Every finding on record at Avir at Veterans Memorial

Based on interviews and record reviews, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 2 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 remained free from abuse when CR #1 sexually abused Resident #1 on 08/01/2026 and 1:1 supervision was not implemented right away, and CR #1 eloped and was showing erratic and aggressive behavior that evening. An IJ was identified on 08/05/2026 at 05:39 p.m. The IJ template was provided to the facility on [DATE] at 05:39 p.m. While the IJ was removed on 08/07/2026 at 05:38 p.m., the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of continued abuse and harm. The findings included: Record review of Resident #1's face sheet reflected, she was a [AGE] year-old female originally admitted on [DATE], with diagnosis that include hypertension (high blood pressure, force of blood against the artery walls consistently too high). hemiplegia (paralysis on one side) and hemiparesis (weakness: inability to move on one side of the body) following cerebral infarction (stroke, this affects your blood flow to the brain) affecting right dominant side of her body, and central pain syndrome (damage to the central nervous system). Record review of Resident #1's Care Plan dated 04/28/2026, reflected, Focus: resident receiving psychology/psychiatry services in the facility. Goal: Resident to remain receiving psychology/psychiatry services in the facility. Target Date: 10/21/2026, Interventions: Communicate with Resident #1 on the progress of the psychology/psychiatry services. Ensure psychological needs are being met. Notify MD and family of any changes in condition. Record review of Resident #1's Care Plan dated 08/01/2026, reflected, Focus: resident at risk for psychosocial well-being problem r/t alleging a male resident entered her room and inappropriately made physical contact with her. Goal: Resident will be monitored for psychosocial well-being concern r/t alleging inappropriate physical contact by a male resident through the review date. Interventions: Allow resident time to answer questions and to verbalize feelings, perceptions, and fears as indicated. Resident assessed for physical signs of injury - none noted. Nursing team ensured Resident#1 was in a safe environment. Record review of Resident #1's MDS dated [DATE], reflected, she had a BIMS score of 12 out of 15, suggesting moderate impairment in cognition. Her mood interview reflected, a score of 03 suggesting low depressive symptoms. Record review of Resident #1's Change in Condition Evaluation dated 08/01/2026 at 07:41 p.m., reflected: Location: Resident #1 reported to LVN A a man in his wheelchair (CR #1) came into her room and touched her inappropriate. Resident #1 was assessed for emotional states and also skin assessment was conducted. ADM, ADON, MD, RP #2 notified of altercation with another resident. Record review of Resident #1's Skin Check dated 08/01/2026 at 08:47 p.m., reflected, LVN A performed a skin check evaluation of Resident #1's left breast and buttocks - generalized: Skin was warm, dry and color WNL, with normal turgor (skin quickly returns to its flat, original position after being pinched). Findings: No new skin issues found during evaluation, Record review of CR #1's face sheet reflected, he was a [AGE] year-old male originally admitted on [DATE], readmitted on [DATE] and discharged on 08/02/2026. CR #1's diagnoses included hypertension (high blood pressure, force of blood against the artery walls consistently too high), psychosis (a mental state marked by a loss of contact with reality) not due to a substance or known physiological condition (the state of the body and how its internal systems, organs, and cells function), adjustment disorder (an emotional or behavioral reaction to a stressful life event) with mixed anxiety (anxious and depressed at the same time) and depressed mood (a persistent feeling of sadness, emptiness, or low spirits that lasts most of the day, nearly every day), major depressive disorder (serious mental health condition), recurrent, mild, adjustment disorder (an emotional or behavioral reaction to a stressful life events) with anxiety, vascular dementia (a decline in thinking skills caused by blocked or reduced blood flow to the brain), moderate, with other behavioral disturbance (a sudden or ongoing change in how a person acts, thinks, or feels that disrupts daily life). Record review of CR #1's Care Plan reflected, 08/19/2023, had impaired cognitive function/impaired thought processes r/t Dementia, with interventions, administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of CR #1's Care Plan reflected, 08/19/2023, had behavioral problems r/t restlessness/agitation. CR #1 got very agitated when staff tried to redirect him. Record review of CR #1's Care Plan reflected, 08/20/2023, required assistance with all ADLs, with interventions of allowing breaks between tasks, break tasks up into smaller steps, give verbal cues to help prompt, refer to OT to work on ADL retraining. Record review of CR #1's Care Plan reflected, 08/01/2026, had an inappropriate behavior with another resident. Due to his poor cognition, staff continued to monitor, with interventions, monitored on 1:1 supervision and notified hospice/physician and family of changes in condition. Record review of CR #1's Care Plan reflected, 08/01/2026, placed to secure unit, due to active exit seeking. Record review of CR #1's Care Plan reflected, 08/02/2026, discharged AMA with RP #1 on 08/02/2026. Record review of CR #1's MDS dated [DATE], reflected, a BIMS score of 07 out of 15 suggesting some cognitive changes or impairment. His mood interview reflected, a score of 03 suggesting low depressive symptoms. Record review of CR #1's Change of Condition dated 08/01/2026 at 06:00 p.m., reflected, an observation, evaluation, and recommendation found that a female resident (Resident #1) described CR #1 as a male that entered her room and began touching/rubbing her ankle and up her leg until reaching brief until she screamed for help. LVN A question CR #1 who admitted that he went into Resident #1's room but denied touching the female resident. Behavioral changes described as: Inappropriate sexual behavior towards another resident. Recommended psychiatric consultation and urinalysis for culture. During an interview on 08/04/2026 at 09:51 a.m., Resident #1 stated on 08/01/2026 at 05:30 p.m., CR #1 came into her room and picked a pillow off her the floor and gave it to her. She stated CR #1 then began rubbing on her right ankle all the way up her leg until he reached her brief where he attempted to go inside her brief. She stated she began screaming and pressing the call light for help. She stated no staff came and CR #1 left out of the room. She stated she continued screaming for help, no staff came, and CR #1 reentered the room, and immediately went out. She stated finally a staff came into the room and she reported the incident. She stated she was upset that CR #1 came into her room, and she had not felt safe since the incident. She stated that speaking about the incident repeatedly had not given her a chance to get over it and made her fearful feels continue. She stated she no longer wanted to speak about the incident. During an interview on 08/04/2026 at 12:02 p.m., LVN A stated that she was at the nurse's station on 08/01/2026 at 5:30 p.m., when CNA A reported to her Resident #1 was found in her room screaming for help and reported CR #1 inappropriately touched her. She stated she went to CR #1's room and found him there in his motorized wheelchair. She stated she went to ask CR #1 questions about his whereabouts, when he repeated, I didn't do it,. She stated he initially denied going into Resident #1's room and having touched her and then admitted he was in the room, picked up a pillow, exited the room without touching her on the leg or attempting to go in her brief. She stated she told CR #1 to remain in his room until she sorted everything out. She stated she returned to the nurse's station and reported to LVN B who was CR #1's nurse of the reported incident and that CR #1 required 1:1 supervision. She stated she and LVN C then went to Resident #1's room to perform the skin/pain assessments. She stated it was her understanding that LVN B assigned a staff to provide CR #1 with 1:1 supervision. She stated on 08/02/2026, CR #1 was assigned to the memory care unit due to his high risk of elopement and RP #1 discharged him the same day. During an interview on 08/04/2026 at 12:32 p.m., LVN D stated on 08/01/2026, he came on shift at 6:00 p.m. He stated LVN B informed him that CR #1 had sexually touched Resident #1 and required 1:1 supervision. He stated when he returned to shift the following day at 6:00 p.m., CR #1 had been discharged . During an interview on 08/04/2026 at 03:18 p.m., CNA E stated she had worked with CR #1 over 3-years and found him to be a great person who she learned was a man, Who loved women. She stated she often had to redirect his close proximity to female residents to ensure there were no incidents from him getting too close. She stated she had never seen or heard that he had inappropriate touch with any residents in the past and he was always respectful and complied with her redirection requests. During an interview on 08/04/2026 at 04:56 p.m., CNA A stated on 08/01/2026 around 5:00 p.m., she was in the hallway when she heard Resident #1 calling out for help. She entered the room and Resident #1 who appeared to be afraid and scared stated that a male resident had come into her room and touched and rubbed up and down her leg and attempted to get into her brief. She stated Resident #1 began screaming and the male resident left and returned a second time doing nothing and then left out the room. She stated she went to the nurse's station and told LVN A to come to the resident's room. She stated they returned to the resident's room and the resident gave a brief description of a male, black, in a motorized wheelchair, with a black t-shirt that read something about, being a Dad, came into her room, grabbed her call light and TV remote and began rubbing her leg, trying to get into her brief, left the room, returning a second time, and left again. She stated LVN A asked her to write a statement, and she checked on Resident #1 periodically thereafter to ensure she was comfortable with no further reported issues. She stated around 08:00 p.m., CR #1 was located outside of the facility. She stated at that time it had been confirmed to her that CR #1 was the resident that had gone into Resident's #1's room as he had on a Dad' shirt. She stated she left shift just after midnight on 08/02/2026, and CR #1 was provided with 1:1 supervision from CNA F. During an interview on 08/04/2026 at 05:10 p.m., LVN B stated that on 08/01/2026, she worked 06:00 a.m. - 06:00 p.m. and was assigned to provide CR #1 patient care during her shift. She stated at 05:30 p.m., while still in the hall passing medication, LVN A told her CR #1 had an incident and required 1:1 supervision and LVN A had asked CR #1 to remain in his room. She stated from the hall, she could see CR #1's room and him at his doorway trying to come out. She stated she had told him he required supervision and needed to remain in his room. She stated that CR #1 denied needing 1:1 supervision but was compliant with staying in his room. She stated she had finished passing the medication and asked CR #1 to come with her to the nurse's station and he followed in his motorized wheelchair. She stated at 06:00 p.m., LVN D came on shift and relieved her and was now responsible for providing CR #1 with supervision. She stated she left shift and returned 08/02/2026, and the ADON asked her to write a statement of what occurred on the 08/01/2026 shift and then CR #1 was reassigned to the memory care with 1:1 supervision. She stated on 08/02/2026, she received in-service training on ANE. During an interview on 08/04/2026 at 05:29 p.m., CNA F stated on 08/01/2026, at 08:00 p.m., LVN B told him that CR #1 had done something wrong/inappropriate to Resident #1 and they were trying to figure out what to do with CR #1. He stated he began providing CR #1 supervision in the lobby near the door. He stated on 08/02/2026, he received in-service training on ANE. During an interview attempt on 08/05/2026 at 09:09 a.m., RP #2 had been unsuccessful contacted to provide a statement. During an interview on 08/05/2026 at 09:37 a.m., CNA G stated on 08/01/2026 at 05:30 p.m., CNA A asked her to check on Resident #1 who seemed distraught. She stated that Resident #1 told her that CR #1 came into her room and touched her leg, rubbing all the way to her brief. She stated Resident #1 described CR #1 as a man wearing a black t-shirt with Daddy written on the front and she was understandably emotional. She stated she and CNA A immediately reported the incident to LVN A who provided Resident #1 with a physical exam finding no skin or pain issues. She stated on 08/02/2026, she received in-service training on ANE. During an interview on 08/05/2026 at 10:22 a.m., CNA F stated on 08/01/2026, he came on shift at 10:00 p.m., and was assigned to provide CR #1 1:1 supervision until his shift ended at 06:00 a.m. He stated on 08/02/2026, he received in-service training on ANE. During an interview on 08/05/2026 at 10:45 a.m., ADON stated that on 08/01/2026 she received a text from LVN A statedCR #1 went into Resident #1's room at 05:35 p.m., began rubbing Resident #1's right leg from the ankle to her brief, Resident #1 screamed for help, and CR #1 left the room. She stated LVN A spoke to CR #1 who at first denied and later admitted going into Resident #1's room and had not touched Resident #1. She stated that LVN A and LVN C provided Resident #1 a physical assessment to determine any injuries and pain, finding none, completed charge assessment reports for both residents summarizing the incident, and notified their RPs and physicians. She stated both residents were ordered psychosocial assessments with their psychologist and psychiatrist to determine psychosocial health and safety after the incident. She stated LVN C stated Resident #1 felt safe with the door open and her curtain pulled open to see passerby in the hallway. She stated LVN B began 1:1 supervision for CR #1 until LVN D came on shift at 6:00 p.m. She stated on 08/02/2026 she began providing in-service training on ANE. She stated that the ANE in-service training dated 08/01/2026 reflected all the signatures of all staff who work at the facility. She stated that not all the staff were on shift on 08/01/2026, and as they came on shift on 08/02/2026 they signed the in-service document. She stated that not all staff working for the facility were on shift 08/02/2026 and she would write initiated on the ANE in-service training document to indicate that the training was initiated on 08/01/2026 and on-going as staff came on shift after 08/01/2026. She stated she would provide a schedule for when each staff actually received and signed off on the ANE in-service training. She stated on 08/2026, she arrived at the facility at 07:50 p.m. and left the facility at 02:00 a.m. on 08/02/2026. During an interview on 08/05/2026 at 04:19 p.m., SW stated on 08/02/2026, the ADON informed her that Resident #1 and CR #1 required safe surveys after a one on resident-to-resident altercation. She stated she asked Resident #1 what happened, and Resident #1 said that she had not wanted to talk about the incident and asked if CR #1 still in the facility. She stated she informed her that he was not. She stated Resident #1 asked was RP #2 informed, and was told he had been, and Resident #1 stated she would speak about the incident on 08/03/2026, once RP #2 was present. She stated she was able to determine that Resident still had a BIMS score of 14 indicating the resident had intact cognition. She stated Resident #1 had not agreed to questions from the safety survey form needed to determine if the resident felt safe after the incident without the presence of RP #2. She stated on 08/03/2026, she attempted to complete the safe survey with Resident #1 and RP #2, and RP #2 stated he had not had time, and informed RP #2 that Resident #1 would continue to receive psychologist, psychosocial, and physician services as a result of the incident to monitor and manage Resident #1's diagnosed anxiety. She stated on 08/02/2026, discharged . She stated that on 08/02/2026, ADON began in-service training ANE. She stated on the morning of 08/05/2026, Resident #1 stated she was stable. The ADM and DON were notified on 08/05/2026 at 05:39 p.m. that an IJ was determined. The ADM was provided and signed the IJ template on 08/05/2026 at 05:42 p.m. and Plan of Removal was requested. The following plan of removal was submitted by the facility and was accepted on 08/07/2026 at 09:13 a.m. Immediate Jeopardy (the facility) On 08/05/2026 the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 600 Date: 08/05/2026: On 08/05/2026 an abbreviated survey was initiated at 6:43pm. On 08/05/2026, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: the facility failed to ensure Resident #1 was free from sexual abuse