze, apply alginate to wound bed and cover with gauze island dressing with borders as needed for loosening/dislodgement- one time daily. Order initiated on 7/3/23. (Site 4) Cleanse wound to right heel normal saline pat dry with gauze, apply alginate to wound bed and cover with gauze island dressing with borders as needed for loosening/dislodgement- one time daily. Order initiated on 6/19/23. (Site 5) Cleanse wound to left heel with normal saline pat dry with gauze, apply alginate to wound bed and cover with gauze island dressing with borders as needed for loosening/dislodgement- one time daily. Order initiated on 6/19/23. (Site 6) Cleanse wound to the left lower back normal saline pat dry with gauze, apply alginate to wound bed and cover with gauze island dressing with borders as needed for loosening/dislodgement- one time daily. Order initiated on 6/19/23. (Site 8) Cleanse wound to left dorsal 4th toe with normal saline pat dry with gauze, apply alginate to wound bed and cover dry with dressing as needed for loosing/dislodgement one time a day. Order initiated on 6/28/23. Record review of Resident #1's TAR for June 2023 indicated there was no wound care to any of the wound sites for 6/21/23, 6/24/23, 6/28/23, and 6/29/23. During an interview with the DON on 7/11/23 at 3:30 p.m. she said she could not provide any information regarding why the wound care was not documented for Resident #1. She said the treatment nurse said she had never come in and her old bandages were still on residents. The DON said the nurses were supposed to provide treatments as ordered when the parttime treatment nurse was not available. Record review of Resident #1's computerized physician's orders indicated her medications were: Amlodipine 10 mg one time daily for hypertension Aspirin 81 mg chewable one daily for cardiac prophylaxis Atorvastatin Calcium 20 mg one tablet daily for hyperlipidemia Carvedilol Oral one tablet two times daily for hypertension Doxepin HCL one capsule at bedtime for depression Huprocodone acetaminophen 5-325 one tablet every 8 hours for pain Lisinopril 40 mg one tablet daily for hypertension Metoclopramide HCL 5 mg one tablet two times a day for Esophageal reflux disease Mirtazapine Oral 15 mg at bedtime for depression Montelukast Sodium oral 10 mg give 0.5 at bedtime for allergies Pantoprazole sodium oral delayed release 40 mg one tablet two times a day for esophageal reflux Record Review of Resident #1's ADL Nutrition Sheet for June 2023 indicated the amount of food eaten: On 6/16/23 - breakfast blank- lunch blank dinner 26-50 percent On 6/17/23 - breakfast blank- lunch blank dinner 26-50 percent On 6/18/23- breakfast 26-50 percent- lunch 51-75 percent dinner 26-50 percent On 6/19/23 - breakfast blank- lunch blank dinner 51-75 percent On 6/20/23- breakfast 26-50 percent- lunch 51-75 percent dinner 26-50 percent On 6/21/23- breakfast -not available- lunch 26-50 percent dinner 0 percent On 6/22/23- breakfast 26-50 percent- lunch 51-75 percent dinner 75-100 percent On 6/23/23- breakfast 26-50 percent- lunch 26-50 percent dinner blank On 6/24/23- breakfast not available- lunch 26-50 percent dinner 0 percent On 6/25/23- breakfast 51-75 percent- lunch 75-100 percent dinner 51-75 percent On 6/26/23- breakfast 26-50 percent- lunch 26-50 percent dinner 0 percent On 6/27/23- breakfast 51-75 percent- lunch 51-75 percent dinner 51-75 percent On 6/28/23- breakfast 26-50 percent- lunch 26-50 percent dinner 26-50 percent On 6/29/23- breakfast 26-50 percent- lunch 26-50 percent dinner 75-100 percent ON 6/30/23- could not determine Record review of Resident #1's Wound Evaluation and Management Summary dated 6/26/23 completed by the Wound Care Doctor. The evaluation indicated Resident #1 presented with wounds on her sacrum, left abdomen, lower back, left buttock, right heel and left heel. The medication affecting wound healing was lisinopril oral tablet 40 mg once daily. Her appetite was fair, and she was not on any supplements. Musculoskeletal system deconditioning. (Site 1) Unstageable (due to necrosis) of left abdomen, full thickness- etiology pressure- 9 x1.4x0.1 cm, surface area 12.60 cm. exudate- light serous, slough 30 percent and skin 70 percent. Wound progress improved as evidenced by decreased drainage and decreased surface area. Dressing plan Leptospermum honey apply once daily. Gauze island dressing. Recommendations limit sitting to 60 minutes, off load wound, reposition per facility protocol and turn side to side in bed every 1-2 hours. (Site 2)Pressure wound of the left buttock full thickness, etiology pressure stage 3, 4x3x0.1 cm- surface area 12.00 cm exudated moderate serous drainage, slough 40 percent, skin 60 percent. Wound progress, no change. Dressing treatment plan apply alginate to wound bed and cover with gauze island dressing (Site 3) Unstageable due to necrosis Sacrum full thickness- etiology pressure, 7x7x 0.1 cm surface area 49.00 cm moderate serous exudate slough 30 percent skin 70 percent. Wound progress improved as evidenced by decreased surface area. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 4) Unstageable due to necrosis of the right heel full thickness- etiology pressure, 3x3x 0.1 cm surface area 9.00 cm moderate serous exudate- black necrotic tissue eschar 100 percent. Wound progress no change. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 5) Unstageable due to necrosis of the right heel full thickness- etiology pressure, 2x2x 0.1 cm surface area 4.00 cm moderate serous exudate- black necrotic tissue eschar 100 percent. Wound progress, no change. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 6) Unstageable due to necrosis of the left lower back full thickness- etiology pressure, 4x4x 0.1 cm surface area 16.00 cm moderate serous exudate- Slough 50 percent, granulation tissue 50 percent. Wound. Wound progress improved as evidenced by decreased surface area and decreased drainage. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. (Site 7) Non Pressure wound of the left posterior thigh full thickness, etiology trauma injury, 1.8x0.3x0.1 surface area 0.54, moderate serous exudate, granulation tissue 100 percent. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. (Site 8) Arterial wound of the left, dorsal fourth foot full thickness. Etiology arterial 1x1x0.1 surface area 1.00 cm. moderate serous exudate, granulation tissue 100 percent. Record review of Resident #1's Wound Evaluation and Management Summary indicated there were no assessments completed for the week of 6/26/23. Record review of Resident #1's ADL sheet for eating for July 2023 indicated on 7/1/23 the resident refused breakfast. On 7/2/23 Resident #1 did not eat dinner (not applicable.) On 7/3/23 Resident #1 was not available for breakfast and did not eat dinner. On 7/4/23 Resident #1 did not eat dinner. Record review of Resident #1's July 2023 TAR indicated she did not receive treatment to her wounds on Sunday, 7/2/23. Record Review of Resident #1's facility Wound Assessments for 7/3/23 indicated she was admitted with all areas: (Site 1)Pressure ulcer to the left abdomen, unstageable, 5x1.4x0.1 cm, serous drainage thin and watery with light amount, no odor, progress healing, support devices were repositioning, nutritional therapy-none, skin turgor good (Site 3) Pressure ulcer to the Sacrum, Stage 4, 7x8x0.1 cm, serous drainage thin and watery with moderate amount, odor foul, wound edges macerated, undermining, 80 percent slough, progress worsening, support devices were repositioning, nutritional therapy-none, no culture done, skin turgor good (Site 4) Pressure ulcer to the right heel, unstageable, 3x3.5x0.1 cm, serous drainage thin and watery with moderate amount, no odor, progress no change, support devices were repositioning, nutritional therapy-none, skin turgor good (Site 5) Pressure ulcer to the left heel, unstageable, 2x3x0.1 cm, serous drainage thin and watery with moderate amount, no odor, progress worsening, support devices were repositioning, nutritional therapy-none, skin turgor good (Site 6) Pressure ulcer to the lower back, Stage 3, 3x4x0.1 cm, serous drainage thin and watery with moderate amount, no odor, progress worsening, support devices were repositioning, nutritional therapy-none, skin turgor good (Site 8) Arterial Ischemic to the left dorsal foot 1x1x0.1 cm, serous drainage thin and watery with moderate amount, no odor, progress- no change, support devices were repositioning, nutritional therapy-none, skin turgor good Record review of Resident #1's Wound Evaluation and Management Summary dated 7/3/23 completed by the Wound Care Doctor. The evaluation indicated Resident #1 presented with wounds on her sacrum, left abdomen, lower back, left dorsal fourth toe, left posterior thigh, left buttock, right heel, and left heel. The medication affecting wound healing was lisinopril oral tablet 40 mg once daily. Her appetite was fair, and she was not on any supplements. Musculoskeletal system deconditioning. (Site 1) Unstageable (due to necrosis) of left abdomen, full thickness- etiology pressure- 5 x1.4x0.1 cm, surface area 7.00 cm. exudate- light serous, slough 30 percent and skin 70 percent. Wound progress improved as evidenced by decreased drainage and decreased surface area. Dressing plan Leptospermum honey apply once daily. Gauze island dressing. Recommendations limit sitting to 60 minutes, off load wound, reposition per facility protocol and turn side to side in bed every 1-2 hours. (Site 2)Pressure wound of the left buttock full thickness, etiology pressure stage 3, indicated resolved (Site 3) Sacrum full thickness- etiology pressure, Stage 4-7x8x 3 cm surface area 56 cm. the wound had undermining 2cm at 3 o'clock. moderate serous exudate slough 80 percent. Other visible tissues 20 percent muscle. Wound progress deteriorated due to generalized decline of patient. Dressing treatment apply Dakins to wound bed and cover with gauze island dressing. Additional recommendations were to obtain labs WBC( white blood count can indicate infections), ESR(erythrocyte sedimentation rate- test that measures proteins in the blood with the amount of inflammation in the body, CRP( C-reactive protein test determines inflammation in body) ( Site 4) Unstageable due to necrosis of the right heel full thickness- etiology pressure, 3x3.5x 0.1 cm surface area 10.50 cm moderate serous exudate- black necrotic tissue eschar 100 percent. Wound progress deteriorated due to generalized decline of patient. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 5) Unstageable due to necrosis of the right heel full thickness- etiology pressure, 2x3x 0.1 cm surface area 6.00 cm moderate serous exudate- black necrotic tissue eschar 80 percent, thick adherent devitalized necrotic tissue 10 percent and granulation tissue 10 percent. Wound progress deteriorated due to generalized decline of the patient. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. ( Site 6) Stage 3 the left lower back full thickness- etiology pressure, 3x4x 0.1 cm surface area 12.00 cm moderate serous exudate- Slough 50 percent, granulation tissue 50 percent. Wound. Wound progress improved as evidenced by decreased surface area and decreased drainage. Dressing treatment apply alginate to wound bed and cover with gauze island dressing. (Site 7) Non Pressure wound of the left posterior thigh full thickness, etiology trauma injury. The wound progress resolved (Site 8) Arterial wound of the left, dorsal fourth foot full thickness. Etiology arterial 1x1x0.1 surface area 1.00 cm. Wound progress o change moderate serous exudate, granulation tissue 100 percent. Record review of Resident #1's Wound Evaluation and Management Summary indicated the same information for 7/3/23 that the Wound Care Doctors assessment indicated except: the Assessment for the Sacrum indicated it was a stage 4 measuring 7x8x0.1 with serous thin watery drainage at a moderate amount and a foul odor. Signed by the treatment nurse. Record review of Resident #1's nursing note dated 7/5/23 at 7:02 a.m. indicated the resident was not responding to a sternum rub. Her oxygens stats were going from 80-90. She was sent out to hospital. Record review of Resident #1's Hospital admission records dated 7/5/23 indicated she was admitted from the nursing home bedfast with chronic medical problems. She was found to be less responsive today and noted with low blood pressure. At the time of admission, she had a very foul odor from her necrotic wounds. She was admitted to ICU for vasopressor9 a powerful dug used to induce mean arterial pressure) therapy. There was a marked abnormality of the sacrum with stage 4 wound and foul odor. The impression was sepsis(a serious condition resulting form the presence of harmful microorganisms in the blood or other tissues nd the body's response to their presence, potentially leading to malfunctioning of various organs, shock and death) /septic shock likely source was the sacral wound. The sacral of pressure wound with probable penetration with plus or minus osteomyelitis (inflammation of the bone usually due to infection), likely source sepsis. Resident #1's overall condition was very poor. She was a nursing home patient with previous stokes, ESRD/HD, multiple pressure sores, and now an onset of septic shock. She will need extensive wound care, and debridement and there was a high likelihood of not surviving the hospitalization . Record review of the Hospital Pressure Injury Review dated 7/6/23 indicated Resident #1 was admitted with multiple areas of deep tissue and full thickness injury. All wounds were present on admission, and present on previous admission as well. Though pressure is a component for the wounds the presence of multiple injuries and the extensive areas affected indicate that skin failure is almost certainly a contributing factor. The patient was admitted for sepsis/septic shock and was already in ESRD/HD, and anemia. The patient was placed on comfort care which was appropriate as the patient's capacity to heal these extensive wounds would be severely limited even with surgical intervention. The current orders were Vashe-dampened gauze dressings daily are appropriate for comfort care as they will reduce the odor and provide moist wound management. During an interview on 7/11/23 at 9:09 a.m. LVN A said Resident #1 was admitted to the facility with several wounds. She said Resident #1 had pain all over her body, and was totally dependent on staff. LVN A said on 7/5/23 Resident #1 was lying in bed lethargic, did a sternal rub (the application of painful stimulus with the knuckles of the closed fist to the center of the chest f a patient who is not alert and does not respond to verbal stimuli), and she did not complain of pain. The resident had a blank stare, and her blood pressure was low. Resident #1 was sent to the hospital. During an interview on 7/11/23 at 9:43 a.m. CNA E said she worked at the facility for 3 years. Resident #1 went to dialysis and had a lot of pressure sores that she was admitted with. She said Resident #1 had hole on bottom they treated every day. She said on one day Resident #1 asked to be brought back from dialysis because she was hurting so bad. CNA E said anytime Resident #1 was touched she would say she hurt. She said they would give her pain medications before they were able to provide any care to the resident. She said when Resident #1 first came to the facility she was eating good, some days when she came back from dialysis she would not eat. She said her appetite was never good, but she ate less and less. CNA E said she would let the nurses know Resident #1 was not eating much. She said Resident #1 appeared to get weaker and weaker and the wounds on her bottom was just dead skin. During an interview on 7/11/23 at 9:54 a.m. CNA F said she worked at the facility about 2 months. She said when Resident #1 was admitted she was hurting, but she would eat, had a bunch of sores, some cleared up, always in pain, if touch would moan in pain. She said Resident #1's health declined fast. She was only at the facility a short while and would not eat anything. She said Resident #1 said the food was nasty. CNA F said the staff took care of Resident #1's wounds. She said she went in with the nurse one day to do treatment and the wound on Resident #1's bottom looked and smelled bad. During an interview on 7/11/23 at 12:00 p.m. the SW said she received a grievance from Resident #1's family after the resident was sent to the hospital. She said the grievances were Resident #1 was not getting blood sugar checks, baths, supplements, and was not treated for being septic. The SW said she went to nursing and there were no orders for blood pressure check or supplements. She said the staff told her when the resident did not eat, she got supplements. The SW said she believed Resident #1 received assistance with eating. She said the nursing staff told her the Doctor at the hospital said Resident #1 was not eating but had not given an order for her to have any additional nutrition. She said the family member complained the resident had an odor. The SW said the staff said Resident #1 was getting a bath, it was the wounds that smelled bad. The SW said the family complained after the resident was discharged , they did not complain while Resident #1 was at the facility. During a interview on 7/11/23 at 2:09 pm. ADON said Resident #1 required a Hoyer lift to weigh her and the Hoyer was broken during the time Resident #1 was at the facility. The ADON said that was the reason they did not have any weights on Resident #1. The ADON and DON said the resident had no nutritional supplements prescribed. During interview on 7/11/23 at 2:25 p.m. the Dietary Manager said she had two communication forms regarding Resident #1 and Resident #1 was not on any special diet. The Dietary Manager said no one notified her she needed to be. She said Resident #1 received a regular tray with chopped meats. During a telephone interview on 7/11/23 at 3:10 p.m. Treatment Nurse/LVN D said Resident #1's wounds had odors from the time she was admitted and drainage. The Treatment Nurse/LVN D said on 7/3/23 the wound on Resident #1's sacrum had a foul odor. She said there were no orders for a wound culture. She was not aware of any nutritional interventions that were in place to promote wound healing for Resident #1. She said she was not aware wound care was not being provided. The Treatment nurse said on weekends when was off she set the wound care treatments up for the nurses. She could not say if the wound care was provided or not. She said when she came in there was never any bandages she had left over the weekend still on the residents. During an interview on 7/12/23 at 8:30 a.m. LVN A said when Resident #1 was admitted her wounds had an odor but smelled worse as time went by. She said on 7/5/23 when Resident #1 went to the hospital she did not provide wound care that day, it was early that morning. She said the aides were getting Resident #1 up to go to dialysis when they noted a change in her condition. LVN A said on the day Resident #1 was sent out when they turned her over there was a strong odor. She said it smelled like BM, they checked her, and it was not BM, it was the wounds smelling. LVN A said the pressure sore treatments were provided by the Treatment Nurse, and she handled anything to do with the wounds. LVN A said she thought the wounds may have been infected but Resident #1 was not on antibiotics. LVN A said she had not reported her concerns to the doctor. She said Resident #1 would eat a little but would say the food was nasty. She said an aide reported to her Resident #1 was not eating and she tried to feed her once and offered her a health shake that she would not take. During an interview on 7/12/23 at 8:48 a.m. CNA G said she worked at the facility for 3 and a half years. She said Resident #1 needed a lot of assistance getting in and out of the bed. CNA G said Resident #1's pressure sores smelled bad. She said they made Resident #1 as comfortable as they could. CNA G said when she walked in the room there was no smell, but when she undid Resident #1's brief the smell was strong During an interview on 7/12/23 at 8:52 a.m. CNA F said Resident #1 had a decline and they were putting her in Geri chair. She was leaning and they were scared she would fall out of a regular chair. She said when Resident #1 was first admitted she was alert, talking, and eating. The longer she stayed the less active and alert she became. CNA F said when Resident #1 first was first admitted her wounds had an odor. She said she could smell them in the hallway and could not tell if they had gotten better or worse. During an interview and record review on 7/12/23 at 9:03 a.m. the DON and ADON said there was not any nutritional recommendations from the Dietician or a Dietician Nutritional Assessment for Resident #1 in her clinical record. They said Resident #1 was on Remeron 15 mg as an appetite stimulant that she was admitted with. They said Resident #1 was always in pain. She was given pain medication on a regular basis. Review of her ADL meal sheets indicated she did not eat well. However, the DON said she was eating between 25 to 50 percent and she was sure they were offering her a supplement. The DON said it may not have been documented but that is what they were supposed to do. The DON and ADON said they did not have weights on Resident #1 because the Hoyer lift weight was broken and they just received a new one about two weeks ago. They said they never considered getting weights from dialysis that she attended three times a week. During a telephone interview on 7/12/23 at 9:15 a.m. with Resident #1's Physician revealed he was also the facility Medical Director. He said he could not recall if Resident #1 had any nutritional interventions in place for her many wounds while at the facility. The physician said he did not remember if Resident #1 was septic prior to or after her admission to the hospital. The Physician said no one had mentioned to him anything about Resident #1's hospitalization other than her blood pressure was low and she had a change in condition. He said Resident #1 was in poor health when she was admitted to the facility. The physician said, if Resident #1 refused to eat, which he was not aware of, she could have been at risk for malnutrition. He said he was not aware of any documentation in her chart about malnutrition. He said if Resident #1 needed any additional care they would have sent her to the hospital. The Physician said Resident #1 was admitted from the hospital to the facility and if she needed any additional treatments the hospital would have made recommendations. He said if she needed nutritional interventions the Dietician would have seen her in the hospital. He said they did all the necessary things to care for Resident #1 at the hospital. The physician said when Resident #1 was admitted to the facility on [DATE] she had everything she needed according to hospital recommendations. He said they go by the hospital recommendations. Record Review of Resident #1's Hospital discharge summary indicated she was admitted to the hospital on 6/13/23 and discharged on [DATE]. The hospital Physician was her facility Physician. Resident #1's admission diagnosis was acute encephalopathy (a broad term for any brain disease or that alters brain function). The summary indicated for Pressure Ulcer; scattered pressure wounds over the patient's entire body. Continue to treat per wound care guidance and continue with strict offloading and turning every two hours and use wedges and heel lift boots. She had a severe protein, malnutrition as result of poor protein and caloric intake. Will consult dietitian for appropriate intake and ensure that she is fed since she cannot feed her [TRUNCATED]

