Every finding on record at Avir at Seguin

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 1 of 1 communal area (secure unit), reviewed for safe environment. Common area in the secure unit had two hanging overhead light covers. This failure could place residents at risk of experiencing a diminished quality of life, accidents and hazards. The findings included: Observation on 7/22/26 from 8:30 a.m. to 9:30 a.m. of the secure unit communal area revealed two overhead light ceiling covers were hanging overhead near Resident #1 who was ambulatory, alert and not oriented and not interview-able sitting on a chair. [The census in the secure unit was 7]During an interview on 7/22/26 at 9:31 a.m., the Maintenance Director, the Maintenance Director stated the overhead covers light have become loose on the rails and needed fixing. The Maintenance Director stated he made daily environmental rounds and saw no issues with the light covers the previous day (7/21/26). The Maintenance Director stated no staff in the secure unit had informed him of the overhead light covers hanging and there were no work orders in the Maintenance Log that addressed the light ceiling covers. The Maintenance Director stated that if the covers had fallen on a resident, it could have caused an injury.During an interview on 7/22/26 at 10:14 a.m., the Administrator stated she had no explanation for the loose covers in the secure unit. The Administrator stated the hanging covers needed to be fixed to avoid an accident or injury to a resident if the covers fell. During an interview on 7/22/26 at 10:55 a.m., the Regional Maintenance Director stated no explanation why two overhead ceiling covers were hanging in the communal area in the secure unit.Record review of facility's Maintenance Service policy, dated revised December 2009, read: Maintenance service shall be provided to all areas of the building, grounds, and equipment. [The policy did not address hot water temperatures in rooms to include common shower rooms]

Based on observation, interview, and record review, the facility failed to ensure residents were provided with a sanitary and comfortable environment for one (1) of five (5) residents (Resident #3) reviewed for physical environment. The facility failed to ensure Resident #3's room's HVAC vent was free from grey particle buildup and staining. This failure could place residents at risk for decreased quality of life.The findings included: Record review of Resident #3's Face Sheet, dated 07/14/2026, revealed a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #3's Diagnosis Report, dated 07/14/2026, revealed diagnoses including type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), alcohol abuse (the impaired ability to stop or control alcohol use despite negative consequences in various aspects of life), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #3's Annual MDS Assessment, dated 04/20/2026, revealed Resident #3 had a BIMS score of 11, indicating he was moderately cognitively impaired. He was independent for mobility and had not had any infections or pulmonary diagnoses (such as: asthma, lung diseases, and medical conditions in which the lungs cannot balance the oxygen and carbon dioxide in the blood) in the last seven (7) days (04/14/2026 to 04/20/2026). During an observation and interview on 07/14/2026 at 12:46 p.m., an HVAC vent located on the ceiling of Resident #3's room and was observed to have dark grey to black spots and an unknown substance. The vent was observed to be located above an unoccupied bed, located next to the hallway entrance or exit, with personal items spread out on the bed. Resident #3 was observed to be occupying the second bed in the room, next to the outside wall and window. Resident #3 stated he did not have a roommate and the personal items on the bed under the vent were his. He stated the vent was dirty and he had told the lady (clarified he was referring to the ADMIN) about it and she had stated it had been tested. He was unable to provide an approximate date in which he had reported the dirty vent to the ADMIN. He stated he had also asked for the vent to be cleaned. He stated the vent's cleanliness remained the same. He stated he did not like how it felt to have a dirty vent and it bothered him because he used to install air conditioners and knew that if the vent looked that way (dirty), then he knew the air ducts would have been the same and needed to be cleaned. During an interview on 07/14/2026 at 04:22 p.m., the Maint Dir stated he had been the facility maintenance director for about a month and a half. He stated when he first started, the dirty vents were one of the first things he noted that needed to be done. He stated the task of cleaning the air vents was not on the facility's electronic maintenance task program but he knew the task would fall to him. He stated had ordered the supplies to clean all the facility HVAC vents and had cleaned a few but had not gotten to all of them. He stated he had not heard any residents voice any concerns about their vents. He stated the impact of dirty vents was that it could impact the air flow into the room. He stated he did not believe any residents had been impacted because he had not been notified of any complaints or anyone having said anything about them. During an interview on 07/14/2026 at 05:57 p.m., the DON stated she believed the impact of a dirty vent in a resident's room would depend on what the dirt or staining was from. She stated she was not aware of any residents voicing complaints about that. During an interview on 07/14/2026 at 06:16 p.m., the ADMIN stated the staining on the HVAC vents was from moisture and humidity in the air vents. She stated she knew the Maint Dir was working on addressing that task. She stated she had not had any residents complain about the vents to her. She stated she did not believe the residents' care or health would have been impacted by stained vents or vents with particle buildup on them. Record review of policy titled Maintenance Service, dated revised December 2009, revealed Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.d. maintaining the heat/cooking system, plumbing fixtures, wiring, etc., in good working order.

Based on observation, interviews, and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (1) of five (5) residents (Resident #2) reviewed for accurate medical records. The facility failed to ensure Resident #2's diagnosis list was complete. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.The findings included: Record review of Resident #2's Face Sheet, dated 07/14/2026, revealed a [AGE] year-old female. She was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's Diagnosis Report, dated 07/14/2026, revealed No Records Found. Record review of Resident #2's electronic medical record MDS tab, accessed 07/14/2026 at 02:14 p.m., revealed Resident #2 had two (2) MDS Assessments on record, an accepted Entry MDS, dated [DATE], and an In Progress Discharge Return Not Anticipated MDS, dated [DATE]. A comprehensive MDS with active diagnoses was not available. Record review of Resident #2's BIMS Evaluation, dated 07/10/2026, revealed a score of 10.0, indicating Resident #2 was moderately cognitively impaired. Record review of Resident #2's Order Summary Report, dated 07/14/2026, revealed the following medical diagnoses included in order summaries: shortness of breath, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements or feelings), hyperlipidemia (high fat levels in the blood), and pain. Record review of Resident #2's hospice clinical documentation for respite stay (a temporary break for caregivers from the primary residence), dated 06/24/2026, revealed Resident #2 had the following diagnoses/procedures:- chronic obstructive pulmonary disease (a type of progressive lung disease), - shortness of breath, - dependence on supplemental oxygen, - muscle weakness,- insomnia (trouble falling and/or staying asleep), - anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness),- chronic pain,- chronic migraine (a type of headache characterized by intense throbbing pain), - history of traumatic brain injury (a brain injury caused by an external force that disrupts brain function),- other specified postprocedural states (the health conditions, statuses, or effects that occur after a surgical, medical, or other intervention),- mixed hyperlipidemia, - history of transient ischemic attack (a brief blockage of blood supply to the brain) and cerebral infarction (a disruption in the brain's blood flow), and - idiopathic (a condition that arises spontaneously or without an identifiable cause) epilepsy (a brain disorder that causes seizures). Record review of Resident #2's Progress Note, dated 06/26/2026 at 02:20 p.m., revealed Resident #2's nursing clinical admission was completed by LPN B. During an observation and interview on 07/14/2026 at 02:34 p.m., Resident #2 was observed sitting on her bed. Resident #2 stated the care provided by the staff had been okay. During an interview on 07/14/2026 at 05:11 p.m., LPN B stated she completed Resident #2's admission. She stated the admitting nurse did not enter the resident diagnoses. She stated Resident #2's diagnoses should have already been entered, especially since Resident #2 was a repeat admission. LPN B stated she believed the resident diagnoses were normally entered by either the MDS Nurse or the business office when they reviewed the resident's documentation prior to admission. She stated the nurses would only put in a diagnosis when they received a new order with a new diagnosis. During an interview on 07/14/2026 at 05:54 p.m., the MDS Nurse stated she had worked for the facility for around two (2) months and was still learning the protocols. She stated at the prior facility she worked at; the admitting nurse would enter the diagnoses as part of the admission process. The MDS Nurse stated she needed to clarify who was the staff member responsible for this task. She stated the impact of a resident not having diagnoses was that the staff could be at risk of not knowing hot to treat the resident; however, the direct care nurses had access to the resident's discharge paperwork (paperwork from where the resident had previously received care) which would include the resident's diagnoses. During an interview on 07/14/2026 at 05:57 p.m., the DON stated she had just learned the MDS Nurse was responsible for entering the residents' diagnoses lists. She stated for nine (9) out of ten (10) cases, when the facility had an admitting resident, she would go into the resident's record and enter the resident's diagnoses if they had not already been entered. The DON stated she had been out during Resident #2's two admissions, so she was not able to check Resident #2's record as she normally would have. The DON stated she did not believe Resident #2's care was impacted by not having her diagnoses list entered because the ordered medications that Resident #2 received, had the diagnoses noted. The DON stated she did not believe any other residents were impacted by this process having been missed, because Resident #2's admission was the only admission during her, the DON's, time out of the office. During an interview on 07/14/2026 at 06:16 p.m., the ADMIN stated to her knowledge, the MDS Nurse was responsible for entering admitting resident's diagnoses. She stated she believed the MDS Nurse might not have been aware of that part of her job tasks. The ADMIN stated she did not believe having the diagnoses not entered into the electronic medical record impacted Resident #2's care because the direct care staff were able to view the resident's diagnoses on Resident #2's admitting paperwork. Record review of policy titled Comprehensive Assessments, dated updated February 2025, did not specify the process of entering resident diagnoses into the resident's medical record. Record review of policy titled Physician Orders, dated updated February 2025, did not specify the process of entering resident diagnoses into the resident's medical record.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided with such care, consistent with professional standards of practice, for one (1) of two (2) residents (Resident #1) reviewed for respiratory care. The facility failed to properly secure Resident #1's oxygen tubing off the floor. This failure could place residents at risk for cross-contamination and respiratory infection.The findings included: Record review of Resident #1's Face Sheet, dated 07/14/2026, revealed an [AGE] year-old female. She was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 07/14/2026, revealed diagnoses including pneumonia (a lung infection), wheezing (a high-pitched whistling sound that occurs when the airways are narrowed or obstructed), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). Record review of Resident #1's Annual MDS Assessment, dated 05/13/2026, revealed the resident was rarely/never understood and was severely impaired for making decisions regarding tasks of daily life. She had not received oxygen therapy while a resident of the facility and within the last 14 days (04/30/2026 to 05/13/2026). Record review of Resident #1's Order Summary Report, dated 07/14/2026, revealed the following order summary with order status, order date, start date, and end date if available: - O2 PER NC - SOB or anxiety 2LPM for Mild discomfort 3LPM for Mild to moderate 4LPM for Moderate to Severe 5LPM for Severe discomfort every shift, noted as active, order date of 07/10/2026, start date of 07/11/2026, and no end date. During an observation and attempted interview on 07/14/2026 at 02:43 p.m., a portion of Resident #1's oxygen tubing was observed to be directly touching the floor between the connection from the oxygen concentrator on one side and a nasal cannula on the other side. The oxygen was observed to be provided at the time of observation with a nasal cannula in place. Resident #1 was observed to be asleep and did not wake when stating her name. During a telephone interview on 07/14/2026 at 03:02 p.m., Resident #1's family member stated when she visits Resident #1, the oxygen tubing was usually in a bag on the oxygen concentrator. During an observation and interview on 07/14/2026 at 03:43 p.m., Resident #1's family member stated the staff usually put the oxygen tubing in the bag. She was observed picking Resident #1's oxygen tubing off the floor and attempting to place the oxygen tubing into the bag attached to the concentrator. The tubing was observed to not stay in the bag and fell out immediately after Resident #1's family member stopped holding it. During an observation and interview on 07/14/2026 at 03:44 p.m., Resident #1's oxygen tubing was observed to be in the same position, connected to the oxygen concentrator on one side and a nasal cannula on the other side with the oxygen tubing between directly touching the floor. CNA A stated he was not sure why the oxygen tubing would be on the ground. He stated he and the nurse, LPN B, check the tubing during their rounds (checking every resident at scheduled intervals). He stated the tubing should be rolled up. He stated the tubing would not have been touching the floor very long because he last provided direct care for Resident #1 around 02:00 p.m. During an interview on 07/14/2026 at 05:11 p.m., LPN B stated staff were supposed to keep the excess oxygen tubing in a bag with the resident's name and the bag would be dated. She stated she did not know how the tubing came to be out of the bag. She stated the concern of the tubing touching the floor would be possible contamination. LPN B stated Resident #1's tubing had been replaced. During an interview on 07/14/2026 at 06:05 p.m., the DON (with the ADMIN present during the interview) stated her expectation was for staff to use the right length of tubing, put the excess tubing in a bag on the oxygen concentrator, and keep the concentrator at a good distance from the resident per the length of the tubing. She stated staff were expected to replace the oxygen tubing when it touched the floor. She stated she did not feel Resident #1 was at any risk of harm because the staff keep an eye on the oxygen tubing throughout the day while they do their rounds. During an interview on 07/14/2026 at 06:06 p.m., the ADMIN (with the DON present during the interview) stated residents can move around resulting in the oxygen tubing having fallen. She stated she did not have any concerns for harm regarding the oxygen tubing touching the floor. Record review of facility policy titled Oxygen Administration, dated revised October 2010, did not specify preventing or procedure for contamination of oxygen equipment.