after CR# 1 sexually abused her on 08/01/2026. Immediate Actions: All staff education regarding Abuse & Neglect Policy and Procedures initiated on 8/1/2026. Residents safe surveys were initiated on 8/1/26 continued on 8/5/26 regarding Abuse. There was no sexual abuse allegations noted. All staff education regarding Abuse & Neglect Policy and Procedures continued on 8/5/26 for new staff working. On 8/1/26, CR# 1 began on one-on-one supervision and was discharged from the facility 08/02/26 at 4:16pm by his responsible party and will not return. The medical director was immediately notified by ADON on 8/5/2026 of Immediate Jeopardy. Person(s) Responsible: ADON/DesigneeDate: 08/01/2026Completion: 08/05/2026Action: All employees were educated on Abuse & Neglect Policy and Reporting Abuse/Neglect Policy Person(s) Responsible: ADON/DesigneeDate: 08/01/2026Completion: 08/05/2026Action: All employees were educated on Types of Abuse & Neglect and Recognizing Signs and Symptoms of Abuse/Neglect Person(s) Responsible: ADON/DesigneeDate: 08/01/2026Completion: 08/05/2026Action: All employees were educated on Safety and Supervision of Residents Person(s) Responsible: ADON/DesigneeDate: 08/01/2026Completion: 08/05/2026Action: All employees were educated on One-on-One Clinical Protocol Person(s) Responsible: ADON/DesigneeDate: 08/01/2026Completion: 08/05/2026Action: Education on Resident Rights Person(s) Responsible: Regional [NAME] PresidentDate: 08/01/2026Completion: 08/05/2026Action: Education of Abuse & Neglect and One on One Supervision for ADON and Administrator Person(s) Responsible: Don/DesigneeDate: 08/01/2026Completion: 08/05/2026Action: One no One Education on One-on-One Supervision for noted charge nurse, LVN C Review of the pain assessment and management policy: Facility reviewed and validated the current policy to ensure alignment with regulatory requirements. Person Responsible: ADON/DesigneeAction: Safe Surveys initiated with Residents regarding Abuse & Neglect. Start Date: 08/01/2026Completion Date: 08/05/2026Response: There was no sexual abuse allegations noted and there were no other residents found to have been affected when safe surveys were completed. Person Responsible: ADON/DesigneeAction: All employees will be educated prior to working a shift for anyone that has not received the education due to PTO, scheduling, and PRN regarding Abuse & Neglect policy and procedure, Types of Abuse & Neglect, Recognizing Signs and Symptoms of Abuse & Neglect, and Safety & Supervision of Resident Start Date: 08/01/2026 Responsible: AdministratorAction: Facility Abuse & Neglect Policy reviewed and no changes madeStart Date: 08/01/2026Completion Date: 08/01/2026 Responsible: Psychologist/DesigneeAction: Resident #1 received psych visit on 8/5/26 which noted she was doing fine and denied experiencing any flashbacks or intrusive memories; she also acknowledged staff have been checking on her frequently and educated to knock before entering to prevent any distress. Resident #1 expressed feeling supported and reassured by measures. Start Date: 08/05/2026Completion Date: 08/05/2026 Responsible: ADON/AdministratorAction: Ad Hoc QAPI regarding Abuse Start Date: 08/05/2026Completion Date: 08/05/2026Response: Safe surveys will be completed weekly by management team for all residents for the next 30 days. Psych to follow up weekly with Resident #1 and will notify DON/Designee of progress. Person(s) Responsible: ADON/DesigneeAction: Abuse & Neglect Quiz for all staffStart Date: 08/05/2026Completion Date: 08/05/2026 Administrator and ADON initiated investigation on 08/01/2026 after receiving noted allegations and reported to HHSC. Intervention initiated, CR1 put on a 1:1, CR1 was determined that CR1 had a change in condition which included wandering, exit seeking, agitation, and sexual behaviors. Staff failed to follow facility protocols related to 1:1 monitoring, as a result CR1 followed a family member out of the facility without staff being aware. Staff were able to locate CR1 and transport CR1 back to the facility without injury. Elopement assessments completed for all residents. Education was provided to all staff regarding elopement and wandering and a 1:1 monitoring education, elopement drill completed and separate education to LVN C for the 1:1 monitoring education. Audit was conducted to determine if any residents were sexually active or exhibiting any sexual behaviors. The audit concluded that we have 2 male residents on the secure unit that previously exhibited sexual behaviors. Both residents are receiving psych services and are prescribed medication for sexually inappropriate behaviors, which they are tolerating well. Both residents have not had any sexual behaviors, and their care plans were updated. Staff will continue to monitor residents to ensure the safety of all residents on the unit. During an interview on 08/05/2026 at 06:31 p.m., LVN C stated that on 08/01/2026, at 05:30 p.m., LVN A asked her to assist in a skin and pain assessment of Resident #1. She stated during the assessment, Resident #1 stated that CR #1 came into the room picked a pillow up off the floor and began rubbing her calf up her leg and body trying to rub on her right breast, and due to Resident #1's contracted right arm laying right under that breast, CR #1 was unable to continue to rub upward without running into Resident #1's arm and began trying to get into CR #1's brief. She stated Resident #1 asked would CR #1 be coming back and she informed her that CR #1 would be moved to secure unit. She stated on 08/02/2026, she received in-services training on abuse. During an interview on 08/06/2026 at 10:10 a.m., RN A stated on 08/02/2026, she received in-service training on ANE. Record review of CNA L's handwritten Accident/Incident Investigation Witness Statement dated 08/02/2026, reflected, she came on shift on 08/02/2026, she was told by an (unnamed) supervisor that she would be providing CR #1 1:1 supervision after a series of events that took place on 08/01/2026. She stated she was instructed by (unnamed) staff that CR #1 needed to be followed closely, wherever he went she needed to be in close vicinity. She stated she provided 1:1 supervision to CR #1 until RP #1 discharged him on 08/02/2026. Record review of LVN B's email statement dated 08/03/2026 at 08:09 a.m. reflected, on 08/01/2026, LVN B stated towards the end of the shift (06:00 p.m.), while at the nurse's station, she was notified of an incident (between Resident #1 and CR #1) and to provide 1:1 supervision for CR #1 until oncoming nurse (LVN D) was notified and made aware of incident. Record review of MD's email statemen dated on 08/07/2026 at 01:17 p.m., reflected on 08/05/2026 at 09:00 p.m., ADON informed her of the IJ and at 10:00 p.m., she took part in QAPI. Record review of policy titled: Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 reflected, Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies;f. family members;g. legal representatives;h. friends; i. visitors; and/orJ. any other individual. 2. Develop and implement policies and protocols to prevent and identify:a. abuse or mistreatment of residents;b. neglect of residents; and/orc. theft, exploitation or misappropriation of resident property.3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. Record review of policy titled: Resident-to-Resident Altercation dated 2001 reflected, Policy Statement: all altercations including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Policy Interpretation and Implementation:Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors or to the staff.Behavior that may provoke a reaction by residents or others includeVerbal aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidatingB physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting spitting, threatening [NAME], throwing objects:Sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing, Talking touching or rummaging through other's property, and Wandering into others' rooms/space3. Occurrences of such incidents are promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.4. If two residents are involved in an altercation, staff:a. separate the residents, and institute measures to calm the situation;b. identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;c. notify each resident's representative and attending physician of the incident;d. review the events with the nursing supervisor and director of nursing services, and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents;e. consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem;f. make any necessary changes in the care plan approaches to any or all of the individuals involved;g. document in the resident's clinical record all interventions and their effectiveness:h. consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team:i. complete a report of Incident/Accident Form and document the incident, findings and any corrective measures taken in the resident's medical/clinical record andj. report incidents, findings, and corrective measures to appropriate agencies as outlined in Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating.5. Inquiries concerning resident-to-resident altercations are reflected to the director of nursing services or to the administrator. During an interview on 08/07/2026 at 11:24 a.m., CNA H stated she received in-serviced training on ANE on the morning of 08/07/2026. She stated all ANE were to be reported to the ADM immediately and as soon as suspected. She stated if a resident reported abuse, she would remain with the resident, pressing the call light and yell out for help. She stated she would ensure the resident was calm, and when help arrived, she would review the resident's chart and chart the incident. She stated the importance of reporting is to ensure residents are safe. She stated she would ensure the residents were calm, review their chart and chart the incident. During an interview on 08/07/2026 at 11:43 a.m., the HR Manager stated he was a part of the team that provided the staff with the in-service training on ANE. He stated that he was responsible for performing daily rounds and checking on Resident #1. He stated she had not reported feeling unsafe since the 08/01/2026 incident. During an interview on 08/07/2026 at 11:54 a.m., BOM stated in the last few days the facility had been providing in-service training on ANE and incidents via staffing huddles, and mass texts to the staff. During an interview on 08/07/2026 at 12:10 p.m. SW stated she had received in-service training in the last few days on resident rights. She stated after a resident-to-resident altercation the residents were to remain separated, the aggressive resident would be movement away from other residents and provided activities they enjoyed, ensure they remained calm and comfortable, and provide them with immediate 1:1 supervision. She stated all incidents were to be reported to the charge nurse, DON, ADON, ADM, resident's MD and RP, incident charted and intervention implemented immediately. She stated nurses were responsible for communicating the incident and interventions to all department managers who communicated the information to the floor staff and on coming to staff, so all were aware in the event staff needed to intervene. During an interview on 08/07/2026 at 12:47 p.m., LVN G stated she received in-service training on notifying the MD, RP, ADM, DON, charge nurse, and ADON immediately after an ANE incident, providing immediate 1:1 supervision after an incident, reporting incidents, and Resident Rights. She stated after reporting, providing residents involved with head-to-toe assessments, calling 911 for help when appropriate, and ensuring that the aggressive resident received immediate 1:1 eyesight supervision until safety placement was arranged. She stated all incidents were to be reported to the oncoming shifts and residents received extra monitoring throughout the oncoming shifts to report signs and symptoms of change in condition as a result of the incidents. During an interview on 08/07/2026 at 1:06 p.m., HR Manager stated he provided Resident #1 with a follow-up safety survey on the morning of 08/06/2026 with RP #2 present. He stated the safety found no adverse changes or concerns and Resident #1 and RP #2 were complimentary of the care Resident #1 was provided after the incident with CR #1. During an interview on 08/07/2026 at 01:33 p.m., PT Director stated on 08/06[TRUNCATED]

Based on interview and record review, the facility failed to ensure that the resident's environment remained as free from accident hazards as possible and failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (CR #1). The facility failed to ensure LVN A and LVN C provided CR #1 with 1:1 supervision after Resident #1 alleged CR #1 sexually abused her, resulting in CR #1 eloping from the facility. An IJ was identified on 08/06/2026 at 02:04 p.m. The IJ template was provided to the facility on [DATE] at 02:04 p.m. While the IJ was removed on 08/07/2026 at 05:38 p.m., the facility remained out of compliance at a scope of an isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failure could place residents at-risk of injury or death due to not being adequately supervised. The findings included: Record review of CR #1's face sheet reflected, he was a [AGE] year-old male originally admitted on [DATE], readmitted on [DATE] and discharged on 08/02/2026. CR #1's diagnoses included hypertension (high blood pressure, force of blood against the artery walls consistently too high), anxiety disorder (mental health condition that causes ongoing, extreme fear, worry, or panic), restlessness and agitation (tense, uneasy, and unable to sit still), unsteadiness on feet (lack balance or stability while standing or walking), generalized muscle weakness (a whole-body lack of physical strength where extra effort is needed to move), need for assistance with personal care, psychosis (a mental state marked by a loss of contact with reality) not due to a substance or known physiological condition (the state of the body and how its internal systems, organs, and cells function), adjustment disorder (an emotional or behavioral reaction to a stressful life event-such as a job loss, divorce, or move-that occurs within three months of the event) with mixed anxiety (happens when you feel both anxious and depressed at the same time) and depressed mood (a persistent feeling of sadness, emptiness, or low spirits that lasts most of the day, nearly every day), major depressive disorder (serious mental health condition), recurrent, mild, adjustment disorder (an emotional or behavioral reaction to a stressful life events) with anxiety, vascular dementia (a decline in thinking skills caused by blocked or reduced blood flow to the brain), moderate, with other behavioral disturbance (a sudden or ongoing change in how a person acts, thinks, or feels that disrupts daily life). Record review of CR #1's MDS dated [DATE], reflected, a BIMS score of 07 out of 15, suggesting some cognitive changes or impairment. His mood interview reflected, a score of 03 suggesting low depressive symptoms. Record review of CR #1's Care Plan reflected, 06/06/2023, CR #1 received psychology/psychiatry services in the facility, with interventions to communicate with CR #1 and progress with psychology/psychiatry services, interventions communicate with CR #1 and the progress of the psychology/psychiatry services. Record review of CR #1's Care Plan reflected, 08/19/2023, had impaired cognitive function/impaired thought processes r/t Dementia, with interventions, administer medications as ordered. Monitor/document for side effects and effectiveness. Communication: Use the resident's preferred name. Identify yourself at each interaction. Face resident when speaking and making eye contact. Reduce any distractions-turn off TV, radio, and close door etc. The residents understand consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Cue, reorient and supervise as needed. Engage resident in simple, structured activities that avoid overly demanding tasks. Keep the residents' routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Monitor/document and report PRN as changes in cognitive function, specifically changes in decision making ability, memory recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of CR #1's Care Plan reflected, 08/19/2023, had behavioral problems r/t restlessness/agitation. CR #1 got very agitated when staff tried to redirect him. CR #1 yells and cusses towards staff when he does not get his way, with interventions anticipate and meet needs, staff to provide opportunity for positive interaction, attention, stop and talk with him as he passes by, explain/reinforce why behavior was inappropriate and/or unacceptable to the resident, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove form situation and take to alternative location as needed, monitor behavior episodes as attempted to determine underlying cause. Consider location, time of day, persons involved, and situation, document behavior and potential causes. Record review of CR #1's Care Plan reflected, 08/20/2023, required assistance with all ADLs, with interventions of allowing breaks between