Based on observation, interview, and record review the facility failed to provide supervision to prevent accidents for 1 of 5 residents sampled for accidents (Resident #1). Resident #1 was not strapped in the facility van during transport on 6/26/2023. She fell and had to have staples to the back of the head. This facility failure could place residents at risk of harm. Findings included: Record review of Resident #1's Admission Record indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses were encephalopathy, (broad term used to describe a brain disease or disorder), ESRD/HD and diabetes. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was moderately impaired. Resident #1 was dependent of two people assistance with bed mobility, dressing, and transfers. The resident was not ambulatory and required the assistance of one person for toilet use and personal hygiene. Record review of Resident #1's Care Plan dated 6/27/23 indicated a focused area of the resident is at risk for falls due to deconditioning. Some of the approaches were to follow the facility fall protocol. Review of a provider investigation report dated 7/5/23 indicated Resident #1 reportedly received two staples to the back of her head at the local hospital due to a small skin tear related to a recent fall. Resident #1 had a fall in the facility van on 6/26/23 while being transported to dialysis. Van Driver B reported the incident and called 911. The resident was taken to the local hospital for treatment. Van Driver B did not see any immediate affects or injuries. The Administrator provided disciplinary action in accordance to company policy. The Administrator conducted an in service related to the van and resident safety to prevent accidents. The resident returned to the facility the same day. The facility Administrator followed up with nursing and Resident #1. Facility staff in service conducted and verified the appropriate care for this resident was in place. Record review of Van Driver B's personal records indicated her date of hire was 9/29/21. Records indicated Van Driver B had completed Facility Safety Policy on Wheelchair Restraints video on 10/22/21 and 6/26/23. Record review indicated Van Driver B had completed Facility Wheelchair lift training on 10/22/21. The form indicated Van Driver B had been trained on the safe and proper operation of the facility wheelchair lift and proper usage of the wheelchair tie downs and restraint system vehicle and transport van. The training followed and as recommend by the manufacture. It said I have done a return demonstration to confirm I know the procedures signed by Van Driver B. However, there was no return demonstration witness signature. Record review of a nursing note dated 7/5/23 at 7:02 a.m. indicated the resident was not responding to a sternum rub. Her oxygens stats were going from 80-90. Sent out to hospital. Resident #1 did not return. Record review of Resident #1's nursing notes dated 6/27/23 at 10: 33 a.m. indicated the nurse on duty was notified from administration that Resident #1 fell in the van on the way to dialysis and the dialysis company was aware and instructed the resident to go to the ER. The resident was transported to the hospital. The family was notified by the administrator. When the resident arrived back to the facility, she had two staples and no new orders. The CT scan was negative. Resident # 1 complained of her head hurting and was given PRN pain reliever. During an interview on 7/11/23 at 9:09 a.m. LVN A said Resident #1 was transported to dialysis, slid out of her wheelchair, and had two staples in the back of her head. During a telephone interview on 7/11/23 at 12:55 p.m. Van Driver B said on 6/26/23 she was running a little late and was in a hurry. She placed Resident #1 and her wheelchair on the van. She locked the bottom of the wheelchair cross ties and put the right side and the left side on. She said there were 4 ties for the wheelchair, 2 right and 2 left. Van Driver B said she was in a hurry and did not buckle Resident #1 in. Van Diver B said she had been driving about 8 minutes, and stopped when coming to a red light. She said Resident #1 slid out of the wheelchair. Van Driver B said the wheelchair stayed stabilized and Resident #1 just slid out, as she was not able to hold herself, or prevent herself from falling. Van Driver B said she could not pick Resident #1 up. She said Resident #1 required a Hoyer lift transfer. She said when she arrived at the dialysis clinic, dialysis staff could not move Resident #1 either and they did a nonemergency transport. Van Driver B said one of the nurses checked Resident #1, and when she moved Resident #1's head to put it on a pillow there was blood on her hand. Van Driver B said they took her to the hospital and Resident #1 got some staples to the back of her head. She said she was in serviced on the same day Monday, 6/26/23. During an interview on 7/11/23 at 1:31 p.m. the Administrator said Van Driver B was counseled and trained. The Administrator said on 6/26/23 he talked to Resident #1 and she did not have any visible injury. He said they tried to do everything to make sure this type of incident did not happen again. During an interview on 7/11/23 at 2:00 p.m. the DON said the van driver basically said she was in a hurry and forgot to strap Resident #1 in the van with the seat belt and that was why she slid to the floor. During an interview and observation on 7/11/23 at 2:20 p.m. Van Driver C demonstrated how he would strap a person who used a wheelchair on the van. He said when the floor ties were used to make sure the wheelchair was tight. He said they tested the wheelchair to make sure it was stable. He said they then put a waist restraint on the resident. He said that it took time to strap a resident into the van. He said everything must be tight and secure before transport. Record review of Management training Checklist indicated when securing the resident in the van, secure safety seat belt around the resident. Ensure all straps are secure to keep the chair from tipping or moving backward.

Based on interview and record review the facility failed to ensure that all violations involving abuse were thoroughly investigated, failed to take corrective actions and prevent further potential abuse for 2 of 7 (Resident #1 and Resident #2) reviewed for abuse. CNA C and HA J witnessed CNA A choke Resident #1; CNA A continued to work at the facility and approximately 2-3 days later CNA C and CNA H witnessed CNA A punch Resident #2 in the stomach and smash his head into the pillow. Resident #2 reported CNA B was rough and mistreated him on several occasions for about 2 months and this alleged incident was not investigated and CNA B continued to work with Resident #2 until surveyor intervention on 9/16/2021. CNA C, CNA H, HA J, RN I, CNA D, AA P, , LVN E, RN G and MA R were aware of abuse and/or allegation of abuse and they did not report or protect the residents from further abuse. The Administrator, who is the Abuse Coordinator, failed to thoroughly investigate and prevent further potential abuse and mistreatment by allowing the alleged perpetrators to remain in the facility and allowed them to have direct contact with the residents. An Immediate Jeopardy (IJ) situation was identified on 9/17/2021 at 11:26 a.m. While the IJ was removed on 9/20/2021, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected residents who made outcries of abuse and placed them at risk for continued and or unrecognized abuse and emotional distress. Findings included: 1.Review of Resident #1's admission record revealed he was [AGE] year-old male who was admitted into the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed his cognitive skills for daily decision making was moderately impaired, he rejected care daily, and he required extensive assistance of one persona physical assist for bed mobility, dressing, toileting and personal hygiene. Review of Resident #1's Order Summary Report dated 9/17/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's undated care plan revealed he was dependent on staff for meeting emotional, intellectual, physical, and social needs due to physical limitations. Record Review of the Abuse Pledge revealed As a blessed care giver, I do Pledge that it is my duty to ensure that my residents and workplace remain free from all forms of abuse. I pledge to report all suspicions or knowledge of such to my Nursing Home Administrator Immediately. The following staff signed this form: -CNA C signed the form on 5/9/2019 -CNA H signed the form on 10/28/2020 -HA J signed the form on 7/6/2020 During an interview on 9/17/2021 at 11:08 a.m., Resident # 1 stated that a Caucasian male staff member put his hands around his neck and chocked him on 2 separate occasions. Resident #1 stated the staff member no longer worked at the facility, and he could not remember the staff member's name. He stated it made him feel bad when the staff member chocked him. During an interview on 9/16/2021 at 11:55 a.m., CNA D stated that she heard that HA J walked in on or witnessed CNA A mistreat and choke Resident #1. She stated she did not remember when the alleged incident occurred, nor did she know if it was reported to the administrator. She said everyone in the facility was talking about CNA A chocking Resident #1 after it happened. During an interview on 9/16/2021 at 3:53 p.m., CNA C stated that she went to assist CNA A and HA J with providing care to Resident #1. She said that she was in the room and when she turned around, she observed CNA A with his hands around Resident #1's neck and he was choking him. She stated she was in shock and denied that she not HA J stepped in to stop CNA A. CNA C said after they finished providing care for Resident #1, they left the room and HA J told her that CNA A chocked Resident #1 three times prior to her entering the room. She said she told HA J to report the incident and she left the facility and went home because her shift was over. She stated the next day she saw CNA A at work, so she asked HA J if she reported that CNA A chocked Resident #1 and she said HA J said No, because CNA A had a gun in his car and she was afraid for her life. CNA C said she also did not report the abuse to the administrator (the abuse coordinator) or the DON. She said she thought it was HA J's responsibility to report the incident. CNA C stated she did report the abuse to other staff in the facility. She could not remember which staff she reported it to other than to CNA H. She said she was unsure of the exact date the incident occurred with Resident #1, but she knew it was in June 2021 because a few days after that she witnessed CNA A punch Resident #2 in his stomach. During an interview on 9/16/2021 at 4:31 p.m., CNA H, she stated that CNA C told her that she witnessed CNA A choke Resident #1 when she was in the room helping CNA A and HA J provide care to the resident. She stated she could not remember when that incident occurred; however, a few days after that she personally witnessed CNA A punch Resident #2 in the stomach. She denied reporting Resident #1 abuse to the administrator or the DON. During a telephone interview on 9/16/2021 at 5:00 p.m., RN I stated she was off duty, but she remembered that HA J told her that she observed CNA A put his hands around Resident #1's neck and choke him. She said she informed HA J that she needed to report it to the administrator because she was the abuse coordinator. She stated that HA J stated that she was scared to report it because CNA A looked her in her face and told her I do not care if you report it or not. and she was afraid CNA A would hurt her. She stated that HA J told her that CNA C was also in the room and witnessed CNA A choke Resident #1. She said she thought that HA J reported the incident, but she did not know who she reported it to. She stated she could not remember when the incident occurred. On 9/16/2021 at 5:05 p.m., and on 9/17/2021 at 1:34 p.m., an attempt was made to call HA J, and both attempts were unsuccessful. During an interview on 9/17/2021 at 11:00 a.m., the administrator stated that she was not aware that CNA A chocked Resident #1. She stated the incident was not reported to the state agency, and it was not investigated. 2. Review of Resident #2's admission record revealed he was [AGE] year-old male who was originally admitted into the facility on [DATE]. Review of Resident #2's MDS dated [DATE] revealed he had a BIMS score of 10. It also revealed he required extensive assistance of two-person physical assist for bed mobility, transfers, dressing, toileting and personal hygiene. According to website ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC 56/ that was assessed on 9/21/2021 revealed that The MDS 3.0 added the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener expressly designed to facilitate cognitive screening. For residents who are deemed unable to participate in this standardized cognitive screener, or unable to complete the interview questions, their cognitive functioning is assessed by nursing staff using standardized instructions It also revealed that a BIMS score of 8-12 indicated that an individual was identified as having moderately impaired cognition. Review of Resident #2's Order Summary Report dated 9/16/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan revealed the following: -revision date of 1/14/2020 .he had impaired cognitive function/dementia or impaired thought process related to dementia. -revision date of 6/28/2021 . he has potential to be verbally and physically aggressive to staff related to Dementia. The intervention revealed that if the resident became agitated the staff were to engage calmly in conversation and if the response was aggressive, staff were to walk away. Record review of the care plan revealed Resident #2 was not care planned for making false allegations toward staff. Record Review of Provider Investigation Report dated 6/25/2021 revealed that on 6/25/2021 at 10:15 p.m., Resident #2 hit CNA A in the stomach/groin area while attempting to provide care. According to the statements CNA A and Resident #2 had a verbal altercation before entering the room. After Resident #2 hit CNA A, CNA A struck Resident #2 in the stomach/chest area and pushed his head down with the pillow. There were 2 witnesses in the room when this incident occurred. Under the Provider response section on the form it was documented that There was no other allegations of abuse. Staff interviews were also conducted and there were no allegations of abuse that they knew of previously. It also documented that CNA A was terminated. Interviews from residents and staff were conducted to make sure there were no other allegations unknown. This Provider Investigation Report was signed by the administrator on 7/2/2021. Record review of an email confirmation the administrator presented dated 9/16/2021 and timed 4:10 p.m., indicated that the administrator reported to HHSC regarding the alleged abuse allegation between CNA B and Resident #2. This was reported after surveyor intervention. Record Review of the Abuse Pledge revealed As a blessed care giver, I do Pledge that it is my duty to ensure that my residents and workplace remain free from all forms of abuse. I pledge to report all suspicions or knowledge of such to my Nursing Home Administrator Immediately. The following staff signed this form: -CNA B signed the form on 12/8/2020 -RN G signed the form on 8/23/2019 Record Review Reporting Abuse, Neglect and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/16/2021 at 11:23 a.m., Resident #2 stated he did not remember being mistreated by CNA A. He stated that CNA B mistreated him often and he stated that he reported it to the administrator and the social worker about 2-3 weeks ago and their response was Oh, that's too bad. He stated that CNA B would treat him rough during care. He stated she would ask him to turn over to clean him and if he did not turn over correctly then she would roughly put her hands and fingernails in his back and push him over. He stated that she would curse at him and she would point her middle finger at him. He stated that the last time CNA B was rough with him was that morning. He stated he has had 2 strokes and he's unable to walk and he stated that it made him feel like a little kid, and it belittles him when CNA B mistreats him and curses at him. During an interview on 9/16/2021 at 12:18 p.m., LVN E stated that CNA D told her earlier this week that Resident #2 said that someone hit him in his back. She stated that she asked the resident about it and he denied it, so she let it go. She stated that she did not report the allegation to the DON or the administrator because the staff told her that Resident #2 often made false allegations about staff, s heshe assumed he was making another false allegation. She stated that the abuse coordinator was the administrator and she should have probably told her about the allegation, but she didn't. During an interview on 9/16/2021 at 12:36 p.m., CNA D stated that Resident #2 was prejudice and he always made false accusations. She stated that one weekend when she came on shift at 6:00 a.m., RN G told her, LVN E and CNA B that Resident #2 told her that someone pushed him in the back. She said she told RN G that she would not push a resident in the back, and at that moment RN G stated I am not talking about you, I am talking about CNA B . CNA D stated she did not report it to the administrator or the DON because she assumed that the nurse would report it since they were aware of it also. She was unable to remember when RN G told them about it, she stated that all she remembered was that it occurred recently at the beginning of her shift on a weekend. During an interview on 9/16/2021 at 12:53 p.m., CNA B stated that she worked with Resident #2 every time she worked at the facility. She stated that Resident #2 would tell her often that she was rough when she cared for him or turned him during care. She stated that she was a small framed lady, so she had to use more strength to turn him, but she denied being rough with the resident. She stated that Resident #2 was prejudice and would often call her racial names. She stated that recently on a Sunday morning at around 6 a.m., RN G told her and CNA D to be careful and not to go into Resident #2's room alone because he accused someone of hitting him in the back, and she stated that RN G told her that the resident said she was rough with him. She stated that she was aware that the administrator was the abuse coordinator, but did not report Resident #2's allegations nor did she report how he treated her because she knew what he was saying was not true so she did not worry about it. During an interview on 9/16/2021 at 2:06 p.m., the administrator stated that she was not aware that Resident #2 alleged that CNA B, was rough with him or mistreated him. She stated that she did not have evidence that the allegation was investigated, and the allegation had not been reported to the state agency. She stated that Resident #2 made false accusations all the time and he was prejudice toward African Americans. She stated that it was her and the DON's responsibility to ensure that staff were educated and trained regarding abuse and that they reported abuse when they became aware of it. She stated after surveyor intervention, she would talk to Resident #2 and call the allegation into the state and investigate it. During a telephone interview on 9/16/2021 at 3:01 p.m., RN G stated that on Saturday night she worked from 10:00 p.m. - 6:00 a.m. and during the shift Resident #2 told her that people that worked with him were mean and rough with him. She stated that he did not name any specific names and he did not go into details. She said she was the weekend supervisor and she tried to handle situations like that on her own, because Resident #2 reported things constantly. She stated that she told the staff to make sure that they were gentle with him when they turned him or provided care to him. RN G stated that she should have reported it to the administrator, who is also the abuse coordinator, but she failed to do so. During an interview on 9/16/2021 at 3:53 p.m., CNA C stated that a few days after CNA A abused and choked Resident #1 she witnessed CNA A abuse Resident #2. She stated that her and CNA H was in Resident #2's room to provide care to him and CNA A walked in and Resident #2 said Why did yall bring that queer in here with yall She said CNA A got upset, snatched the covers off of Resident #2 and punched him in the stomach with his fist. She said he punched Resident #2 so hard that the resident made a grunting sound. She stated that CNA A then took the palm of his hand and smashed it into Resident #2's face and you could see spit coming from Resident #2's mouth. She said that CNA H intervened and told CNA A to stop and to leave the room. She stated that CNA A started pacing the room, he was sweaty, his face was red, and his hair was all over his head. She stated that CNA A was mad and refused to leave the room until after her and CNA H finished providing incontinent care to Resident #2. She said that they reported the incident RN G and she told them that she did not want anything to do with it, so they reported it to LVN Q. She stated that LVN Q immediately reported it to the administrator. She said she did not see CNA A working at the facility after that incident. During an interview on 9/16/2021 at 4:31 p.m., CNA H stated that her and CNA C went to provide incontinent care to Resident #2 and when CNA A walked into the room Resident #2 called him a few names. She stated that CNA A got mad, he pulled back Resident #2's covers and punched him hard in the stomach with his fist. She stated that CNA A then took the palm of his hand and smashed it into the resident's face and pushed his head into the pillow on the bed. She said she intervened and asked CNA A to stop and to leave the room. She stated that CNA A refused to leave the room, he started pacing back and forth, and he was angry. She stated that she was afraid of CNA A herself and after they finished caring for Resident #2, they all left the room and she reported the incident to RN G. She stated that RN G said Well, what do you want me to do, the best thing you can do is to go report it to LVN Q. She stated that she reported it to LVN Q. She stated that LVN Q immediately called and reported it to the administrator. During a telephone interview on 9/16/2021 at 6:00 p.m., CNA A indicated he did not remember choking Resident #1, nor did he remember punching Resident #2 into the stomach. He stated that he was diagnosed with [CONDITION(S)] and he would no longer be working as a CNA. During an interview on 9/17/2021 at 1:47 p.m., the SW stated that Resident #2 reported to her about 2 months ago that CNA B was rough