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs for 1of 7 residents (Residents #1) reviewed for care plans. The facility failed to ensure Resident #1 had a care plan in his electronic medical record. This failure could place residents at risk of not having their needs met and not receiving appropriate care.The findings included:Record review of Resident #1's face sheet, dated 06/23/2026, reflected resident was an [AGE] year-old male, initially admitted [DATE] and re-admitted [DATE], with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities) and depression (a mood disorder that causes a persistent feeling or sadness and loss of interest). Record review of Resident #1's admission MDS assessment, dated 03/13/2026, reflected that the resident had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #1's electronic medical record reflected no comprehensive care plan. During an interview on 06/23/2026 at 03:00 PM, CNA B and CNA C revealed they knew how to care for residents by word of mouth. They revealed Resident #1 was able to feed himself, transfer himself, and was independent. They further revealed Resident #1 was able to ask for help and he had behaviors of walking up and down the hallway. They further stated that he was typically out of his room, so they were able to keep an eye on him. During an interview on 06/23/26 at 3:29PM: LVN A revealed she used care plans to know what care to provide for each resident. She revealed Resident #1 wandered and was exit seeking. She revealed she could not pull up the care plan in Resident #1's electronic medical record. She further revealed Resident #1 paced a lot as a way of coping with anxiety and restlessness. She revealed staff took Resident #1 out of the secured unit to attend activities. During an interview and observation on 06/23/26 at 03:35 PM, Resident #1was pacing up and down the secured unit hallway. He revealed he was dependent and was able to do eat, walk, use the restroom on his own. He felt that the nursing staff were great and helped him with his care. During an interview on 06/23/2026 at 03:52 PM, the ADON and Regional nurse revealed there was not a care plan in Resident #1's electronic medical record. The Regional Nurse revealed they had transferred to [a new platform] for the facility's electronic medical record and some care plans transferred under the Miscellaneous tab, but they could not find a care plan for Resident #1. The Regional nurse revealed the DON and nursing team all oversaw the care plans to ensure the care plans were updated. The DON revealed they did not have a hard copy of Resident #1's care plan but the facility was working on updating all the care plans. The Regional nurse revealed the care plans were a teaching tool for how to care for residents. She revealed the CNAs and nurses knew how to care for residents by talking to each other. She revealed the pertinent tasks done by CNAs for Resident #1 were under the tasks tab in Resident #1's electronic medical record and the tasks that the nurses needed to complete for Resident #1 were in Resident #1's doctor's orders. Record review of the facility's policy Care Plans, Comprehensive Person-Centered, revised March 2022, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 4 residents (Residents #2, #3, and #4) reviewed for care plans: The facility failed to ensure Resident #2, Resident #3 and Resident #4's comprehensive care plans were developed and implemented to include care areas identified in the admission MDS assessments. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:Record review of Resident #2's face sheet dated 2/06/2026 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: chronic combined systolic and diastolic congestive heart failure, chronic obstructive pulmonary disease (progressive lung disease making it difficult to breathe), vitamin deficiency, drusen (degenerative) of macula bilateral (small white or yellow deposits that accumulate on the retina and lead to vision problems), atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the coronary arteries leading to reduced blood flow and episodes of chest pain), dysphagia following cerebral infarction (trouble swallowing after a stroke), pain, diabetes mellitus due to underlying condition with diabetic autonomic poly neuropathy (diabetes resulting in damage to the nerves and nerve pain), hyperlipidemia (high levels of fat in the blood), essential primary hypertension, acute myocardial infarction (heart attack), constipation, anxiety disorder, muscle wasting and atrophy (decrease in muscle mass and strength), generalized muscle weakness, need for assistance with personal care and unsteadiness on foot. Record review of Resident #2's admission MDS assessment dated [DATE] revealed the resident had impaired vision and required corrective lenses, a BIMS score of 10 which indicated a moderate cognitive impairment. Her function ability was maximal assistance for toileting and showering, moderate assistance with dressing and personal hygiene. She was dependent on staff for moving and positioning and used a wheelchair. The assessment indicated Resident #2 was incontinent of bowel and bladder. She had active diagnoses which included medically complex conditions, coronary artery disease (heart disease), heart failure, hypertension (high blood pressure), renal insufficiency, renal failure or end-stage renal disease (kidney disease), diabetes mellitus, hyperlipidemia, cerebrovascular accident (stroke), anxiety disorder, asthma, chronic obstructive pulmonary disease or chronic lung disease, cataracts (cloudiness of the lens of the eye), glaucoma or macular degeneration (eye disease causing visual problems), dysphagia (trouble swallowing) and polyneuropathy (nerve pain in multiple locations). The assessment was coded for therapeutic diet, antidepressant, antiplatelet use, and oxygen use. The MDS assessment triggered the following care areas: cognitive loss/dementia, visual function, communication, ADL Function/Rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer and psychotropic drug use. Record review of Resident #2's comprehensive care plan revealed the resident desired to be full code status was the only portion of the care plan that had been started/developed. No other conditions/problems were addressed. Record review of Resident #3's face sheet dated 2/06/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: Type 2 diabetes mellitus, vitamin D deficiency, depression, insomnia, essential hypertension, low back pain, dementia, muscle wasting and atrophy, generalized muscle weakness, difficulty in walking, unsteadiness on feet, lack of coordination and cognitive communication deficit. Record review of Resident #3's admission MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated a moderate cognitive impairment. The assessment indicated a functional status of supervision or touch assistance and independence with rolling, sit to stand and transfers. The resident was continent of both bowel and bladder. He had active diagnoses which included: hypertension, diabetes, non-Alzheimer's dementia, depression, insomnia, low back pain, cognitive communication deficit (difficulty with communication), muscle wasting and atrophy of multiple sites, generalized muscle weakness, lack of coordination and unsteadiness on feet. The assessment indicated Resident #3 utilized a pressure reducing device for bed, was taking antidepressants and was utilizing speech therapy and physical therapy. The assessment triggered the following care areas: cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence/indwelling catheter, falls, nutritional status, and psychotropic drug use. Record review of Resident #3's comprehensive care plan initiated on 12/31/2025 revealed it listed the resident as full code status. No other care area had been developed. Record review of Resident #4's face sheet dated 2/06/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: cerebral infarction (stroke), age-related osteoporosis (weakening of the bones), hyperlipidemia, vascular dementia with agitation and behavioral disturbance, alcohol dependence in remission, major depressive disorder, single episode severe without psychotic features, generalized anxiety disorder, insomnia, chronic pain, essential hypertension, atherosclerotic heart disease of nature coronary artery without angina pectoris, atrial fibrillation, combined systolic and diastolic congestive heart failure, speech and language deficits following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and paralysis on one side of the body), disorder of arteries and arterioles (blood vessels), constipation, gout (a type of arthritis), contracture left hand (muscle stiffness and tightness), chronic kidney disease, overactive bladder, benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), dysphagia, lack of coordination, cognitive communication deficit, weakness and inferior subluxation of left humorous sequela (dislocation of shoulder joint). Record review of Resident #4's admission MDS assessment dated [DATE] revealed a minimal difficulty hearing loss in some environments, impaired vision with the use of corrective lenses, a BIMS score of 5 which indicated a severe cognitive impairment without behaviors. The assessment indicated Resident #4 utilized a wheelchair for movement, was unable to ambulate and required maximal assistance with movement and transfers. He required maximal assistance with dressing, showering and toileting/hygiene and set up assistance with personal hygiene, oral hygiene and eating. He was frequently incontinent of bowel and bladder. The assessment indicated active diagnoses which included: medically complex conditions, atrial fibrillation or other dysrhythmias (irregular heartbeat), coronary artery disease, heart failure, hypertension, benign prostatic hyperplasia, renal insufficiency, renal failure of end-stage renal disease, hyperlipidemia, arthritis, osteoporosis, cerebrovascular accident, non-Alzheimer's dementia, hemiplegia or hemiparesis, anxiety disorder, depression, cerebral infarction, chronic kidney disease, contracture, left hand, speech/language deficits following cerebral infarction. The assessment indicated the resident received scheduled pain medication, for pain that occasionally affected sleep and interfered with therapy activities and day-to-day activities. The assessment indicated the resident had shortness of breath when lying flat, was a current tobacco user and was at risk for pressure ulcers/injuries. Resident #4 was coded for taking the following classes of medication: antidepressant, anticoagulant, diuretic, opioid, antiplatelet, and anticonvulsant. The MDS assessment triggered the following care areas for the care plan: cognitive loss/dementia, visual function, communication, ADL functional/Rehabilitation Potential, urinary Incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, psychotropic drug use, and pain. Record review of Resident #4's comprehensive care plan initiated on 1/14/2026 revealed a care area for verbally inappropriate behaviors. No other care areas had been developed. During an interview on 2/06/2026 at 2:40 p.m., the Administrator stated the facility did not currently have a MDS Coordinator. She stated Corporate was doing the work remotely. During an interview on 2/06/2026 at 2:44 p.m., a Corporate LVN stated she had been remotely assigned MDS Coordination for the facility for about one week. She stated the facility's full time MDS Coordinator left. She stated they were looking to hire someone permanently at the facility for the position. The Corporate LVN stated she had not looked at any care plans yet, since she had just started about one week ago. During an interview on 2/06/2026 at 2:50 p.m., the DON stated she was aware some residents did not have comprehensive care plans. She stated she had been working on them when she could Corporate had started filling in for that role. The DON stated Resident #2, #3 and #4's comprehensive care plans had not been developed. She stated she was not certain why the care plans were not developed in December when they had a MDS Coordinator before she left a couple of weeks ago. The DON stated it seemed like the previous MDS Coordinator had been struggling even though she had tried to make the things easier for her and gave her samples of care plans to use when she completed the MDS assessments for triggered care areas. The DON stated a comprehensive care plan should be developed and implemented within 20 days of admission. The DON stated the comprehensive care plans were important, so staff knows how to care for each resident. She stated the comprehensive care plan paints a general picture of the resident and the care they need. Record review of the facility policy, titled Care Plans, Comprehensive Person-Centered dated March 2022 revealed: 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on interviews and record reviews, the facility failed to protect right of residents to be free from physical abuse for 1 of 4 (Resident #1) reviewed for abuse.Resident #1 was hit on the head by NA B.The noncompliance was identified as a PNC. The facility corrected the noncompliance on 8/6/2025 before the surveyor's entry to the facility.This failure could place residents at risk for abuse with injury, intimidation and a decreased quality of life. The findings were: Record review of Resident #1's face sheet dated 1/29/2026 revealed an [AGE] year-old male was admitted to the facility on [DATE] with diagnoses: major depressive disorder, dementia, hypertension (high blood pressure) and anxiety disorder. Record review of Resident #1's CP dated 08/11/2025 revealed he was care planned for impaired cognitive function due to dementia, fall risk, and aggressive behaviors of throwing objects, and trying to hit staff.Record review of Resident#1's QMDS dated [DATE] revealed he had a BIMS score of 3, indicative of severe cognitive deficit.Record review of NA B's witness statement dated 8/6/2025 stated, My co-worker CNA C was only telling me to lay Resident #1 down only. I was getting ready to lock his wheelchair to get him ready to be change out of nowhere Resident #1 had hit me in face. I had hit him back in the head out of reflexes. Record review of Resident #1's progress note dated 8/6/2025 revealed Resident #1 was assessed by LVN A and a light discoloration was noted to his forehead without bruising. LVN A stated there was possible edema noted to jaw area and slight discoloration to left upper ribs. X - rays were ordered (8/6/2025) to skull, jaw and ribs series for precautions. Interview on 1/29/2026 at 8:17AM CNA D said, when NA B hit Resident #1, NA B came out of the room and was talking about what happened to everyone as if she was in shock it happened. CNA D said NA B was new and was removed immediately from the floor. Interview on 1/29/2026 at 12:03PM the ADM said NA B was providing care for Resident #1 and Resident #1 swung and hit NA B in the face and NA B hit Resident #1 back in the head. The ADM said NA B was told to pass water but NA B refused, sitting in a chair in the main dining room, crying. The ADM said she told NA B to clock out because she was not fit to take care of the residents and that was when NA B admitted what she had done when she was on the secured unit and Resident #1 hit her. The ADM said NA B was terminated immediately and sent to the Human Resources office. The ADM said the police were called. Interview on 1/30/2026 at 11:46AM CNA C said she was in the room with another resident when she heard NA B yell, Don't do that! CNA C said by the time she ran out of the room to see what happened, NA B told CNA C that Resident #1 hit her and she hit Resident #1 back. Interview on 1/30/2026 at 12:15PM the ADM said it was important to keep the residents safe from abuse because they have the right to be safe in the place they live and to maintain the safest quality of life. Interview on 1/30/2026 at 12:25PM the HR said she had gone on the secured unit to get NA B to talk with her about something else, but was not aware of what happened until NA B confessed it to the ADM. NA B told her after she was terminated and waited for the police that: my mother always told me growing up that if somebody hit you, you hit them back. The HR said that lesson may not have been the best lesson for NA B to learn. Record review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation Prevention Program dated April 2021 stated in part: Residents have the right to be free from abuse; 1. Protect residents from abuse.by anyone including facility staff. Record review on 1/29/2026 of the 3613- facility's self-report revealed an investigation was done with Resident #1 who said, he was roughed up and with staff; NA B admitted to hitting the resident in the head and was immediately terminated and the police were called. Interviews on 1/29 and 1/30/2026 revealed 17 employees from different disciplines and schedules verbalized they understood the in-services for Abuse and Neglect and Dealing with Difficult Residents.Record review on 1/30/2026 of NA B's personnel file revealed NA B was hired 5/4/2025 and was terminated immediately on 08/ 6 /2025 for resident abuse. The ADM made a referral to EMR for employee misconduct. Record review on 1/30/2025 revealed the police report was dated 8/6/2025. Record review of Resident #1's progress notes dated 8/6/2025 revealed the physician and the family were notified and an assessment of injuries was done, and x-rays were ordered for precautions. Record review of staff in-service training for Abuse and Neglect and Dealing with Difficult Residents dated 8/6/2025 revealed all staff received the in-services. The staff who were not on duty that day received the in-service by phone or before they were allowed to work on the units on their scheduled day.