tasks, break tasks up into smaller steps, give verbal cues to help prompt, refer to OT to work on ADL retraining. Record review of CR #1's Care Plan reflected, 11/27/2023, dependent on staff for meeting emotional, intellectual, physical, and social needs r/t dementia. Enjoyed wheeling around the facility, listening to music, with interventions, invited the resident to scheduled activities and thanked him for his attendance. Record review of CR #1's Care Plan reflected, 01/01/2025, had behaviors of using his motorized wheelchair in full speed down the hallways while playing music loud and becomes agitated when being redirected, with interventions of communicating with CR #1 the need for safety around the facility when using his motorized wheelchair and communicated with family on encouraging safety. Record review of CR #1's Care Plan reflected, 08/01/2026, had an inappropriate behavior with another resident. Due to his poor cognition, staff continued to monitor, with interventions, monitored on 1:1 supervision and notified hospice/physician and family of changes in condition. Record review of CR #1's Care Plan reflected, 08/01/2026, was an elopement risk/wanderer as evidenced by actively exit-seeking, with interventions, attempt to engage in pleasant, meaningful, purposeful enjoyable, activities, during episodes of constant wandering, placed on 1:1 supervision, observe for changes in gait/mobility/balance and notify the nurse of any changes, and placed to secure unit on 08/02/2026, due to active exit seeking. Record review of CR #1's Care Plan reflected on 08/02/2026, discharged AMA with RP #1 on 08/02/2026, with interventions, nurse witnessed RP #1 refusal to sign AMA form. Record review of CR #1's Progress Notes dated 08/03/2026 at 09:36 p.m., reflected, on 08/01/2026 at 05:00 p.m., LVN A contacted RP #1 regarding incident for inappropriate behavior and the elopement, and a physician ordered for a psych consult and UA. RP #1 stated that, CR #1 would never do such a thing, do not contact your doctor and get an order, he was under Hospice care, and you are not to contact your doctor. I am not authorizing that. LVN A informed RP #1 that the facility had to follow protocol, and RP #1 repeated her request and that she would be to the building the following day and hung up the phone. Record review of CR #1's Progress Notes dated 08/02/2026 at 09:15 p.m., reflected, on 08/01/2026 at 11:45 p.m., LVN C observed CR #1 in the front lobby with CNA B. CNA B reported that CR #1 was up in the lobby, chewing artificial flowers and was asked to spit them out, and did. CR #1 was offered a sandwich and CR #1 agreed to eat the sandwich instead of artificial flowers. Will continue to monitor. Record review of CR #1's Progress Notes dated 08/02/2026 at 02:46 a.m., and completed by LVN A reflected, a skin assessment performed found CR #1's skin warm and dry skin color WNL and turgor (skin's ability to change shape and spring back to normal) normal. No skin issues identified and no new skin issues identified. Record review of CR #1's Discharge Recapitulation Summary completed by LVN E and dated 08/02/2026 at 04:54 p.m., reflected, CR #1 discharged . Reason for discharge: RP #1 took resident AMA. RP #1 came to the unit and demanded CR's medications stating she was taking him home. RP # 1 refused to sign discharge papers or AMA forms. RP #1 grabbed a laundry basket with clothes and CR's phone. The remaining personal items were in CR's room. Record review of CR #1's Change of Condition dated 08/01/2026 at 06:00 p.m., and completed by MD A reflected, an observation, evaluation, and recommendation found that a female resident described CR #1 as a male that entered her room and began touching/rubbing her ankle and up her leg until reaching brief until she screamed for help. MD A questioned CR #1 who admitted that he went into Resident #1's room but denied touching the female resident. Behavioral changes described as: Inappropriate sexual behaver towards another resident. Recommended psychiatric consultation and urinalysis for culture. Record review of CR #1's Elopement Evaluation dated 08/02/2026 at 02:44 p.m., and completed by LVN D reflected, CR #1 had a history of elopement while at home, wandering behavior, and pattern or goal-direction, wanders aimlessly or non-goal-directed, had wandering behavior likely to affect the safety or well-being of self/others, wandering behavior not-likely to affect the privacy of others, and CR #1 had not accepted the situation. On a 0-10 point scale, CR #1's elopement risk scored a 07, indicating, 7 out of 10 as a very high, imminent risk for elopement. During an interview on 08/04/2026 at 12:02 p.m., LVN A stated that she was at the nurse's station on 08/01/2026 at 5:30 p.m., when CNA A reported to a female resident (Resident #1) had been found in her room screaming for help and reported CR #1 inappropriately touched her. She stated she went to CR #1's room and found him there in his motorized wheelchair and immedately stated he had not done anything before she was able to ask him any questions. She stated CR #1 denied going into Resident #1's room, then admitted having gone into the room, and continued denied he had touched Resident #1. She stated she told CR #1 to remain in his room until she sorted everything out. She stated she returned to the nurse's station and reported to LVN B who was CR #1's nurse of the reported incident and that CR #1 required 1:1 supervision. She stated she and LVN C then went to Resident #1's room to perform the skin/pain assessments. She stated it was her understanding that LVN B assigned a staff to provide CR #1 with 1:1 supervision. She stated at 07:30 p.m., CNA C reported to her that CR #1 was seen outside in his motorized wheelchair in front of the facility in the street. She stated she immediately told LVN C and LVN D and they all went outside to their personal vehicles to locate CR #1 in the community. She stated that CR #1 was located down the street at the intersection at the traffic light. She stated that LVN C, LVN D, and herself tried convincing CR #1 to return to the facility and/or get into one of their vehicles to be transported back. She stated CR #1 refused and accused them of trying to trick him, and that he knew what they were trying to do to him. She stated she called RP A to speak to CR #1 who too was unable to convince CR #1 to return to the facility. She stated that LVN D had to call 911 for law enforcement to assist with encouraging CR #1 to return to the facility and too was unsuccessful. She stated CR #1 cussed at them and was not trustful of the efforts of getting him back to the facility. She stated after nearly 30 minutes, CR #1 agreed to get into her vehicle, and she returned to the facility where it took another 30 minutes to encourage him to get out of her vehicle into a manual wheelchair arguing was not his chair. She stated he had a manual chair and had to be convened it was his manual wheelchair; he got into the chair and came back into the facility's lobby area. She stated she called RP #1 and informed her of CR #1's elopement and need for MD A to assess, order a UA, and psychological consults for his best interest. She stated RP #1 refused to allow the assessments arguing hospice was his physician providers who were responsible for assessments and hung up the phone. She stated on 08/02/2026, CR #1 was ssigned under her care, and it was determined by the ADM to place him in the memory care unit due to his high risk of elopement. She stated that RP A came in and was extremely upset saying they had no right to place CR #1 in memory care without her consent, and RP A let CR #1 out of the secure memory care unit while she packed up his items for discharge. During an interview on 08/04/2026 at 02:37 p.m., RP #1 stated that on 08/01/2026, she received a call from the facility while out of town and learned, CR #1 had inappropriately touched another resident. She stated later that same day, she received additional missed calls learning, CR #1 had eloped 6-7 blocks from the facility near dark in the August heat. She stated on 08/02/2026, she arrived at the facility, finding CR #1 had been moved to the secure unit without her knowledge. She stated when questioning the DON why CR #1 was in the memory care unit without her knowledge and consent, DON told her he was not cognitively intact and, They were the professionals, and would do what they thought was best as the reasoning for CR #1's memory care placement. She stated she felt CR #1 was being punished for something he had not done, and she felt he was no longer safe at the facility and made the decision at that moment to discharge him. She stated she requested the resident's medication and was presented with an AMA form she refused to sign, and the facility refused to provide all of CR #1's medications. She stated she refused to sign the AMA form because there had been no physician consult provided to show he was not safe to discharge. She stated she was able to contact CR #1's hospice clinical team that filled his medications and she had found a new facility to admit the resident into. During an interview on 08/04/2026 at 12:32 p.m., LVN D stated on 08/01/2026, he came on shift at 6:00 p.m. He stated LVN B informed him that CR #1 had sexually touched Resident #1 and required 1:1 supervision. He stated it took them awhile to find a CNA to provide CR #1 1:1 supervision because there were not enough staff to work the facility and cover CR #1's supervision. He stated about 07:30 p.m. he had designated CNA C to provide CR #1's 1:1 supervision, and before he could pair CNA C with CR #1, he heard someone in the hall yelling out that CR #1 had eloped from the building. He stated he got into his personal vehicle and began driving around the community and found CR #1 at the corner near the traffic light. He stated CR #1 refused to return to the facility stating he did not trust anyone at the facility. He stated he called back to the nurse's station to alert the staff the resident had been located and obtain assistance encouraging the resident to return to the facility. He said no one answered and had no other option to call 911 for law enforcement assistance. He stated then LVN A and LVN C pulled up and began unsuccessfully, encouraging CR #1 to get into their vehicles. He stated law enforcement arrived, and they were unsuccessful encouraging CR #1 to return to the facility. He stated that LVN A called CR #1's RP, hoping the RP would encourage him to return, but he repeatedly refused. He stated that CR #1 stated that the staff were trying to trick him into returning, and that he did not care what RP #1 said, he was a grown man and could do what he wanted to do, and the facility was not going to trick him to return. He stated finally, CR #1 agreed to get into LVN A's vehicle. He stated once inside the facility, CR #1 was placed on 1:1 supervision with CNA C. He stated that CR #1 remained in the lobby area, refusing to move away from the front door the majority of the evening. He stated CR #1 exhibited erratic, aggressive, and radical behaviors trying to eat the plastic flowers off the fake plants, cussing, yelling at staff, and repeatedly trying to get out of the door whenever opened. He stated that eventually, CR #1 tired in the early morning hours and CNA C got CR #1 into bed. He stated when he returned to shift the following day at 6:00 p.m., CR #1 had been discharged . During an interview on 08/04/2026 at 03:08 p.m., CNA D stated on 08/01/2026 at 07:25 p.m., she was outside of the facility and believed she saw who looked like CR#1 in in his motorized wheelchair in front of the facility in the street. She stated she immediately went into the facility and informed LVN A that CR #1 was outside. She stated they went outside to bring CR #1 back into the facility, but he was no longer in sight. She returned into the facility and LVN A grabbed her car keys to drive the community to locate CR #1. She stated a short time later, she saw CR #1 in his manual wheelchair receiving 1:1 supervision from CNA C in the lobby area. She stated CR #1 was extremely upset, cussing and yelling out in disagreement to the 1:1 supervision and that he wanted to leave the facility. She stated she did not see CR #1 anymore that shift and when she returned to shift next, he had discharged from the facility. During an interview on 08/04/2026 at 03:18 p.m., CNA E stated on 08/01/2026, she was on shift from 2:00 pm - 10:00 pm and learned sometime during the shift from a staff whom she could not recall, CR #1 had eloped, was found rather quickly and had been assigned 1:1 supervision to prevent further elopements. She stated when she left shift, CR #1 was in the lobby near the door and she heard him say, I am a grown man, I don't need supervision while trying to kick at staff who came in and out of the door. During an interview on 08/04/2026 at 03:37 p.m., ADON stated on 08/01/2026, CNA C provided CR #1 supervision until 10:00 p.m., and CNA F provided CR #1 supervision from 10:00 p.m., until 06:00 a.m. on 08/02/2026. During an interview on 08/04/2026 at 04:56 p.m., CNA A stated on 08/01/2026 around 5:00 p.m., she was in the hallway when she heard Resident #1 calling out for help. She entered the room and Resident #1 reported a male resident (CR #1) had come into her room and touched and rubbed up and down her leg and attempted to get into her brief. She stated she went to the nurse's station and told LVN A to come to the resident's room. She stated at 07:30 p.m., CNA D asked if she had seen CR #1 who was missing. She stated she told CNA D the last time she had seen him was at the nurse's station, but she could not recall the time. She stated all the staff began searching for CR #1 and she searched the inside of the facility. She stated around 08:00 p.m., CR #1 was located outside of the facility. She stated at that time it had been confirmed to her that CR #1 was the resident that had gone into Resident's #1's room. She stated she left shift just after midnight on 08/02/2026, and CR #1 was in his manual wheelchair in the lobby area seemly asleep. She stated it had been her understanding that CR #1 wanted to be in the lobby and had not wanted to go to his room. During an interview on 08/04/2026 at 05:10 p.m., LVN B stated that on 08/01/2026, she worked 06:00 a.m. - 06:00 p.m. and was assigned to provide CR #1 patient care during her shift. She stated while passing medication in the hall (time unknown), CR #1 spoke to her in a robotic voice and made a gesture for her to come closer, when she leaned in, CR #1 told her he wanted to go back to truck driving and leave the facility. She stated CR #1 turned in his motorized wheelchair and went into his room. She stated at 05:30 p.m., while still in the hall passing medication, LVN A told her CR #1 had an incident and required 1:1 supervision and LVN A had asked CR #1 to remain in his room. She stated from the hall, she could see CR #1's room and him at his doorway trying to come out. She stated she had told him he required supervision and needed to remain in his room. She stated that CR #1 denied he needed 1:1 supervision but was compliant with staying in his room. She stated she had finished passing the medication and asked CR #1 to come with her to the nurse's station and he followed in his motorized wheelchair. She stated at 06:00 p.m., LVN D came on shift and relieved her and was now responsible for providing CR #1 with supervision. She stated she left shift and returned 08/02/2026, and LVN D told her that CR #1 eloped after following someone out the door and still required 1:1 supervision. She stated on 08/02/2026, the ADON asked her to write a statement of what occurred on the 08/01/2026's shift and then CR #1 was reassigned to the memory care with 1:1 supervision. She stated on 08/02/2026, she received in-service training on elopement and ANE. During an interview on 08/04/2026 at 05:29 p.m., CNA F stated on 08/01/2026, he worked 6:00 a.m. - 10:00 p.m. He stated that morning, he provided CR #1 with patient care and CR #1 seemed to be fine, his old fun, jokey, playful self and throughout the day saw CR #1 laughing. He stated CR #1 was an independent resident, who was able to move around the facility independently with a motorized and manual wheelchair. He stated about 07:30 p.m., while assisting a resident, CNA A had asked had he had seen CR #1 who seemed to be missing, and told her the last time he saw CR #1, he was sitting at the nurse's station with LVN B. He stated he finished what he was doing and began looking for CR #1 in the facility and LVN A told him that CR #1 required 1:1 supervision, and when found, he would be providing CR #1's supervision. He stated that CR #1 was found and sat at the nurse station in his manual wheelchair with LVN C. He stated he was outside the facility on break, and LVN B told him that CR #1 had eloped after doing something wrong/inappropriate to Resident #1 and they were trying to figure out what to do with CR #1. He stated at 08:00 p.m., he began providing CR #1 supervision in the lobby near the door. He stated that he had to pull CR #1 away from the door several times as CR #1 kicked and pushed at the