with him and that she threw him around. SW stated that Resident #2 told her that he did not want CNA B to come back into his room because she was mean rough and had a bad attitude. She stated that Resident #2's story was clear and each time he repeated it he had the same details about it. She stated that she had other residents also complain that CNA B was rough with them. She stated that this had been an ongoing issue at the facility, and she has been reporting it to the administrator and the DON and nothing was done about it. During an interview on 9/17/2021 at 2:07 p.m., the DON denied being aware of Resident #2 or other residents alleging that CNA B was mean and rough with them. During an interview on 9/20/2021 at 1:20 p.m., LVN Q said that CNA H came to her office and reported that she witnessed CNA A punch Resident #2 in the stomach because the resident did not want CNA A touching him because he thought he was fruity. She stated she could not remember the exact date that it was reported but she stated she immediately reported it to the administrator. She stated the administrator told her to immediately suspend CNA A and to tell him to leave the facility. She stated that CNA A had already left the facility so she called him on the phone and told him he was suspended, and he could not return until he spoke with the administrator and he stated ok. She said she think that CNA H initially reported the allegation to RN G, but she was not acting on it so CNA H reported it to her instead. Record review of Abuse Investigation and Reporting policy with a revision date of July 2017 revealed . All reports of resident abuse. Neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown sores (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current allegations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The Administrator, DON and Regional Nurse was notified of the Immediate Jeopardy on 9/17/2021 at 11:26 a.m. and the administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 9/18/2021 at 3:49 p.m. and reflected the following: What immediate interventions were initiated for resident identified? STEP 1: On 9/17/21 Administrator was made aware of the alleged incident on 6/21/21 by the surveyor. Administrator interviewed the resident and DON performed a physical assessment, and Social Worker performed a psychosocial assessment. Incident was reported to HHSC. The alleged perpetrator is no longer employed by the facility. This was done on 9/17/21 by the administrator What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? STEP 2: On 9/17/21 Resident satisfaction rounds was completed on all residents to determine if there were any additional concerns related to abuse. If the resident is unable to communicate concerns a head to toe skin assessment will be completed to identity any signs or symptoms of abuse. The one active staff member who failed to report abuse on 06/21/2021 was suspended pending investigation. On 09/16/2021 the alleged perpetrator related to incident on 09/11/2021 was suspended pending investigation. On 09/17/2021 the weekend supervisor who failed to report alleged allegation of abuse was suspended pending investigation. This was done on 9/17/21 by the administrator What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? STEP 3: On 9/17/21, education was initiated with staff on Abuse to include reporting immediately, reporting any questionable activity witnessed or heard of, abuse definitions, types, signs and what to do if abuse is witnessed, and how and who to report concerns to. Employees will be required to complete this education prior to the start of their next shift. Statements of acknowledgement to be signed by each employee declaring the understanding of importance of reporting and responsibility to do so. This will be added to the new hire orientation process. POR interventions will be completed on 09/20/2021. Once allegation is made any employee identified as perpetrator will be immediately suspended pending investigation. This was scheduled to be completed on 9/20/21 by the administrator. Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan STEP 4: Administrator will randomly choose 5 employees daily x 2 weeks, then weekly for 4 weeks and randomly thereafter across all departments to conduct interviews regarding any abuse concerns. Social Worker or designee will perform resident satisfaction surveys 3 times weekly for 4 weeks. Any system failures will be reviewed during monthly QAPI for 3 months. This was initiated on 9/17/21 by the administrator and Social Worker Monitoring of the facilities plan or removal occurred on 9/20/2021 and included the following: Interviews, and record reviews were conducted on 9/20/2021 starting at 11:15 a.m. and continued through 9/20/2021 at 1:35 p.m. with two charge nurses, five certified nurse aides and two MA that were on duty during this time. The in-services included abuse, neglect and reporting and 79 of 103 staff had signed that the in-service training form. During an interview on 9/20/2021 at 11:15 a.m., CNA K stated that months ago she heard that CNA A abused one of the residents. She stated that the aides were talking about it at the time clock. She stated that she was not aware of which residents he abused. She stated that she heard it two days after it occurred, and by then he no longer worked at the facility. She stated she was recently educated about abuse and if they witnessed it or heard about it than they were required to report it to the administrator immediately. She stated that she was educated this weekend. She stated that from now on she will report all allegations of abuse even if she overheard it and had not witnessed it. During an interview on 9/20/2021 at 11:27 a.m., CNA L stated she has been working at the facility 4-5 years. She denied knowing or hearing about staff to resident abuse in the facility. She denied hearing about staff mistreatments by CNA A. She stated that the facility educated her on Abuse Friday (9/17/2021) and that if she heard about abuse or witnessed it was to be immediately reported to the administrator or the DON as soon as possible. During an interview on 9/20/2021 at 11:33 a.m., LVN M stated that she has been working at the facility full time since July 2021. She stated that she has not witnessed or heard about any staff mistreat or abuse a resident. She stated that she would immediately report it to the administrator. She stated that even if she heard it and did not witness it, she was going to report it. She stated that the facility recently re-educated her on abuse, what abuse was and when and who to report it to. During an interview on 9/20/2021 at 11:43 a.m., CNA N stated that she had not heard about staff mistreating a resident. She stated that the facility re-educated her on Abuse Neglect last Friday (9/17/2021). She stated that she was educated on abuse, what abuse was and who to report and when to report. She stated that even if she heard about abuse and had not witnessed it, she would still report it. During an interview on 9/20/2021 at 11:46 a.m., Activity Director stated that she signed abuse in-service Saturday (9/18/2021) morning. She stated that they are educated on abuse monthly; however, on Saturday she was educated that all allegations of abuse must be reported to the administrator immediately. During an interview on 9/20/21 at 11:51 a.m., CNA D she stated that she was in-in-serviced on Friday (9/17/2021) on what abuse was, when to report it and who to report it to. She stated that she's supposed to report all allegations of abuse and you will report it immediately. She stated that even if she heard about abuse or allegations of abuse, she still must report it even if she had not witnessed it. She stated that she did not report it before because the nurse was aware of it, she stated that she was wrong and now she know that she should have reported it and that she will report it from now on. During an interview on 9/20/2021 at 11:58 a.m., CNA O said that the facility educated her last Friday (9/17/2021) on what abuse was, when it was to be reported and who it was to be reported to. She stated she was educated on the different types of abuse. She stated that she would even report hear say allegations of abuse to the administrator immediately because she was not sure if it was correct or not. During an interview on 9/20/2021 at 12:02 p.m., AA P stated that in the past she heard that CNA A had abused Resident #1 and Resident #2. She stated that she heard about him abusing the residents in July 2021. She stated that she heard the CNA's talking about it in the smoking area. She stated that she did not report it because it had already been reported. She stated that a young lady reported it, buy she was not aware of her name. She stated that the DON educated her on yesterday (9/19/2021) regarding what abuse was, when to report it and who to report it to. She said she would report it immediately to the administrator even if she heard it as a rumor and not witnessed it. During an interview on 9/20/2021 at 12:08 p.m., MA F said the facility educated her on abuse on Friday (9/17/2021). She stated she was educated what abuse was, when to report it and who to report it to. She stated that she would report it immediately even if she heard someone else talking about it. During an interview on 9/20/201 at 12:11 p.m., LVN E stated the facility educated her on abuse on 9/20/2021. She said she was educated on when to report abuse, what abuse was and who to report the abuse allegation to. She stated that now she aware that she must contact the administrator and the DON immediately if she witnessed or heard about abuse in the facility. During an interview on 9/20/2021 at 1:31 p.m., MA R she said the facility educated her on abuse and reporting abuse on 9/17/2021. She stated that if she overheard someone talk about allegations of abuse, she would report it to the charge nurse, and the administrator immediately. She stated that she heard that CNA A chocked Resident #1, but she could not remember when she heard about it. She stated that she asked the nurse if she heard about it and the nurse denied hearing about it. An Immediate Jeopardy/Immediate Threat was identified on 9/17/2021. While the Immediate Jeopardy was removed on 9/20/2021, the facility remained out of compliance at a scope of a pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal.

Based on interview and record review the facility failed to ensure the right to be free from abuse was provided for 2 of 7 residents reviewed for abuse and neglect. (Resident #1 and Resident #2) CNA C and HA J witnessed CNA A choke Resident #1; CNA A continued to work at the facility and approximately 2-3 days later CNA C and CNA H witnessed CNA A punch Resident #2 in the stomach and smash his head into the pillow. Resident #2 reported CNA B was rough and mistreated him on several occasions for about 2 months. Resident #2 was not protected from CNA B who continued to work with Resident #2 until surveyor intervention on 9/16/2021. CNA C, CNA H, HA J, RN I, CNA D, AA P, . LVN E, RN G and MA R were aware of abuse and/or allegation of abuse and they did not report or protect the residents from further abuse. The Administrator, who is the Abuse Coordinator, failed to thoroughly investigate and prevent further potential abuse and mistreatment by allowing the alleged perpetrators to remain in the facility and allowed them to have direct contact with the residents: An Immediate Jeopardy (IJ) situation was identified on 9/17/2021 at 11:26 a.m. While the IJ was removed on 9/20/2021, the facility remained out of compliance at a potential for more than minimal harm with a scope identified a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death. Findings included: 1. Review of Resident #1's admission record revealed he was [AGE] year-old male who was admitted into the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed his cognitive skills for daily decision making was moderately impaired, he rejected care daily, and he required extensive assistance of one persona physical assist for bed mobility, dressing, toileting and personal hygiene. Review of Resident #1's Order Summary Report dated 9/17/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's undated care plan revealed he was dependent on staff for meeting emotional, intellectual, physical, and social needs due to physical limitations. Record Review of the Abuse Pledge revealed As a blessed care giver, I do Pledge that it is my duty to ensure that my residents and workplace remain free from all forms of abuse. I pledge to report all suspicions or knowledge of such to my Nursing Home Administrator Immediately. The following staff signed this form: -CNA C signed the form on 5/9/2019 -CNA H signed the form on 10/28/2020 -HA J signed the form on 7/6/2020 During an interview on 9/17/2021 at 11:08 a.m., Resident # 1 said a Caucasian male staff member put his hands around his neck and chocked him on 2 separate occasions. Resident #1 stated the staff member no longer worked at the facility, and he could not remember the staff member's name. He stated it made him feel bad when the staff member chocked him. During an interview on 9/16/2021 at 11:55 a.m., CNA D stated that she heard that HA J walked in on or witnessed CNA A mistreat and choke Resident #1. She stated she did not remember when the alleged incident occurred, nor did she know if it was reported to the administrator. She said everyone in the facility was talking about CNA A chocking Resident #1 after it happened. During an interview on 9/16/2021 at 3:53 p.m., CNA C stated that she went to assist CNA A and HA J with providing care to Resident #1. She said she was in the room and when she turned around, she observed CNA A with his hands around Resident #1's neck and he was choking him. She stated she was in shock and denied that she not HA J stepped in to stop CNA A. CNA C said after they finished providing care for Resident #1, they left the room and HA J told her that CNA A chocked Resident #1 three times prior to her entering the room. She said she told HA J to report the incident and she left the facility and went home because her shift was over. She stated the next day she saw CNA A at work, so she asked HA J if she reported CNA A chocked Resident #1 and she said HA J said No, because CNA A had a gun in his car and she was afraid for her life. CNA C said she also did not report the abuse to the administrator (the abuse coordinator) or the DON. She said she thought it was HA J's responsibility to report the incident. CNA C stated she did report the abuse to other staff in the facility. She could not remember which staff she reported it to other than to CNA H. She said she was unsure of the exact date the incident occurred with Resident #1, but she knew it was in June 2021 because a few days after that she witnessed CNA A punch Resident #2 in his stomach. During an interview on 9/16/2021 at 4:31 p.m., CNA H, stated CNA C told her she witnessed CNA A choke Resident #1 when she was in the room helping CNA A and HA J provide care to the resident. She stated she could not remember when the incident occurred; however, a few days after that she personally witnessed CNA A punch Resident #2 in the stomach. She denied reporting Resident #1 abuse to the administrator or the DON. During a telephone interview on 9/16/2021 at 5:00 p.m., RN I stated she was off duty, but she remembered that HA J told her that she observed CNA A put his hands around Resident #1's neck and choke him. She said she informed HA J she needed to report it to the administrator because she was the abuse coordinator. She stated HA J stated she was scared to report it because CNA A looked her in her face and told her I do not care if you report it or not. She said she was afraid CNA A would hurt her. She stated HA J told her CNA C was also in the room and witnessed CNA A choke Resident #1. She said she thought HA J reported the incident, but she did not know who she reported it to. She stated she could not remember when the incident occurred. On 9/16/2021 at 5:05 p.m., and on 9/17/2021 at 1:34 p.m., an attempt was made to call HA J, and both attempts were unsuccessful. During an interview on 9/17/2021 at 11:00 a.m., the administrator stated she was not aware CNA A chocked Resident #1. She stated the incident was not reported to the state, and it was not investigated. 2. Review of Resident #2's admission record revealed he was [AGE] year-old male who was originally admitted into the facility on [DATE]. Review of Resident #2's MDS dated [DATE] revealed he had a BIMS score of 10. It also revealed he required extensive assistance of two person physical assist for bed mobility, transfers, dressing, toileting and personal hygiene. According to website ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC 56/ that was assessed on 9/21/2021 revealed that The MDS 3.0 added the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener expressly designed to facilitate cognitive screening. For residents who are deemed unable to participate in this standardized cognitive screener, or unable to complete the interview questions, their cognitive functioning is assessed by nursing staff using standardized instructions It also revealed that a BIMS score of 8-12 indicated that an individual was identified as having moderately impaired cognition. Review of Resident #2's Order Summary Report dated 9/16/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan revealed the following: -revision date of 1/14/2020 .he had impaired cognitive function/dementia or impaired thought process related to dementia. -revision date of 6/28/2021 . he has potential to be verbally and physically aggressive to staff related to Dementia. The intervention revealed that if the resident became agitated the staff were to engage calmly in conversation and if the response was aggressive, staff were to walk away. Record review of the care plan revealed Resident #2 was not care planned for making false allegations toward staff. Record Review of Provider Investigation Report dated 6/25/2021 revealed that on 6/25/2021 at 10:15 p.m., Resident #2 hit CNA A in the stomach/groin area while attempting to provide care. According to the statements CNA A and Resident #2 had a verbal altercation before entering the room. After Resident #2 hit CNA A, CNA A struck Resident #2 in the stomach/chest area and pushed his head down with the pillow. There were 2 witnesses in the room when this incident occurred. Under the Provider response section on the form it was documented that There was no other allegations of abuse. Staff interviews were also conducted and there were no allegations of abuse that they knew of previously. It also documented that CNA A was terminated. Interviews from residents and staff were conducted to make sure there were no other allegations unknown. This Provider Investigation Report was signed by the administrator on 7/2/2021. Record review of an email confirmation the administrator presented dated 9/16/2021 and timed 4:10 p.m., indicated that the administrator reported to HHSC regarding the alleged abuse allegation between CNA B and Resident #2. This was reported after surveyor intervention. Record Review of the Abuse Pledge revealed As a blessed care giver, I do Pledge that it is my duty to ensure that my residents and workplace remain free from all forms of abuse. I pledge to report all suspicions or knowledge of such to my Nursing Home Administrator Immediately. The following staff signed this form: -CNA B signed the form on 12/8/2020 -RN G signed the form on 8/23/2019 Record Review Reporting Abuse, Neglect and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/16/2021 at 11:23 a.m., Resident #2 stated he did not remember being mistreated by CNA A. He stated that CNA B mistreated him often and he stated that he reported it to the administrator and the social worker about 2-3 weeks ago and their response was Oh, that's too bad. He stated that CNA B would treat him rough during care. He stated she would ask him to turn over to clean him and if he did not turn over correctly then she would roughly put her hands and fingernails in his back and push him over. He stated that she would curse at him and she would point her middle finger at him. He stated that the last time CNA B was rough with him was that morning. He stated he has had 2 strokes and he's unable to walk and he stated that it made him feel like a little kid, and it belittles him when CNA B mistreats him and curses at him. During an interview on 9/16/2021 at 12:18 p.m., LVN E stated that CNA D told her earlier this week that Resident #2 said that someone hit him in his back. She stated that she asked the resident about it and he denied it, so she let it go. She stated that she did not report the allegation to the DON or the administrator because the staff told her that Resident #2 often made false allegations about staff, so she assumed he was making another false allegation. She stated that the abuse coordinator was the administrator and she should have probably told her about the allegation, but she did not. During an interview on 9/16/2021 at 12:36 p.m., CNA D stated that Resident #2 was prejudice and he always made false accusations. She stated that one weekend when she came on shift at 6:00 a.m., RN G told her, LVN E and CNA B that Resident #2 told her that someone pushed him in the back. She said she told RN G that she would not push a resident in the back, and at that moment RN G stated I am not talking about you, I am talking about CNA B . CNA D stated she did not report it to the administrator or the DON because she assumed that the nurse would report it since they were aware of it also. She was unable to remember when RN G told them about it, she stated that all she remembered was that it occurred recently at the beginning of her shift on a weekend. During an interview on 9/16/2021 at 12:53 p.m., CNA B stated that she worked with Resident #2 every time she worked at the facility. She stated that Resident #2 would tell her often that she was rough when she cared for him or turned him during care. She stated that she was a small framed lady, so she had to use more strength to turn him, but she denied being rough with the resident. She stated that Resident #2 was prejudice and would often call her racial names. She stated that recently on a Sunday morning at around 6 a.m., RN G told her and CNA D to be careful and not to go into Resident #2's room alone because he accused someone of hitting him in the back, and she stated that RN G told her that the resident said she was rough with him. She stated that she was aware that the administrator was the abuse coordinator, but did not report Resident #2's allegations nor did she report how he treated her because she knew what he was saying was not true so she did not worry about it. During an interview on 9/16/2021 at 2:06 p.m., the administrator stated that she was not aware that Resident #2 alleged that CNA B, was rough with him or mistreated him. She stated that Resident #2 made false accusations all the time and he was prejudice toward African Americans. She stated that it was her and the DON's responsibility to ensure that staff were educated and trained regarding abuse and that they