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #53) reviewed for pharmacy services.Resident #53's ordered daily Lyrica (pain medication) was not available for the resident from admission on [DATE] to 7/28/25. The resident missed 7 doses.This failure could result in increased pain, and a decreased quality of life. The findings were: Record review of Resident #53's face sheet dated 7/31/25 indicated the resident was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. The resident's diagnoses included metabolic encephalopathy (a condition where brain function is disrupted due to chemical imbalances in the body, often resulting from illnesses or organ dysfunction), abscess of vulva (a collection of pus that forms in the skin or tissues of the vulva, the external female genitalia), malignant neoplasm of breast (a malignant tumor that develops in breast tissue), and low back pain. Record review of Resident #53's entry MDS dated [DATE] had no BIMS or pain information. Record review of Resident #53's pain MDS interview dated 7/22/25 indicated in the past 5 days the resident had pain, her sleep was not interrupted but her daily activities were limited due to pain and the resident had a pain scale of 4 and had received as needed [PH1] [PE2] pain medications. Record review of Resident #53's care plan undated did not address pain.Record review of Resident #53's physician orders revealed an order with a start date of 7/22/25 for Lyrica oral capsule 150 mg by mouth at bedtime for pain. Record review of Resident #53's physician orders revealed an order with a start date of 7/22/25 for tramadol oral tablet 50 mg by mouth every 6 hours as needed for pain. Record review of Resident #53's EMAR for July 2025 revealed Lyrica oral capsule 150 mg by mouth at bedtime for pain was documented as not given with a 9 indicating other/see progress notes from 7/22/25 to 7/28/25. Record review of Resident #53's EMAR for July 2025 revealed the resident's pain level was documented for day shift on 7/23/25 as a 3, on 7/26/25 as a 5, 7/27/25 as a 4, and on 7/30/25 as a 3. On 7/24/25, 7/25/25, 7/28/25, and 7/29/25 was documented as 0. Documentation for night shift pain level from 7/23/25 to 7/29/25 was documented as 0. Record review of Resident #53's EMAR for July 2025 revealed tramadol 50 mg by mouth every 6 hours as needed for pain was given on the following dates: - 7/25/25 at 8:57 p.m. with a pain level of 7 and documented as effective, -7/26/25 at 9:43 p.m. with a pain level of 8 and was effective, -7/27/25 at 8:42 a.m. with a pain level of 4 and was effective, -7/27/25 at 8:54 p.m. with a pain level of 8 and was effective, -7/28/25 at 1:41 p.m. with a pain level of 9 and was effective, 7/29/25 at 10:46 a.m. with a pain level of 8 and was effective, and 7/29/25 at 5:07 p.m. with a pain level of 8 and was effective.[PE3] Record review of Resident #53's progress notes revealed a nursing note by an unknown staff dated 7/29/25 at 11:15 a.m., the resident's Lyrica pain medication had not come from the pharmacy, and it needed to be called in to the pharmacy and a message was sent to the physician. In an observation and interview on 7/31/25 at 1:55 p.m., Resident #53 was in the activity room sitting at a table, well-groomed and dressed appropriately. The resident was seated in a wheelchair at a table by herself playing bingo. The resident was sitting calmly with no fidgeting or facial mask of pain. The resident stated she was doing okay but had chronic pain. The resident stated her pain level was normal at this time and when asked for a specific pain level the resident rated it at an 8 at this time and stated her pain was chronic with her back and she had no pain to her surgical areas. The resident stated she did not have her Lyrica here at the facility for several days at first and stated she had been on Lyrica previously, but it did not matter and not having it did not really affect her pain levels as she was in constant pain and was used to it. The resident further stated the staff had given her the tramadol pain medication PRN and her pain was controlled as much as it could be or had been before. In an interview on 7/31/25 at 3:45 p.m., with the DON and ADON. The ADON stated she was notified on 7/29/25 the Lyrica had not arrived and she contacted the physician, as the pharmacy stated Lyrica was on back order starting on 7/21/25. The ADON stated the pharmacy told her they had notified the physician. The ADON notified the physician, and the resident received the generic for Lyrica the same day on 7/29/25. The ADON stated the facility used agency nurses and it was missed but it had been on back order. The DON and ADON both stated there were not any consequences to the resident as the lyrica takes time to work and the resident had been medicated with other pain medication. The DON stated she asked the pharmacy to send documentation the medication was on backorder and the physician was notified and the DON stated the pharmacy told her they could not do that. In an interview on 7/31/25 at 4:00 p.m., the resident's PCP stated he could not recall if the pharmacy notified him that Resident #53's Lyrica was on back order or not. The PCP stated he was aware the resident had not had it since admission but did have it currently. The PCP further stated he did not feel it would cause the resident harm as Lyrica takes 2 weeks to work and the resident had other prn pain medication. In an interview on 7/31/25 at 3:45 p.m., the DON stated there was not a facility policy specific to Resident #53 not receiving her Lyrica pain medication.

Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #28) reviewed for hospice services, in that: The facility failed to ensure Resident #28's hospice documents including: The most recent hospice plan of care specific to each patient, hospice election form, physician certification and recertification of the terminal illness specific to each patient, names and contact information for hospice personnel involved in hospice care of each patient, and instructions on how to access the hospice's 24-hour on-call system. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #28's admission Record, dated 07/30/25, revealed a [AGE] year-old male admitted on [DATE] with diagnosis of malignant neoplasm of rectum (rectal cancer), glaucoma (damage to the optic nerve of the eye), and obstructive and reflux uropathy (urine can't flow through your ureter, bladder, or urethra due to some obstruction). Record review of Resident #28's admission MDS assessment, dated 6/25/25, revealed the resident had fully intact cognition for daily decision making. Record review of Resident #28's comprehensive care plan, initiated on 6/13/25, contained focus areas for nutrition stating the resident met criteria for severe PCM (protein calorie malnutrition) due to low body weight and was on hospice care. Record review of Resident #28's EHR revealed a document titled hospice Documents revealed a form with hospice orders dated 6/12/25 and an illegible DNR. There was no other hospice documents located in the resident's EHR. During an interview on 7/30/25 at 3:06 p.m. the DON stated the SW and her were responsible for ensuring the residents hospice documents were available at the facility. During an interview on 7/30/25 at 3:08 p.m. The SW stated she was not responsible for the hospice binder. During a follow up interview on 7/30/25 at 3:09 p.m. the DON stated she was responsible for the Residents hospice binders. The DON stated she was unsure where Resident #28's hospice binder was at but they were looking for it. During an interview on 7/30/25 at 3:20 p.m. The hospice admission nurse stated she could not say if Resident #28's hospice binder had ever been delivered to the facility however they were working on getting the binder delivered. During an interview on 7/31/25 at 2:04 p.m. the Administrator stated the DON was responsible for resident's hospice binders. During a follow up interview on 7/31/25 at 2:17 p.m. the DON stated they were unaware that Resident #28's hospice binder was not at the facility. The DON stated she did not think the missing hospice documents would affect the resident care at the facility since they already had orders in the EHR. Record review of the facility's policy titled Hospice Program, dated 7/2017, stated Policy Statement Hospice services are available to residents at the end of life. 12. Our facility has designated ___________ (Name) __________ (Title) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the state scope of practice act). He or she is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family; c. Ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians; d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form; (3) Physician certification and recertification of the terminal illness specific to each resident; (4) Names and contact information for hospice personnel involved in hospice care of each resident; (5) Instructions on how to access the hospice's 24-hour on-call system; (6) Hospice medication information specific to each resident; and (7) Hospice physician and attending physician (if any) orders specific to each resident. e. Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The cooler had a package of sliced lunch meat with a lot of juice in the package that was sliced opened and not closed. The freezer had a bag of frozen sugar cookie dough that was left open. These failures could place residents that received meals and or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 7/28/2025 at 10:21AM revealed a bag of sliced lunchmeat in the cooler that was in its original package with a substantial amount of liquid from the meat, was sliced open and was placed in a food grade plastic bag with a knot that was torn open. The bag nor the package was sealed which left the sliced lunchmeat opened. A bag of sugar cookie dough was in the freezer open and not sealed.The DM said, Oh, I'll fix that right away.Observation on 7/28/2025 at 3:30PM revealed the bag of cookie dough remained in the freezer with the bag tied closed. Interview on 7/28/2025 at 3:30PM the surveyor asked the DM about the cookie dough, she said, It was used last week on Thursday, and I thought it was okay to keep it. The surveyor asked if it was safe to keep the bag of cookie dough and she said, No, because it could have freezer burn. The DM removed the bag of cookie dough and discarded it in the garbage. Interview on 7/30/2025 at 11:28AM the RD said it was important to store food properly to prevent cross contamination of food and to prevent food borne illness to the residents. She said food stored in the freezer should be closed as well to keep the taste and so it would not have the taste of freezer burn. Record review of facility policy titled, Food Receiving and Storage dated Revised November 2022 stated' Food shall be received and stored in a manner that complies with safe food handling practices Under the section titled, Refrigerated/Frozen Food Storage stated, 1. All food stored in the refrigerator and freezer are covered, labeled, and dated ( used by date). Record review of FDA titled, Are You Storing Food Safely?' dated 1/18/2023 under the section Keep foods covered stated Store refrigerated foods in covered containers or sealed storage bags. Under Freezer Facts stated, Freezer burn is a food quality issue, not a food safety issue. It can occur when food is not securely wrapped in air-tight packaging.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #5 and Resident #28) reviewed for care plans: 1. The facility failed to ensure Resident #5's comprehensive care plan was completed in a timely manner and included his PICC line (is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart). 2. The facility failed to ensure Resident #28's comprehensive care plan was completed in a timely manner and included his code status. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.The findings included: Record review of Resident #5's admission record, dated 7/30/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted last on 6/7/25 with diagnoses including arthritis due to other bacteria and methicillin susceptible Staphylococcus aureus infection as the cause of disease classified elsewhere. Record review of Resident #5's admission MDS assessment, dated 6/9/25, revealed Resident #5's cognition was fully intact for daily decision making. Section O revealed he had IV access. Record review of Resident #5's Comprehensive Care Plan, initiated on 6/11/25, contained focus for nutrition and code status only. Record review of Resident #5's physician orders, dated 7/30/25, revealed an order for dressing change to PICC site every 7 days and PRN every day shift every Friday, with a start date of 6/13/25, and no end date. During an observation and interview on 7/28/25 at 2:59 p.m. Resident #5 stated he had an IV he received antibiotics nightly for a leg infection through. He stated they did provide care to the IV site, and he had no issues with the IV. Resident #5 had an intact IV access with a bandage covering the IV insertion site. 2. Record review of Resident #28's admission Record, dated 07/30/25, revealed a [AGE] year-old male admitted on [DATE] with diagnosis of malignant neoplasm of rectum (rectal cancer), glaucoma (damage to the optic nerve of the eye), and obstructive and reflux uropathy (urine can't flow through your ureter, bladder, or urethra due to some obstruction). Record review of Resident #28's admission MDS assessment, dated 6/25/25, revealed the resident had fully intact cognition for daily decision making. Record review of Resident #28's comprehensive care plan, initiated on 6/13/25, contained focus areas for nutrition stating the resident met criteria for severe PCM (protein calorie malnutrition) due to low body weight and was on hospice care, and the resident had a foley. Record review of Resident #28's order summary, dated 6/30/25, revealed an order for DNR with a start date of 6/12/25, and no end date. During an interview on 7/30/25 at 3:08 p.m. The SW stated she had not seen the Resident's OOH DNR in the resident EHR. The SW stated either her or MDS B were responsible for adding the code status to the resident's care plan. During an interview on 7/30/25 at 3:15 p.m. MDS B stated Resident #5 and Resident #28's comprehensive care plans were in progress and not completed. MDS B stated the facility had recently switched medical record systems and were working on in putting all resident's care plans into the new system. MDS B stated they were behind, and she was newer to the position. During an interview on 7/31/25 at 2:11 p.m. the DON stated they were trying to get everyone caught up on care plan since they switched over EHRs. The DON stated this did not affect the residents because nurses had access to the residents in MARs and TARs. The DON stated staff knew the residents and how to care for them without the care plans. Record review of the facility's policy, titled Comprehensive Care Plans, dated 3/2022, stated Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Record review of the facility's policy titled Advance Directives, dated 10/16/24, stated Resident has the right to formulate advanced directives to convey decisions about end of life ahead of time The social service director (SSD)/ designee will complete an advanced care planning plan of care and indicate the residence choice regarding advanced directives and code status.