door. He stated he attempted to block CR #1 from going towards the door and asked CR #1 to relax and would he like to lay down. He stated that CR #1 said, I don't wanna lay down, I want to get the fuck out of here, I am going to Los Angeles. He stated that the ADON told him to give CR #1 some space, not to let him leave out the facility, and not crowd him. He stated as soon as he had given CR #1 space, CR #1 kicked and punched at the door. He stated he feared CR #1 would bust the door open and every time anyone entered or exited the door, CR #1 attempted kick and swing his fist at the individuals. He stated CR #1 cussed and fussed, and he felt it was an act or a facade, because soon as no one paid attention, CR #1 would look up to see who was watching him, and if he caught their eye, he would begin fussing and cussing and going towards the door. He stated at 10:00 p.m., when he left shift, CR #1 was at the exit door in the lobby with CNA F still trying to kick and push at the door. He stated on 08/02/2026, he received in-service training on elopement and ANE. During an interview on 08/05/2026 at 09:37 a.m., CNA G stated on 08/01/2026 at 05:30 p.m., CNA A asked her to check on Resident #1 who reported CR #1 came into her room touched her leg, rubbing all the way to her brief. She stated about 07:30 p.m., she heard a commotion at the nurse's station as CR #1 was missing. She stated she looked within the facility and other staff looked for CR #1 outside in the community. She stated at 10:00 p.m., when she left shift, CR #1 was in the facility lobby with CNA F rather agitated trying to leave the building, swinging his arms and kicking his legs trying to get out the door. She stated on 08/02/2026, she received in-service training on elopement and ANE. During an interview on 08/05/2026 at 10:22 a.m., CNA F stated on 08/01/2026, he came on shift at 10:00 p.m., and was assigned to provide CR #1 1:1 supervision until his shift ended at 06:00 a.m. He stated on 08/02/2026, he received in-service training on elopement and ANE. During an interview on 08/05/2026 at 10:28 a.m., ADON stated that on 08/01/2026 she received a text from LVN A at 05:35 p.m., that CR #1 went into Resident #1's room and began rubbering her right leg from the ankle to her brief. She stated LVN B began 1:1 supervision for CR #1 until LVN D came on shift at 6:00 p.m., She stated at 7:30 p.m., she received a call from LVN A that CR #1 had eloped from the facility, and all staff were performing an immediate search for him. She stated she remained on the phone with LVN A learned LVN D had found CR #1 at the intersection and traffic light and CR #1 was refusing to get into any of the staff's vehicles to return to the facility and had to give the okay for them to call 911 for law enforcement assistance. She stated she ended the call with LVN A who called RP #3 in hopes RP #3 would encourage CR #1 to return to the facility with no success. She stated LVN A eventually got CR #1 into her vehicle, and it took CR #1 another 15-20 minute refusing to get out of LVN A's vehicle arguing with staff about not wanting to get into a manual wheelchair. She stated that CR #1's motorized wheelchair was left where CR #1 was found and LNV C eventually drove it back to the facility. She stated once inside, CNA C was assigned to provide CR #1 1:1 supervision and CR #1 remained in the lobby area cussing and shouting out derogatory and negative language towards staff for not allowing him to leave the facility. She stated that CNA C had to move CR #1 away from the door several times because of his attempts to leave out the door and combative behavior towards those who came in or out of the door and stopped him from going out the door. She stated LVN A tried to contact RP #1 several times, and her calls went to a voicemail system that was full and would not allow new messages. She stated she contacted the Maintenance Director to review the video footage and learned that on 08/01/2026 at 07:21 p.m., CR #1 was in his motorized vehicle and without any direct supervision. She stated at 07:26 p.m., RN A came around the corner wheeling another resident, unlocked the door to allow that RP and resident to leave, when RP #3 held the door for CR #1 to leave out the door. She stated at 09:50 p.m., CNA F began providing CR #1 supervision and distracting him from exit seeking behavior. She stated CR #1 told CNA F, I am a grown man with 6-kids, I can do what I want and began eating the artificial leaves off a fake tree located near the door. She stated when the CNA F tried to pull CR #1 away from the tree and door, he would swing his arms and cuss to leave him alone. She stated she instructed the staff involved in CR #1's supervision and elopement recovery to write statements. She stated SW began conducting safety surveys with CR #1 and Resident #1. She stated as the evening progressed and CR #1 began to calm down, CNA F was able to move CR #1 slowly towards the nurse's station and by 02:00 a.m., CR #1 agreed to go to his room and be placed into bed. She stated on 08/02/2026, LVN G made the decision to move CR #1 to the memory care unit which provided a locked and secure area for his and everyone else's safety after all the events and observations that occurred on 08/01/2026. She stated RP #1 came to the facility and requested CR #1 be discharged and was upset that CR #1 was placed in the memory care unit. She stated LVN B explained to RP #1 that CR #1's exit seeking behavior had continued changing his elopement risk, RP #1 had refused for CR #1 to receive an UA, psychological consults, and it was then in CR #1's and other's best interest for him to be placed in the memory care unit. She stated that RP #1 discharged CR #1 without signing an AMA form. She stated that CR #1 was an alert and oriented resident times 3-4 out of 5 indicating high cognitive orientation with a low elopement risk. She stated after the elopement, CR #1's elopement risk increased. She stated on 08/02/2026 the facility began providing in-service training on ANE and elopement risk protocols, notifying physicians and families. During an interview on 08/05/2026 at 01:28 p.m., Maintenance Director stated late on 08/01/2026, he received a call from ADON requesting he review the video footage of the front door to see when CR #1 exited the building. He stated on 08/01/2026, CR #1 sat at the farthest corner of the reception desk for about 5-minutes watching the door in his motorized wheelchair. He stated at 07:26 p.m., RN A came around the corner wheeling another resident and RP #3, unlocked the door to allow RP #3 to leave with that other resident, when CR #1 said something to RP #3 who looked back to CR #1, held the door for CR #1, and CR #1 left out of the building. He stated the video footage erased automatically after 2-days and he was not instructed to save or review any other parts of the video footage. During an interview on 08/05/2026 at 04:19 p.m., SW stated on 08/02/2026, the ADON informed her that Resident #1 and CR #1 required safe surveys after a one on resident-to-resident altercation. She stated she asked Resident #1 what happened, and Resident #1 said that she had not wanted to talk about it and asked was CR #1 still here, and she informed her that he was not. She stated on 08/012026, at 09:50 p.m., CR #1 refused to answer the safe survey questions and on 08/02/2026, discharged . She stated that on 08/02/2026, ADON began in-service training on wandering, elopements, 1:1 supervision, and ANE. During an interview on 08/05/2026 at 06:31 p.m., LVN C stated that on 08/01/2026, at 05:30 p.m., LVN A asked her to assist her in performing a skin and pain assessment for Resident #1, after it was stated that CR #1 had gone into Resident 1's room. She stated that Resident #1 told her that CR #1 rubbed up her calf, leg, and body trying to rub on her right breast, and go into her brief. She stated at 07:30 p.m., while at the nurse's station, CNA D reported that CR #1 was missing and all the staff began searching for him. She stated she got into her vehicle and began searching the community and found LVN D at the traffic intersections with his vehicle flashers on with CR #1. She stated she pulled up behind LVN D and seen him trying to encourage CR #1 to get into his vehicle. She stated CR #1 refused, stating he would not be fooled by them, and he was going to a family member's home in the community. She stated she was not aware that CR #1 had any family in the community. She stated that because CR #1 refused to get into LVN D's vehicle and return to the facility, LVN D called 911 in hopes law enforcement could convince CR #1 to return. She stated LVN A and law enforcement arrived, and they called RP #1 all attempting to encourage CR #1 to get into her vehicle and return to the facility. She stated after 10 more minutes of refusal, he finally agreed to get into LVN A's vehicle, and she drove it back to the facility. She stated she then drove CR #1's wheelchair back to the facility, facing oncoming traffic with law enforcement falling behind her with his flashers on. She stated that there were no sidewalks in front of the nursing facility. She stated she placed the wheelchair in an empty room and CR #1 was placed into his manual wheelchair and provided 1:1 supervision for the remainder of evening. She stated she was unaware how CR #1 had eloped because staff were required to unlock the door for it to open and anyone to come in or out. She stated on 08/02/2026, she returned to shift and RP #1 was upset CR #1 was reassigned to the memory care unit and discharged him AMA. She stated on that day, she received in-services training on elopements, 1:1 supervision, abuse, and notifying the ADM, DON, ADON, physicians, and family after an incident. During an interview on 08/06/2026 at 10:10 a.m., RN A stated on 08/01/2026, she let several family members in and out of the facility during her 6:00 a.m. to 6:00 p.m. shift and could not remember seeing CR #1 in or around the door at 07:30 p.m. She stated she was not aware of a resident-

Based on observation, interviews, and record reviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for two rooms (102 & 305) of 1 of 1 facility reviewed for physical environment. The facility failed to maintain an effective pest control program so that rooms [ROOM NUMBERS] were free of roaches.This failure could place Residents at risk of a reduced quality of life.Findings:Record review of pest control dates:August 14, 2025- Treated the exterior of the facility for spiders and ants; replaced fly light device in kitchen; and exterior rodent stations were inspected.August 20, 2025-Treated and wiped down kitchen wall for gnat activity; a liquid application was applied around all baseboards throughout the entire kitchen including the dishwasher area; all dead roaches were vacuumed from the floor; and treatment was applied around the exterior perimeter of the kitchen to target American roaches.September 10, 2025-Follow-up of kitchen, still presence of German roaches in two areas. A gel was applied to the area. Activity of roaches was found underneath the shelves area.September 11, 2025-Full-service treatment was performed including room [ROOM NUMBER] (bait treatment was placed along the windowsills and restrooms), 201(bait treatment was applied to the air conditioners, windowsills, baseboards, and restroom corners). The break room was treated with a liquid application and replaced the bait in the cabinet. The laundry room, exterior exit doors, the Administrator's office and three other offices. It was noted the grass was too high, which could contribute to pest activity.October 14, 2025-Treated rooms 215 for roaches from the logbook. Treated all common area entry/exit points, administrative office, and exterior perimeter. Rooms 201 revealed serval dead roaches around bed B. room [ROOM NUMBER] had signs of roach activity within open areas of the baseboards which was reported by the Resident. Kitchen mentioned condition has improved but small roaches are still behind the microwave.November 7, 2025-Treatment of therapy room, laundry room, all entry/exit doors. Treated hallway 3 where a few requests from rooms 310, 311, 312, 315, and 316. room [ROOM NUMBER] had light gnat activity. November 25, 2025-Visit revealed room [ROOM NUMBER] had German cockroach activity, room [ROOM NUMBER] had major German cockroach infestation at Bed A, room [ROOM NUMBER] had minor activity at bed A near food dispenser, room [ROOM NUMBER] had activity at bed and inside a resident phone, room [ROOM NUMBER] had significant harborages inside nightstands and within a damaged wall void, room [ROOM NUMBER] had minor activity, room [ROOM NUMBER] had a minor activity, and room [ROOM NUMBER] had a minor activity. It was noted room [ROOM NUMBER] had major sanitation issues contributing to heavy infestation; these conditions are directly attracting and supporting roach activity.December 03, 2025-Treatment of all rooms in the 300 hallways. Bait only treatment applied to rooms [ROOM NUMBER]. room [ROOM NUMBER] had live German cockroaches activity observed. Activity closet was observed with activity and treated. Administrator's office was treated per her request due to live roach sighted early that day.December 3, 2025-Treated common area, interior, and residents room. The targeted pests: American Roaches, Asian Roaches, [NAME] Banded Roaches, German Roaches, and Oriental Roaches.December 12, 2025-Treated the front desk and nurses' station per request. Treated rooms 201, 202, 203, 204, 205,206,207, 208, 209,210, 211, 212, 213, 214, 215, 216. Additional areas in 200 hall: kitchen (roaches), maintenance office, shower rooms 1 & 2, clean linen room (roaches), and social worker office. All areas were treated for German roach activity. Identify roach activity in room [ROOM NUMBER], 214, 215, and 216 (80 activity found). The facility requested 12 glue boards and was provided.December 12, 2025-Treated Hall 400 per request of maintenance supervisor.December 19, 2025-Treated rooms 401-414 and 416-422 for roaches. It was discussed with the Environmental Service Director the loose or damaged baseboard, corner walls in multiple units, and around toilet seals that needed to be sealed.December 26, 2025- Treated room B216 per request log. Also treated 100 hall and dining/laundry room.January 1, 2026-Treated 300 hall per request in log book. Treated room [ROOM NUMBER]-316. It was reported by the dietary manager a roach was in the microwave. It was noted there were food crumbs and other debris on the floor which provided potential food source for roaches.January 9, 2026 -Pest Control supervisor came to the facility with his worker. Treated rooms [ROOM NUMBERS] per request of the Director of Environmental Services. There was one dead German cockroach vacuumed up from unit 216 and one live roach.January 16, 2026- Treated the therapy room per a request. There were four dead roaches located in the break room where trash was stored inside the cabinets.February 10, 2026-Treated dining room, units 314, 316, 109, and the therapy gym for gnats.March 12, 2026-Treated medication room per request. It was noted one of the toilets was not properly fixed, needed to be repaired to help prevent potential pest problems.April 10, 2026-Treated rooms 305, 307, 311, 314, 315, janitorial closet, shower room, and storage area per a request. Two dead cockroaches were observed.On 5/21/2026 at 10:50 a.m. the surveyor and Director of Environmental Service observed a live roach in room [ROOM NUMBER] and a dead roach in room [ROOM NUMBER] while observing rooms on each hall for roach activity.In an interview on 5/21/2026 with the Environment Service Director, he stated he has been working at the facility for 11 years. He stated he does understand the importance of maintaining effective pest control. He stated it was his responsibility to ensure the facility does have effective pest control. He stated the facility does have a monthly service pest control, they were just at the facility on 05/19/2026 and the roaches were running to get away from the pest control spray. He stated he treats the facility monthly with a spray. He stated the facility does have a log for the employees to report any citing of pests. He stated the risk to the residents was they can be harmed and it may affect them. In an interview on 05/21/2026 at 1:43 pm with the Administrator, she stated she had been working at the facility for over six years. She stated she understands the importance of maintaining effective pest control. She stated to her knowledge the pest control was scheduled for effectiveness also with any additional concerns of pest control, so when pest control was aware of any issue upon their visit they are addressed. She stated if anything arose in between the maintenance supervisor will address these issues. She stated all staff was responsible for ensuring effective pest control, so that was properly logged and communicated to be addressed properly. She stated she understands the risk to the residents which was possible germs.Record review of the facility policy tilted Pest Control revised May 2008 revealed Our facility shall maintain an effective pest control program.