reported abuse when they became aware of it. She stated after surveyor intervention, she would talk to Resident #2 and call the allegation into the state and investigate it. During a telephone interview on 9/16/2021 at 3:01 p.m., RN G stated that on Saturday night she worked from 10:00 p.m. - 6:00 a.m. and during the shift Resident #2 told her that people that worked with him were mean and rough with him. She stated that he did not name any specific names and he did not go into details. She said she was the weekend supervisor and she tried to handle situations like that on her own, because Resident #2 reported things constantly. She stated that she told the staff to make sure that they were gentle with him when they turned him or provided care to him. RN G stated that she should have reported it to the administrator, who is also the abuse coordinator, but she failed to do so. During an interview on 9/16/2021 at 3:53 p.m., CNA C stated that a few days after CNA A abused and choked Resident #1 she witnessed CNA A abuse Resident #2. She stated that her and CNA H was in Resident #2's room to provide care to him and CNA A walked in and Resident #2 said Why did yall bring that queer in here with yall She said CNA A got upset, snatched the covers off of Resident #2 and punched him in the stomach with his fist. She said he punched Resident #2 so hard that the resident made a grunting sound. She stated that CNA A then took the palm of his hand and smashed it into Resident #2's face and you could see spit coming from Resident #2's mouth. She said that CNA H intervened and told CNA A to stop and to leave the room. She stated that CNA A started pacing the room, he was sweaty, his face was red, and his hair was all over his head. She stated that CNA A was mad and refused to leave the room until after her and CNA H finished providing incontinent care to Resident #2. She said that they reported the incident RN G and she told them that she did not want anything to do with it, so they reported it to LVN Q. She stated that LVN Q immediately reported it to the administrator. She said she did not see CNA A working at the facility after that incident. During an interview on 9/16/2021 at 4:31 p.m., CNA H stated that her and CNA C went to provide incontinent care to Resident #2 and when CNA A walked into the room Resident #2 called him a few names. She stated that CNA A got mad, he pulled back Resident #2's covers and punched him hard in the stomach with his fist. She stated that CNA A then took the palm of his hand and smashed it into the resident's face and pushed his head into the pillow on the bed. She said she intervened and asked CNA A to stop and to leave the room. She stated that CNA A refused to leave the room, he started pacing back and forth, and he was angry. She stated that she was afraid of CNA A herself and after they finished caring for Resident #2, they all left the room and she reported the incident to RN G. She stated that RN G said Well, what do you want me to do, the best thing you can do is to go report it to LVN Q. She stated that she reported it to LVN Q. She stated that LVN Q immediately called and reported it to the administrator. During a telephone interview on 9/16/2021 at 6:00 p.m., CNA A indicated he did not remember choking Resident #1, nor did he remember punching Resident #2 into the stomach. He stated that he was diagnosed with [CONDITION(S)] and he would no longer be working as a CNA. During an interview on 9/17/2021 at 1:47 p.m., the SW stated that Resident #2 reported to her about 2 months ago that CNA B was rough with him and that she threw him around. SW stated that Resident #2 told her that he did not want CNA B to come back into his room because she was mean rough and had a bad attitude. She stated that Resident #2's story was clear and each time he repeated it he had the same details about it. She stated that she had other residents also complain that CNA B was rough with them. She stated that this had been an ongoing issue at the facility, and she has been reporting it to the administrator and the DON and nothing was done about it. During an interview on 9/17/2021 at 2:07 p.m., the DON denied being aware of Resident #2 or other residents alleging that CNA B was mean and rough with them. During an interview on 9/20/2021 at 1:20 p.m., LVN Q said that CNA H came to her office and reported that she witnessed CNA A punch Resident #2 in the stomach because the resident did not want CNA A touching him because he thought he was fruity. She stated she could not remember the exact date that it was reported but she stated she immediately reported it to the administrator. She stated the administrator told her to immediately suspend CNA A and to tell him to leave the facility. She stated that CNA A had already left the facility so she called him on the phone and told him he was suspended, and he could not return until he spoke with the administrator and he stated ok. She said she think that CNA H initially reported the allegation to RN G, but she was not acting on it so CNA H reported it to her instead. Record review of Abuse Investigation and Reporting policy with a revision date of July 2017 revealed . All reports of resident abuse. Neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown sores (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current allegations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to appropriate individual. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse or had resulted in serious bodily injury 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. The Administrator, DON and Regional Nurse was notified of the Immediate Jeopardy on 9/17/2021 at 11:26 a.m. and the administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 9/18/2021 at 3:49 p.m. and reflected the following: What immediate interventions were initiated for resident identified? STEP 1: On 9/17/21 Administrator was made aware of the alleged incident on 6/21/21 by the surveyor. Administrator interviewed the resident and DON performed a physical assessment, and Social Worker performed a psychosocial assessment. Incident was reported to HHSC. The alleged perpetrator is no longer employed by the facility. This was done on 9/17/21 by the administrator What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? STEP 2: On 9/17/21 Resident satisfaction rounds was completed on all residents to determine if there were any additional concerns related to abuse. If the resident is unable to communicate concerns a head to toe skin assessment will be completed to identity any signs or symptoms of abuse. The one active staff member who failed to report abuse on 06/21/2021 was suspended pending investigation. On 09/16/2021 the alleged perpetrator related to incident on 09/11/2021 was suspended pending investigation. On 09/17/2021 the weekend supervisor who failed to report alleged allegation of abuse was suspended pending investigation. This was done on 9/17/21 by the administrator What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? STEP 3: On 9/17/21, education was initiated with staff on Abuse to include reporting immediately, reporting any questionable activity witnessed or heard of, abuse definitions, types, signs and what to do if abuse is witnessed, and how and who to report concerns to. Employees will be required to complete this education prior to the start of their next shift. Statements of acknowledgement to be signed by each employee declaring the understanding of importance of reporting and responsibility to do so. This will be added to the new hire orientation process. POR interventions will be completed on 09/20/2021. Once allegation is made any employee identified as perpetrator will be immediately suspended pending investigation. This was scheduled to be completed on 9/20/21 by the administrator. Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan STEP 4: Administrator will randomly choose 5 employees daily x 2 weeks, then weekly for 4 weeks and randomly thereafter across all departments to conduct interviews regarding any abuse concerns. Social Worker or designee will perform resident satisfaction surveys 3 times weekly for 4 weeks. Any system failures will be reviewed during monthly QAPI for 3 months. This was initiated on 9/17/21 by the administrator and Social Worker Monitoring of the facilities plan or removal occurred on 9/20/2021 and included the following: Interviews, and record reviews were conducted on 9/20/2021 starting at 11:15 a.m. and continued through 9/20/2021 at 1:35 p.m. with two charge nurses, five certified nurse aides and two MA that were on duty during this time. The in-services included abuse, neglect and reporting and 79 of 103 staff had signed that the in-service training form. During an interview on 9/20/2021 at 11:15 a.m., CNA K stated that months ago she heard that CNA A abused one of the residents. She stated that the aides were talking about it at the time clock. She stated that she was not aware of which residents he abused. She stated that she heard it two days after it occurred, and by then he no longer worked at the facility. She stated she was recently educated about abuse and if they witnessed it or heard about it than they were required to report it to the administrator immediately. She stated that she was educated this weekend. She stated that from now on she will report all allegations of abuse even if she overheard it and had not witnessed it. During an interview on 9/20/2021 at 11:27 a.m., CNA L stated she has been working at the facility 4-5 years. She denied knowing or hearing about staff to resident abuse in the facility. She denied hearing about staff mistreatments by CNA A. She stated that the facility educated her on Abuse Friday (9/17/2021) and that if she heard about abuse or witnessed it was to be immediately reported to the administrator or the DON as soon as possible. During an interview on 9/20/2021 at 11:33 a.m., LVN M stated that she has been working at the facility full time since July 2021. She stated that she has not witnessed or heard about any staff mistreat or abuse a resident. She stated that she would immediately report it to the administrator. She stated that even if she heard it and did not witness it, she was going to report it. She stated that the facility recently re-educated her on abuse, what abuse was and when and who to report it to. During an interview on 9/20/2021 at 11:43 a.m., CNA N stated that she had not heard about staff mistreating a resident. She stated that the facility re-educated her on Abuse Neglect last Friday (9/17/2021). She stated that she was educated on abuse, what abuse was and who to report and when to report. She stated that even if she heard about abuse and had not witnessed it, she would still report it. During an interview on 9/20/2021 at 11:46 a.m., Activity Director stated that she signed abuse in-service Saturday (9/18/2021) morning. She stated that they are educated on abuse monthly; however, on Saturday she was educated that all allegations of abuse must be reported to the administrator immediately. During an interview on 9/20/21 at 11:51 a.m., CNA D she stated that she was in-in-serviced on Friday (9/17/2021) on what abuse was, when to report it and who to report it to. She stated that she's supposed to report all allegations of abuse and you will report it immediately. She stated that even if she heard about abuse or allegations of abuse, she still must report it even if she had not witnessed it. She stated that she did not report it before because the nurse was aware of it, she stated that she was wrong and now she know that she should have reported it and that she will report it from now on. During an interview on 9/20/2021 at 11:58 a.m., CNA O said that the facility educated her last Friday (9/17/2021) on what abuse was, when it was to be reported and who it was to be reported to. She stated she was educated on the different types of abuse. She stated that she would even report hear say allegations of abuse to the administrator immediately because she was not sure if it was correct or not. During an interview on 9/20/2021 at 12:02 p.m., AA P stated that in the past she heard that CNA A had abused Resident #1 and Resident #2. She stated that she heard about him abusing the residents in July 2021. She stated that she heard the CNA's talking about it in the smoking area. She stated that she did not report it because it had already been reported. She stated that a young lady reported it, buy she was not aware of her name. She stated that the DON educated her on yesterday (9/19/2021) regarding what abuse was, when to report it and who to report it to. She said she would report it immediately to the administrator even if she heard it as a rumor and not witnessed it. During an interview on 9/20/2021 at 12:08 p.m., MA F said the facility educated her on abuse on Friday (9/17/2021). She stated she was educated what abuse was, when to report it and who to report it to. She stated that she would report it immediately even if she heard someone else talking about it. During an interview on 9/20/201 at 12:11 p.m., LVN E stated the facility educated her on abuse on 9/20/2021. She said she was educated on when to report abuse, what abuse was and who to report the abuse allegation to. She stated that now she aware that she must contact the administrator and the DON immediately if she witnessed or heard about abuse in the facility. During an interview on 9/20/2021 at 1:31 p.m., MA R she said the facility educated her on abuse and reporting abuse on 9/17/2021. She stated that if she overheard someone talk about allegations of abuse, she would report it to the charge nurse, and the administrator immediately. She stated that she heard that CNA A chocked Resident #1, but she could not remember when she heard about it. She stated that she asked the nurse if she heard about it and the nurse denied hearing about it. An Immediate Jeopardy/Immediate Threat was identified on 9/17/2021. While the Immediate Jeopardy was removed on 9/20/2021, the facility remained out of compliance at a scope of a pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal.

Based on interview and record review the facility to ensure that all alleged violations involving abuse or mistreatment were reported to the administrator and State Survey Agency immediately, but no later than 2 hours after the allegation was made for allegations that involved abuse for 2 of 7 residents (Resident #1 & Resident #2) reviewed for abuse. The facility failed to report and investigate all allegations of abuse when: -CNA C and HA J witnessed CNA A choke Resident #1 and did not report the abuse and this was not investigated and CNA A continued to work at the facility and approximately 2-3 days later CNA C and CNA H witnessed CNA A punch Resident #2 in the stomach and smash his head into the pillow. -Resident #2 also reported that CNA B was rough and mistreated him on several occasions for about 2 months and this alleged incident was not investigated and CNA B continued to work with Resident #2 until surveyor intervention on 9/16/2021. CNA C, CNA H, HA J, RN I, CNA D, AA P, LVN E, RN G and MA R were aware of abuse and/or allegation of abuse and they did not report or protect the residents from further abuse. An Immediate Jeopardy (IJ) situation was identified on 9/17/2021 at 11:26 a.m. While the IJ was removed on 9/20/2021, the facility remained out of compliance at a potential for more than minimal harm with a scope identified a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and neglect. Findings included: 1.Review of Resident #1's admission record revealed he was [AGE] year-old male who was admitted into the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed his cognitive skills for daily decision making was moderately impaired, he rejected care daily, and he required extensive assistance of one persona physical assist for bed mobility, dressing, toileting and personal hygiene. Review of Resident #1's Order Summary Report dated 9/17/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's undated care plan revealed he was dependent on staff for meeting emotional, intellectual, physical, and social needs due to physical limitations. Record Review of the Abuse Pledge revealed As a blessed care giver, I do Pledge that it is my duty to ensure that my residents and workplace remain free from all forms of abuse. I pledge to report all suspicions or knowledge of such to my Nursing Home Administrator Immediately. The following staff signed this form: -CNA C signed the form on 5/9/2019 -CNA H signed the form on 10/28/2020 -HA J signed the form on 7/6/2020 During an interview on 9/17/2021 at 11:08 a.m., Resident # 1 stated that a Caucasian male staff member put his hands around his neck and chocked him on 2 separate occasions. Resident #1 stated the staff member no longer worked at the facility, and he could not remember the staff member's name. He stated it made him feel bad when the staff member chocked him. During an interview on 9/16/2021 at 11:55 a.m., CNA D stated that she heard that HA J walked in on or witnessed CNA A mistreat and choke Resident #1. She stated she did not remember when the alleged incident occurred, nor did she know if it was reported to the administrator. She said everyone in the facility was talking about CNA A chocking Resident #1 after it happened. During an interview on 9/16/2021 at 3:53 p.m., CNA C stated that she went to assist CNA A and HA J with providing care to Resident #1. She said that she was in the room and when she turned around, she observed CNA A with his hands around Resident #1's neck and he was choking him. She stated that she was in shock and denied stepping in to stop CNA A. CNA C said after they finished providing care for Resident #1, they left the room and HA J told her that CNA A chocked Resident #1 three times prior to her entering the room. She said she told HA J to report the incident and she left the facility and went home because her shift was over. She stated the next day she saw CNA A at work, so she asked HA J if she reported that CNA A chocked Resident #1 and she said HA J said No, because CNA A had a gun in his car and she was afraid for her life. CNA C said she also did not report the abuse to the administrator (the abuse coordinator) or the DON. She said she thought it was HA J's responsibility to report the incident. CNA C stated she did report the abuse to other staff in the facility. She could not remember which staff she reported it to other than to CNA H. She said she was unsure of the exact date the incident occurred with Resident #1, but she knew it was in June 2021 because a few days after that she witnessed CNA A punch Resident #2 in his stomach. During an interview on 9/16/2021 at 4:31 p.m., CNA H, she stated that CNA C told her that she witnessed CNA A choke Resident #1 when she was in the room helping CNA A and HA J provide care to the resident. She stated she could not remember when that incident occurred; however, a few days after that she personally witnessed CNA A punch Resident #2 in the stomach. She denied reporting Resident #1 abuse to the administrator or the DON. During a telephone interview on 9/16/2021 at 5:00 p.m., RN I stated she was off duty, but she remembered that HA J told her that she observed CNA A put his hands around Resident #1's neck and choke him. She said she informed HA J that she needed to report it to the administrator because she was the abuse coordinator. She stated that HA J stated that she was scared to report it because CNA A looked her in her face and told her I do not care if you report it or not. and she was afraid CNA A would hurt her. She stated that HA J told her that CNA C was also in the room and witnessed CNA A choke Resident #1. She said she thought that HA J reported the incident, but she did not know who she reported it to. She stated she could not remember when the incident occurred. On 9/16/2021 at 5:05 p.m., and on 9/17/2021 at 1:34 p.m., an attempt was made to call HA J, and both attempts were unsuccessful. During an interview on 9/17/2021 at 11:00 a.m., the administrator stated that she was not aware that CNA A chocked Resident #1. She stated the incident was not reported to the state agency, and it was not investigated. 