Based on observation, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 (Resident #28) of 8 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure Resident #28's OOH DNR was legible and able to use in emergency situations. This failure could affect any residents who have medical records and could result in misinformation about professional care provided.Findings included: 1. Record review of Resident #28's admission Record, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] with diagnosis of malignant neoplasm of rectum (rectal cancer), glaucoma (damage to the optic nerve of the eye), and obstructive and reflux uropathy (urine can't flow through your ureter, bladder, or urethra due to some obstruction). Record review of Resident #28's admission MDS assessment, dated [DATE], revealed the resident had fully intact cognition for daily decision making. Record review of Resident #28's baseline care plan, dated [DATE], revealed the resident had elected DNR status. Record review of Resident #28's order summary, dated [DATE], revealed an order for DNR with a start date of [DATE], and no end date. Record review of Resident #28's OOH DNR revealed, the document was not legible. The document was dark, and this surveyor was unable to see the information. During an interview on [DATE] at 3:06 p.m. the DON stated the SW was responsible for OOH DNR paperwork. During an interview on [DATE] at 3:08 p.m. The SW stated she had not previously seen the OOH DNR in the resident's EHR. The SW stated the information on the document was not visible. The SW stated they would request a legible copy to add to the resident's EHR. The SW stated she was unsure if an emergency occurred if they would be able to use the OOH DNR. The SW stated she was unsure if this would effect the residents wish for code status in an emergency. During an interview on [DATE] at 2:04 p.m. the Administrator stated she did not believe EMS would have accepted Resident #28's OOH-DNR if there was an emergency event. The Administrator stated she did not think if affected the resident unless he had some type of event that required emergency services. The Administrator stated she did not know if it the illegible DNR honored Resident #28's wishes of a do not resuscitate order. The Administrator stated the social worker was responsible for the resident's advance directives. During a follow up interview on [DATE] at 2:17 p.m. the DON stated she was unsure if EMS would honor the Resident's OOH DNR. The DON stated the OOH DNR was not the best copy and they had obtained a better copy of the DNR since. Record review of the facility's policy titled Advance Directives, dated [DATE], stated Resident has the right to formulate advanced directives to convey decisions about end of life ahead of time. Advanced directives are honored in accordance with state law and facility policy. Advanced directives that have been completed, will be copied and uploaded into the resident's electronic health record (EHR) and the EHR will be updated to reflect whether or not the resident has executed any advanced directives . The social service director (SSD)/ designee will complete an advanced care planning plan of care and indicate the residence choice regarding advanced directives and code status. The social worker/ designee will also ensure that: a.) Ensure that a copy of the OOH-DNR is uploaded into the EHR.

Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 4 days [PH1] reviewed for nursing services. The daily staff posting was not posted on 7/28/25. This failure could result in residents and visitors not knowing how many staff were providing services to the residents. The findings were: In an observation on 7/28/25 at 9:35 a.m., the daily staff posting was not observed in the facility lobby, at the nursing station, or the beginning of each hall. In an observation on 7/28/25 at 12:30 p.m., the daily staff posting was not observed in the facility lobby, at the nursing station, or on any of the halls in the facility. In an observation and interview on 7/28/25 at 3:55 p.m., CNA A stated she was unsure of what the daily staff posting was or where it was located. The daily staff posting could not be located throughout the nursing station area. In an observation an interview on 7/28/25 at 4:00 p.m., the ADON stated she was unsure of where the daily staff posing was located and it could not be located in the nursing station area. The HR director stated she was responsible for posting the daily staff posting and got busy and had not done it today. In an observation on 7/29/25 at 10:45 a.m., the daily staff posting was in a frame hanging on the wall across from the nursing station and was current and complete. In an interview on 7/31/25 at 4:55 p.m., the DON stated possible consequences of the daily staff posting not being posted could be that people would not know the current staffing. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers revised August 2022, indicated Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. 1. Within two hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for residents who eat in their rooms in one (Hall 500) of six halls observed for in-room dining services. While passing lunch trays in hallway 500, CNA-A did not sanitize or clean her hands in between residents. This failure could place residents at risk for infection. Findings included: Observation of meal services on Hall 500 on 03/12/2025 at 12:17 p.m. revealed CNA-A was in process of distributing lunch trays to residents in their rooms on Hall 500. CNA-A was observed to check a tray card on the lunch tray, and then carry the tray to a resident in room [ROOM NUMBER]. CNA-A then returned to the rack of lunch trays, checked tray card on another lunch tray and carried that lunch tray to room [ROOM NUMBER]A, where she assisted Resident #1 with set up of her lunch tray by placing the tray on a nearby table, cleared Resident #1's bedside table of the previous meal's tray, then placed the lunch tray on her bedside table, and moved the table over Resident #1's lap. CNA-A raised the head of bed for Resident #1 by using the bed remote, and then helped set up the tray by removing plastic covers from the drink containers, and opening the utensils wrap. Without sanitizing her hands, CNA-A then went back to the rack of lunch trays and grabbed another lunch tray and brought it to room [ROOM NUMBER]. CNA- A pushed the rack of lunch trays down the hall and repeated this process for rooms [ROOM NUMBERS]. CNA-A did not wash or sanitize her hands in between delivering trays to the different residents' rooms, or before and after assisting Resident #1 with her lunch tray set-up, and touching several items in Resident #1's environment (bed remote, bedside table, previous meal tray) in process. Interview on 03/12/2025 at 12:33p.m. with CNA-A revealed she was an agency staff who had only worked at the facility about 2 months. CNA-A stated she had received training in infection control and stated that she did not sanitize her hands in between delivering each tray to different residents and helping them set up their trays, because it would dry out her hands too much. The CNA-A did not respond when asked what the result could be of not sanitizing her hands in between working with different residents, and stated she washed her hands prior to starting the meal service. During an interview with the ADON on 03/12/2025 at 12:43 p.m., the ADON stated all staff much sanitize their hands in between working with different residents, which included when passing lunch trays to different residents' rooms. The ADON stated that by not sanitizing hands in-between working with different residents, it could result in the spread of infection. Record review of facility policy titled Handwashing/Hand Hygiene dated 2001 revealed a policy statement: this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Continued review revealed: Hand hygiene is indicated: a. immediately before touching a resident . after touching a resident and .after touching a resident's environment.

Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice to including but not limited to the residents choice to activities, schedules (including sleeping and waking times), healthcare and providers of healthcare services consistent with his or her interest, assessments, and plan of care and other applicable provisions of this part for 1 (Resident #1) of 4 residents reviewed for resident rights. The facility failed to honor Resident #1's request to be assisted out of bed at least once a day. This failure could place residents at risk for depression, diminished quality of life and isolation. Findings included: Record review of Resident #1's face sheet dated 03/14/2025 revealed an admitted [DATE] with latest re-admission on 09/04/2024, and with diagnoses which included: Cerebral infarction (stroke); Hemiplegia (weakness or paralysis on one side of body)affecting right dominant side; Aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction; Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood); and Morbid obesity due to excess calories (Body Mass Index of 40 or higher which can increase risk of serious health problems and can shorten lifespan). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed her BIMS score was left blank, and she was assessed as being dependent for transfers and mobility with wheelchair. Record review of Resident #1's Care Plan dated 01/29/2925 revealed a problem area which included: - Resident requires use of hoyer/mechanical lift and is at risk for injury, with intervention of 2 staff at all times for transfer with mechanical lift; and - Resident has low attendance in activities, goal Resident will attend activities 1xw. Record review of Resident #1's Physician Orders dated 03/14/2025 revealed an order for Resident may attend activities and social events of choice and ADL-Transfer: Total dependence x2 [mechanical] lift Record review of Resident #1's vital signs record revealed her current weight is 316lbs., down from 328.2 lbs in December 2024. Record review of Resident #1's Point of Care History for ADL's -Transfers from 1/10/2025 through 3/4/2025 revealed that her log was marked as Activity did not occur on 22 days during that time period. Those days marked as did not occur were: 3/9/2025, 3/6/2025, 3/2/2025, 3/1/2025, 2/28/2025, 2/23/2025, 2/22/2025, 2/21/2025, 2/20/2025, 2/16//2025, 2/12/2025, 2/9/2025, 2/5/2025, 2/1/2025, 1/31/2025, 1/28/2025, 1/25/2025, 1/24/2025, 1/23/2025, 1/22/2025, 1/13/2025, and 1/10/2025. Further review revealed all of the other days are noted with at least one entry of total dependence and 4 days have entries of limited assistance. Further review of the days marked as mechanical lift having been done with total dependence revealed the majority were done in late afternoon- early evening. Observation and interview with Resident #1 on 03/11/2025 at 10:42 a.m. revealed Resident #1 was lying in a large, oversized bed, and was unable to move her right arm and leg. Due to speech disorder which resulted from her stroke, Resident #1 was only able to say a few single words over and over, but she was able to point to what she wants/needs and could nod her head yes/no to answer basic questions. During this interview, she pointed to the overhead light, and activated her call light. CNA-B answered the call light within a few seconds and saw Resident #1 point to the overhead room light, and CNA-B asked her if she wanted the light off, Resident #1 shook her head yes, and CNA-B turned off the light. During a telephone interview with family members #1 and #2 on 03/12/2025 at 10:59 a.m., family member #1 stated that Resident #1 was not getting out of bed, and when they request she be assisted up into her wheelchair, they have been told they do not have 2 people on duty to do that. Family #2 stated the staff tell them that they get her up for lunch every day, but she was never up when the family comes to visit and noted that family visits about every other day and on weekends. Family Member #2 stated sometimes the staff will get Resident #1 up in her wheelchair for special occasions, but they always have to ask in advance. During a telephone interview with family member #3 on 03/14/2025 at 10:02 a.m. revealed she was aware Resident #1 was very overweight, and was difficult to transfer her to her wheelchair, but stated Resident #1 was left in bed way too much. Family member #3 asked how is she supposed to be active and lose weight if she never gets out of bed? Family member #3 stated she that if Resident #3 was able to be up in her wheelchair more, she would build up tolerance for it and participate in activities, go to exercises with therapy, and all of this would help her be more active, exercise more and help her lose that weight. Family member #3 stated the only time staff get Resident #1 up into her wheelchair is when they, her family, are there and request it. During interview with the Social Worker on 3/14/2025 at 9:48 a.m. the Social Worker clarified that Resident #1's BIMS score was 00, indicating severe cognitive impairment, not only due to her speech impediment, but noted that even by nodding her head, she was unable to remember the words given to her during the assessment. The Social Worker also stated that Resident #1's family has requested that Resident #1 be assisted up into her wheelchair at noon meals every day, or to get her up for at least one meal a day out of her room. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed her BIMS score was left blank. During an interview with the Social Worker on 3/14/2025 at 9:48 a.m. the Social Worker clarified that Resident #1's BIMS score was 00, indicating severe cognitive impairment, not only due to her speech impediment, but noted that even by nodding her head, she was unable to remember the words given to her during the assessmentInterview on 3/14/2025 at 9:48 a.m. with the Social Worker revealed that the family has requested that Resident #1 be assisted up into her wheelchair at noon meals every day, or to get her up for at least one meal a day out of her room. Observation on 03/11/2025 at 12:25 p.m. on Hall 500 revealed Resident #1 was in her room, in her bed, and was provided a lunch tray in her room. Observation and interview with Resident #1 on 03/12/2025 at 12:26 p.m. revealed she was sitting in her bed, with her lunch tray on the bedside table in front of her eating lunch. When asked if she wanted to get up into her wheelchair and eat lunch in the dining room, she nodded affirmatively, indicating yes. When asked if she would like to get up in her wheelchair every day for lunch, she nodded affirmatively. When asked if staff get her up in her wheelchair for lunch, she shook her head negatively, indicataing no. Observation on 03/12/2025 at 1:46 p.m. of a mechanical lift transfer for Resident #1 from her bed to her wheelchair by CNA -B and CMA-E revealed privacy was provided, and proper procedure followed for the transfer. When she was initially being lifted in the sling, Resident #1 verbalized loudly and pointed to the back of her knees, indicating she felt pain there. The staff stopped the transfer, lowered her back to the bed and provided padding to the area behind her knees and when Resident #1 indicated she no longer felt pain, the transfer was resumed. Resident #1 did express some discomfort through grunts and facial expressions while being lifted in the mechanical lift sling. Observation revealed that her body was pressed together tightly with the sling, but her breathing did not appear compromised. As soon as Resident #1 was seated safely in her wheelchair and released from the sling, she smiled and indicated with head nods that she was okay, but did nod her head affirmatively when asked if the mechanical lift sling caused her discomfort. She shook her head negatively when asked if she felt fear during the mechanical lift transfer. Interview on 3/11/2025 at 10:49 a.m. with CNA-B revealed she was agency staff and has worked at this facility about 3 years and knows Resident #1 well. CNA-B stated Resident #1 does have a specially made wheelchair that they store in one of the empty rooms due to space concerns. She stated Resident #1 requires a 2-person mechanical lift, and that sometimes therapy will get her up into her wheelchair for special occasions, but not very often. For showers, she stated Resident #1 receives bed baths with 2 staff. Interview on 3/11/2025 at 11:52 a.m. with CMA-E revealed she has worked at the facility for about 3 years and works as both a CMA and a CNA. CMA-E stated that Resident #1 is not gotten out of bed into her wheelchair very often, and she has only seen her get out of bed when family are here and request it. CMA-E noted that it is difficult and takes a lot of time to transfer Resident #1, and that Resident #1 is only able to tolerate sitting up for about 30 minutes, and then wants to be transferred back to bed. CMA-E stated that Resident #1 gets bed baths only and is very cooperative with staff when they provide care to her. Interview on 3/13/2025 at 7:34 a.m. with LVN-D revealed she was a facility staff who had been at the facility about 2 months. She stated Resident #1 was able to communicate by pointing to what she wants, or pointing to where she hurts, and by answering yes/no questions with head nods. LVN-D stated Resident #1 will repeat the same 2-3 words over and over and will continue pointing and gesturing until staff can understand what she is trying to communicate. LVN-D stated Resident #1 required a mechanical lift with 2 staff assist, but also stated Resident #1 does not get out of bed very often. LVN-D stated that the last time she saw Resident #1 out of bed was for her Mammogram appointment the previous week. Interview with the ADON on 03/12/2025 at 12:43 p.m. revealed that Resident #1 had a stroke years ago, and has gained a lot of weight. She stated Resident #1 has a specially made wheelchair to accommodate her and required use of a mechanical lift with at least 2 persons to assist. She further stated Resident #1 gets up and into her wheelchair about one time a week, for activities or meals. She stated for medical appointments Resident #1 is taken via stretcher by Ambulance. The ADON stated that they are working with the family, and her interdisciplinary team to aide in her weight loss, and noted she was recently put on a new medication to aid in weight loss. Interview with the Director of Rehabilitation on 03/13/2025 at 2:05 p.m. revealed Resident #1 was receiving physical therapy 3 times a week, and specifically was on a functional maintenance program. She stated physical therapy was working on increasing her bed mobility, for example using her left leg to help her turn over in bed. She stated Resident #1 needs a mechanical lift transfer with 2 staff. She stated she had not been notified by any staff of any concerns in using the mechanical lift to transfer Resident #1. Interview with PTA-C on 03/14/2025 at 10:45 a.m. revealed that Resident #1 received physical therapy services 3 times a week for 40- minute sessions, working on increasing her range of motion, and reaching exercises. She stated the therapy was done in her room, with Resident #1 lying in bed. She stated she has never seen Resident #1 get up in her wheelchair for her therapy sessions, but that it would be good if she could, as she felt Resident #1 could benefit from working on some of the equipment they have in the therapy room. She further stated that she has never gotten Resident #1 up in her wheelchair using the mechanical lift, because she would not feel safe doing that unless there were 3-4 staff there to help. PTA-C stated that Resident #1 was not able to tolerate being up in the wheelchair very long, and will cry because it causes her pain if she stays up too long in her wheelchair. During an interview with the Administrator, RN-F and the ADON on 03/14/2025 at 12:15 p.m., RN-F stated Resident #1 was transferred out of her bed regularly, and that this is documented in their EHR system. RN-F pulled up the ADL [Mechanical Lift] transfer log in their EHR system for January 10- March 4 2025 and provided a copy for the State Surveyor. RN-F did note there were some gaps of several days on the log, noting no mechanical lift transfers occurred on the days around 2/21/2025. The ADON stated that Resident #1 does refuse transfers at times because the transfers hurt her, but was not able to identify where these refusals are documented, Record review of facility policy titled Resident Rights revised February 2021 revealed: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence and self-determination.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests for 1 of 4 residents (Resident #1) reviewed for pest control, in that: The facility failed to ensure an effective pest control program was in place to keep flies out of resident rooms resulting in an infestation of maggots in Resident #1's right heel wound. The noncompliance was identified as PNC. The IJ began on 06/16/2024 and ended on 06/18/2024. The facility had corrected the noncompliance before the investigation began. The failure could place residents with wounds at risk for infection or infestations from pests. The findings included: Record review of Resident #1's electronic face sheet (printed 6/20/2024) revealed Resident #1 was admitted on [DATE]. His diagnoses included: pressure ulcer of right heal (stage 4 pressure injury a full-thickness wound with skin loss with extensive destruction, tissue necrosis, and damage to the underlying muscle, tendon, bone, or other exposed supporting structures.), unspecified dementia, protein-calorie malnutrition, UTI, cognitive communication deficit, pathological fracture right femur, iron deficiency, vitamin deficiency. Record review of Resident #1's MDS (Quarterly), dated 2/9/2024 revealed Resident #1 had a BIMS Score of 4, indicating severe cognitive impairment. Record review of Resident #1's Careplan, reflected the following: Potential for altered skin integrity related to dementia as evidenced by noncompliance of care (as of 2/14/2024). Goals included, Will have intact skin, with minimal redness, blisters or discoloration through review date. Interventions included, Notify family of any new areas of skin breakdown; Obtain and monitor lab/ diagnostic work as ordered. Report to MD and follow up as indicated; Monitor nutritional status. Serve diet as ordered, monitor intake and record; Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bath or daily care; Body audits at least weekly by licensed staff. Record review of Resident #1's Careplan, reflected the following: Problem: (Resident #1) has a pressure ulcer to right heel (as of 5/8/2024). Interventions included, Wound care as per MD orders; Wound care physician to see (Resident #1) as needed; Position with pillows to elevate pressure points off the bed as needed; Turn and reposition resident throughout the shift. Record review of Resident #1's 6/16/2024 progress note revealed, (Resident #1) supine in bed refusing snacks and beverages. (Resident #1)had body temp of 99 at 2 PM and is now at 96.6. He is shivering as if cold even with blanket. His heart rate is 98, R20. (Resident #1) has low urine output today. Wound care done and (Resident #1) found to have necrotic tissue with maggots coming out of foot heel. Wound cleaned and dressed. MD notified and wants (Resident #1) to be sent to ER. Supervisor notified. (Responsible Party) notified and notification to (Hospital Staff) in ER. Interview on 6/19/2024 at 10:10 AM, the Administrator stated Resident #1 was not currently at the facility. The Administrator was asked if Resident #1 was at the hospital and stated that he was. Initial rounds on 6/19/2024 at 10:54 AM, staff were appropriately engaged with residents, staffing appeared sufficient, no profuse or lingering odors were detected. No flies or other insects were observed during these rounds. Observation on 6/19/2024 at 12:15 PM of the dining area during lunch meal service Reveal no flies or insects in the dining area. Interview on 6/19/2024 at 12:20 PM, the Administrator stated interventions had been put into place including electric fly traps on the interior of the building, air curtains, and water traps, which utilized yeast to attract and trap flies on the exterior of the building. The administrator stated that when the temperatures became warmer outside along with the additional rain, some flies had been able to enter the building when residents would exit and enter the building during smoke breaks. He said they recently had pest control treat the facility for this issue. Observation and attempted interview on 6/19/2024 at 1:29 PM, of Resident #1 at the hospital revealed Resident #1 was in bed sitting in an upright position. Resident #1 appeared clean and well kept. Resident #1 did not exhibit any s/s of pain or grimacing. During an interview at this time, Resident #1 did not respond to questions but stared blankly at the wall. Interview on 6/19/2024 at 1:35 PM, Hospital RN A stated Resident #1 was recently admitted several days ago with a necrotic wound to his heal which resulted in a below the knee amputation. Hospital RN A said Resident #1 was currently on isolation precautions with dx, ESBL of the urine and was not alert or oriented. Interview on 6/19/2024 at 2:05 PM, Hospital DR B, stated Resident #1 was admitted to the hospital with a stage 4 ulcer to his heal. The Hospital DR B said it was likely acquired following surgery for hip fracture in April of 2024. Hospital DR B said it was likely that given Resident #1's dementia and comorbidities, he was likely more prone to acquiring that type of an injury. Interview on 6/19/2024 at 2:21 PM, Hospital DR C, stated he was a part of Resident #1's hospital admission and stated that in his professional opinion, he did not believe that the presence of maggots to Resident #1's wound had an impact on the outcome of Resident #1's below the knee amputation, indicating Resident #1 would likely have had to have the amputation even if the maggots were not in Resident #1's wound. Hospital DR C opined that the resident had multiple diagnoses that made him more susceptible to acquiring said wound. Interview on 6/20/2024 at 11:43 AM, Treatment Nurse, LVN C said she was reassigned to Resident #1's Hall on 6/16/2024 and said upon removing Resident #1's dressing for treatment, she discovered approximately 5 maggots on his wound. LVN C said she then called the Resident #1's physician and subsequently sent Resident #1 to the hospital. Observation and interview on 6/20/2024 at 12:05 PM, Resident #2 was observed sitting in his bed watching the television. Resident #2 appeared clean and well kept. No s/s of pain or grimacing were observed. Resident #2 was asked how long he had been at the facility and responded, since May. Resident #2 was asked if he had any concerns regarding fly infestations and responded that he would occasionally see flies but that it had improved. Interview on 6/20/2024 at 2:15 PM, the Administrator stated about 2-3 weeks ago the facility became overwhelmed by flies, likely due to the weather conditions and the frequency with which the residents who smoked would open and close the door leading to the smoking area adjacent to the dining area. The administrator was asked if Resident #1 would leave his room and responded that staff would wheel Resident #1 to the dining area for meals and to watch television. Observation and interview on 6/20/2024 at 3:18 PM, Resident #3 was observed watching television in her room. Resident #3 appeared clean and well kept. During an interview at this time, Resident #3 was asked if she had any concerns specific to flies in the facility. Resident #3 grabbed a fly swatter and said several weeks ago, they were really bad. Resident #3 said the fly infestation seemed have improved. Telephone interview on 6/20/2024 at 3:32 PM, Wound Care Physician, TDR E, said he worked on Resident #1's wounds once per week and said he had no concerns specific to the care Resident #1 was receiving. TDR E said Resident #1's wounds were covered on every visit he had with the resident. TDR E said that at times Resident #1 seemed non-compliant and combative so may have removed coverings on those occasions but was never something he had observed. TDR E was asked how long it would take for a fly larvae (maggot) to hatch once the egg was laid and he responded, approximately 7-24 hours. The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR dated 6/18/2024 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, and HHSC. Record review dated 6/17/2024- 46 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Wound Information. STAFF INTERVIEWS ON TRAINING: 6/20/2024 from 3:30 PM to 6:00 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts. On 6/20/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the maggot identification, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed flies and/or maggots and to let the charge nurse know if either was identified. On 6/20/2024, the Administrator was interviewed and revealed all interventions that the facility proactively put into place in response to pest control which included the purchase of air curtains, electronic fly traps, water traps, baiting around the exterior of the facility, trash cans, and dumpsters, and a treated wipe down of the entire facility. Observation rounds were conducted on 6/20/2024 and revealed screens were on all resident windows on the 500 hall, trash cans and dumpsters were located at an appropriate distance from the facility, electronic fly traps were activated, and the facility appeared to be free of fly infestations. Sampled residents were also interviewed and stated significant improvement specific to the presence of flies at this facility. Record review of a document, not dated, revealed an invoice, not titled. Further review of this document stated, Order placed 6/4/2024 in the amount of $422.16, and stated, Arriving Friday - Gardner WS-95 Wall Sconce Flight light Trap Lamp . Record review of a document, titled, Order Summary, dated 6/5/2024, stated, Fly bait used to control fly problem at facility. Suggested by pest control. Further review of section, Total, revealed a charge of $63. Record review of document titled, Additional Service/Equipment Proposal, Commercial Pest Management Program, dated 6/17/2024, stated, Service needed for - Flies. Section, Estimated Price of Proposed Services, stated, Targeted Fly Wipe-down $300 . Full Facility Wipe-down - $750. Record review of a facility policy, Flies, not dated, stated, Sources - open exterior doors, filth, smoking patios, dumpsters/garbage . Control Methods - Keep doors closed; keep dumpsters closed and trash-drip area clean; frequently power wash dumpsters/smoking areas and empty ashtrays . Record review of a facility policy, Fly Protocol, not dated, stated, There is not a single tactic that can keep flies out. It requires using a combination of multiple chemicals and equipment, along with diligent good habits from the facility to keep flies mitigated The noncompliance was identified as PNC. The IJ began on 06/16/2024 and ended on 06/18/2024. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview and record review the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 4 Residents (Resident #1) whose records were reviewed for pressure ulcer care. The facility failed to obtain a physician order for treatment and wound care for Resident #1's right heel resulting in the wound declining from a blister to a stage 4 pressure injury that was later found to have maggots. An IJ was identified on 7/5/2024. The IJ template was provided to the facility on [DATE] at 8:26 pm. While the IJ was removed on 7/6/2024 the facility remained out of compliance at a scope of pattern and severity level of no actual harm because of the facility's need to evaluate the effectiveness of their plan of removal. The findings included: Record review of Resident #1's electronic face sheet (printed 7/5/2024) revealed Resident #1 was admitted on [DATE]. His diagnoses included: pressure ulcer of right heal (stage 4 wound which reveals skin and bone), unspecified dementia, protein-calorie malnutrition, cognitive communication deficit, pathological fracture right femur, iron deficiency, and vitamin deficiency. Record review of Resident #1's MDS (Quarterly), dated 2/9/2024 revealed Resident #1 had a BIMS Score of 4, indicating severe cognitive impairment. Record review of Resident #1's Care plan, reflected the following: Potential for altered skin integrity related to dementia as evidenced by noncompliance of care (as of 2/14/2024). Goals included, Will have intact skin, with minimal redness, blisters or discoloration through review date. Interventions included, Notify family of any new areas of skin breakdown; Obtain and monitor lab/ diagnostic work as ordered. Report to MD and follow up as indicated; Monitor nutritional status. Serve diet as ordered, monitor intake and record; Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bath or daily care; Body audits at least weekly by licensed staff. Record review of Resident #1's Care plan, stated the following: Problem: (Resident #1) has a pressure ulcer to right heel (as of 5/8/2024). Interventions included, Wound care as per MD orders; Wound care physician to see (Resident #1) as needed; Position with pillows to elevate pressure points off the bed. Record review of Resident #1's EMR progress note on 6/1/2024 authored by Agency LVN A revealed Resident #1 had an open blister to right heel identified by facility a CNA. Record review of Resident #1's last skin assessment on 5/30/2024 revealed no issues. Record review of Resident #'1's skin assessment dated [DATE] identified Stage 2 pressure injury to right heel 5.5cm x 8.2cm x 0.1cm with granulation tissue Record review of Resident # 1's skin assessment dated [DATE] indetified Stage 4 pressure injury to right heel, 3.2cm x 7.5cm x 0.1cm with necrotic tissue Record review of Residnt # 1 skin assessment dated [DATE] indetified Stage 4 pressure injury to right heel, 5.2cm x 7.2cm x 0.1cm with necrotic tissue. Record review revealed Agency LVN A did not obtain a physician order on 6/1/2024 for wound care. Record review of Resident #1's EMR revealed no documentation for deterioration in wound from 6/1/2024-6/4/2024. Record review of Resident #1's EMR revealed on 6/4/2024 wound care physician observed Resident #1's right heel to be a Stage 4 and ordered a wound care treatment plan. Record review of Resident #1's EMR revealed on 6/16/2024 Resident #1 was transferred to hospital for wound care debridement and due to maggots in wound. Resulting in a right below knee amputation. Record review of Resident #1's physician consolidated orders for 6/1/2024-7/2/2024 revealed no physician order on 6/1/2024 when right heel wound was identified. Record review of Resident #1's physician consolidated orders revealed Orders dated 06/02/2024 to Cleanse with wound cleanser, Apply TAO open area to patient;s right heel, dry dressing until healed. Start date 06/02/2024-06/03/0224 (Dc Date) Record review of Resident #1's physician consolidated orders revealed Orders dated 06/02/2024 to Cleanse with wound cleanser, apply CA alginate to open area to patient's right heel then dry dressing QD until healed Start date 06/03/2024006/04/2024 (Dc Date) Unable to reach Agency LVN A for interview after 2 attempts. Unable to reach Agency Nurse Aide B for interview after 2 attempts. During a telephone interview on 7/2/2024 at 10:28 am facility DON stated she was first informed of Resident #1 having a blister to his left heel on 6/1/2024. DON stated she saw Resident #1's wound to right heel on 6/1/2024 and determined a blister was present and advised Agency nurse to notify MD for treatment. During an interview on 7/2/2024 at 1:10 pm, Regional Nurse Consultant (RNC) stated if a nurse needed an order from a physician to provide care, the nurse would call the residents physician and then write the order so that it would transcribe to the resident's treatment record. She further revealed any orders written by nursing staff would transcribe to the Facility Activity Report and the nurses would give report from shift to shift. When asked if there was an order written for Resident #1 [Heel cleaned with normal saline and covered with boarded gauze.} RNC stated I do not see one in the EMR until the next day on t 6/2, though the treatment was done on 6/1. She stated there should have been an order written. Unable to reach wound care physician for interview. During a telephone interview on 7/6/2024 at 9:10 am Resident #1's primary physician stated he was aware of Resident #1's right heel wound and further revealed he knew the wound care physician was addressing the treatment plan for Resident #1, prior to a right below the knee amputation. The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 7/5/2024 at 8:31 p.m. and a plan of removal was requested. On 7/6/2024 at 11:09 am, the facility provided a plan of removal that was accepted. It was documented as follows: On 7/5/24, a complaint survey resulted in Immediate Jeopardy (IJ). On 7/5/24, the administrator was provided with an Immediate Jeopardy template notification that the Regulatory Services has determined that the practice at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows; The facility failed to obtain a physician order for treatment and wound care for Resident #1 and the facility failed to assess and document residents wound care in a manner consistent with professional standards of practice and in accordance with the facility policy. On 7/5/24, the director of nursing in-serviced all licensed nursing staff regarding the policy when a new wound is identified. The licensed nurse will create an incident report, notify the physician to receive new orders, and enter those orders into the Matrix EMR. The licensed nurse will then enter the assessment of the wound into the Matrix EMR wound management system and notify the director of nursing and the resident's responsible party. Nursing staff not available for this in-service will receive it before starting their next assigned shift. Agency nursing staff will receive the training before starting their assigned shift. The in-service will be kept, to refer to, in the nursing 24hr book. On 7/5/24, under the direction of the director of nursing, a full facility skin sweep was completed on all residents. Any new areas of concern were documented per the facility policy listed above On 7/6/24, the facility DON in-service facility CNAs about notifying the charge nurse for any concerns with the resident's skin. Any CNAs not receiving the initial education will not be allowed to work their next assigned shift until they receive the information. On 7/6/24, the director of nursing in-service licensed nursing staff on how to complete a skin assessment. Agency nurses will receive this information before starting their next assigned shift and the information will be kept in the 24hr nursing book for reference. The director of nursing/assistant director of nursing will be responsible for reviewing the skin assessment documentation on any newly identified skin abnormality and re-educating when necessary. The regional nurse consultant will monitor compliance of the wound management system by reviewing the facility activity report, weekly, to identify concerns. An Ad-Hoc QAPI meeting was held on 7/6/24, with the Medical Director, Regional Director of Operations, Director of Nursing, and the Regional Nurse Consultant to review the deficiency, policy and procedures, and the plan for removal of immediacy. Policies for monitoring the wound care system were discussed. Verification: began 7/6/2024 at 11:30 am: 1. Record review on 7/6/2024 of Inservice titled Wounds Skin System with policy and procedure revealed signatures of 8 of 10 staff nurses and 4 agency nurses who attended the in service. 2. During an interview on 7/6/2024 at 11:40 am Regional Nurse Consult stated the 2 prn staff nurses would receive in service before working their next shift. 3. During interviews conducted on 7/6/2024 from 11:30 am - 3:30 pm with 6 day shift 6 am- 6pm nursing staff (LVN's RN ) an 6pm-6am nursing staff (LVN's RN) revealed they had been in-serviced on wounds , skin system with policy and procedures. . 1. Record review of Facility Wound Summary Report dated: 6/6/2024-7/6/2024 revealed current wounds being treated in facility were 1- Resident with Stage IV to right heel and left heel with measurements and orders for treatment. 1- Resident with arterial ulcer right heel with measurements and orders for treatment. 2. During an observation on 7/6/2024 at 11:13 am with RN treatment done to right heel of Resident in 608 per physician orders and infection control with no issues. Measurements and appearance were as documented on facility wound record dated 6/6/2024-7/6/2024. On 7/5/24, all current resident skin abnormalities were audited by the regional nurse consultant to validate that there was a physician's order and that the skin abnormality was in the wound management system and was being documented on. Any concerns were corrected immediately. 1. Record review of Facility Wound Summary Report dated 6/6/2024- 7/6/2024 revealed residents with a total of: 2 skin tear, 1 stage vii,3 other,1 arterial ulcer, 1 surgical incision, 1 abrasion,1 laceration. 2. Record review of Residents EMR dated 7/1/2024-7/6/2024 revealed residents on the Facility Wound Summary Report with current treatment orders. To total: 10 residents. On 7/5/24, the Regional Nurse Consultant re-educated the director of nursing and the assistant director of nursing regarding the process for monitoring and validating completion of nursing tasks in relation to skin abnormalities by reviewing the facility activity report, daily for new orders, as well as the dashboard of the EMR for any new incident reports. The wound management system will be reviewed weekly during the Quality of Care, meeting to validate completeness and to ensure wounds are entered correctly. Notifications will also be reviewed at that time. The ADON will be responsible for this process when the DON is not available. The Regional Nurse Consultant will attend the Quality of Care meeting weekly with the IDT for one month and randomly thereafter. The regional nurse consultant will be available for consultation when needed. Any concerns will be addressed immediately upon discovery. 1. During an interview on 7/6/2024 at 1:35 pm facility DON stated she was in serviced by the RNC regarding the process for skin system follow up and problem identification. 2. During an interview on 7/6/2024 at 1:36 pm facility ADON stated she was in serviced by the RNC regarding the process for skin system follow up and problem identification. During an interview on 7/6/2024 1:45 pm RNC stated we(Regional Director of Operations, DON and Administrator, RNC.) met this morning(7/6/2024), (Medical Director was not available ). During an interview on 7/6/2024 at 2:25 pm facility Administrator stated Medical Director had called him back and was informed of POR and IT . Medical Director told administrator he would see them at QAPI. The Administrator was notified of the IJ was identified on 7/5/2024. The IJ template was provided to the facility on [DATE] at 8:26 pm. While the IJ was removed on 7/6/2024 the facility remained out of compliance at a scope of pattern and severity level of no actual harm because of the facility's need to evaluate the effectiveness of their plan of removal.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. 