Based on interviews, and record review, the facility failed to ensure residents were free from abuse for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse.1. The facility failed to ensure each resident was free from abuse when R#1 was hit on the hand by CNA A and2. The facility failed to ensure each resident was free from abuse when Resident #2 received rough ADL treatment by CNA AThis failure placed residents at risk of physical harm, emotional distress, and mental anguish.Findings IncludeRecord review or Resident #1's face sheet revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Alzheimer's (irreversible brain disorder affecting memory, thinking, and behavior) disease.Record review of Resident #1's Comprehensive MDS assessment, dated 02/42026, reflected the Resident #1had a BIMS score of 03, which indicated a severe problem with thinking and memory. Record review of Resident #1's care plan reflected the following:Focus: Resident #1 was resistive to ADL care and oftentimes refuses showers. Staff encouragement is met with resistance and avoidance. Goal: Resident #1 will cooperate with ADL care and improve decision making processes as it relates to participation in tasks through the next review dateInterventions: Allowed Resident #1 to make decisions about ADL care and tasks to promote a sense of control. When decisions have the possibility to intercept in meeting overall care goals; offer alternatives that align with the goals. Encourage as much participation by Resident #1 as possible during care activities. Ensure Resident #1 can complete the task independently with only supervision or as tolerable, capable. Provide her with the tools to complete each task. Give clear explanation of all care activities prior to and as they occur during each contact. If possible, negotiate the time for ADL so that the resident participates in the decision-making process. Return at the agreed upon time. If resident resists ADL care, reassure resident that you respect her decision, however, you will try again at a later time.Record review of Resident #1's Orders revealed, Sertaline 50MG tablet by mouth for major depressive disorder, recurrent mild (start 10/29/26 at 9:00am), Divalproex Sodium oral capsule 125 MG used for mood disorder (start 8/8/25 a t9:00pm), Namenda tablet 10 MG, give 1 by mouth every morning and at bedtime for dementia (start 5/5/25 9:00pm),During a telephone interview on 5.5.26 at 3:02pm with FM A she revealed she put a surveillance camera in Resident #1's room on 5.2.26 because she became concerned with Resident #1's ADL care after visiting, and on a few occasions, Resident #1 would always have on the same clothing and her brief needed changing. FM A stated she observed no sheets on the bed earlier and was getting ready to visit. She stated while getting dressed to come to the facility, she further observed CNA A come in Resident #1's room to change her, and get her up out of the bed. FM A stated Resident #1 did not want to be changed or to get out of bed. FM A stated CNA A began grabbing Resident #1, then Resident #1 hit her on the arm, and CNA A hit Resident #1 on the hand. FM A stated on Sunday 5.3.26, she arrived during CNA A's shift and spoke with CNA A. FM A stated, during this time, Resident #1 still was not changed and CNA A told her that Resident #1 would not allow her to change her. FM A stated then CNA A said Resident #1 had hit her. FM A stated, on the video, CNA A was pulling on Resident #1 and Resident #1 told CNA A to stop and CNA A continued trying to pull Resident #1 up and get her out of bed. She stated then the resident hit CNA A on arm, and CNA A hit Resident #1 on her hand and said, you are not going to do this to me I'm trying to help you. FM A stated the CNA A began to explain to another family member who told FM A that CNA A told them FM A was upset that there was no linen on the bed.Record review of video recording in Resident #1's room, revealed Resident #1 swatted at CNA A in an attempted to make CNA A stop pulling on her. At this time, CNA A hit the resident on her right hand while Resident #1 was lying on her side. CNA A then stated to Resident # 1, don't you do that I'm trying to help you sit up so come on. Don't do that to me.During observation and interview with Resident #1 on 5.5.26 at 3:20pm revealed Resident #1 was in her room, sitting on her bed call light was within reach. Resident #1 immediately was asked about being hit on her hand by CNA A and she stated, baby ain't nobody ever hit me. If they did, I would hit them back. She stated her aide is really nice. Resident #1 denied being hit.During an interview on 5.5.26 at 3:53pm with the DON, she stated she received a telephone call from FM A on Monday after 5.4.26 regarding concerns about her Resident #1. DON stated at that time she was informed that CNA A had assaulted Resident #1. DON stated she immediately completed a head-to-toe assessment on Resident #1 herself. The DON stated she questioned Resident #1 regarding the incident and Resident #1 could not recall the incident or being hit. DON stated she notified the Admin, who was the abuse coordinator and Resident #1's physician. The DON stated there were orders for CBC (blood test to detect any type of infection), and Urinalysis. The DON stated she contacted non-emergency police. The DON stated police came to assess and interview Resident #1 that evening, but Resident #1 could not remember the incident. She stated Resident #1 told the police that she was not hit. The police case report was completed and case number given to facility. The DON stated CNA A was contacted and asked about this incident. She stated CNA A initially stated Resident #1 didn't want to get up so she just left her room. However, the DON She stated she told CNA A that the camera said otherwise. The DON stated CNA A then told her that CNA A's behavior (hitting Resident #1) was a reaction, and she didn't think anything of it. The DON stated CNA A was suspended immediately pending outcome of investigation. The DON stated she told CNA A her license would be reported and police notified. The DON stated termination documents were sent to HR to terminate CNA A's employment. The DON stated CNA A's behavior was considered physical abuse. During an on interview on 5.6.26 at 5:30pm with the Admin stated CNA A was immediately suspended and termination of her employment has been recommended. The Admin stated she immediately started a safe survey for residents to answer questions regarding their encounter with CNA A (to question each resident regarding their feelings of being abused or uncomfortable speaking with staff about any issues they may have had and to ensure they were comfortable). The Admin stated that the management staff members are involved in the Angel rounds program, which they are assigned to certain rooms and residents. She stated management staff are to speak with each resident daily and report any concerns in the morning meeting so any issues can be immediately addressed. There was one resident (did not get her name) she spoke with that felt uncomfortable with CNA A because the resident stated her brief wasn't put on correctly. She stated at this time the resident was informed of the open lines of communication with her and other nursing staff and encouraged to voice concerns as they arise. During a telephone interview on 5.6.26 at 8:00pm with CNA A, she stated was terminated from the facility. She stated, regarding the incident with Resident #1, she had gone into Resident #1's room to wake her up and get her up for breakfast. CNA A stated Resident #1 usually get up to go to the dining room for 7:00-7:15am breakfast. She stated when she went in, she tried to get Resident #1 up by grabbing her shoulders because Resident #1 said her back hurt. CNA A stated Resident #1 reached out her hand to her and when she grabbed her hand, Resident #1 fell back on the bed. CNA A stated she attempted to pick Resident #1 up by the side of her shoulders, but Resident #1 stated she did not want to get up. CNA A stated, Resident #1 tapped her on the hand during the time she was trying to pick her up or put a pillow under her (she can't remember which one) and she had tapped her hand back. CNA A stated she had no intent to harm Resident #1. CNA A stated it was a small tap. She stated she reported the incident too. She stated she did not report the swatting to anyone but Resident #1's FM A.2.Record review of Resident #2's undated face sheet revealed, an [AGE] year-old female who was admitted to the facility with diagnoses of congestive heart failure (heart unable to pump blood , which leads to fluid buildup in the lungs and other parts of the body), hypertension (force of blood against artery walls), diabetes type 2, hypothyroidism, chronic kidney disease stage 4, chronic pulmonary disease with acute lower respiratory infection, lymphedema, muscle weakness, difficulty in walking, and acute respiratory failure with hypoxia (need additional oxygen to breath).Record review of Resident #2's Comprehensive MDS revealed resident has a BIMS score of 13 which indicates Resident #2'scognition was intact.Record review of Resident #2's Orders revealed, Acetaminophen ER Oral tab 650mg 3 times daily -start date 4/17/26 at 7:00pm; Methocarbamol Oral tablet 750 MG give on tablet by mouth 3 times day for muscle spasm-start date 4/17/26; Oxycodone 5 mg give 1 tablet by mouth 3 times a day for severe back pain-start date 4/17/26; Pregabalin oral capsule 75 MG by mouth 3 times a day for pain).During an interview on 5.5.26 at 1:26am with Resident #2, she stated she had a lot of health issues and she was blind in one eye. She stated that she had a lot of issues with CNA A and one of the issues was CNA A is rough with her during ADL care, which is why she'd refuse ADL care when she works. Resident #2 stated when receiving ADL care from CNA A, the bed is usually lowered, which puts a lot of pressure and pain on her legs. Resident #2 stated she told CNA A that letting the bed down all the way hurts her back and legs, but telling CNA A didn't seem to matter as on some occasions, CNA A would put the head of the bed down all the way and leave saying she was going to get a gown, but would not returned. She stated she would be in a lot of pain and cry. Resident #2 stated she did not mention it to nursing staff because she didn't want to get anyone in trouble and didn't want retaliation. Resident #2 stated all other care providers were nice and helpful to her. Resident #2 stated nursing staff came around with a questionnaire about feeling safe or feeling misused. She stated she found out CNA A was no longer working so she told the truth at this time. Resident #2 stated she felt safe.During an interview on 5.5.26 at 1:44pm with Resident #3, she stated that she was Resident #2's roommate and she witnessed some of the rough treatment between her roommate CNA A. She stated that she witnessed CNA A pull on Resident #2's legs while providing care and Resident #2 telling her that it hurt. Resident #3 stated that she believes it is a personality difference. She stated that she could hear Resident #2 telling CNA A that she was being too rough during her care.During an interview on 5.6.26 at 1:46pm with LVN Ahe stated that Resident #2, during the safe survey questionnaire, stated CNA A was rough with her while completing her ADL's. LVN A stated that Resident #2 also stated she asked CNA A if she would rearrange her bedside table so that she can eat her meals because there was so many things on top of it, and CNA A responded that she was able to do it herself. LVN A stated, he asked during an interview on 5.5.26 at 1:26am with Resident #2, why didn't she say anything before? Resident #2 stated she did not want to get anyone in trouble. LVN A stated that he did not speak with the CNA A because she was not working and in fact had been suspended when he was informed. LVN A stated that the behaviors of CNA A could be considered abuse. LVN A stated that he was informed of this issue on 5.4.26 during safe surveys. He stated he did not report the complaint to the abuse coordinator because it was already reported by Resident #2's angel life assigned staff, which was SW. During an interview on 5.6.26 at 3:53pm with the SW she stated Resident #2 was assigned to her as one of her angel life residents. She stated during her rounds on Monday 5.4.26, Resident #2 informed her that her CNA (later identified as CNA A) was a little rough with her during ADL care. SW stated Resident #2 did not explain what she meant by rough in that she asked CNA A to get something off her bedside table, and CNA A told her she can do a lot for herself that she says she can't do and then CNA A walked out of the room without assisting Resident #2. SW stated she informed the Admin and also put it on a grievance form.During a Telephone Interview on 5.6.26 at 8:00pm with CNA A, she denied treating residents bad. She stated Resident #2 was always in a lot of pain, and a lot of times will refuse care. CNA A stated when she does provide ADL care to Resident #2, she is very careful not to cause any more pain than Resident #2 is already dealing with. CNA A denied not assisting Resident #2 with moving items off of her tray to make room for her food. She stated if she did it's because she was on her way providing care for another resident and probably told Resident #2 she'd be right back. She stated she just can't remember this alleged incident.During a follow -up interview with Resident #2 on 5.7.2026 at 11:00am she stated she is now receiving the respect and care she needs from staff. She states she really enjoys the facility and does not want to leave. She stated she knows the abuse coordinator is the administrator and next time she will ensure to inform her of any mistreatment.Record review of grievances dated 5.4.26 revealed the SW completed her interview documentation and the grievance on Resident #2's behalf.Record review of In-Service Training report completed 5/4/2026 revealed DON, ADON, SC, CNAs A, B, C, and D, LVN A, LVN B and housekeeping staff were immediately in-serviced on managing unmanageable residents, Resident rights, dignity & respect, Types of abuse & recognizing signs and symptoms, Communication (explaining care to be provided to resident and allowing resident time to process what is being communicated).Record review of the facility's Unmanageable Residents policy dated April 2010 revealed that each resident will be provided with a safe place of residence.Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way spent with jeopardize his or her safety or the safety of others, the nurse supervisor slash charge nurse must immediately:c. Notify the director of nursing services; andd. Notify the residence representative (sponsor).Record review of the facility's Abuse and Neglect policy revised April 2021 revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary second religion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the residents symptoms.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations within timeframes required by federal requirements.10. Protect residents from any further harm during the investigations.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 24 residents (Resident #1) reviewed for quality of care.- The facility failed to transfer Resident #1 to the hospital by means of emergency services after she was observed to be in pain, had a bruise to the left lower extremity, and her extremity was observed to be out of normal alignment on 3/29/2026 at 12:00pm. Resident #1 was transferred to the hospital at 8:55pm.An Immediate Jeopardy (IJ) was identified on 4/16/26. The IJ template was provided to the facility on 4/16/26 at 10:51am. While the IJ was removed on 4/18/26 at 5:01pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm, with the potential for minimal harm that is not immediate jeopardy, due to the facility's need to finish in-servicing all staff and the need to evaluate the effectiveness of the corrective systems.This failure placed residents at risk for a delay in treatment, pain, and hospitalization.Findings include:1. Record review of Resident #1's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia (decline in cognitive function), lack of coordination, unsteadiness on feet, muscle weakness, osteoarthritis (gradual breakdown of cartilage), moderate protein calorie malnutrition, and sarcopenia (loss of muscle mass, strength, and function due to age).Record review of Resident #1's Annual MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. The resident had impairment on one side of her lower extremities and was dependent (helper does all of the effort and resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required) for all ADLs. According to the assessment Resident #1 was always incontinent of bowel and bladder.Record review of Resident #1's Care Plan dated 7/18/23 revealed a Focus: Resident #1 was observed lying on the floor on her floor mat, no injuries were noted. 8/25/25- was noted on the side of her bed laying on the floor, on top of fall mat, no injury noted. 11 /23/25-Resident was observed on the floor mat next to her bed. Upon assessment no injury or discomfort noted. 