2. Review of Resident #2's admission record revealed he was [AGE] year-old male who was originally admitted into the facility on [DATE]. Review of Resident #2's MDS dated [DATE] revealed he had a BIMS score of 10. It also revealed he required extensive assistance of two-person physical assist for bed mobility, transfers, dressing, toileting and personal hygiene. According to website ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC 56/ that was assessed on 9/21/2021 revealed that The MDS 3.0 added the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener expressly designed to facilitate cognitive screening. For residents who are deemed unable to participate in this standardized cognitive screener, or unable to complete the interview questions, their cognitive functioning is assessed by nursing staff using standardized instructions It also revealed that a BIMS score of 8-12 indicated that an individual was identified as having moderately impaired cognition. Review of Resident #2's Order Summary Report dated 9/16/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan revealed the following: -revision date of 1/14/2020 .he had impaired cognitive function/dementia or impaired thought process related to dementia. -revision date of 6/28/2021 . he has potential to be verbally and physically aggressive to staff related to Dementia. The intervention revealed that if the resident became agitated the staff were to engage calmly in conversation and if the response was aggressive, staff were to walk away. Record review of the care plan revealed Resident #2 was not care planned for making false allegations toward staff. Record Review of Provider Investigation Report dated 6/25/2021 revealed that on 6/25/2021 at 10:15 p.m., Resident #2 hit CNA A in the stomach/groin area while attempting to provide care. According to the statements CNA A and Resident #2 had a verbal altercation before entering the room. After Resident #2 hit CNA A, CNA A struck Resident #2 in the stomach/chest area and pushed his head down with the pillow. There were 2 witnesses in the room when this incident occurred. Under the Provider response section on the form it was documented that There was no other allegations of abuse. Staff interviews were also conducted and there were no allegations of abuse that they knew of previously. It also documented that CNA A was terminated. Interviews from residents and staff were conducted to make sure there were no other allegations unknown. This Provider Investigation Report was signed by the administrator on 7/2/2021. Record review of an email confirmation the administrator presented dated 9/16/2021 and timed 4:10 p.m., indicated that the administrator reported to HHSC regarding the alleged abuse allegation between CNA B and Resident #2. This was reported after surveyor intervention. Record Review of the Abuse Pledge revealed As a blessed care giver, I do Pledge that it is my duty to ensure that my residents and workplace remain free from all forms of abuse. I pledge to report all suspicions or knowledge of such to my Nursing Home Administrator Immediately. The following staff signed this form: -CNA B signed the form on 12/8/2020 -RN G signed the form on 8/23/2019 Record Review Reporting Abuse, Neglect and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/16/2021 at 11:23 a.m., Resident #2 stated he did not remember being mistreated by CNA A. He stated that CNA B mistreated him often and he stated that he reported it to the administrator and the social worker about 2-3 weeks ago and their response was Oh, that's too bad. He stated that CNA B would treat him rough during care. He stated she would ask him to turn over to clean him and if he did not turn over correctly then she would roughly put her hands and fingernails in his back and push him over. He stated that she would curse at him and she would point her middle finger at him. He stated that the last time CNA B was rough with him was that morning. He stated he has had 2 strokes and he's unable to walk and he stated that it made him feel like a little kid, and it belittles him when CNA B mistreats him and curses at him. During an interview on 9/16/2021 at 12:18 p.m., LVN E stated that CNA D told her earlier this week that Resident #2 said that someone hit him in his back. She stated that she asked the resident about it and he denied it, so she let it go. She stated that she did not report the allegation to the DON or the administrator because the staff told her that Resident #2 often made false allegations about staff, s heshe assumed he was making another false allegation. She stated that the abuse coordinator was the administrator and she should have probably told her about the allegation, but she didn't. During an interview on 9/16/2021 at 12:36 p.m., CNA D stated that Resident #2 was prejudice and he always made false accusations. She stated that one weekend when she came on shift at 6:00 a.m., RN G told her, LVN E and CNA B that Resident #2 told her that someone pushed him in the back. She said she told RN G that she would not push a resident in the back, and at that moment RN G stated I am not talking about you, I am talking about CNA B . CNA D stated she did not report it to the administrator or the DON because she assumed that the nurse would report it since they were aware of it also. She was unable to remember when RN G told them about it, she stated that all she remembered was that it occurred recently at the beginning of her shift on a weekend. During an interview on 9/16/2021 at 12:53 p.m., CNA B stated that she worked with Resident #2 every time she worked at the facility. She stated that Resident #2 would tell her often that she was rough when she cared for him or turned him during care. She stated that she was a small framed lady, so she had to use more strength to turn him, but she denied being rough with the resident. She stated that Resident #2 was prejudice and would often call her racial names. She stated that recently on a Sunday morning at around 6 a.m., RN G told her and CNA D to be careful and not to go into Resident #2's room alone because he accused someone of hitting him in the back, and she stated that RN G told her that the resident said she was rough with him. She stated that she was aware that the administrator was the abuse coordinator, but did not report Resident #2's allegations nor did she report how he treated her because she knew what he was saying was not true so she did not worry about it. During an interview on 9/16/2021 at 2:06 p.m., the administrator stated that she was the abuse coordinator and she not aware that Resident #2 alleged that CNA B, was rough with him or mistreated him. She stated that she did not have evidence that the allegation was investigated, and the allegation had not been reported to the state agency. She stated that Resident #2 made false accusations all the time and he was prejudice toward African Americans. She stated that it was her and the DON's responsibility to ensure that staff were educated and trained regarding abuse and that they reported abuse when they became aware of it. She stated that the last abuse and neglect in-service was done on 7/29/2021. She stated after surveyor intervention, she would talk to Resident #2 and call the allegation into the state and investigate it. During a telephone interview on 9/16/2021 at 3:01 p.m., RN G stated that on Saturday night she worked from 10:00 p.m. - 6:00 a.m. and during the shift Resident #2 told her that people that worked with him were mean and rough with him. She stated that he did not name any specific names and he did not go into details. She said she was the weekend supervisor and she tried to handle situations like that on her own, because Resident #2 reported things constantly. She stated that she told the staff to make sure that they were gentle with him when they turned him or provided care to him. RN G stated that she should have reported it to the administrator, who is also the abuse coordinator, but she failed to do so. During an interview on 9/16/2021 at 3:53 p.m., CNA C stated that a few days after CNA A abused and choked Resident #1 she witnessed CNA A abuse Resident #2. She stated that her and CNA H was in Resident #2's room to provide care to him and CNA A walked in and Resident #2 said Why did yall bring that queer in here with yall She said CNA A got upset, snatched the covers off of Resident #2 and punched him in the stomach with his fist. She said he punched Resident #2 so hard that the resident made a grunting sound. She stated that CNA A then took the palm of his hand and smashed it into Resident #2's face and you could see spit coming from Resident #2's mouth. She said that CNA H intervened and told CNA A to stop and to leave the room. She stated that CNA A started pacing the room, he was sweaty, his face was red, and his hair was all over his head. She stated that CNA A was mad and refused to leave the room until after her and CNA H finished providing incontinent care to Resident #2. She said that they reported the incident RN G and she told them that she did not want anything to do with it, so they reported it to LVN Q. She stated that LVN Q immediately reported it to the administrator. She said she did not see CNA A working at the facility after that incident. During an interview on 9/16/2021 at 4:31 p.m., CNA H stated that her and CNA C went to provide incontinent care to Resident #2 and when CNA A walked into the room Resident #2 called him a few names. She stated that CNA A got mad, he pulled back Resident #2's covers and punched him hard in the stomach with his fist. She stated that CNA A then took the palm of his hand and smashed it into the resident's face and pushed his head into the pillow on the bed. She said she intervened and asked CNA A to stop and to leave the room. She stated that CNA A refused to leave the room, he started pacing back and forth, and he was angry. She stated that she was afraid of CNA A herself and after they finished caring for Resident #2, they all left the room and she reported the incident to RN G. She stated that RN G said Well, what do you want me to do, the best thing you can do is to go report it to LVN Q. She stated that she reported it to LVN Q. She stated that LVN Q immediately called and reported it to the administrator. During a telephone interview on 9/16/2021 at 6:00 p.m., CNA A indicated he did not remember choking Resident #1, nor did he remember punching Resident #2 into the stomach. He stated that he was diagnosed with [CONDITION(S)] and he would no longer be working as a CNA. During an interview on 9/17/2021 at 1:47 p.m., the SW stated that Resident #2 reported to her about 2 months ago that CNA B was rough with him and that she threw him around. SW stated that Resident #2 told her that he did not want CNA B to come back into his room because she was mean rough and had a bad attitude. She stated that Resident #2's story was clear and each time he repeated it he had the same details about it. She stated that she had other residents also complain that CNA B was rough with them. She stated that this had been an ongoing issue at the facility, and she has been reporting it to the administrator and the DON and nothing was done about it. During an interview on 9/17/2021 at 2:07 p.m., the DON denied being aware of Resident #2 or other residents alleging that CNA B was mean and rough with them. During an interview on 9/20/2021 at 1:20 p.m., LVN Q said that CNA H came to her office and reported that she witnessed CNA A punch Resident #2 in the stomach because the resident did not want CNA A touching him because he thought he was fruity. She stated she could not remember the exact date that it was reported but she stated she immediately reported it to the administrator. She stated the administrator told her to immediately suspend CNA A and to tell him to leave the facility. She stated that CNA A had already left the facility so she called him on the phone and told him he was suspended, and he could not return until he spoke with the administrator and he stated ok. She said she think that CNA H initially reported the allegation to RN G, but she was not acting on it so CNA H reported it to her instead. Record review of Abuse Investigation and Reporting policy with a revision date of July 2017 revealed . All reports of resident abuse. Neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown sores (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current allegations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to appropriate individual. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse or had resulted in serious bodily injury 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. The Administrator, DON and Regional Nurse was notified of the Immediate Jeopardy on 9/17/2021 at 11:26 a.m. and the administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 9/18/2021 at 3:49 p.m. and reflected the following: What immediate interventions were initiated for resident identified? STEP 1: On 9/17/21 Administrator was made aware of the alleged incident on 6/21/21 by the surveyor. Administrator interviewed the resident and DON performed a physical assessment, and Social Worker performed a psychosocial assessment. Incident was reported to HHSC. The alleged perpetrator is no longer employed by the facility. This was done on 9/17/21 by the administrator What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? STEP 2: On 9/17/21 Resident satisfaction rounds was completed on all residents to determine if there were any additional concerns related to abuse. If the resident is unable to communicate concerns a head to toe skin assessment will be completed to identity any signs or symptoms of abuse. The one active staff member who failed to report abuse on 06/21/2021 was suspended pending investigation. On 09/16/2021 the alleged perpetrator related to incident on 09/11/2021 was suspended pending investigation. On 09/17/2021 the weekend supervisor who failed to report alleged allegation of abuse was suspended pending investigation. This was done on 9/17/21 by the administrator What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? STEP 3: On 9/17/21, education was initiated with staff on Abuse to include reporting immediately, reporting any questionable activity witnessed or heard of, abuse definitions, types, signs and what to do if abuse is witnessed, and how and who to report concerns to. Employees will be required to complete this education prior to the start of their next shift. Statements of acknowledgement to be signed by each employee declaring the understanding of importance of reporting and responsibility to do so. This will be added to the new hire orientation process. POR interventions will be completed on 09/20/2021. Once allegation is made any employee identified as perpetrator will be immediately suspended pending investigation. This was scheduled to be completed on 9/20/21 by the administrator. Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan STEP 4: Administrator will randomly choose 5 employees daily x 2 weeks, then weekly for 4 weeks and randomly thereafter across all departments to conduct interviews regarding any abuse concerns. Social Worker or designee will perform resident satisfaction surveys 3 times weekly for 4 weeks. Any system failures will be reviewed during monthly QAPI for 3 months. This was initiated on 9/17/21 by the administrator and Social Worker Monitoring of the facilities plan or removal occurred on 9/20/2021 and included the following: Interviews, and record reviews were conducted on 9/20/2021 starting at 11:15 a.m. and continued through 9/20/2021 at 1:35 p.m. with two charge nurses, five certified nurse aides and two MA that were on duty during this time. The in-services included abuse, neglect and reporting and 79 of 103 staff had signed that the in-service training form. During an interview on 9/20/2021 at 11:15 a.m., CNA K stated that months ago she heard that CNA A abused one of the residents. She stated that the aides were talking about it at the time clock. She stated that she was not aware of which residents he abused. She stated that she heard it two days after it occurred, and by then he no longer worked at the facility. She stated she was recently educated about abuse and if they witnessed it or heard about it than they were required to report it to the administrator immediately. She stated that she was educated this weekend. She stated that from now on she will report all allegations of abuse even if she overheard it and had not witnessed it. During an interview on 9/20/2021 at 11:27 a.m., CNA L stated she has been working at the facility 4-5 years. She denied knowing or hearing about staff to resident abuse in the facility. She denied hearing about staff mistreatments by CNA A. She stated that the facility educated her on Abuse Friday (9/17/2021) and that if she heard about abuse or witnessed it was to be immediately reported to the administrator or the DON as soon as possible. During an interview on 9/20/2021 at 11:33 a.m., LVN M stated that she has been working at the facility full time since July 2021. She stated that she has not witnessed or heard about any staff mistreat or abuse a resident. She stated that she would immediately report it to the administrator. She stated that even if she heard it and did not witness it, she was going to report it. She stated that the facility recently re-educated her on abuse, what abuse was and when and who to report it to. During an interview on 9/20/2021 at 11:43 a.m., CNA N stated that she had not heard about staff mistreating a resident. She stated that the facility re-educated her on Abuse Neglect last Friday (9/17/2021). She stated that she was educated on abuse, what abuse was and who to report and when to report. She stated that even if she heard about abuse and had not witnessed it, she would still report it. During an interview on 9/20/2021 at 11:46 a.m., Activity Director stated that she signed abuse in-service Saturday (9/18/2021) morning. She stated that they are educated on abuse monthly; however, on Saturday she was educated that all allegations of abuse must be reported to the administrator immediately. During an interview on 9/20/21 at 11:51 a.m., CNA D she stated that she was in-in-serviced on Friday (9/17/2021) on what abuse was, when to report it and who to report it to. She stated that she's supposed to report all allegations of abuse and you will report it immediately. She stated that even if she heard about abuse or allegations of abuse, she still must report it even if she had not witnessed it. She stated that she did not report it before because the nurse was aware of it, she stated that she was wrong and now she know that she should have reported it and that she will report it from now on. During an interview on 9/20/2021 at 11:58 a.m., CNA O said that the facility educated her last Friday (9/17/2021) on what abuse was, when it was to be reported and who it was to be reported to. She stated she was educated on the different types of abuse. She stated that she would even report hear say allegations of abuse to the administrator immediately because she was not sure if it was correct or not. During an interview on 9/20/2021 at 12:02 p.m., AA P stated that in the past she heard that CNA A had abused Resident #1 and Resident #2. She stated that she heard about him abusing the residents in July 2021. She stated that she heard the CNA's talking about it in the smoking area. She stated that she did not report it because it had already been reported. She stated that a young lady reported it, buy she was not aware of her name. She stated that the DON educated her on yesterday (9/19/2021) regarding what abuse was, when to report it and who to report it to. She said she would report it immediately to the administrator even if she heard it as a rumor and not witnessed it. During an interview on 9/20/2021 at 12:08 p.m., MA F said the facility educated her on abuse on Friday (9/17/2021). She stated she was educated what abuse was, when to report it and who to report it to. She stated that she would report it immediately even if she heard someone else talking about it. During an interview on 9/20/201 at 12:11 p.m., LVN E stated the facility educated her on abuse on 9/20/2021. She said she was educated on when to report abuse, what abuse was and who to report the abuse allegation to. She stated that now she aware that she must contact the administrator and the DON immediately if she witnessed or heard about abuse in the facility. During an interview on 9/20/2021 at 1:31 p.m., MA R she said the facility educated her on abuse and reporting abuse on 9/17/2021. She stated that if she overheard someone talk about allegations of abuse, she would report it to the charge nurse, and the administrator immediately. She stated that she heard that CNA A chocked Resident #1, but she could not remember when she heard about it. She stated that she asked the nurse if she heard about it and the nurse denied hearing about it. An Immediate Jeopardy/Immediate Threat was identified on 9/17/2021. While the Immediate Jeopardy was removed on 9/20/2021, the facility remained out of compliance at a scope of a pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal.

Based on interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 1 of 1 resident reviewed for quality of care. (Resident #1) The facility did not implement interventions when Resident #1 failed to eat, drink, take medications, and had an infiltrated IV for 2 days resulting in a hospitalization . The resident died 3 days later at the hospital. These failures could place residents at risk for not receiving necessary care and services to meet their needs, serious impairment, and death. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: A face sheet with a print date of [DATE] indicated Resident #1 admitted on [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. The baseline care plan dated [DATE] indicated the use of [MEDICAL CONDITION] medications with the intervention of monitoring for any adverse reactions including refusal to eat, dry mouth, and loss of appetite. The care plan did not address the resident's, dehydration, not eating, and IV or IV fluids. The MDS dated [DATE] indicated Resident #1 had adequate hearing, clear speech, understood others and was also understood. He had severely impaired cognition, short and long-term memory problems and had moderately impaired decision-making skills. He had continuous inattention and disorganized thinking. He frequently rejected care and wandered. He required the extensive assistance of one staff member with bed mobility, dressing, toilet use and hygiene. He required the supervision and physical assistance of 1 staff member with eating. The MDS did address the use of antipsychotic medications but did not address the use of IV fluids. The December physician's orders [REDACTED].#1 had an order for [REDACTED]. Hospital physician notes dated [DATE] (prior to admission to the facility) indicated Resident #1 was admitted to the hospital due to increased agitation and combative behaviors. He was diagnosed with [REDACTED]. The physical examination of Resident #1 described him as confused, disoriented, and noncooperative. The assessment and plan for Resident #1 indicated he had not been eating or drinking for the last few days and he required IV hydration. He was to continue his [MEDICATION NAME] medication for his [MEDICAL CONDITION] disorder and depression. Laboratory results from the hospital dated [DATE] (prior to the admission to the facility) indicated Resident #1's BUN (blood urea nitrogen level, a test that measures kidney function) was 15 (the appropriate range is ,[DATE]mg/dL) and his sodium level was 140 (the appropriate range is ,[DATE]mmol). An undated hospital discharge form indicated Resident #1 discharged with [DIAGNOSES REDACTED]. He had been at risk for falls, had been restrained in the hospital, wandered, had noted confusion and had been refusing medications. A Discharge Medication List from the hospital dated [DATE] indicated Resident #1 was to receive [MEDICATION NAME] 300 mg daily with or after meals. A progress note dated [DATE] at 10:00 p.m. indicated Resident #1 arrived at the facility and was described as confused and demented. He was able to make his needs known and spoke with his family member over the telephone. During an interview on [DATE] at 11:54 a.m. LVN E said he notified the NP and the physician of Resident #1's condition, medications and diagnoses. He said the resident had an issue with dementia and was having problems with eating. He said staff offered residents fluids every 2 hours. He said the resident didn't drink much but took some sips of water. He said he notified the NP when the resident wasn't drinking much, and the NP gave an order for [REDACTED]. He said the resident was always confused because of his dementia, but he had a sitter and they monitored him. He says regarding his nurse's note from [DATE] that he ate upwards of 50% of chicken and yogurt. A progress note dated [DATE] at 4:49 a.m. indicated Resident #1 had been walking the facility halls most of the day, was very unsteady, and had to be redirected. He had a sitter at his bedside. A progress note dated [DATE] at 9:07 p.m. indicated Resident #1 had been restless and pacing in the facility hallways. He had a sitter at his bedside and was able to communicate with staff. A progress note dated [DATE] at 12:28 a.m. indicated Resident #1 had a sitter at his bedside and had begun [MEDICATION NAME] 1mg as needed every 6 hours. The note stated the resident needed a psychiatric consult. A physician's orders [REDACTED]. He was to have an IV placed and normal saline fluid started at 100mL/hour on [DATE]. The orders included a stat (immediate) urinalysis lab for the resident. A Therapeutic Drug Monitoring laboratory Services report dated [DATE] indicated Resident #1 had a [MEDICATION NAME] level of 3.2 (reference range XXX,[DATE].2). The report indicated the resident had a severe toxicity level. The urinalysis lab result dated [DATE] for Resident #1 indicated there were no abnormalities. A progress note dated [DATE] at 8:53 a.m. indicated an order was received to hold Resident #1's [MEDICATION NAME] for 7 days and reevaluate his [MEDICATION NAME] level. A progress note dated [DATE] at 11:41 a.m. indicated Resident #1 had a 24-gauge IV placed to his right forearm. Normal saline was started at 100mL/hour. A progress note dated [DATE] at 12:21 a.m. indicated the nurse received a call regarding Resident #1's [MEDICATION NAME] level of 3.2 (the appropriate range is 0XXX,[DATE].2) at 11:48 p.m. on [DATE]. The nurse notified the nurse practitioner via text message. During an interview on [DATE] at 11:09 a.m., LVN A said Resident #1 was frail and needed a sitter due to missing his family member. She said he had behaviors due to not adjusting to the facility well and he wandered the facility. She said he ate and drank on her shifts. She said she and the DON placed his first IV due to his labs being abnormal. The December physician's orders [REDACTED].