1. The facility failed to ensure all open items in the freezers were labeled and dated. a. 4 bags of open frozen foods not labeled with contents or date opened/used by 2. The facility failed to ensure all foods in the refrigerator were labeled and dated. a. Two trays of portioned foods covered and not labeled in the reach in refrigerator (1 of 2) 3. The facility failed to ensure all equipment was clean and sanitary. a. Spilled and partially dried liquid in the bottom of the reach in refrigerator (1 of 2) b. The table-mounted can opener had sticky black and brown grime on the blade and along the base of the equipment. These failures affect all the residents who received meals from the kitchen and place them at risk for foodborne illness. Findings included: Observation of the facility's only kitchen on 06/02/2024 at 9:39 AM revealed 4 bags of opened foods in reach in freezer (1 of 3) were unlabeled and undated. Contents of the opened bags were not labeled on the open bags. Reach in refrigerator (1 of 2) had two trays of portioned foods in small bowls covered in plastic wrap unlabeled with the contents or the date prepared. Reach in refrigerator (1 of 2) had spilled and partially dried liquid on the bottom. Interview with Dietary Aide K on 06/02/2024 at 10:15 AM revealed she received training when she started on food storage and labeling by the Dietary Manager. DA K stated that all kitchen staff are responsible to label any stored foods in the refrigerator, freezer and dry storage when opened. DA K stated that opened food should be labeled with the contents and date used by. DA K stated that the kitchen has a cleaning check list to ensure equipment is clean. Interview with Dietary Manager on 06/04/2024 at 9:48 AM revealed all staff hired receive training from the Dietary Manager or designee on proper food storage and labeling. DM stated that all kitchen staff are responsible to label all food stored in the refrigerator and freezer with the contents and date used by. DM stated the kitchen has a cleaning check list that all kitchen staff work on daily. DM stated by not labeling foods being stored in the refrigerator and freezer the residents were at risk of food born illness. DM also stated by not cleaning up spills or cleaning the table mounted can opener also put residents at risk for food born illness. Record review of the kitchen's daily cleaning check list for the month of June on 06/04/2024 revealed nothing on the checklist had been signed as completed. Record review of the facility's policy Food Receiving and Storage dated December 2008 revealed 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Record review of Facility's policy Sanitization dated December 2008 revealed 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Sea ls, hinges and fasteners will be kept in good repair. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Base d on observation, interview and record review the facility failed to provide Preadmission Screening for individuals with a mental disorder for 1 of 1 Resident (Resident #61) whose records were reviewed for PASRR services. The facility failed to recognize on the Level 1 PASRR screening that Resident #61 had a mental illness diagnosis of Bi-polar Disorder which would qualify her for a PASRR evaluation. This deficient practice could affect residents with a mental illness and could result in Resident's not receiving mental health services as needed. The findings were: Review of Resident #61's quarterly MDS assessment, dated 3/31/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, Manic Depression (Bi-polar disorder) and Seizure Disorder. Further review revealed Resident #61's BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of Resident #61's Care Plan dated 3/31/24 read: Resident has bipolar disorder, current episode depressed, severe, with psychotic features and is at risk for hallucinations, delusions and behaviors. Two (2) of the approaches included Administer medications as ordered, monitor effectiveness, side effects and notify MD as needed. Psych consult as needed per MD referral. Review of Resident #61's electronic medical record revealed there was no PASRR level 1 on file. Observation and interview on 6/2/24 at 10:24 AM revealed Resident #61 was lying in bed. Resident #61 expressed her concerns and immediately became very loud and presented as being very angry. Resident #61 expressed frustration about the facility not being supportive of her mental health. She stated she had been Bi-polar for [AGE] years and required psychiatric services and anti-psychotic medication which assisted with managing her disorder. Interview on 06/05/24 at 03:41 PM with Regional reimbursement MDS Coordinator and the MDS Coordinator revealed she provided the MDS Coordinator with guidance when completing the screenings. She stated they coded Resident #61 not being mentally ill when she was initially admitted to the facility. However, it was an error and would be correcting it. Regional reimbursement MDS Coordinator stated the purpose of ensuring the screenings were filled out correctly and referring Residents to the LA for assessment was so the Resident's could receive the services they needed based on their identified needs. She further stated that if Residents met the criteria to receive services they would also be eligible for community services in the event they returned to the community.

Based on observation, interview and record review revealed residents has a right to a clean and comfortable and homelike environment, including but not limited to receiving support for daily living including clean bed for 1 of 8 Residents (Resident #56) for 3 of 4 survey days (6/2/24 to 6/5/24) whose environment was observed for clean linens. Nursing staff failed to ensure they changed Resident #56's bed sheets for 3 of 4 survey days (6/2/24 to 6/5/24. Resident #56's bed sheets were stained with brown spots and had residue all over them. This deficient practice could affect any resident and contribute to feelings of low self-esteem. The findings were: Review of Resident #56's quarterly MD'S assessment, dated 4/12/24, revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Hypertension (high blood pressure), ESRD (also called end-stage kidney disease or kidney failure, occurs when chronic kidney disease, the gradual loss of kidney function, reaches an advanced state. In end-stage renal disease, your kidneys no longer work as they should to meet your body's needs) and PVD (a condition that affects the blood vessels outside of the heart and brain). Further review revealed Resident #56's BIMS was 12 out of 15 indicative of some cogntive impairment; required supervision or touching assistance, from partial to moderate assistance by 1 staff for ADL's and had limited range of motion on one side, lower extremity. Review of Resident #56's Care Plan, revised 3/20/24, revealed there was no mention of interventions for Resident #56's ADL's. Observation on 6/2/24 at 10:21 AM revealed Resident #56's bed was not made; the linens including the sheets, pillow case and blankets were dingy. The fitted sheet had brown stains and crumbs all over it. Observation and interview on 06/05/24 at 12:45 PM revealed Resident #56's bed was not made. The linens including the sheets, pillow case and blankets were dingy. The fitted sheet had brown stains and crumbs all over it. Interview with Resident #56 revealed the male CNA A, who showered him would not change out his sheets. Resident #56 stated he mentioned his sheets were dirty to the CNA's, but it did not do any good. Resident #56 stated he was a clean man and liked to sleep on clean linens but what could he do. He could complain but it didn't matter because it didn't help. Interview on 6/5/24 at 1 PM with MA D revealed she was working as an aide today (6/5/24) and knew Resident #56 very well. She stated he was a clean man. She looked at his bed and stated the linens were not clean; the fitted sheet was stained and there were crumbs all over it. She stated the pillow case was bad, very dirty. CMA stated she would feel horrible if she had to lay down in the bed with the sheets looking like they did. She stated Resident #56 was fairly independent but he did not help with showering and changing his linens. Interview on 6/5/24 at 1:45 PM with the DON revealed the CNA's were responsible for changing out the Resident's bed linens on shower days. She stated the nurse's could make sure this was done when they made their daily rounds. The DON stated that maintaining a clean envioronment including changing out the Resident's sheets was a basic right. It promoted feelings of satisfaction. Review of a facility policy, Resident Rights, revised October 2009) read: Employees shall treat all residents with kindness, respect and dignity. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity.

Based on record reviews and interviews, the facility failed to ensure that residents had the right to be free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse, in that: -Resident #1 was involved in an altercation in which Housekeeper A verbally abused, shouted and spoke offensive language to Resident #1 and Housekeeper A threatened to kill Resident #1. -The facility failed to ensure Resident #1's safety after the threat as Housekeeper A was allowed to continue to work at the facility and failed to ensure Housekeeper A was knowledgable in how to respond to resident behavior appropriately. These failures resulted in identification of Immediate Jeopardy (IJ) on 10/29/2020. While the IJ was removed on 10/30/2020, the facility remained out of compliance at a severity of no actual harm, but with potential for more than minimal harm that is not IJ with a scope identified as isolated due to the facility requiring more time to monitor and assess the plan of removal for effectiveness to ensure the safety of the residents from physical, verbal, and psychosocial harm. This deficient practice could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm. The findings were: Record review of Resident #1's face sheet, dated 10/29/2020 revealed an admission date of [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment for daily decision-making skills. Review of Resident #1's Care Plan, revised on 9/23/2020, revealed Resident #1 was at risk for signs and symptoms of mood distress as evidenced by verbalizing feeling down, depressed, or hopeless. Resident #1's Care Plan further revealed he had episodes of anxiety and was at risk for fluctuations in mood. The goal identified was that Resident #1 would discuss feelings that lead to feeling down, depressed or hopeless. The interventions only addressed pharmacological and physician interventions. Review of the facility's incident reports for Resident #1 revealed an incident report was not completed for the verbal altercation that occurred on 10/27/2020 between Resident #1 and Housekeeper A until 10/29/2020. Review of Resident #1's medical record revealed there was no documentation of an assessment, interventions, or Resident #1's well-being after the verbal altercation on 10/27/2020. Review of Housekeeper A's Employee Counseling dated 10/28/2020 stated Housekeeper A failed to treat residents, visitors, co-workers, supervisors, officers of the facility, and the public at large with an appropriate level of decency and respect. Any further insubordination or disrespect shown to co-workers, supervisors, or residents will result in immediate termination. Review of the Admission Paperwork on 10/29/2020 given to new admissions revealed the Resident Handbook which included the Resident Rights. Further review of the Admission Paperwork did not include who the Abuse Coordinator was and how that person could be contacted. In an interview on 10/29/2020 at 9:25 a.m. Resident #1 stated on 10/27/2020 Housekeeper A was helping to move him to a new room. Housekeeper A picked up his remotes and took them. Housekeeper A told him he did not need them. Housekeeper A then went to the Human Resources office and left them on her desk. Resident #1 stated shortly after Housekeeper A took the remotes, he went to the HR office and Housekeeper A said, they were not mine in front of the HR Manager. Resident #1 stated he told them he bought them with his own money. When he left the HR office, Housekeeper A was waiting outside the door of the HR office and told him he was going to kill him and let's go outside. Housekeeper A used some curse words and had an aggressive stance, in a threatening manner. Resident #1 stated he felt intimidated when it happened. In an interview on 10/29/2020 at 9:39 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, the Housekeeping Director stated he was not around when the altercation occurred. The Housekeeping Director stated it started out with a room move and Housekeeper A showed two remotes to the HR Manager that were not Resident #1's. Housekeeper A was arguing with Resident #1 in the doorway of the HR office. Resident #1 and Housekeeper A left the HR office and continued to argue. The HR Manager and the DON came, and the DON told Housekeeper A he had to leave for the day. In an interview on 10/29/2020 at 9:47 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, Housekeeper A stated he was moving Resident #1 to a different room. Housekeeper A stated he had Resident #1's remotes and he (Housekeeper A) put them to the side. Housekeeper A stated he saw Resident #1 with the remotes and grabbed them and said ou do not need these because one said the name of a local cable company. Resident #1 went to HR's office and Housekeeper A was called there. Resident #1 said he wanted the remotes and he paid for them and then he started cussing at Housekeeper A. Housekeeper A stated he was frustrated and blew up. Housekeeper A further stated he told Resident #1 that he would whoop his a** right here and he did not care. Housekeeper A stated he told Resident #1 he blew the wrong person's button, let's go outside, and you are going to lose. Housekeeper A stated he told Resident #1 that he would kill him. Housekeeper A stated to the surveyor that he did not threaten to hit Resident #1, but if they went outside across the street he would have hit him. In an interview on 10/29/2020 at 10:06 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, the HR Manager stated Resident #1 came to her and stated Housekeeper A had taken his remotes that he bought with his own money. HR stated she paged Housekeeper A and told him to go get the remotes. Resident #1 started cussing in Spanish and I told them to leave my office. The HR Manager stated after that she heard a bunch of yelling. The DON and I asked Housekeeper A to leave the facility. The HR Manager further stated she had to get the okay from the DON for Housekeeper A to return to work. The DON said it was okay and he could come back on Wednesday (10/28/2020). In an interview on 10/29/2020 at 10:12 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, the former DON stated she was down the hall on the day of the incident and heard voices. Resident #1 was yelling, and Housekeeper A looked angry. The former DON further stated she did not hear Housekeeper A curse or threaten to kill Resident #1. The former DON stated she sent Housekeeper A to her office and told his supervisor to send him home. Housekeeper A was written up for insubordination and customer service. In an interview on 10/29/2020 at 10:19 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, the Administrator stated she was not in the building when the incident occurred. The Administrator stated she received a phone call from the DON on Tuesday (10/27/2020) there was loudness and commotion. Housekeeper A told Resident #1 you are not going to raise your voice and talk to me like that. The DON said she was going to write up Housekeeper A. In an interview on 10/29/2020 at 10:28 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, LVN B stated she was sitting at the nurses' station and heard a loud voice. She saw Housekeeper A and Resident #1 outside the door of HR. Housekeeper A was yelling at Resident #1 saying, I will kill you, I will kill you, I will kill you right now. At that time the DON and HR Manager were there trying to calm Housekeeper A down, but he was still saying I will kill, I will kill you. LVN B stated she assumed the DON was handling the situation as she reassured her at that time she was. LVN B stated she went to ADON E and ADON E reassured her that the Administrator was informed of the situation. In an interview on 10/29/2020 at 10:35 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, CNA C stated she heard Housekeeper A yelling at Resident #1 that he was going to f*****g kill him, I will kill you. I will f*****g kill you and let's step outside. In an interview on 10/29/2020 at 10:54 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, CNA D stated she was standing at the nurse's station and saw Housekeeper A yelling at Resident #1 saying, Let's go outside. I will f*****g kill you. CNA D stated when she saw Housekeeper A back at work on 10/28/2020 she was shocked and uncomfortable. CNA D stated the situation was reported to the DON on 10/27/2020. In an interview on 10/29/2020 at 11:06 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, ADON E stated staff told her there was an outburst and Housekeeper A cursed at Resident #1 and made comments about going outside. ADON E further stated she talked to the DON and told her staff were concerned about the way Housekeeper A spoke to Resident #1. On 10/28/2020 when Housekeeper A returned to work, the employees were asking why Housekeeper A was back in the building. ADON E stated she spoke with the DON who stated counseling was done and he was allowed to return to work. In an interview on 10/29/2020 at 11:13 a.