1/25/26-Unwitnessed fall. Writer was called to the patient's room by PCA. Patient was found lying on a floor mat, positioned on the left side with head to dresser and foot towards wall, with active bleeding noted to the left side of the head. Patient was assisted off the floor by three staff members for further assessment. Assessment revealed a laceration to the left side of the head and bruising to the right forehead region, neuros initiated. Interventions included a low bed, monitoring frequently, fall mat, and ensuring personal items were within reach. Focus: Resident #1 had a left tibia (bone in lower leg) fracture, requiring splint placement at this time. Interventions included keeping the call light within reach, responding promptly to the resident, following orders for weight bearing, monitoring/documenting pain, and repositioning as necessary.Record review of Resident #1's Progress Notes revealed an eInteract SBAR dated 3/29/26 at 12:30pm by LVN A which revealed the resident had a change in condition. The note revealed the resident had discoloration to her skin and pain. LVN A document, LLE noted to be discolored, warm to touch, and patient complained of pain when touch.Extremity observed to be out of normal alignment. The note revealed at 12:10pm LVN A placed a call to NP B and at 12:20pm he called back to order a STAT x-ray of the resident's LLE tibia/fibula (bones of lower leg). Record review of Resident #1's Progress Notes revealed a Nurse's Note dated 3/29/26 at 12:39pm by LVN A that reflected, LLE noted to be discolored, warm to touch, and patient complained of pain.Extremity observed to be out of normal alignment. There was a timeline mentioned on the note that revealed the following:12:10pm: LVN A called the provider on call and waited for a call back12:20pm: NP B called back and ordered the STAT xray12:30pm: LVN A notified the DON and House Supervisor. Waiting for xray technician12:40pm: RP notified and informed she would get a call back after results3:45pm: Xray technician arrived and xray completed6:40pm: LVN A received a call from the xray company regarding results. Attempted to notify RP.6:50pm: RP called back and LVN A informed her of xray results6:55pm: LVN A called provider regarding xray results and waited for a call back7:00pm: LVN A gave report to oncoming nurseRecord Review of Resident #1's x-ray completed to her left leg on 03/29/2026 at 3:50pm revealed findings of displaced fractures (broken bone ends moved out of alignment) to the mid tibia and fibula. Record review of Resident #1's Progress Notes revealed a Nurse's Note dated 3/29/26 at 6:30pm by LVN C that revealed, she received the resident awake and alert with LLE discolored, painful to touch, hot and dry. She documented that the resident also had discoloration to her right and left forearm, had a temperature of 100.4 degrees Fahrenheit, heart rate 109, and at 7:37pm she gave a dose of Tylenol 325mg that was scheduled PRN.Record review of Resident #1's Progress Notes revealed a Nurse's Note dated 3/29/26 at 7:00pm by LVN C that revealed, the PA returned the call and the xray results were given to her. She ordered the resident to be sent to the ER. LVN C notified the RP and at 7:45pm the DON was notified.Record review of Resident #1's Progress Notes revealed an eInteract SBAR dated 3/29/26 at 8:40pm by LVN C that revealed, the resident had a new irregular pulse and the xray showed displaced fractures to the mid tibia and fibula.Record review of Resident #1's Progress Notes revealed a Nurse's Note dated 3/29/26 at 8:40pm by LVN C that r a call had been placed to 911 for transfer and at 8:55pm the resident was transferred to the hospital via stretcher with 3 EMS.Record review of a written witness statement dated 3/29/2026 by LVN A, revealed Resident #1 was observed to have swelling, pain, and an extremity that appeared misaligned.Record review of Resident#1's hospital records revealed an admission Note dated 3/26/26 at 9:21pm that reflected she was being treated for a left tibia and fibula fracture. Record review of Resident #1's hospital records revealed a note dated 3/29/26 at 9:42pm by RN M that reflected the resident's leg was supported in a stable position to prevent further injury and deformity, and there was a visible large bruise and edema (swelling) to her left lower leg.Record review of Resident #1's hospital records revealed a note dated 3/29/26 at 10:48pm by MD T that reflected the resident presented with leg bruises and had a tibio-fibular fracture (lower leg) noticed on x-rays. She was put in a trilaminar splint (stabilize severe ankle fractures), treated with Fentanyl 25mcg (strong pain medication), and admitted for further treatment.Record review of Resident #1's hospital records revealed an xray of the tibia and fibula report dated 3/29/26 at 11:34pm that reflected, There are acute mildly displaced oblique fractures [slanted break in bone causing misalignment] of the distal [towards feet] tibial and fibular diaphyses [midsection of a bone] with lateral displacement [misalignment to the side] and foreshortening [bone appears shorter].Record review of Resident #1's Physician Orders as of 4/16/26 revealed the following orders from MD R:- May send to the ER due to abnormal xray of left tib/fib. Ordered on 3/29/26 at 6:02pm.- Eliquis (blood thinner) Oral Tablet 2.5mg, 1 PO BID for prevention of DVT for 30 days. Ordered on 3/31/26 and ends on 4/30/26.- Monitor splint to LLE Qshift to ensure proper placement along with skin check, every shift. Ordered on 4/1/26.- Hydrocodone-Acetaminophen (pain medication) Oral Tablet 5-325mg, 1 PO Q6hr PRN, not to exceed 4 tablets in 24hr. Ordered on 4/8/26.- Assess Left Lower Extremity QShift Daily and notify MD of any noted abnormalities Dx: Fx, Every shift for skin assessment. Ordered on 4/9/26.In an observation on 4/14/26 at 9:41am, revealed Resident #1 was lying in bed on her back with her leg propped up on a pillow. She had wedges on both sides of her and a fall mat next to the bed. Resident #1 was on the secure unit and was confused and unable to answer questions when an interview was attempted.In an interview on 4/15/26 at 12:05pm, LVN J said if there was visible trauma to a resident there could be a fracture and that would warrant an immediate transfer to the ER without calling the provider for orders.In an interview on 4/15/26 at 12:12pm, RN G said if the resident had a suspected fracture or their limb was not symmetrical she would send the resident directly to the hospital without calling the provider first.In an interview on 4/15/26 at 12:44pm, NP A said NP B was notified after Resident #1was observed with bruising and pain to her left lower extremity. She said that LVN A documented Resident #1 had an extremity out of normal alignment that was confirmed to be a displaced fracture. She said based on the progress note entered by LVN A, Resident #1 should have been transferred to the hospital by means of emergency services and treatment was delayed. In an interview with LVN A on 4/15/26 at 1:43pm, she said a resident with visible trauma should be sent to the hospital by means of emergency services via 911. She said on 3/29/2026 at 12pm Resident #1 was observed with a left lower extremity that was bruised, swollen, and painful to touch. She said Resident #1's left lower lateral extremity was not symmetrical and had an indentation when compared to the right lower extremity. She said she notified NP B and told him that Resident #1's leg was swollen, bruised, painful, and out of alignment. She said she also requested an x-ray. In a phone interview on 4/15/26 at 2:00pm, NP B said he could not recall Resident #1 or being notified by the facility staff of a change in condition. He said if the nurse documented the left lower extremity was out of normal alignment/misaligned it would lead him to think the left lower extremity was not aligned with the joint and there would be concern for a displaced fracture. He said that change in condition would warrant the resident being transferred to the hospital by emergency medical services via 911. He said that 9 hours was too long to wait with a displaced fracture and treatment was delayed. In an interview with the ADON on 4/15/26 at 3:20pm, the ADON said visible trauma warranted a transfer to the hospital by means of emergency medical services by 911. She said 911 should have been called when the injury was observed. The ADON said Resident #1 was transferred to the hospital at 8:55pm when the trauma was observed at 12:39pm, and treatment was delayed.In an interview on 4/15/26 at 4:25pm, the DON said emergency services should be contacted by means of 911 when an injury could not be managed in house. She reviewed the progress note entered by LVN A and said out of normal alignment meant there was some type of abnormality, but she could not define what that was because she did not see it. She said at 12pm on 3/29/2026 LVN A contacted her and informed her Resident #1 had left lower extremity that was bruised, discolored, warm to touch, and she experienced pain. LVN A told the DON that she notified NP B and he ordered an x-ray. The DON said LVN A also told her Resident #1 had stable, managed pain. The DON said she did not know Resident #1's extremity was out of alignment and she was in pain, otherwise she would have sent the resident straight to the ER. Record review of the facility's policy and procedures on Change in Resident's Condition or Status (revised April 2025) revealed in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition. The nurse will notify the resident's attending physician or physician on call when there has been a(an):.discovery of injuries of an unknown source.significant change in the resident's physical/emotional/mental condition.need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting).Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.Unless otherwise instructed by the resident, a nurse will notify the resident's representative. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.An Immediate Jeopardy (IJ) was identified on 4/16/26 and the ADM was notified. The IJ template was provided to the facility on 4/16/26 at 10:51am. The Plan of Removal was accepted on 4/17/26 at 1:40pm.The plan of removal reflected the following:Date: 04/17/2026[Facility]PLAN OF REMOVALFORIMMEDIATE JEOPARDYSummary of Details which lead to outcomes.On April 16, 2026, an annual survey was conducted at [facility], [address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the facility constitute immediate jeopardy to resident health.Problem: Quality of Care (F684) The facility failed to transfer Resident #1 to the hospital by means of emergency services after she was observed to be in pain with a bruise to the left lower extremity that was observed to be out of normal alignment 03/29/2026 at 12:00pm. Resident#1 was transferred to the hospital at 8:55pm.Plan:1. Medical Director has been notified of the Immediate Jeopardy by the Administrator on 04/16/2026. QAPI was discussed with Medical Director. Medical Director educating NP A and NP B on the importance of transferring residents out to ER when made aware of potential fracture and change of condition. Completion Date: 4/16/262. DON/designee initiated in-service on 04/15/26 with all staff on the following: All staff in-service regarding notification to the charge nurse regarding change of condition for verbal and non-verbal changes in resident. Effective Communication direct line staff to charge nurse, from charge nurse to admin nurse, and Physician/NP on 4/15/26. Completion Date: 4/16/26Changes in condition will be reported via [EMR] clinical alert. DON/ADON/[ADM]/Charge Nurse are responsible to ensure timely/accurate assessments, MD notification and timely follow up of MD orders/interventions such as transport to higher level of acuity. Monitoring will occur during clinical morning meetings and 24-hour report reviewed by weekend supervisor for resident changes and new orders. 3. Audit initiated of residents who transferred to the ER over the last 90 days for timeliness of treatment and transfer. The Sbar change of condition assessment completed with no negative findings noted. DON completed this audit and review. Completion Date: 4/16/264. DON will initiate one on one education with LVN A regarding change of condition, resident assessment, resident treatment, and documentation; along with notification to physician, nurse admin, and timeliness of transfer to a higher level of care for treatment due to LVN A's communication with nurse admin and NP on 3/29/26. Education will be completed before LVN A's next scheduled shift. Completion Date: 4/16/26 5. Regional Nurse to educate DON regarding daily review of 24-hour report to ensure timeliness of treatment and transfer to a higher level of care. Completion: 04/16/266. All staff who are not working during the time of in-service on Change of Condition and timeliness of transfer to a higher level of care for treatment, will be in-serviced prior to their next scheduled shift. Newly hired staff will receive the in-services during their orientation period. Agency nurses will be in-serviced prior to beginning their shift; initiated 4/16/26.7. Licensed and certified nursing staff will be given a competency-based quiz on change of condition and communication to charge nurse, from charge nurse to admin nurse, and Physician/NP; initiated 4/16/26. Completion Date: 4/16/268. Monitoring will occur during the clinical morning meeting Monday through Friday by DON/Nurse admin/Designee; weekend supervisor will review the 24 Report for resident changes and new orders. DON will oversee this process and any negative outcomes will be communicated with administrator. 9. Weekend supervisor was in-serviced on monitoring the 24-Hour Report and follow-up on orders i.e., Change of Condition and timelines of transfer to a higher level of care. Completed: 04/16/2610. The facility's policy and procedures regarding change of condition was reviewed on 4/15/26. There were no changes made to current policy and procedure. All staff in-service was initiated. Completion Date: 04/16/26On 4/18/26 a monitoring visit was conducted to ensure the facility was following its POR. The visit revealed:Record review of an email from the Medical Director dated 4/16/26 revealed she submitted guidelines on pain management and residents being transferred to an acute setting for further workup. The Medical Director notified NP A, NP B, and MD R of the guidelines via email.Record review of an in-service revealed the in-service was given to the DON on 4/16/26 by the RNC regarding Changes in Condition: Including any Changes that are Abnormal From Resident's Baseline. Pain Management: Pain is Subjective, Nurse Should Assess for Verbal and Non-Verbal Signs and Symptoms of Pain. If Pain Intervention is Ineffective Notify the MD. Effective Communication: Ensure Nurse's Assessment is Effectively and Accurately Communicated to MD. Storage of Supplies: All Facility Supplies and Equipment to be Stored in Designated Area Not in Resident's Room. Abuse & Neglect: Recognizing and Timely Reporting of Abuse and Neglect. Stop and Watch: Daily Checks of Alerts on [EMR] Dashboard.Record review of a Quality of Care Quiz revealed the quiz was given with 10 questions, and 85 out of 122 staff members had completed it as of 4/18/26.Record review of the Guidelines for Daily Clinical Meeting sheet revealed it was blank so far. Record review of a QAPI Meeting revealed the meeting was held on 4/16/26 at 6:00pm with its board members. The identified concern that was discussed was: the facility failed to escalate care by emergency services after left lower extremity was observed to have obvious deformity leaving the resident in pain for approx. 9 hours. Plan of action: The Medical Director in-serviced the NPs on escalating care to emergency services for potential fractures. Audit completed for all hospital transfers x 90 days. The DON to review 24hr report daily to ensure timeliness of care and treatment, and transfer to the ER if needed. All licensed staff will receive a post-test regarding changes in condition and communication to the Charge Nurse, DON, MD, and RP. Monitoring: The DON to review 24hr report M-F for changes in condition, notification to MD, RP, and as needed timely escalation of care.Record review of an in-service revealed the in-service was given on 4/15/26 and 4/16/26 by the DON regarding the Stop and Watch, Change of Condition, Pain Management, and Communication. There were 68 staff signatures.Record review of staff education revealed the staff were re-educated on the Stop and Watch: Staff are expected to document resident changes and Charge Nurses were expected to monitor for daily alerts in [EMR]. Change of Condition: Staff were expected to report changes that were abnormal for resident's baseline.Record review of staff education revealed the staff were re-educated on Effective Communication: Ensure nurse's assessment was effectively and accurately communicated to the MD/NP and admin nurse. Record review of a Hospital Transfer Audit dated 4/16/26 revealed 27 residents listed between 1/15/26 and 4/16/26.Record review of an in-service revealed the DON had a 1 on 1 in-service with LVN A on 4/17/26 regarding Assessment, Change of Condition, Reporting, Completion of New Orders, Pain Management, and Use of EMS Services.In interviews on 4/18/26 from 10:27am-11:25am, CNA E, Med Aide K, CNA H, CNA K, CNA O, CNA P, Med Aide G, and CNA Q stated they had been in-serviced on changes in condition. They stated they went over if any changes in condition were seen, to report it to the nurse and document. They gave examples of a change in condition like weakness, being incontinent, or any bruised or skin tears. They said if there was a change in condition, like pain, they would ask how much pain the resident was in and they would let the nurse know, and they would keep checking on the resident. They stated they got in-serviced on communication as well so if the nurse did not do anything then they would tell the ADON or DON. They also were able to verbalize what the stop and watch was and where to find it.In interviews on 4/18/26 from 11:56am-12:15pm with LVN H, LVN D, LVN N, and LVN O who all worked the day shift, were able to confirm what a change in condition was, where they would document it, and what they would do if they noticed a change in condition. They also said they were in-serviced about transfers.In an interview on 4/18/26 at 12:20pm the Weekend Supervisor said she was in-serviced on the 24 Hour Report, Changes of Condition, and Timelines of Transfers. She was able to communicate the different types of abuse, who she should report abuse to, and when. The Weekend Supervisor discussed types of changes in condition like changes