#1 was to have an IV placed and normal saline fluid started at 100mL/hour on [DATE]. A progress note dated [DATE] at 5:16 a.m. indicted Resident #1 had been walking in his room and shaking his bedrails. He was resistant to care and had to be redirected several times. The nurse indicated she had been notified the resident had not been eating or drinking. Upon her assessment, the residents IV had infiltrated (when the IV remains in the body but is no longer in the vein. The fluids leak into the surrounding soft tissues, causing pain, tenderness and swelling. Resulting in the fluids not being pumped into the body's vascular system) and she did not start a new one due to the resident being noncooperative. During an interview on [DATE] at 2:38 p.m., LVN F said she did not know Resident #1 was not eating or drinking until [DATE] when the resident's sitter told her. She said she notified the oncoming nurse of his refusal to eat or drink. She said the NP told the facility to get recommendations from the kitchen and ordered labs on [DATE]. She said the labs were ordered on [DATE] for his increased confusion, and the facility then re-assessed his labs on [DATE]. She said she asked the sitter if the sitter had notified anyone of the resident's refusal to eat or drink. The sitter told her she had notified someone but was unsure of who she told. The LVN said the kitchen was supposed to have begun cooking foods the resident preferred, but she was unsure if they had. She said when the residents IV was found to be infiltrated, she did not replace it because he refused. She said she charted about the IV infiltration but did not notify the physician or NP. She said she notified the oncoming shift and another IV was placed later. A nutrition therapy assessment dated [DATE], completed by the dietitian, indicated Resident #1 was on a regular diet, ate 60% of meals, had supplemental IV fluids, fed himself, and no other dietary interventions were recommended. The note indicated there was no documentation of height, usual body weight, BMI (body, mass, index), or weight changes. During an interview on [DATE] at 2:24 p.m., the registered dietitian said she did not enter the facility and observe Resident #1. She said she conducted a phone visit with facility staff. She said the resident was given IV fluids on [DATE]. She said the facility had already begun offering supplements such as fortified foods and health shakes to the resident. She said she incorrectly documented that he consumed 60% of his meals. She said the nursing staff should notify her of issues with eating and then schedule a consult. She said she did not recall if the facility contacted her about the resident on [DATE] or [DATE]. A nutrition report for Resident #1 indicated the following: *[DATE] documented at 11:13 a.m. ,[DATE] % of meal was eaten, documented at 12:23 p.m. resident refused, documented at 5:29 p.m. the resident ate ,[DATE] % of the meal *[DATE] documented at 8:22 a.m. ,[DATE]% of meal was eaten, documented at 12:12 p.m. ,[DATE]% of meal was eaten no other information was documented *[DATE] documented at 9:39 a.m. ,[DATE]% of meal was eaten no other information was documented *[DATE] documented at 8:32 a.m. ,[DATE] % of meal was eaten, documented at 1:58 p.m. 0% of meal was eaten no other information was documented *[DATE] documented at 9:21 a.m. 0 % of meal was eaten, documented at 1:00 p.m. ,[DATE]% of meal was eaten and documented at 8:44 p.m. 0 % of meal was eaten *[DATE] documented at 9:21 a.m. 0 % of meal was eaten, documented at 1:00 p.m. ,[DATE]% of meal was eaten and documented at 8:44 p.m. 0 % of meal was eaten *[DATE] documented at 8:15 a.m. ,[DATE] % of meal was eaten, documented at 12:56 p.m. ,[DATE]% of meal was eaten, and no other information was documented The task tab in the electronic medical record dated [DATE] at 5:59 a.m. indicated Resident #1's meal intake was NA. The resident's meal intake at 10:55 a.m. was marked as 26%-50%. The resident's meal intake at 1:00 p.m. was marked as 26%-50%. The task tab in the electronic medical record dated [DATE] at 12:44 a.m. indicated Resident #1's meal intake was marked NA. The resident's meal intake at 8:55 a.m. was marked as 0%-25%. The resident's meal intake at 1:21 p.m. was marked as 0%-25%. The task tab in the electronic medical record dated [DATE] 1:15 p.m. indicated Resident #1's meal intake was marked Refused. The resident's meal intake at 9:48 p.m. was marked as 76%-100%. The resident's meal intake at 9:50 p.m. was marked as 76%-100%. The task tab in the electronic medical record dated [DATE] at 8:55 a.m. indicated Resident #1's meal intake was 51%-75%. The resident's meal intake at 1:19 p.m. was marked as 0%-25%. The resident's meal intake at 6:59 p.m. was marked as Refused. The task tab in the electronic medical record dated [DATE] at 8:17 a.m. indicated Resident #1's meal intake was marked as 26%-50%. The resident's meal intake at 1:28 p.m. was marked as 0%-25%. The task tab in the electronic medical record had no fluid intake recorded from [DATE] to [DATE]. The MAR for [DATE] indicated Resident #1 weighed 118 pounds on [DATE]. There was no weight documented for the week of [DATE]. laboratory results dated [DATE] indicated Resident #1's BUN was 60 (the appropriate range is ,[DATE]mg/dL) and his sodium level was 145 (the appropriate range is ,[DATE]mmol). A progress note dated [DATE] at 5:47 p.m. indicated Resident #1's laboratory results were received, and the nurse practitioner was notified. A new order was received to begin infusing normal saline at 100mL/hour and have more labs drawn on [DATE]. The nurse started a 22 gauge IV in the resident's right forearm. A progress note dated [DATE] at 1:34 a.m. indicated Resident #1 was alert, restless and required frequent redirection. He had a sitter at his bedside and his IV fluids were infusing. Laboratory results, dated [DATE], indicated Resident #1's BUN was 40 (the appropriate range is ,[DATE]mg/dL) and his sodium level was 160 (the appropriate range is ,[DATE]mmol). The vital sign tab in the electronic medical record dated [DATE] at 12:34 pm indicated Resident #1's heart rate was 126 bpm. There was not a progress note for Resident #1 dated [DATE] indicating the physician was notified of the resident's elevated heartrate recorded at 12:34 pm. A progress note dated [DATE] at 12:47 a.m. indicated Resident #1 was in bed, alert and murmuring. He had unclear speech and was flailing in his bed. He was refusing food and fluids. His IV fluids were infusing. The nurse noted his most recent lab values for [DATE] and an order to recheck lab values later in the morning. The note indicated the nurse attempted to provide oral care; however, the resident pushed her hand away. During an interview on [DATE] at 12:05 p.m., the ADON said she had been the night nurse for Resident #1 off and on during his stay. She said he was up and walking around during her first encounter with him. She said he did not like to eat and behaved like a typical Alzheimer's or dementia patient. She said he was not drinking, and she could only get him to sip water. She said she was unaware it took a week for the resident to have labs drawn after his admission. She said she was also unaware of his IV infiltrating and staff not restarting the new IV when it initially occurred. She said her expectation of staff is to notify the nurse practitioner, or physician, in a timelier manner. Laboratory results, dated [DATE], indicated Resident #1's BUN was 36 (the appropriate range is ,[DATE]mg/dL). There was not a sodium level at this time. His [MEDICATION NAME] level was 2.8mmol (the appropriate range is 0XXX,[DATE].2). The laboratory reference range listed levels above 2.5 as severe toxicity. A progress note dated [DATE] at 4:02 p.m. indicated Resident #1 continued to have abnormal labs and an elevated heartrate. The heartrate was not documented. The nurse practitioner gave an order to send the resident out to the hospital. The nurse also noted the resident had not been eating or drinking. During a phone interview on [DATE] at 12:34 p.m., LVN D said Resident #1 had dementia and behaviors. She said he was on IV fluids but was not aware of why. She said the resident would not take his medications. She said she discharged the resident to the hospital due to his abnormal labs and his refusing to eat or drink. She said his heart rate was elevated and the nurse practitioner told her to send the resident to the hospital. During an interview on [DATE], the DON said Resident #1 was admitted to the facility for 11 days for [MEDICATION NAME] toxicity and was combative with staff. She said the resident's family member notified the facility that he would not eat without her there and the facility attempted to accommodate them. She said the resident died recently and it had been related to his [MEDICATION NAME] levels. During an interview on [DATE] at 11:14 a.m., CNA B said she had been a sitter for Resident #1. She said he wandered and she would follow him around. She said he barely ate and drank very little. She said he drank enough to coat his throat. She said he did not seem dehydrated to her because he urinated twice on her 8-hour shift. During an interview on [DATE] at 11:25 a.m., the nurse practitioner said Resident #1 had stopped eating and drinking when he admitted . She said the facility standard were to perform labs a week after resident admission. She said no one in the facility alerted her to the fact that the resident had an acute kidney injury and was on [MEDICATION NAME]. She said she would have ordered labs for the resident sooner if she had known of his [DIAGNOSES REDACTED].#1 admitted to the facility on [DATE] with [MEDICATION NAME] toxicity. She said she was not made aware of the resident's IV infiltration and would have ordered another IV be placed and fluids started sooner than 2 days later. During an interview on [DATE] at 11:45 a.m., MA C said Resident #1 was sweet and alert when he admitted but began not eating well. She said he would not take his medicine and would get hostile with staff. She said staff encouraged him to eat and drink. She said he drank very little. She said the nurses told her to document when the resident refused his medications. During an interview on [DATE] at 12:20 p.m., CNA G said she took care of Resident #1 after he arrived. She said she was asked to speak with him because they were of the same nationality. She said he had been refusing to talk and was getting aggressive with staff members. She said he had a large decline from the first time she saw him to the next 2 times she saw him. She said he had been standing and walking the first time she saw him and the next 2 times he was laying down. She said the first time she met him, she offered him food and he refused. She said she notified the nurse and the nurse also attempted to feed him, but he refused again. She said the second and third times she saw him, she attempted to feed him, but he still refused. The nurses offered him shakes for supplement and he refused those as well. She said he was not drinking and every time they put the drink up to his mouth, he would close his lips. She said if they put food up to his mouth, he would just leave the food on his lips. He wouldn't chew his food or swallow it. During an interview on [DATE] at 12:26 p.m., CNA G said she sat with Resident #1 before his decline. She said he did not eat or drink very much. She said the day she sat with him, he did not eat his food and all he consumed on her shift was a health shake. She said he drank approximately 18 oz on her 8-hour shift. She said she notified the nurse of this and the nurse came in the room to offer him more to drink, which he refused. During an interview on [DATE] at 12:38 p.m., CNA H said Resident #1 did not eat or drink much. She said he would eat maybe 1 or 2 bites of his food and hardly drank. She said he hardly sat down or stopped moving. She said she had not been sitting with him when he declined. She said she notified the nurse when he refused to eat or drink, and the nurse would try to feed him. During an interview on [DATE] at 3:08 p.m., the DON said she read the nurse's progress notes the day after they were charted. She said she usually would be the one to recommend labs or fluids to the nursing staff. She said getting labs on a resident about a week after admission is the standard. She said the staff notified Resident #1's family member whenever he did not eat, and they notified the physician and NP when there was an issue. During an interview on [DATE] at 3:12 p.m., the director of dietary services said she had been in the facility when Resident #1 admitted . She said he wanted a sandwich which he did not eat. She said they began giving him health shakes, but he would only drink them sometimes. She said when she gave him one and held it for him, he drank it. She said the resident's family member told her he would not eat without her there. She said she went to the store and bought him foods that were more culturally appropriate for him, but she said he would not eat those either. She said they were offering him the health shakes and other supplements as well. During a phone interview on [DATE] at 4:53 p.m., the admitting hospital doctor indicated he was familiar with Resident #1 from previous hospitalization s. He said the resident had been walking and talking during his previous admission in December. He said the resident had been confused but had been in good shape He said when the resident was admitted on [DATE], he was shocked at the condition the resident was in. The resident was very dehydrated, and his mouth was very dry. He had a film over his tongue and throughout his oral cavity. He said the resident could not walk and had drastically declined. He said he attributed the resident's death to malnutrition due to the appearance of the resident and he had not consumed anything by mouth for an undetermined amount of time. The admitting hospital physician notes dated [DATE] indicated Resident #1 admitted with [MEDICATION NAME] toxicity, elevated sodium, kidney failure and dehydration. The physical examination documentation at the hospital dated [DATE] indicated Resident #1 weighed 58.9 kg (129.6 pounds) upon admission. The examination indicated the resident's heartrate was 113 bpm. Hospital lab results dated [DATE] indicated Resident #1's sodium level was 166, BUN was 42 and [MEDICATION NAME] was 2.4. The urinalysis lab results indicated the resident had trace amounts of protein and [MEDICATION NAME] in his urine. The resident's [MEDICATION NAME] result for [DATE] was within normal limits. The consulting physician notes dated [DATE] indicated the assessment and plan for Resident #1 included severe dehydration and rehydrating the resident with IV fluids. He also had increased sodium levels directly related to his dehydration and would be rehydrated. The physician's physical examination of the resident noted the resident was alert, did not follow commands, and had involuntary movements. Hospital lab results dated [DATE] indicated Resident #1's sodium level was 171 and BUN was 44. Hospital lab results dated [DATE] indicated Resident #1's sodium level was 166 and BUN was 42. The [MEDICATION NAME] level was 3.0 (range-3XXX,[DATE].8). Hospital lab results dated [DATE] indicated Resident #1's sodium level was 169 and BUN was 69. The [MEDICATION NAME] level was 2.6. Physician notes from [DATE] indicated Resident #1 was alert with eye opening only. He did not follow commands. Physician notes from [DATE] indicated Resident #1 was poorly responsive and having apneic (ceasing breathing) episodes. The hospital discharge summary dated [DATE] indicated Resident #1's causes of death included cardiopulmonary failure, [MEDICAL CONDITION], severe dehydration, [MEDICATION NAME] toxicity, and kidney injury. The Resident Hydration and Prevention of Dehydration policy with a revision date of [DATE] indicated: .5. Nurses will assess for signs and symptoms of dehydration during daily care. 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis a part of daily care. a. Intake will be documented in the medical records. b. Aides will report intake less than 1200mL/day to nursing staff. 7. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output will be initiated and incorporated into the care plan. a. ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. b. The physician will be notified . .12. Nursing will monitor, and document fluid intake and the dietitian will be kept informed of status. The Interdisciplinary Team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. The Hydration - Clinical Protocol policy with a revision date of [DATE] indicated: .2 The staff, with the physician's input, will identify and report to the physician individuals with signs and symptoms (for example, [MEDICAL CONDITION], lethargy .) or lab test results (for example, [MEDICAL CONDITION] .) that might reflect existing fluid and electrolyte imbalance. 3. The physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance; for example, individuals .who are not eating or drinking well. The Peripheral IV Catheter Insertion policy with a revision date of [DATE] indicated: .1. Notify the supervisor if the resident refuses the procedure or if the procedure is unsuccessful . The administrator and DON were notified on [DATE] at 11:20 a.m., an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on [DATE] at 5:48 p.m. and included: Identify Residents who could be affected Short stay residents requiring assistance with food and fluids. Long term residents with significant clinical changes and decline in meal intake. Residents who are dependent on staff for food and fluid intake. Residents on specialty medications . Corrective Actions: *In-service completed on [DATE] regarding MD, NP, family notification of admission orders [REDACTED]. *[DATE] added specialty medication and lab monitoring to admission/readmission checklist. *In-Serviced nursing staff to notify Dietician and MD notification of any/all residents refusing more than 2 meals in a 24 hour period. Reviewed and validated for completion 5 days weekly during clinical review *Reviewed residents with specialty medications for appropriate lab monitoring [DATE] through current date. *Food and fluid intake monitoring via medical record will be reviewed during clinical meeting by DON/designee to ensure adequate meal intake for all residents. Dietician to observe residents via video monitoring or in person visit to ensure accuracy of assessments and recommendations. *[DATE] In-serviced staff on the need to offer supplement if resident consumes less than 50% of any meal and notify family and MD, for further intervention and possible IV hydration family. *Reviewed 3 residents with decreased PO intake for dietician, MD notification and timely intervention since alleged incident. The Inter Disciplinary Team (IDT) along with Medical Director Khoren Hekimian DO CMD conducted QAPI meeting on [DATE] via phone to review and discuss facility notification, admission process, facility citations, corrective actions, policy and procedures, performed in servicing, and identify the above corrective actions to establish compliance. A QAPI meeting was held on [DATE] with the IDT and Medical Director Hekimian DO CMD to review and discuss items identified by the surveyor regarding citations. A Plan of removal was developed, implemented, and completed as designed in this document. It is requested that the Plan of Removal be accepted, and the Immediate Jeopardy is lifted as of [DATE] . On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: A QAPI meeting was held via phone on [DATE] regarding any new admissions/readmissions will have medications, labs, and pertinent information discussed and reviewed for any needed changes. All medications requiring lab monitoring will be discussed and orders given. A QAPI meeting was held via phone on [DATE] regarding any residents with change of condition or decrease in PO food/fluid intake will be discussed when 2 meals have not been consumed in 24 hours. The physician, ADON, DON, and administrator were in attendance. An in-service dated [DATE] indicated: All CNAs: If you have a resident that consumes less than 50% of any meal, it is imperative that you notify the charge nurse. Charge nurses, if the resident is refusing PO meal/fluid intake, for more than two meals, please make sure that you notify the MD/NP/DON immediately for possible further intervention, such as, supplements, IV fluids, food/fluid recommendations, etc. If you have any questions. Please notify nursing administration. An in-service dated [DATE] indicated: To all nurses: On admission, new residents should have medication review completed with MD/NP. Ensure that all pertinent labs, medication, interventions, treatment, etc. is discussed at time of notification. Medication review and resident arrival should be relayed to MD/NP as soon as the resident is admitted to the facility. Obtain weight, height, and other pertinent information at that time. The DON should be notified upon arrival of new residents to the facility. If you have any questions or concerns, notify DON/ADON. Disciplinary action will take place if failure to complete above tasks. Thank you. During a record review on [DATE] at 11:15 a.m. a printed audit of resident medications and labs was reviewed. All residents with medications that require labs were marked with dates of last labs and dates of next labs. During an interview on [DATE] at 11:35 a.m., LVN D said she was in-serviced on admission of new residents and to review meds with the physician or NP. She should also get labs and medications ordered. She said the computer system guides them on what is needed for the resident's chart. She said she was told this morning, [DATE], during their meeting about the expectation of the charge nurses in notifying the physician, NP and DON of resident's not consuming 2 meals in one day. During a record review on [DATE] at 11:50 a.m., an electronic charting system communication board dated [DATE] at 8:45 a.m. indicated MD, family notification must be completed and documented for any resident consuming 50% or less of 2 or more meals in a 24 hour period. If a resident refuses a meal, a supplement must be offered and documented. An SBAR assessment must be completed with each and every clinical change. If you are calling the MD/NP for any reason, a SBAR must be completed prior to calling. Any new admission or readmission must have orders reviewed and verified with MD/NP upon admission. Please be checking for any specialty medications that may require blood level monitoring to ensure we have an order for [REDACTED]. Attention all CNAs! Please document your POC. Needs to be 100% each shift. During a record review on [DATE] at 12:00 p.m., An Alert Audit Report conducted by the DON indicated Resident #2 had eaten less than 50% for 2 or more meals on [DATE]. The dietician was notified of this on [DATE], and an appetite stimulant was suggested. The physician was notified on [DATE] of the dietician's suggestion and [MEDICATION NAME] 15mg was ordered, with a start date of [DATE] at 8 p.m. Resident #3 ate less than 50% of 2 meals or more on [DATE]. An SBAR was completed on [DATE] to notify the MD/NP the resident had begun refusing meals and ADLs. Orders were received for a UA, CBC, CMP, CT of chest and x-ray due to his complaints of abdominal upset and pain. Resident #4 ate less than 50% of 2 meals or more on [DATE]. Per previous nurse's notes, she had been having GI issues and has had STAT labs, a fecal sample and is awaiting a GI appointment [DATE]. During a record review on [DATE] at 12:30 p.m., an admission/readmission checklist the facility uses has an added a check box to ensure specialty medications that lab require lab monitoring are addressed, with a spot to fill in the date the lab was ordered. During a record review on [DATE] at 12:40 p.m., dietary recommendations from the dietician on [DATE] were appropriate and completed by the facility. During an interview on [DATE] at 12:55 p.m., RN J said he was in-serviced this morning on resident's meal intake. He said if the resident eats less than 50% of 2 separate meals and offer a supplement. If the physician does not respond, they are to notify the DON for a follow up to get la(TRUNCATED)