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, CNA F stated he was at the nurse's station during the altercation. Housekeeper A came out of HR's office yelling at Resident #1 saying, I'm going to kill you. I don't care about this job, I'm going to kill you, you f*****g b***h. CNA F stated the DON heard it because she came out from where she had been working. In an interview on 10/29/2020 at 2:35 p.m. regarding the incident between Housekeeper A and Resident #1, the Administrator stated she could not answer if anyone had addressed the issue with Resident #1 and ensured how he felt regarding safety. The DON had called her and said there was an incident in the building where Resident #1 was cussing and yelling at Housekeeper A. The DON stated she and the HR Manager heard yelling and intercepted the situation. The Administrator further stated she did not know what the DON had done to ensure whether it was a credible threat or not. The Administrator stated she had spoken with staff this morning (10/29/2020) on the phone before arriving at the facility and the staff all assumed the DON told her what happened. The Administrator stated she spoke with the DON and HR Manager on the phone this morning (10/29/2020) and the DON denied hearing what was said. Then CNA C got on the phone with the DON and HR Manager and told the DON that she (the DON) was there and we all heard the same thing. In an interview on 10/29/2020 at 2:47 p.m. regarding the 10/27/2020 incident between Housekeeper A and Resident #1, the former DON stated the only thing she heard was Resident #1 cussing at Housekeeper A. The former DON further stated she did not know there was an incident. Resident #1 never said a word to her about the incident. During an interview on 10/29/2020 at 3:00 p.m., Resident #1 stated no one checked on him after the incident and asked if he felt safe or how he was doing. You are the first person to ask me. In an interview on 10/29/2020 at 3:40 p.m., the Social Worker stated she was made aware of the situation with Resident #1 on Wednesday, 10/28/2020. The Social Worker further stated she had not spoken with Resident #1 about the situation or his safety nor had anyone asked her to. She stated she should have done it on her own. In an interview on 10/30/2020 at 9:11 a.m., Resident #1 stated when he saw Housekeeper A at work on 10/28/2020, they made eye contact but ignored each other. In an interview on 10/30/2020 at 9:21 a.m., CNA F confirmed that the DON and HR Manager witnessed the incident between Resident #1 and Housekeeper A. In an interview on 10/30/2020 at 11:01 a.m., LVN G stated she was sitting at the nurse's station and heard yelling from Housekeeper A. He was saying, I will kill you. I will kill you. When she turned around, she saw that Housekeeper A was yelling at Resident #1. LVN G stated the HR Manager and the DON came out of the offices (HR office and MDS office) and told them to stop. In an interview on 10/30/2020 at 11:31 a.m., LVN G stated the DON was right there when the situation was occurring. LVN G further stated the DON heard and saw everything. Review of the facility policy titled Abuse Prevention Program dated August 2006 revealed 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff . 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED]. The protection of residents during abuse investigations; f. Timely and thorough investigations of all reports and allegations of abuse. Review of the facility policy titled Abuse and Neglect - Clinical Protocol dated April 2013 revealed Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Cause Identification: 1. The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. Treatment/Management: 1. The facility management and staff will institute measure to address the needs of residents and minimize the possibility of abuse and neglect. Monitoring and Follow-Up: 1. The staff and physician will monitor individuals who have been abused at least until their medical condition, mood, and function have stabilized, and periodically thereafter. In an interview on 10/29/2020 at 11:25 a.m., the Regional Nurse stated she spoke with another Regional Nurse and that the abuse policy that was provided (1 page) and clinical protocol (2 pages) was what was normally given to surveyors. No other abuse policies were provided by the time of exit. On 10/29/2020 at 4:47 p.m., the Administrator and Regional Nurse were notified of an Immediate Jeopardy (IJ) situation for the above failures, a completed IJ template was provided and a Plan of Removal was requested. The facility's Plan of Removal included the following steps to be taken by the facility: 1. On October 29, 2020, the Administrator notified the (local) police department regarding the threat of abuse from a staff member to a resident at the facility. A full body assessment was performed on the male resident on 10/29/2020. The perpetrator staff member was immediately discharged on [DATE] at 10:30 a.m. as well as the director of nursing on 10/29/2020 at 11:10 a.m. The resident was interviewed by the Administrator. 2. On 10/29/2020, the Social Worker and Regional Nurse made quality of life rounds, questioning residents if they had any concerns with abuse and neglect. Any voiced concerns were addressed with the Administrator and reported to HHSC (Incident # 3). 3. On 10/29/2020, the Regional Consultant initiated abuse and neglect training with the facility staff regarding reporting abuse and neglect to the Abuse Coordinator, who the Abuse Coordinator was, and where the contact information was located. 4. On 10/29/2020, the Regional Consultant initiated abuse and neglect reeducation with the residents. The family/residents will be given a copy of the resident rights and abuse coordinator posting at admission, available upon request and posted by the survey book. The residents will be educated/reminded during their monthly resident council. 5. On 10/29/2020, the Chief Operating Officer re-educated the Administrator regarding reporting and investigating allegations of abuse. 6. Effective 10/30/2020, the Administrator and nursing administration will make daily rounds to solicit information from residents on any concerns relating from staff treatment. The weekend supervisor/manager on duty will be responsible for making rounds twice a day to identify any concerns. Any identified problems will be brought to the attention of the administrator immediately upon discovery and the Chief Operating Officer will be notified. 7. Effective 10/30/2020, the Administrator will bring any concerns or trends to the monthly Quality Assurance Performance Improvement meeting for tracking, trending, and further Interdisciplinary Team Recommendations. The surveyor verification of the Plan of Removal on 10/30/2020 was as follows: The full body assessment was reviewed for Resident #1 on 10/30/2020 which showed completion on 10/29/2020. In an interview on 10/30/2020 at 3:50 p.m. the Administrator confirmed a police report had been made and the police were going to attempt to talk to the employee first and then come to the facility to speak with Resident #1. The Administrator confirmed she spoke with Resident #1 regarding the incident. The Administrator confirmed Housekeeper A and the DON had been terminated on 10/29/2020. In an interview on 10/30/2020 at 2:47 p.m. the Social Worker confirmed she and the Regional Nurse made quality of life rounds on the evening of 10/29/2020. TULIP (Texas Unified Licensure Information Portal - a web-based licensure system used to conduct licensure activities and report incidents that occur at facilities) was reviewed and confirmed a self-report had been made to CII (Complaint and Incident Intake) by the Administrator on the evening of 10/29/2020. In-service sign-in sheets dated 10/29/2020 and 10/30/3030 and material covered by the in-services was reviewed onsite on 10/30/2020 which included reporting concerns/complaints or visually witnessed alleged abuse immediately to the abuse coordinator, who the abuse coordinator was, posting for the abuse coordinator and its location, and posting for the Director of Operations for further concerns. The in-services also included customer services which entailed being courteous to residents, ensuring residents needs are met, remembering staff are visitors in the resident's home, respecting resident rights, and reporting any behaviors or issues to management and the charge nurse. In-service sign-in sheets dated 10/29/2020 and 10/30/2020 and material covered by the in-services was reviewed onsite on 10/30/2020 for management which included the Administrator and nursing administration making rounds to solicit any concerns from residents relating to staff treatment. The weekend supervisor/manager on duty would be responsible for making twice daily rounds in the facility to identify any concerns. Any identified problems would be brought immediately to the attention of the administrator upon discovery. The Chief of Operating Officer would be notified of any allegations of abuse to validate reporting and investigation. Staff interviews were conducted on all halls on 2 different shifts (6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m.). Interviews occurred on 10/30/2020 from 2:00 p.m. - 3:50 p.m. with LVN B, CNA C, CNA D, CNA F, LVN G, MA J, MA K, Housekeeper L, CNA M, LVN N, LVN O, CNA P, RN Q, CNA R, and CNA S. All stated that they had received in-services on reporting concerns/complaints or visually witnessed alleged abuse immediately to the abuse coordinator, who the abuse coordinator was, posting for the abuse coordinator and its location, and posting for the Director of Operations for further concerns. All stated they had received in-services on customer services which entailed being courteous to residents, ensuring residents needs are met, remembering staff are visitors in the resident's home, respecting resident rights, and reporting any behaviors or issues to management and the charge nurse. All were able to respond to the questions correctly when asked by the surveyor. Interviews occurred on 10/30/2020 from 2:00 p.m. - 3:50 p.m. with the Interim DON, the Human Resources Manager, the Social Worker, ADON E and ADON H, RN I, LVN T, the Business Office Manager, the Dietary Manager, and the Activity Director. All stated that they had received in-services on reporting concerns/complaints or visually witnessed alleged abuse immediately to the abuse coordinator, who the abuse coordinator was, posting for the abuse coordinator and its location, and posting for the Director of Operations for further concerns. All stated they had received in-services on customer services which entailed being courteous to residents, ensuring residents needs are met, remembering staff are visitors in the resident's home, respecting resident rights, and reporting any behaviors or issues to management and the charge nurse. Additionally, all stated that they had received in-services for management which included the Administrator and nursing administration making rounds to solicit any concerns from residents relating to staff treatment. All were able to respond to the questions correctly when asked by the surveyor. The weekend supervisor/manager on duty would be responsible for making twice daily rounds in the facility to identify any concerns. Any identified problems would be brought immediately to the attention of the Administrator upon discovery. The Chief of Operating Officer would be notified of any allegations of abuse to validate reporting and investigation. Resident interviews were conducted on 10/30/2020 with all sampled residents (Resident #1, #2, #3, #4, #5, and #6) between 3:31 p.m. - 4:50 p.m. All stated that they knew to report any concerns of abuse to the Administrator. Interview on 10/30/2020 at 3:45 the Activity Director confirmed the resident council meetings are held the first Wednesday of the month, with the next being on 11/4/2020, where she would be discussing with them abuse and neglect and how to report it. Interview on 10/30/2020 at 3:50 p.m. the Administrator provided a copy of the new admission packet which included a copy of the resident rights handbook and a copy of the abuse coordinator posting. The Administrator confirmed she received an in-service on 10/29/2020 at 4:52 p.m. with the Chief Operating Officer on abuse and neglect. The Administrator further confirmed QA meetings are held monthly before the second Wednesday of the month. A pre-QA meeting is held with department heads. Then the medical directors and a hospital representative attend via phone with the Administrator and DON. On 10/30/2020 at 4:10 p.m. verification was made of the placement of the survey binder (contains documentation of previous state visits and the results) which included a posting of resident rights and the abuse coordinator's name and phone number. On 10/30/2020 at 5:00 p.m. the Administrator and the Interim DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm, but for potential for more than minimal harm that is not IJ with a scope identified as isolated due to the facility requiring more time to monitor and assess the plan of removal for effectiveness to ensure the safety of the residents from physical, verbal, and psychosocial harm.