in breathing, what she would do to assess, and that she would notify the provider. She confirmed that a change in condition was anything different from the resident's baseline. The Weekend Supervisor said she would document the change in condition in the clinical alerts, assessments, and also make a nurse's note. She was able to explain what she would do if a resident was experiencing pain, how to assess, and what verbal and non-verbal pain looked like.In an interview on 4/18/26 at 1:00pm, Med Aide Y said she worked from 2pm to 10pm. She said she was in-serviced on what a change in condition was and who to report it to. She was also able to verbalize examples of changes in condition.In interviews on 4/18/26 from 1:02pm to 3:22pm, CNA D, CNA J, CNA F, CNA C, CNA S, CNA W, and CNA I, Med Aide P, and CNA T, who worked from 2pm to 10pm, confirmed they received in-services on changes in condition, where to document it, and who to report it to. They were able to verbalize examples of changes in condition. They also stated they received in-services on communication and who to report to if the nurse did not respond.In an interview on 4/18/26 at 3:33pm, LVN A said she had a one on one in-service on communication documentation, stop and watch regarding changes in condition, resident assessments and treatment, and when to transfer a resident out. She also knew what a change in condition was, where to document it, and who to report it to. She also said they had a quiz about changes in condition.In an interview on 4/18/26 at 3:54pm, the DON said she had a one on one in-service on change in condition, reviewing the 24hr report, and timeliness of treatment and transfers. She said she would follow up on any residents with pain and ensuring appropriate interventions were in place. She said 911 was called for residents who were in immediate distress who were not relieved of their discomfort in house, or if the resident was adamant on being sent out.In an interview on 4/18/26 at 4:00pm, LVN G said she worked from 6:00pm to 6:00am. She said she had in-services on what a change in condition was, where to document it, and what to do if there was a change in condition. She said they had a quiz on changes in condition and was able to give examples. She said they also received in-services on communication.In an interview on 4/18/26 at 4:22pm, CNA N said she worked 10:00pm to 6:00am. She was able to explain what a change in condition was, where to document it, and who to report it to.In an interview on 4/18/26 at 4:32pm, CNA A said she received a one on one in-service regarding a change in condition. She was able to describe what a change in condition was, where to document it, and who to report it to. She said she also received an in-service on communication and who to report to if the nurse did not respond.In an interview on 4/18/26 at 4:48pm, RN G said she worked 6am-6pm and was in-serviced on abuse and neglect, and pain. She was able to verbalize types of abuse, when to report abuse, and who to report it to. She was also able to verbalize verbal and non-verbal cues of pain, what to do if a resident has pain, where to document pain, and what to do if pain was not managed.The Administrator was informed that the immediacy was removed on 4/18/2026 at 5:01pm. The facility remained out of compliance at a scope of isolated at a severity level of no actual harm that was not immediate due to the facility's need to finish staff training and evaluate the effectiveness of the corrective systems that were put into place.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 24 residents (Resident #1) reviewed for pain.- The facility failed to monitor and address Resident #1's pain on 3/29/26 from 12:00pm to 9:00pm, when the resident was found to have a fracture to her left lower extremity and would say ouch every time she would be turned/repositioned and during incontinence care.An immediate Jeopardy (IJ) was identified on 4/16/2026. The IJ template was provided to the facility on 4/16/2026 at 10:51am. While the Immediacy was removed on 4/18/2026 at 5:01pm, the facility remained out of compliance at a scope of isolated with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures placed residents at risk of increased or unmanaged pain.Findings Include: 1. Record review of Resident #1's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia (progressive decline in memory), lack of coordination, unsteadiness on feet, muscle weakness, osteoarthritis (cartilage breaks down), moderate protein calorie malnutrition, and sarcopenia (loss of muscle mass, strength, and function due to age).Record review of Resident #1's Annual MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. The resident had impairment on one side of her lower extremities and was dependent (helper does all of the effort and resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required) for all ADLs. According to the assessment Resident #1 was always incontinent of bowel and bladder. Resident #1 revealed that her average pain level over the past 5 days was a 4, on a scale from 0-10. The resident was currently on opioids (pain medications) and anticoagulants (blood thinners).Record review of Resident #1's Care Plan dated 7/18/23 revealed a Focus: Resident #1 was on pain medication therapy putting her at risk for having side effects. Interventions included administering analgesics (pain medications) as ordered and monitoring effectiveness, reviewing for pain medication efficacy, and assessing whether the pain intensity was acceptable to the resident. Focus: Resident #1 had a left tibia fracture, requiring splint placement at that time. Interventions included keeping the call light within reach, responding promptly to the resident, following orders for weight bearing, monitoring/documenting pain, and repositioning as necessary.Record review of Resident #1's SBAR dated 3/29/26 at 12:30pm by LVN A revealed she had grimacing - facial grimacing, rigid - fists clenched, knees pulled up, pulling or pushing away, striking out. The SBAR also revealed the resident was repositioned every 2 hours.Record review of Resident #1's Progress Notes revealed a Nurse's Note dated 3/29/26 at 12:39pm by LVN A that revealed, LLE noted to be discolored, warm to touch, and patient complained of pain.Extremity observed to be out of normal alignment. There was a timeline mentioned on the note that revealed the following:12:10pm: LVN A called the provider on call and waited for a call back12:20pm: NP B called back and ordered the STAT xray12:30pm: LVN A notified the DON and House Supervisor. Waiting for xray technician12:40pm: RP notified and informed she would get a call back after results3:45pm: Xray technician arrived and xray completed6:40pm: LVN A received a call from the xray company regarding results. Attempted to notify RP.6:50pm: RP called back and LVN A informed her of xray results6:55pm: LVN A called the provider regarding xray results and waited for a call back7:00pm: LVN A gave report to oncoming nurseRecord Review of Resident #1's x-ray completed on 03/29/2026 at 3:50pm revealed displaced fractures to the mid tibia and fibula (lower leg bones) of the left leg. Record review of Resident #1's Progress Notes revealed a Nurse's Note dated 3/29/26 at 6:30pm by LVN C revealed she received the resident awake and alert with a LLE that was discolored, painful to touch, hot and dry. She documented that the resident also had discoloration to her right and left forearm, had a temperature of 100.4 degree Fahrenheit, heart rate 109, and at 7:37pm she gave the resident a dose of Tylenol 325mg that was scheduled PRN.Record review of Resident #1's March 2026 MAR-TAR revealed on 3/29/26 she received a scheduled Tramadol (pain medication) 50mg at 8:00am and 3:00pm. She was also given PRN Tylenol 325mg at 7:37pm.Record review of Resident #1's SBAR dated 3/29/26 at 8:40pm from LVN C revealed the resident's heart rate was 109 and her temperature was 100.4 degree Fahrenheit on her forehead.Record review of Resident #1's Progress Notes revealed a Nurse's Note dated 3/29/26 at 8:40pm by LVN C that revealed, a call had been placed to 911 for transfer to the ER and at 8:55pm the resident was transferred to the hospital via stretcher with 3 EMS.Record review of a written witness statement dated 3/29/2026 by LVN A, revealed Resident #1 was observed to have swelling, pain, and an extremity that appeared misaligned.Record review of Resident #1's hospital records revealed an admission Note dated 3/26/26 at 9:21pm that revealed she was being treated for a left tibia and fibula fracture. Record review of Resident #1's hospital records revealed a note dated 3/29/26 at 10:48pm from MD T revealed, the resident presented with leg bruises and had a tibio-fibular fracture noticed on x-rays. She was put in a splint, treated with Fentanyl 25mcg, and admitted for further treatment.In an observation on 4/14/26 at 9:41am, revealed Resident #1 was lying in bed on her back with her left leg propped up on a pillow. She had wedges on both sides of her and a fall mat next to the bed. Resident #1 was on the secure unit and was confused and unable to answer questions when an interview was attempted.In an interview on 4/15/26 at 12:44pm, NP A said she was not the NP who took the call and said NP B was notified after the resident was observed with bruising and pain to the left lower extremity. NP A said staff should have turned Resident #1 onto her side of the uninjured leg and left her in that position and not moved her anymore until EMS arrived.In a phone interview on 4/15/26 at 2:00pm, NP B said he could not recall Resident #1 or being notified by facility staff of a change in condition. He said if the nurse documented the left lower extremity was out of normal alignment/misaligned it would have led him to think the left lower extremity was not aligned with the joint, and there would have been a concern for a displaced fracture. NP B said Resident #1 would have been experiencing a high level of pain and would have needed a higher level of care for pain treatment and would have needed to be sent out to the ER. He said that 9 hours was too long to wait with a displaced fracture, and treatment was delayed. In an interview on 4/15/26 at 2:07pm, CNA A said she worked with Resident #1 on 3/29/26 and noticed bruising to her left lower leg when she repositioned her around 11 am for lunch. CNA A stated she went to reposition the resident and Resident #1 complained of pain stating, ouch. The CNA stated she immediately got the unknown nurse to assess the resident. She stated the nurse assessed the resident and then notified the unit nurse. CNA A stated she waited on instructions from the unknown nurse who informed her to keep the resident's leg elevated with a pillow. The CNA stated she continued to reposition the resident every 2 hours and the resident complained of pain every time she repositioned her. CNA A stated the resident also complained of pain when she would do incontinent care on the resident. The CNA stated she reported the resident's pain to the nurse and she thought that the nurse gave the resident medication.In an interview on 4/15/26 at 3:20pm, the ADON said visible trauma warranted a transfer to the hospital by means of emergency medical services by 911. She said the resident would have been in pain.In an interview on 4/15/26 at 4:25pm, the DON said emergency services should be contacted by means of 911 when an injury could not be managed in house. She reviewed the progress note entered by LVN A and said out of normal alignment meant there was some type of abnormality. The DON said Resident #1 should have had a limited amount of repositioning if she was in pain during movement.Record review of the facility's policy and procedures on Pain Assessment and Management (revised January 2025) revealed in part: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain, Recognizing the presence of pain, Identifying the characteristics of pain, Addressing the underlying causes of the pain.Monitoring for the effectiveness of interventions.Cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. Comprehensive pain assessments are conducted.whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Acute Pain: refers to pain that is usually sudden in onset and time-limited with a duration of less than 1 month and often is caused by injury, trauma, or medical treatments such as surgery.Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain, including: negative verbalizations and vocalizations such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, etc.; changes in.vital signs.Possible Physiological Signs of Pain, including: increased blood pressure;Tachycardia [high heart rate].Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain.Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including.fractures.Review the resident's treatment record or recent nurses' notes to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example: bathing, dressing, or other ADLs.turning or repositioning. The following are considered when establishing the medication regimen.Administering medications around the clock rather than PRN.Monitor the following factors to determine if the resident's pain is being adequately controlled: The resident's response to interventions and level of comfort over time.Contact the prescriber immediately if the resident's pain or medication side effects are not adequatelycontrolled.This was determined to be an Immediate Jeopardy (IJ) on 4/16/2026. The Administrator was notified on 4/16/2026. The IJ template was provided to the facility on 4/16/2026 at 10:51am.The following Plan of Removal (POR) submitted by the facility was accepted on 4/16/2026 at 8:23pm.The plan of removal reflected the following:Date: 04/16/2026[Facility]PLAN OF REMOVALFORIMMEDIATE JEOPARDYSummary of Details which lead to outcomes.On April 16, 2026, an annual survey was conducted at [facility], [address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the facility constitute immediate jeopardy to resident health. Problem: Pain (F697)The facility failed to treat residents' pain in a timely manner. The facility failed to monitor and address Resident #1's pain on 3/29/26 from 12:00pm to 9:00pm, when the resident was found to have a fracture in her left lower extremity and was in pain every time she was being turned/repositioned and during incontinence care. Resident #1 was assessed on 3/29/26 and sent to the ER for further evaluation. Plan: Initial assessments for current residents for pain were initiated on 4/15/26. Completion date: Completion date: 4/16/26.1. Medical Director has been notified of the Immediate Jeopardy by the Administrator on 04/16/2026. QAPI was discussed with Medical Director. Medical Director educating NP A and NP B on pain management orders when a new order is needed to address a resident's pain. Completion Date: 4/16/262. DON/Designee initiated in-service on abuse and neglect on 03/29/26. Completion Date: 4/16/263. DON/designee initiated in-service on 04/15/26 with charge nurses on the following:o Pain Management verbal and non-verbal indicators.o Pain Assessment observation form completion.o Notification to physicians when pain medication is ineffective. Completion Date: 4/16/264. DON/Designee initiated in-service on effective communication from direct line staff to charge nurse, from charge nurse to admin nurse, and Physician/NP for all nursing staff. Completion Date: 4/16/26 5. Regional Nurse to educate DON regarding assessing residents for pain after an incident and of sending the resident to the ER for evaluation if in-house Xray cannot be obtained timely. Completion: 04/16/266. DON/designee conducted an audit regarding effectiveness of pain medication for current residents from 4/8/26 to current for active residents. The outcome of the audit reflected residents who are currently on pain management is effective. No additional residents were identified as to not having their pain managed. Completion date: 04/16/26. 