Based on interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 1 residents reviewed for notification of changes. (Resident #1) The facility failed to consult physician for 2 days when resident IV was infiltrated resulting in hospitalization and death. The facility failed to consult physician when resident failed to eat and take medications. This failure could place residents at risk for unnecessary pain, delay in treatment, and decreased quality of life. Findings included: A face sheet with a print date of [DATE] indicated Resident #1 admitted on [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. The baseline care plan dated [DATE] indicated the use of [MEDICAL CONDITION] medications with the intervention of monitoring for any adverse reactions including refusal to eat, dry mouth, and loss of appetite. The care plan did not address the resident's, dehydration, not eating, and IV or IV fluids. The MDS dated [DATE] indicated Resident #1 had adequate hearing, clear speech, understood others and was also understood. He had severely impaired cognition, short and long-term memory problems and had moderately impaired decision-making skills. He had continuous inattention and disorganized thinking. He frequently rejected care and wandered. He required the extensive assistance of one staff member with bed mobility, dressing, toilet use and hygiene. He required the supervision and physical assistance of 1 staff member with eating. The MDS did address the use of antipsychotic medications but did not address the use of IV fluids. The December physician's orders [REDACTED].#1 had an order for [REDACTED]. Hospital physician notes dated [DATE] (prior to admission to the facility) indicated Resident #1 was admitted to the hospital due to increased agitation and combative behaviors. He was diagnosed with [REDACTED]. The physical examination of Resident #1 described him as confused, disoriented, and noncooperative. The assessment and plan for Resident #1 indicated he had not been eating or drinking for the last few days and he required IV hydration. He was to continue his [MEDICATION NAME] medication for his [MEDICAL CONDITION] disorder and depression. Laboratory results from the hospital dated [DATE] (prior to the admission to the facility) indicated Resident #1's BUN (blood urea nitrogen level, a test that measures kidney function) was 15 (the appropriate range is ,[DATE]mg/dL) and his sodium level was 140 (the appropriate range is ,[DATE]mmol). An undated hospital discharge form indicated Resident #1 discharged with [DIAGNOSES REDACTED]. He had been at risk for falls, had been restrained in the hospital, wandered, had noted confusion and had been refusing medications. A Discharge Medication List from the hospital dated [DATE] indicated Resident #1 was to receive [MEDICATION NAME] 300 mg daily with or after meals. A progress note dated [DATE] at 10:00 p.m. indicated Resident #1 arrived at the facility and was described as confused and demented. He was able to make his needs known and spoke with his family member over the telephone. During an interview on [DATE] at 11:54 a.m. LVN E said he notified the NP and the physician of Resident #1's condition, medications and diagnoses. He said the resident had an issue with dementia and was having problems with eating. He said staff offered residents fluids every 2 hours. He said the resident didn't drink much but took some sips of water. He said he notified the NP when the resident wasn't drinking much, and the NP gave an order for [REDACTED]. He said the resident was always confused because of his dementia, but he had a sitter and they monitored him. He says regarding his nurse's note from [DATE] that he ate upwards of 50% of chicken and yogurt. A progress note dated [DATE] at 4:49 a.m. indicated Resident #1 had been walking the facility halls most of the day, was very unsteady, and had to be redirected. He had a sitter at his bedside. A progress note dated [DATE] at 9:07 p.m. indicated Resident #1 had been restless and pacing in the facility hallways. He had a sitter at his bedside and was able to communicate with staff. A progress note dated [DATE] at 12:28 a.m. indicated Resident #1 had a sitter at his bedside and had begun [MEDICATION NAME] 1mg as needed every 6 hours. The note stated the resident needed a psychiatric consult. A physician's orders [REDACTED]. He was to have an IV placed and normal saline fluid started at 100mL/hour on [DATE]. The orders included a stat (immediate) urinalysis lab for the resident. A Therapeutic Drug Monitoring laboratory Services report dated [DATE] indicated Resident #1 had a [MEDICATION NAME] level of 3.2 (reference range XXX,[DATE].2). The report indicated the resident had a severe toxicity level. The urinalysis lab result dated [DATE] for Resident #1 indicated there were no abnormalities. A progress note dated [DATE] at 8:53 a.m. indicated an order was received to hold Resident #1's [MEDICATION NAME] for 7 days and reevaluate his [MEDICATION NAME] level. A progress note dated [DATE] at 11:41 a.m. indicated Resident #1 had a 24-gauge IV placed to his right forearm. Normal saline was started at 100mL/hour. A progress note dated [DATE] at 12:21 a.m. indicated the nurse received a call regarding Resident #1's [MEDICATION NAME] level of 3.2 (the appropriate range is 0XXX,[DATE].2) at 11:48 p.m. on [DATE]. The nurse notified the nurse practitioner via text message. During an interview on [DATE] at 11:09 a.m., LVN A said Resident #1 was frail and needed a sitter due to missing his family member. She said he had behaviors due to not adjusting to the facility well and he wandered the facility. She said he ate and drank on her shifts. She said she and the DON placed his first IV due to his labs being abnormal. The December physician's orders [REDACTED].#1 was to have an IV placed and normal saline fluid started at 100mL/hour on [DATE]. A progress note dated [DATE] at 5:16 a.m. indicted Resident #1 had been walking in his room and shaking his bedrails. He was resistant to care and had to be redirected several times. The nurse indicated she had been notified the resident had not been eating or drinking. Upon her assessment, the residents IV had infiltrated (when fluids leak into the surrounding soft tissues) and she did not start a new one due to the resident being noncooperative. During an interview on [DATE] at 2:38 p.m., LVN F said she did not know Resident #1 was not eating or drinking until [DATE] when the resident's sitter told her. She said she notified the oncoming nurse of his refusal to eat or drink. She said the NP told the facility to get recommendations from the kitchen and ordered labs on [DATE]. She said the labs were ordered on [DATE] for his increased confusion, and the facility then re-assessed his labs on [DATE]. She said she asked the sitter if the sitter had notified anyone of the resident's refusal to eat or drink. The sitter told her she had notified someone but was unsure of who she told. The LVN said the kitchen was supposed to have begun cooking foods the resident preferred, but she was unsure if they had. She said when the residents IV was found to be infiltrated, she did not replace it because he refused. She said she charted about the IV infiltration but did not notify the physician or NP. She said she notified the oncoming shift and another IV was placed later. A nutrition therapy assessment dated [DATE], completed by the dietitian, indicated Resident #1 was on a regular diet, ate 60% of meals, had supplemental IV fluids, fed himself, and no other dietary interventions were recommended. The note indicated there was no documentation of height, usual body weight, BMI (body, mass, index), or weight changes. During an interview on [DATE] at 2:24 p.m., the registered dietitian said she did not enter the facility and observe Resident #1. She said she conducted a phone visit with facility staff. She said the resident was given IV fluids on [DATE]. She said the facility had already begun offering supplements such as fortified foods and health shakes to the resident. She said she incorrectly documented that he consumed 60% of his meals. She said the nursing staff should notify her of issues with eating and then schedule a consult. She said she did not recall if the facility contacted her about the resident on [DATE] or [DATE]. A nutrition report for Resident #1 indicated the following: *[DATE] documented at 11:13 a.m. ,[DATE] % of meal was eaten, documented at 12:23 p.m. resident refused, documented at 5:29 p.m. the resident ate ,[DATE] % of the meal *[DATE] documented at 8:22 a.m. ,[DATE]% of meal was eaten, documented at 12:12 p.m. ,[DATE]% of meal was eaten no other information was documented *[DATE] documented at 9:39 a.m. ,[DATE]% of meal was eaten no other information was documented *[DATE] documented at 8:32 a.m. ,[DATE] % of meal was eaten, documented at 1:58 p.m. 0% of meal was eaten no other information was documented *[DATE] documented at 9:21 a.m. 0 % of meal was eaten, documented at 1:00 p.m. ,[DATE]% of meal was eaten and documented at 8:44 p.m. 0 % of meal was eaten *[DATE] documented at 9:21 a.m. 0 % of meal was eaten, documented at 1:00 p.m. ,[DATE]% of meal was eaten and documented at 8:44 p.m. 0 % of meal was eaten *[DATE] documented at 8:15 a.m. ,[DATE] % of meal was eaten, documented at 12:56 p.m. ,[DATE]% of meal was eaten, and no other information was documented The task tab in the electronic medical record dated [DATE] at 5:59 a.m. indicated Resident #1's meal intake was NA. The resident's meal intake at 10:55 a.m. was marked as 26%-50%. The resident's meal intake at 1:00 p.m. was marked as 26%-50%. The task tab in the electronic medical record dated [DATE] at 12:44 a.m. indicated Resident #1's meal intake was marked NA. The resident's meal intake at 8:55 a.m. was marked as 0%-25%. The resident's meal intake at 1:21 p.m. was marked as 0%-25%. The task tab in the electronic medical record dated [DATE] 1:15 p.m. indicated Resident #1's meal intake was marked Refused. The resident's meal intake at 9:48 p.m. was marked as 76%-100%. The resident's meal intake at 9:50 p.m. was marked as 76%-100%. The task tab in the electronic medical record dated [DATE] at 8:55 a.m. indicated Resident #1's meal intake was 51%-75%. The resident's meal intake at 1:19 p.m. was marked as 0%-25%. The resident's meal intake at 6:59 p.m. was marked as Refused. The task tab in the electronic medical record dated [DATE] at 8:17 a.m. indicated Resident #1's meal intake was marked as 26%-50%. The resident's meal intake at 1:28 p.m. was marked as 0%-25%. The task tab in the electronic medical record had no fluid intake recorded from [DATE] to [DATE]. The MAR for [DATE] indicated Resident #1 weighed 118 pounds on [DATE]. There was no weight documented for the week of [DATE]. laboratory results dated [DATE] indicated Resident #1's BUN was 60 (the appropriate range is ,[DATE]mg/dL) and his sodium level was 145 (the appropriate range is ,[DATE]mmol). A progress note dated [DATE] at 5:47 p.m. indicated Resident #1's laboratory results were received, and the nurse practitioner was notified. A new order was received to begin infusing normal saline at 100mL/hour and have more labs drawn on [DATE]. The nurse started a 22 gauge IV in the resident's right forearm. A progress note dated [DATE] at 1:34 a.m. indicated Resident #1 was alert, restless and required frequent redirection. He had a sitter at his bedside and his IV fluids were infusing. Laboratory results, dated [DATE], indicated Resident #1's BUN was 40 (the appropriate range is ,[DATE]mg/dL) and his sodium level was 160 (the appropriate range is ,[DATE]mmol). The vital sign tab in the electronic medical record dated [DATE] at 12:34 pm indicated Resident #1's heart rate was 126 bpm. There was not a progress note for Resident #1 dated [DATE] indicating the physician was notified of the resident's elevated heartrate recorded at 12:34 pm. A progress note dated [DATE] at 12:47 a.m. indicated Resident #1 was in bed, alert and murmuring. He had unclear speech and was flailing in his bed. He was refusing food and fluids. His IV fluids were infusing. The nurse noted his most recent lab values for [DATE] and an order to recheck lab values later in the morning. The note indicated the nurse attempted to provide oral care; however, the resident pushed her hand away. During an interview on [DATE] at 12:05 p.m., the ADON said she had been the night nurse for Resident #1 off and on during his stay. She said he was up and walking around during her first encounter with him. She said he did not like to eat and behaved like a typical Alzheimer's or dementia patient. She said he was not drinking, and she could only get him to sip water. She said she was unaware it took a week for the resident to have labs drawn after his admission. She said she was also unaware of his IV infiltrating and staff not restarting the new IV when it initially occurred. She said her expectation of staff is to notify the nurse practitioner, or physician, in a timelier manner. Laboratory results, dated [DATE], indicated Resident #1's BUN was 36 (the appropriate range is ,[DATE]mg/dL). There was not a sodium level at this time. His [MEDICATION NAME] level was 2.8mmol (the appropriate range is 0XXX,[DATE].2). The laboratory reference range listed levels above 2.5 as severe toxicity. A progress note dated [DATE] at 4:02 p.m. indicated Resident #1 continued to have abnormal labs and an elevated heartrate. The heartrate was not documented. The nurse practitioner gave an order to send the resident out to the hospital. The nurse also noted the resident had not been eating or drinking. During a phone interview on [DATE] at 12:34 p.m., LVN D said Resident #1 had dementia and behaviors. She said he was on IV fluids but was not aware of why. She said the resident would not take his medications. She said she discharged the resident to the hospital due to his abnormal labs and his refusing to eat or drink. She said his heart rate was elevated and the nurse practitioner told her to send the resident to the hospital. During an interview on [DATE], the DON said Resident #1 was admitted to the facility for 11 days for [MEDICATION NAME] toxicity and was combative with staff. She said the resident's family member notified the facility that he would not eat without her there and the facility attempted to accommodate them. She said the resident died recently and it had been related to his [MEDICATION NAME] levels. During an interview on [DATE] at 11:14 a.m., CNA B said she had been a sitter for Resident #1. She said he wandered and she would follow him around. She said he barely ate and drank very little. She said he drank enough to coat his throat. She said he did not seem dehydrated to her because he urinated twice on her 8-hour shift. During an interview on [DATE] at 11:25 a.m., the nurse practitioner said Resident #1 had stopped eating and drinking when he admitted . She said the facility standard were to perform labs a week after resident admission. She said no one in the facility alerted her to the fact that the resident had an acute kidney injury and was on [MEDICATION NAME]. She said she would have ordered labs for the resident sooner if she had known of his [DIAGNOSES REDACTED].#1 admitted to the facility on [DATE] with [MEDICATION NAME] toxicity. She said she was not made aware of the resident's IV infiltration and would have ordered another IV be placed and fluids started sooner than 2 days later. During an interview on [DATE] at 11:45 a.m., MA C said Resident #1 was sweet and alert when he admitted but began not eating well. She said he would not take his medicine and would get hostile with staff. She said staff encouraged him to eat and drink. She said he drank very little. She said the nurses told her to document when the resident refused his medications. During an interview on [DATE] at 12:20 p.m., CNA G said she took care of Resident #1 after he arrived. She said she was asked to speak with him because they were of the same nationality. She said he had been refusing to talk and was getting aggressive with staff members. She said he had a large decline from the first time she saw him to the next 2 times she saw him. She said he had been standing and walking the first time she saw him and the next 2 times he was laying down. She said the first time she met him, she offered him food and he refused. She said she notified the nurse and the nurse also attempted to feed him, but he refused again. She said the second and third times she saw him, she attempted to feed him, but he still refused. The nurses offered him shakes for supplement and he refused those as well. She said he was not drinking and every time they put the drink up to his mouth, he would close his lips. She said if they put food up to his mouth, he would just leave the food on his lips. He wouldn't chew his food or swallow it. During an interview on [DATE] at 12:26 p.m., CNA G said she sat with Resident #1 before his decline. She said he did not eat or drink very much. She said the day she sat with him, he did not eat his food and all he consumed on her shift was a health shake. She said he drank approximately 18 oz on her 8-hour shift. She said she notified the nurse of this and the nurse came in the room to offer him more to drink, which he refused. During an interview on [DATE] at 12:38 p.m., CNA H said Resident #1 did not eat or drink much. She said he would eat maybe 1 or 2 bites of his food and hardly drank. She said he hardly sat down or stopped moving. She said she had not been sitting with him when he declined. She said she notified the nurse when he refused to eat or drink, and the nurse would try to feed him. During an interview on [DATE] at 3:08 p.m., the DON said she read the nurse's progress notes the day after they were charted. She said she usually would be the one to recommend labs or fluids to the nursing staff. She said getting labs on a resident about a week after admission is the standard. She said the staff notified Resident #1's family member whenever he did not eat, and they notified the physician and NP when there was an issue. During an interview on [DATE] at 3:12 p.m., the director of dietary services said she had been in the facility when Resident #1 admitted . She said he wanted a sandwich which he did not eat. She said they began giving him health shakes, but he would only drink them sometimes. She said when she gave him one and held it for him, he drank it. She said the resident's family member told her he would not eat without her there. She said she went to the store and bought him foods that were more culturally appropriate for him, but she said he would not eat those either. She said they were offering him the health shakes and other supplements as well. During a phone interview on [DATE] at 4:53 p.m., the admitting hospital doctor indicated he was familiar with Resident #1 from previous hospitalization s. He said the resident had been walking and talking during his previous admission in December. He said the resident had been confused but had been in good shape He said when the resident was admitted on [DATE], he was shocked at the condition the resident was in. The resident was very dehydrated, and his mouth was very dry. He had a film over his tongue and throughout his oral cavity. He said the resident could not walk and had drastically declined. He said he attributed the resident's death to malnutrition due to the appearance of the resident and he had not consumed anything by mouth for an undetermined amount of time. The admitting hospital physician notes dated [DATE] indicated Resident #1 admitted with [MEDICATION NAME] toxicity, elevated sodium, kidney failure and dehydration. The physical examination documentation at the hospital dated [DATE] indicated Resident #1 weighed 58.9 kg (129.6 pounds) upon admission. The examination indicated the resident's heartrate was 113 bpm. Hospital lab results dated [DATE] indicated Resident #1's sodium level was 166, BUN was 42 and [MEDICATION NAME] was 2.4. The urinalysis lab results indicated the resident had trace amounts of protein and [MEDICATION NAME] in his urine. The resident's [MEDICATION NAME] result for [DATE] was within normal limits. The consulting physician notes dated [DATE] indicated the assessment and plan for Resident #1 included severe dehydration and rehydrating the resident with IV fluids. He also had increased sodium levels directly related to his dehydration and would be rehydrated. The physician's physical examination of the resident noted the resident was alert, did not follow commands, and had involuntary movements. Hospital lab results dated [DATE] indicated Resident #1's sodium level was 171 and BUN was 44. Hospital lab results dated [DATE] indicated Resident #1's sodium level was 166 and BUN was 42. The [MEDICATION NAME] level was 3.0 (range-3XXX,[DATE].8). Hospital lab results dated [DATE] indicated Resident #1's sodium level was 169 and BUN was 69. The [MEDICATION NAME] level was 2.6. Physician notes from [DATE] indicated Resident #1 was alert with eye opening only. He did not follow commands. Physician notes from [DATE] indicated Resident #1 was poorly responsive and having apneic (ceasing breathing) episodes. The hospital discharge summary dated [DATE] indicated Resident #1's causes of death included cardiopulmonary failure, [MEDICAL CONDITION], severe dehydration, [MEDICATION NAME] toxicity, and kidney injury.

Based on interview and record review, the facility failed to ensure an effective discharge plan was developed and implemented to prevent readmission for 1 of 1 resident reviewed for transfer and discharge. (Resident #1) The facility did not arrange for Resident #1 to discharge from the facility into a setting that met their needs. Resident #1 required [MEDICAL TREATMENT] 3 days a week, wound care and daily medications. Resident #1 was dropped off at a community shelter with no discharge instructions or medications. The facility did not notify shelter prior to the discharge. The resident was admitted to the hospital 3 days later for pleural effusion (fluid buildup in the space between the layers of the lung) and cardiomegaly (abnormal enlargement of the heart) which was consistent with not receiving [MEDICAL TREATMENT] as ordered. An Immediate Jeopardy (IJ) situation was identified on 7/9/2020 at 8:31a.m. While the IJ was removed on 7/10/2020 at 9:53 a.m., the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: A face sheet in the closed clinical record dated 6/26/20 indicated Resident #1 was [AGE] years old, initially admitted [DATE], and had [DIAGNOSES REDACTED]. The Order Recap Report dated 5/1/20-7/31/20 indicated Resident # 1 orders included the following with a discontinue date of 5/18/20: *Order dated 12/26/19 indicated the resident required [MEDICAL TREATMENT] Tuesday, Thursday, and Saturday; *Order dated 5/18/20 indicated the resident may discharge with current medications and a 30-day refill called into the pharmacy of choice; *Order dated 5/15/20 for Keflex capsule 250 mg two times a day for an open wound; *Order dated 5/11/20 for Sevelamer Carb tablet 800 mg three times a day for [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]); *Order dated 5/11/20 for [MEDICATION NAME] XL ER (extended release) 100 mg one time a day. A Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated Resident #1's cognition was intact. The assessment indicated the resident exhibited daily verbal behaviors, but no other behaviors and no rejection of care was noted. The MDS indicated the resident used a wheelchair, and required extensive assistance with all ADL's including transfers, dressing, eating, and toileting. She was totally dependent on staff for bathing. The resident was always incontinent of bowel and bladder. The MDS indicated active discharge planning was occurring for Resident #1. An MDS Nursing Home Discharge assessment dated [DATE] indicated Resident #1's cognition was intact. The assessment indicated the resident exhibited daily verbal behaviors. The resident exhibited behaviors not directed towards 1 to 3 days during the MDS review period. The MDS indicated the resident required extensive assistance with all ADL's including transfers, dressing, eating, and toileting. She was totally dependent on staff for bathing. The resident was always incontinent of bowel and bladder. The MDS indicated active discharge planning was occurring for Resident #1. A care plan initiated 1/15/20 indicated Resident #1 had an activities of daily living deficit due to weakness, and she required extensive assistance of one staff with bathing and dressing due to the limited range of motion of her fingers. She required a splint to her left hand up to 4 hours a day to treat finger contractures. The care plan indicated the resident had a diabetic ulcer which was to be monitored and treated as ordered. The care plan indicated the resident would receive [MEDICAL TREATMENT] three times a week for End Stage [MEDICAL CONDITION]. The care plan indicated the resident had impaired cognitive function and required cueing, reorienting, and supervising as needed. A care plan initiated 5/4/20 indicated Resident #1 had an area of concern (hematoma) to the resident's posterior rights lower leg above the ankle (initiated 5/4/20). The care plan indicated the treatment was to cleanse the area of concern with normal saline, pat it dry, apply a foam dressing, and change it as needed. The resident's care plan indicated she had limited physical mobility, had behavior problems and was easily angered and agitated, refused to take her medication, and was resistive to care on occasions. A care plan initiated 3/12/20 indicated Resident #1 become anxious at times, and was at risk for psychosocial well-being concern due to medically imposed restrictions due to COVID 19. The care plan indicated Resident #1 had impaired cognitive function/dementia or impaired thought process (cerebral infarction), had hypertension, risk for falls due to an unsteady gait and bilateral wounds, was incontinent, and was totally dependent on staff with toileting. Resident #1's care plan did not address Resident #1's refusals to cooperate with COVID policies, her refusal to stay in her room, and did not address any behaviors that put other residents at risk of harm. A 30 day discharge notice dated 6/21/19 (15 days after Resident #1's initial admission to the facility) indicated Resident #1 would be discharged to another nursing facility because the transfer or discharge was necessary for the resident's welfare and the residents needs could not be met in the facility. The discharge notice indicated Resident #1 continues to prevent her own welfare by not following doctor's orders, and facility guidelines for safety as evidenced by regular refusal of medications, treatments, incomplete [MEDICAL TREATMENT], and leaving facility grounds without signing out. The discharge notice indicated Resident #1 received education about each of these upon admission and again at a team meeting after one week of admission. An immediate discharge notice dated 5/1/20 (approximately 11 months later) indicated Resident #1 would be discharged immediately upon acceptance from another facility. The discharge letter indicated the discharge was necessary for the resident's welfare, the resident's needs could not be met in the facility, and the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident. The letter did not indicate what specific actions led to the determination of that criteria. A physicians progress note dated 5/13/2020 indicated the physician saw the resident for a routine follow up. The progress note indicated the resident was an unreliable historian and had a wound to her heel. A progress note date 5/17/20 at 9:41 p.m. indicated Resident #1 had a dirty bandage to the right ankle. The note indicated the resident had an open area with thick purulent drainage (a thick, milky substance that is released from a wound which almost always signifies an infection). A discharge planning review for Resident #1 dated 5/18/20 completed by the social worker indicated Resident #1 was expected to be discharged to the community. It was noted the discharge was determined to be feasible, the resident's home environment was alone, and the resident had treatment/care needs including [MEDICAL TREATMENT] and dressings to Resident #1's right lower extremity. A nursing note dated 5/18/20 at 11:31 a.m., completed by the ADON indicated the ADON notified a local pharmacy of Resident #1's medications, and all medications were ordered. The note indicated Resident #1 was aware of the medication request to be filled at the pharmacy. A nursing note dated 5/18/20 at 1:35 p.m. indicated Resident #1 was discharged with all personal affects. The nursing note included the address Resident #1 discharged to, but did not include any other information pertaining to the discharge. During a telephone interview on 7/21/2020 at 4:00 p.m., the physician said Resident #1 was discharged from the facility due to non-compliance with COVID (a highly contagious upper respiratory virus that can be fatal) rules and policies. The physician said Resident #1 was a danger to the other residents, she would not wear her mask, and would not stay out of others rooms. He said he gave a telephone order for her to be discharged to the community with her medications. He did not recall when Resident #1 was discharged . Nursing notes from 4/24/20 through 5/4/20 indicated Resident #1 was noncompliant with wearing her mask. Nursing notes from 5/5/20 through 5/18/20 did not address Resident #1's refusals to cooperate with COVID policies, her refusal to stay in her room, and did not address any behaviors that put other residents at risk of harm. During a telephone interview on 7/21/20 at 5:15 p.m., LVN A said Resident #1 was discharged because the resident was non-compliant with the COVID policy, had continued behavior issues, and she refused her medication and treatments many times. The nurse said she was on duty when Resident #1 discharged , and she packed enough medications for Resident #1 for at least that day, and she sent plenty of wound care supplies with the resident. LVN A said Resident #1 needed assistance with wound care dressings and could not manage her own medications. During an interview on 6/26/2020 at 1:21 p.m., the facility van driver said on 5/18/2020, the administrator told her to take Resident #1 to the local community shelter. The van driver said when she arrived at the shelter, no one came to door. The van driver said she called the administrator and the administrator said to leave Resident #1 outside of the shelter. The van driver said Resident #1 was left outside with her discharge paperwork. During an interview on 6/26/2020 at 11:25 a.m., the administrator said she did not know the local community shelter had to be notified of a resident being transfer/discharged to their facility. The administrator said the resident was discharged because the resident was non-compliant with care, taking her medications, and with the COVID rules and policies such as the requirement for each resident to stay in their room. The administrator said Resident #1 was also discharged for behavior issues such as getting angry and belligerent, and she had the potential to cause harm to the other residents. The administrator said she was not concerned about leaving the resident at the community shelter because she thought the community shelter would be a safe discharge. She said she thought the shelter would assist the resident with her needs. She said her social worker had exhausted all other resources for discharge and thought the shelter would be the best place for Resident #1 to go. During an interview on 6/26/2020 at 12:08 p.m., the social worker said she did not notify the local community agency shelter. The social worker said Resident #1's family would not accept the resident, and she thought dropping the resident off at the local community shelter would be the safest place for her to go. She said Resident #1 was discharged because she was a danger to others, was non-compliant with COVID rules, and the facility could not meet Resident #1's needs. During a telephone interview on 6/26/20 at 12:15 p.m., the ombudsman said she did not think dropping Resident #1 off at the community shelter was a safe discharge. She said the resident went to [MEDICAL TREATMENT], was diabetic, and was totally dependent on staff for ADL's. The ombudsman said she was notified on 5/5/2020 that the facility wanted to send the resident to the community shelter, but they did not discharge her then. She said she received a call on 5/18/20 from Resident #1's son saying they were moving Resident #1 to the community shelter. The ombudsman said it was not right for the facility to take a resident to a shelter and drop them off. During a telephone interview on 6/26/20 at 12:33 p.m., Program Director #2 with the community agency shelter said Resident #1 arrived to their shelter on 5/18/20. The program director said they learned Resident #1 was at the shelter when another resident informed her someone was sitting outside. The program director said they had no idea how long Resident #1 sat outside the community agency shelter, but she was hot and sweaty when she was found. The program director said they could not admit the resident because they could not meet her needs. The program director said they were a shelter, and were not a medical facility. The program director said they were not notified before the resident was dropped off. The program director said she asked the resident her name, where she came from, and got the resident's sons and parole officers contact information. She said the resident's son was then called, and the son picked the resident up from the community shelter and took her to a group home in a different town. During a telephone interview on 6/26/20 at 12:33 p.m., the administrator of the community agency shelter said she tried to call the facility to let them know they could not accept Resident #1 after the resident was dropped off at their agency. She said she called the facility several times and was hung up on. She said afterwards, they contacted the son and parole officer and found a facility in a different city to accept her. During a telephone interview on 7/9/20 at 12:20 p.m., Resident #1's son said Resident #1 called him as she was leaving the facility and said the facility was taking her to a shelter. Resident #1's son said Resident #1 was totally dependent, could not walk, required [MEDICAL TREATMENT] due to end stage [MEDICAL CONDITION], was wheel chair dependent, and took insulin. Resident #1's son said Resident #1 was dependent for all ADL's and could not administer her own insulin. He said the facility did not notify him they were taking his mother to a community agency shelter that could not care for her. He said Resident #1's parole officer called and told him to pick the resident up from the community shelter and drive the resident to a group home in a different town, and suggested the group home could only keep the resident for a couple days. Resident #1's son said he picked Resident #1 up from the community shelter on 5/18/20 and took her to a group home that night. During a telephone interview on 7/21/20 at 4:30 p.m., the receiving group home administrator said Resident #1 arrived to the group home the night of 5/18/20. The group home administrator said the resident did not have any medication, transfer information, or instructions regarding the resident's care when she arrived at the facility. She said the resident did not come with any information about wound care or [MEDICAL TREATMENT]. The group home administrator said as a favor to the parole officer, she agreed to accept the resident for a couple days, and attempt to find placement for the resident. The administrator said Emergency Medical Services (EMS) was called on 5/19/20 to assess the resident and possibly take her to the hospital because they could not care for the resident's medical needs. She said EMS determined Resident #1 did not need medical care at that time. She said EMS was called again on 5/21/2020 at 10 p.m. because the resident was weak, was disoriented, was in pain, and was unable to urinate. She said the EMS personnel said Resident #1's oxygen level was low, and then they transported the resident to a local hospital. The administrator said the resident had not received [MEDICAL TREATMENT] or any medications since she arrived to the group home on 5/18/20. A social service note dated 5/19/20 indicated Resident #1's clinical records were faxed to a nursing facility in a different city at the request of Resident #1's parole officer. A History of Present Illness report from the hospital dated 5/21/2020 indicated Resident #1 had generalized weakness and fatigue and reported she had not been to [MEDICAL TREATMENT] for the last 9 days because she recently moved from a different city and had not found a nephrologist. The records indicated Resident #1's chest x-ray was concerning for bilateral pleural effusion and cardiomegaly, consistent with noncompliance with [MEDICAL TREATMENT]. The records indicated Resident #1 would be admitted and a nephrologist would be consulted for [MEDICAL TREATMENT] orders. The records indicated on arrival to the emergency department, the resident was evaluated and her blood pressure was 167/70 (a normal blood pressure is 120/80). During a telephone interview on 7/9/20 at 1:09 p.m., the hospital case manager said she tried to reach the nursing facility many times, however they refused to speak with her and hung up every time she called. A Discharge the Resident policy revised July 2015 indicated .if the resident is being discharged to a hospital or another facility, make sure that a transfer form is completed and telephone report is called to the receiving facility . The administrator was notified on 7/9/20 at 9:15 a.m. an immediate jeopardy situation had been identified due to the above failures. The IJ template was provided to the administrator. The facility's Plan of Removal was accepted on 7/9/2020 at 4:43 p.m. and stated: Plan of Removal 7/9/2020: *In-service completed on 7/9/2020 of facility staff who participate in discharge planning, including Administrator, Director of Nurses, Care Management Nurse, Social worker, Director of Rehabilitation with instruction on prior to the facility for a safe discharge location, ensuring resident is aware, setting up home health and/or medical equipment as needed, prescription set up. This included ensuring that discharge is completed safely prior to discharge to a location that can meet their needs including medical needs, discharge with medication as able/prescribed. *Facility will ensure that a supervised person is present when required by the individual's needs. *The discharge log and checklist will be completed each morning by IDT effective 7/9/2020. *Discharge planning review form will be completed by clinical team, and review at morning clinical meeting. Staff in service on this completed on 7/10/2020. *Notice to Resident/RP of transfer/discharge form to be completed for discharges effective 7/9/2020. In-service completed 7/10/2020. *Follow up phone calls to discharged residents to be completed by admissions, social services or designee effective 7/9/2020. *Audit of discharges at morning clinical daily (Mon-Fri) for 30 days, then twice per week for 30 days, then weekly going forward. *Reviewed 5 discharged residents since 5/18/2020 discharge of identified resident, and 5 of 5 residents were contacted. All replied that they were discharged safely, and had all services set in place as requested per each resident's preference. On 7/10/2020, the surveyor confirmed the plan of removal had been implemented to remove the IJ by: *During an interview on 7/10/2020 at 9:15 a.m., the ADON said on 7/9/20, she completed in-servicing with facility staff who participated in discharge planning. *During an interview on 7/10/2020 at 9:20 a.m., the social worker said she reviewed recent resident discharges to make sure the families were notified of the discharge, and they were. *The surveyor called two resident family members, who indicated the social worker reached out to them, and they had no concerns regarding the resident's discharges from the facility. *During an interview with the MDS nurse, she verified the discharge planning checklist was in place and included each aspect of the discharge planning process that needed to occur leading up to a resident's discharge. *The ADON was observed giving an in-service to the MDS director, social worker, administrator, director of rehab, and other nursing staff regarding discharge planning. *Two discharged resident charts were reviewed for residents who discharged from the facility since 6/26/2020. The charts indicated appropriate notifications were made and the resident's discharges were safe. *Two nurses said they were trained to make sure medications and any required treatments were gathered for residents who are being discharged . *Two CNA's said they were trained on making sure all personal items were packed for the resident prior to discharge. On 7/10/2020 at 9:53 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm and a scope of isolated, due to the facility's need evaluate the effectiveness of their plan of removal.

During interview and record review, the facility failed to ensure residents were free from unnecessary medications based on a comprehensive assessment for 1 of 5 residents reviewed for medications. (Resident #1) Resident #1 was administered [MEDICATION NAME], Trazadone, and Klonopin while the resident was showing signs of decreased level of consciousness. The facility did not monitor the cumulative effect of these medications and Residnt #1 was hospitalized with benzodiazapine or [MEDICATION NAME] overdose. This failure led to Resident #1's hospitalization and could place 17 other residents who resided on the express/wellness hall at risk for adverse consequences from unnecessary drugs. Findings included: The June 2015 physician orders [REDACTED]. The orders indicated the resident should receive Trazadone 50 milligrams (mg) (anti-depressant) every night, [MEDICATION NAME] (muscle relaxer) 20 mg three times a day, [MEDICATION NAME] 300 mg (anticonvulsant and [MEDICATION NAME]) three times a day, and Klonopin (benzodiazepine used for anxiety) 1.0 mg every night and 0.5 mg every 6 hours as needed for anxiety. The MDS dated [DATE] indicated Resident #1 was severely impaired cognitively with behaviors such as signs of [MEDICAL CONDITION] with inattention and disorganized thinking and verbal behavior symptoms directed towards others. The resident required extensive assistance with bed mobility, transfers, and ADLs. A telephone physician order [REDACTED].#1 was discharged to the hospital due to increased temperature, altered mental status, and decreased oxygen saturation. A nursing note dated 06/07/15 timed 2:30 p.m. indicated Resident #1 was readmitted to the facility. The resident was assisted to bed and cries and moans a lot and yells out. The June 2015 MAR indicated [REDACTED] A nursing note dated 06/08/15 timed 8 a.m. indicated Resident #1 was yelling out and was redirected by the nurse. At 3 p.m., the resident was resting quietly in bed without distress. The June 2015 MAR indicated [REDACTED] During an interview on 06/17/15 at 1:55 p.m., LVN B said when she started her shift at 2 p.m. on 06/08/15, Resident #1 was yelling out. She said she asked Resident #1 what was wrong, but the resident said she did not know. She said she administered Klonopin 0.5 mg to the resident. LVN B said Resident #1 did not have any further behaviors or yelling out during her shift. During an interview on 06/16/15 at 1:10 p.m., MA C said on 06/08/15 she administered Resident #1 Trazadone 50 mg, [MEDICATION NAME] 300 mg, and Klonopin 1 mg at the scheduled time (8 p.m.). She said Resident #1 was sleeping and she had to call her name and touch her to wake the resident up. MA C said the resident rolled her eyes open and she administered the crushed medication to the resident. She said the resident swallowed the medications and fell back to sleep. MA C said Resident #1 did not complain of pain or say anything while she was in the resident's room. The individual control drug record indicated on 06/07/15 Resident #1received Klonopin 1 mg at 8:30 p.m. On 06/08/15, Resident #1 received Klonopin 0.5 mg at 1:30 a.m. and 2:30 p.m. and Klonopin 1 mg at 8 p.m. A nursing note dated 06/09/15 timed 12 midnight indicated Resident #1 showed no signs of distress. At 6:30 a.m., the resident responded to tactile stimuli with no acute distress. At 10:15 a.m., the note indicated to see SBAR. During an interview on 06/16/15 at 1:22 p.m., LVN A said Resident #1 yelled out at times, but had no other behaviors. She said 06/09/15 arrived to work at 6 a.m. LVN A said Resident #1 was sleeping and did not wake up to eat breakfast. She said later that morning around 10 a.m. Resident #1 still was not awake and was showing signs of lethargy. She said the nurse practitioner was in the facility and aware of the resident's decline. She said the nurse practitioner ordered Resident #1 to be sent to the hospital. The SBAR communication form dated 06/09/15 timed 10:15 a.m. indicated Resident #1 had decreased consciousness with dilated pupils. The resident was sent to the hospital for evaluation. A hospital emergency physician note dated 06/09/15 timed 11:15 a.m. indicated Resident #1 was admitted with altered mental status. A hospital physician history and physical dated 06/09/15 indicated Resident #1 was admitted to the emergency roiagnom on [DATE] for obtundation (a greatly reduced level of consciousness; not yet comatose but aroused only with very strong stimulus). The physician's impression of Resident #1 indicated she was obtunded likely secondary to benzodiazepine overdose and/or [MEDICATION NAME] overdose. Possible [MEDICATION NAME] toxicity. The plan included to continue supplemental oxygen. I have considered intubation to protect her airway; however, I will try Romazicon and [MEDICATION NAME] to see if it can reverse any drug effect so she can protect her airway. A hopsital physician consultation report dated 06/10/15 indicated Resident #1 was admitted with mental status change and her medications were adjusted. The medications, while hospitalized , included antibiotics, breathing treatments, a gastro-reflux medication, as needed nausea medication, as needed mouth wash, and the normal saline intravenous fluids. The physician's impression indicated Resident #1 had moderate [MEDICAL CONDITION]. This may be toxic metabolic. Medications have been adjusted. Questionable respiratory issue. The report indicated the resident was placed on a Bi-pap machine for respiratory issues. During an interview on 06/12/15 at 1:50 p.m., CNA D said Resident #1 could talk and voice needs including if she was experiencing pain. She said the resident yelled out at times, but had no other behaviors. During an interview on 06/16/15 at 2:45 p.m., the DON said Resident #1 was admitted with an infected pressure ulcer and was sick. She said the resident was sent out once on 06/05/15 for lethargy, decreased level of consciousness, and increased temperature. The DON said she was readmitted (06/07/15) and sent back to the hospital on [DATE] for lethargy. During an interview on 06/18/15 at 2:25 p.m., the DON said she expected staff to hold medications if a resident showed signs of decreased level of consciousness or lethargy. The website, <http://www.drugs.com/drug-interactions>, accessed 06/26/15 indicated the following: .Using [MEDICATION NAME] together with [MEDICATION NAME] may increase side effects such as dizziness, drowsiness, and difficulty concentrating . .Using [MEDICATION NAME] together with [MEDICATION NAME] may increase side effects such as dizziness, drowsiness, and difficulty concentrating . The resident census list dated 06/12/15 indicated there were 17 residents and one resident (Resident #1) at the hospital who resided on the express/wellness hall.