7. DON/designee initiated in-service with nurse aides and medication aides on reporting indicators of pain i.e., verbal, or non-verbal to the charge nurse. Completion Date: 4/16/268. Charge nurses, agency nurses/aides, and certified staff who are not working during the in-service on Pain, will be in-service prior to their next scheduled shift. Newly hired staff will receive the in-services during their orientation period. Agency nurses will be in-serviced prior to beginning their shift.9. Licensed and certified nursing staff will be given a competency-based quiz on pain; initiated 4/16/26. Completion Date: 4/16/2610. Monitoring will occur during the clinical morning meeting Monday through Friday; weekend supervisor will review the 24 Report for resident changes and new orders.11. DON initiated in-service with Weekend supervisor on monitoring the 24-Hour Report and follow-up on orders i.e., X-ray, and residents with pain. Completion Date: 04/16/26 12. The facility's policy and procedures were reviewed on 4/15/26. There were no changes made to current policy and procedure. Nursing staff in-service was initiated. Completion Date: 04/16/26The Plan of Removal was confirmed by the IJ monitoring on 4/18/26 as follows:Record review of an in-service revealed the in-service was given by the DON on 3/29/26 at 11:21am on Abuse Policy with 61 staff signatures on it.Record review of ins-services revealed the in-services were given by the DON on 4/15/26 and 4/16/26 on Stop and Watch, Change of Condition, Pain Management, and Communication: Attendees re-educated regarding Stop and Watch communication to Charge Nurse regarding COC, effective pain management to include verbal and non-verbal communication, accurate relaying of information to clinician and there were 78 staff signatures on it.Record review of A Guidelines for Daily Clinical Meeting form revealed it was filled out for resident 3 residents on 4/15/26. One resident was filled out for [EMR] Dashboard: Review ADTs-admission (complete admission checklist) discharges, clinical alerts ABT-SBAR completed, FU UDAs, psychotropic consents, SE/Behavior Monitoring. The two other residents were filled out for [EMR]: Risk Management-All incident/accidents listed under active and 72-FU documentation & FU UDAs ie, fall neuros. Record review of an in-services revealed the in-services were given by the DON on 4/15/26 and 4/16/26 on Stop and Watch, Change of Condition, Pain Management, and Communication and there were 68 staff signatures on it.Record review a Daily Stand Down Meeting form dated for 4/16/26 revealed the attendees were the ADM, DON, ADON, Dietary, and the SW. They discussed any issues with grievances/complaints, events (falls, bruises, skin issues, elopements) since the morning meeting, wounds (new or worsened), new admissions/readmissions, hospital/ER transfers, outstanding self-reports, and (EMR) compliance.Record review of a QAPI Meeting revealed the meeting was held on 4/16/26 at 6:00pm with the board members. The identified concern that was discussed was: Facility failed to treat resident's pain in a timely manner. Plan of action: All staff in-serviced on abuse and neglect. All nurses in-serviced on verbal and non-verbal indicators of pain, pain observation/assessment, and notification to the MD when pain intervention is effective. In-service completed for communication form direct line staff to Charge Nurse for all changes in condition. The RNC in-serviced DON regarding assessing residents for pain after an incident and determining need for transfers to ER if in house x-rays cannot be obtained timely. Monitoring: M-F in daily clinical meeting, RN supposed to review Sat and Sun.Record review of an in-service revealed a one on one in-service given by the RNC on 4/16/26 to the DON revealed training on Change in Condition: Includes any change that is abnormal from resident's baseline. Pain Management: Pain is subjective, Nurse should assess for verbal and non-verbal signs and symptoms of pain. If pain intervention is ineffective notify the MD. Effective Communication: Ensure nurse's assessment is effectively and accurately communicated to MD. Storage of Supplies: All facility supplies and equipment to be stored in designated areas, not in resident's room. Stop and Watch: Daily Checks of alerts on [EMR] Dashboard. Abuse and Neglect: Recognizing and Timely Reporting of Abuse and Neglect.Record review of a Pain Assessment Quiz with 14 questions revealed 20 of 26 nurses had completed it as of 4/18/26.Record review on 4/18/26 revealed a list of 12 pages of residents currently on Analgesics-Nonnarcotic, 3 pages of residents currently on pain patches, 6 pages of residents currently on opioids, 1 page of residents currently on codeine, and 1 page of residents currently on lyrica for pain. All residents reflected to have effectiveness of their pain medication.Record review on 4/18/26 revealed a Communication Form Log with 8 residents listed dated 4/15/26. In interviews on 4/18/26 from 10:27am-11:25am, CNA E, Med Aide K, CNA H, CNA K, CNA O, CNA P, Med Aide G, and CNA Q stated they had been in-serviced on abuse and neglect, when to report, and who to report to. They were able to verbalize different types of abuse. They said they received in-services about pain management, verbal signs and non-verbal signs, and to ask for a pain scale and report it to the nurse. They were able to verbalize signs of pain in a resident. They also received in-services on communication so if the nurse did not respond then they were to notify the ADON or the DON. They said they had received a quiz on pain as well.In interviews on 4/18/26 from 11:56am-12:15pm with LVN H, LVN D, LVN N, and LVN O who all worked the day shift, were able to confirm different types of abuse, when to report, and who to report to. They confirmed in-services on pain management, verbal and non-verbal cues of pain, how to assess and document, and that they would call the provider for orders if needed or if the pain was not managed.In an interview on 4/18/26 at 12:20pm the Weekend Supervisor said she was in-serviced on the 24 Hour Report, Changes of Condition, and Timelines of Transfers. She was able to communicate the different types of abuse, who she should report abuse to, and when. The Weekend Supervisor discussed types of changes in condition like changes in breathing, what she would do to assess, and that she would notify the provider. She confirmed that a change in condition is anything different from the resident's baseline. The Weekend Supervisor said she would document the change in condition in the clinical alerts, assessments, and also make a nurse's note. She was able to explain what she would do if a resident was experiencing pain, how to assess, and what verbal and non-verbal pain looked like.In an interview on 4/18/26 at 1:00pm, Med Aide Y said she worked from 2pm to 10pm and she was in-serviced on abuse and neglect and was able to give the different types of abuse. She was also able to verbalize when to report abuse and who to report it to. The med aide said she was in-serviced on pain management also, which included verbal and non-verbal cues, and reporting it to the nurse.Record review of an email from the Medical Director dated 4/16/26 revealed she submitted guidelines on pain management and residents being transferred to an acute setting for further workup. The Medical Director emailed NP A, NP B, and MD R of the guidelines via email.In interviews on 4/18/26 from 1:02pm to 3:22pm, CNA D, CNA J, CNA F, CNA C, CNA S, CNA W, CNA I, Med Aide P, and CNA T, who worked from 2pm to 10pm, confirmed they received in-services on abuse and neglect, the different types of abuse, when to report it, and who to report it to. They said they also received in-services on pain regarding how to know if a resident is in pain, what to do if the resident was pain, and who to report it to. They were able to verbalize examples of non-verbal cues of pain.In an interview on 4/18/26 at 3:33pm, LVN A said she had a one on one in-service on communication documentation, stop and watch regarding changes in condition, resident assessments and treatment, and when to transfer a resident out. She also knew what a change in condition was, where to document it, and who to report it to. She also said they had a quiz about changes in condition. The LVN said she also was in-serviced on pain, pain assessment, and what to do if the resident was still in pain.In an interview on 4/18/26 at 3:54pm, the DON said she had a one-on-one in-service on change in condition, reviewing the 24hr report, and timeliness of treatment and transfers. She said she would follow up on any residents with pain and ensuring appropriate interventions were in place. She said 911 was called for residents who were in immediate distress who were not relieved of their discomfort in house, or if the resident was adamant on being sent out.In an interview on 4/18/26 at 4:00pm, LVN G said she worked from 6:00pm to 6:00am. She said she had in-services on what a change in condition was, where to document it, and what to do if there was a change in condition. She said they had a quiz on changes in condition and was able to give examples. She said they also received in-services on communication. The LVN said she also had an in-service on pain, pain assessment, and what to do if the pain was unmanaged.In an interview on 4/18/26 at 4:22pm, CNA N said she worked 10:00pm to 6:00am. She was able to explain what a change in condition was, where to document it, and who to report it to. She was also able to verbalize what to do if a resident was in pain, who to report it to, and where to document it.In an interview on 4/18/26 at 4:32pm, CNA A said she received a one-on-one in-service regarding a change in condition. She was able to describe what a change in condition was, where to document it, and who to report it to. She said she also received an in-service on communication and who to report to if the nurse did not respond. The CNA was able to describe verbal and non-verbal cues of pain, who to report pain to, and where to document it.In an interview on 4/18/26 at 4:48pm, RN G said she worked 6am-6pm and was in-serviced on abuse and neglect, and pain. She was able to verbalize types of abuse, when to report abuse, and who to report it to. She was also able to verbalize verbal and non-verbal cues of pain, what to do if a resident has pain, where to document pain, and what to do if pain was not managed.The Administrator was informed that the immediacy was removed on 4/18/2026 at 5:01pm. The facility remained out of compliance at a scope of isolated at a severity level of no actual harm that was not immediate due to the facility's need to finish staff training and evaluate the effectiveness of the corrective systems that were put into place.

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure each resident was treated with respect and dignity for 2 of 8 (Resident#4 and #43) residents reviewed for resident rights. The facility failed to ensure that Resident #4's television was programmed to view all channels. The facility failed on 04/14/2026 to ensure Resident #43 was treated with dignity when the facilities training mannequin was stored in the unoccupied bed of the residents room. These failures could place all residents at risk of not being treated with dignity and respect. Findings included: 1. Record review of Resident #4's facesheet revealed a [AGE] year-old woman originally admitted on [DATE]. Admitting diagnoses were generalized anxiety disorder, mood disorder with depressive features, and moderate major depressive disorder. Record review of Resident #4's MDS dated [DATE], under Section C- Cognitive patterns revealed a BIMS score of 12 (moderate cognitive impairment, suggesting occasional mistakes in daily routine). Record review of Resident #4's care plan date initiated 04/27/23 revealed that she received psychology/psychiatry services in the facility. Activities care planned on 7/6/21 revealed that she enjoyed word finds, watching tv, talking on the phone and crocheting. Resident #4 had a history of depression and was at risk for poor mood stability, increased depression, and poor quality of life. Intervention documented to assist with developing a program of activities that were meaningful and of interest and she should be encouraged to engage in activities (crocheting, completing puzzles, reading, and watching tv) frequently to increase mood and cognitive stimulation. In an observation and interview 4/14/26 at 9:10 a.m., Resident #4 was laying in bed with the covers pulled up to her chin and the bedside table positioned over her bed. She stated that whenever there was a storm, it would cut the local TV channels out, but maintenance would come and fix the TV. In a follow up interview and observation on 4/15/26 at 10:13 a.m. with Resident #4, she stated that she felt like when she would ask staff to do things for her, it felt like it took a month of Sunday's to get it done and described herself as feeling low on the totem pole. She explained that every time a storm hit, her tv would go haywire and she asked staff three times for them to fix it, stating that they could do everything for everybody else but not tend to her TV. She showed the surveyor that she could not get channel 2, 13, 11, and the game channel, which were all of the channels she liked to watch. Using the remote to click through the channels, she showed the surveyor that she could get channels like the news but she was not interested. Scrolling through the channels, channel 2,3,8, and 11 were skipped but when they were punched into the remote to go directly there, the channels showed a black and white pixelated screen. Resident #4 stated that she had asked 3 times for maintenance to come and fix those channels but was told that it may take a while because there were visitors in the building. Resident #4 explained that fixing the tv was simple and only required them to reprogram the channels. In an interview and observation on 4/16/26 at 3:35 p.m. with CNA T he was asked to accompany the surveyor into 2 rooms on Hall B to check to see if all the channels on their TV were working. room [ROOM NUMBER] and room [ROOM NUMBER] both had smart TV's that came with several applications for viewing. Inside Resident 4's room, her roommate had the same TV as her, but channels 2,3,8, and 11 showed their normal programming. He stated that it was his first day working with Resident #4 and he had not received any requests for her TV to be fixed. In an interview on 4/17/26 at 1:35 p.m., CNA W stated that Resident #4 had mentioned to her that some of the channels on her TV had stopped working after the storm but she could not recall when that was. She stated that she let Resident #4 know that if she could not get all of the channels, she needed to get with maintenance and he would be able to fix it. CNA W stated that she did not tell maintenance or the nurse on behalf of Resident #4 because it probably slipped her and explained that when Resident #4 voiced this concern, she was busy getting her cleaned up and straightened. In an observation and interview on 4/16/26 at 4:00 p.m. with the EVS Director, he stated that certain channels on the Resident #4's tv had probably been knocked off (stopped working) today when the life safety inspector was in the building and the tv needed to be rescanned. When told that Resident #4 had been having issues with her tv before 4/16/26, he stated that he was not aware and no one had relayed it to him. He explained that when there was a storm, he would have to make rounds to rescan all of the tv's who channels were affected by the storm and who did not have smart tv's. EVS Director was observed walking into Resident #4's room to reset her tv and confirmed that all of her channels were now working. 2. Record Review of Resident #43 face sheet revealed a [AGE] year-old male admitted on [DATE] with a primary diagnosis of vascular dementia, moderate with other behavioral disturbances (significant cognitive impairment due to reduce blood flow to the brain). Record review of Resident #43's Quarterly MDS dated [DATE] revealed BIMS 07, indicating a severe cognitive impairment status in section C. Review of Resident #43's Care Plan undated revealed:Focus: Resident #43 has impaired cognitive function/impaired thought processes r/t (related to) DementiaGoal: Resident #43 will be able to communicate basic needs on a daily basis through the review date.Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs. Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Cue, reorient and supervise as needed. Engage the resident in simple, structured activities that avoid overly demanding tasks. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Observation on 04/14/2026 at 10:26am of the room [ROOM NUMBER] with the A bed being unoccupied and the B bed to be occupied by Resident#43. Observation of a training mannequin in the unoccupied bed. Observation of Resident #43 to not be present in the room at the time of the observation. In an interview and observation on 04/14/2026 at 10:27am CNA P stated that training supplies should not be stored in a room that was occupied by a resident. She observed the training mannequin in the unoccupied bed of room [ROOM NUMBER]. She said that the mannequin was usually stored in the DON's office or in an empty room when not being used for training. She said that she did not know who placed the mannequin in the room of Resident#43, why the mannequin was placed in the room, or how long the mannequin had been in the room. She said that she did not know how Resident#43 felt about the mannequin being in the room. She said that she would have the mannequin removed from the room. In an interview and observation on 04/14/2026 at 10:32am with LVN H, who said that CNA P told her about the training mannequin being in the unoccupied bed of room [ROOM NUMBER]. She said that she moved the mannequin back into the office of the DON and she told the DON about the mannequin being in the room if Resident #43. She said that training supplies should not be stored in a room that was occupied by a resident. She said that she did not know who placed the mannequin in the room of Resident#43, why the mannequin was placed in the room, or how long the mannequin had been in the room. She said that she did not know how Resident#43 felt about the mannequin being in the room. In an interview on 04/14/2026 at 10:40am with Resident #43 in the dining hall, he said that the training mannequin had been in his room for two weeks. He said that he has asked multiple times for staff to remove the mannequin from his room. He said that he did not know who placed the mannequin in the room. He said that he went to sleep with a roommate and woke with the mannequin in the room. He said that it felt like a cruel joke, and he did not know why the staff would think it was funny. He said that when he would ask staff to remove the mannequin, they would laugh at him. He could not remember names of the staff that would have laughed and failed to remove the mannequin, or the dates and times staff would have laughed at him. He said that the facility was his home and he should be treated with dignity and respect in his home. In an interview on 04/14/2026 at 11:25am with Central Supply, who said that training supplies should not be stored in a room that was occupied by a resident. She said that the training mannequin was usually stored in the DON's office or in an empty room when not being used for training. She said that she did not know who placed the mannequin in the room of Resident#43, why the mannequin was placed in the room, or how long the mannequin had been in the room. She said that she did not know how Resident#43 felt about the mannequin being in the room. She said that if Resident #43 asked for the mannequin to be moved it should have been done immediately. She said that the facility was Resident #43's home and he had the right to be treated with dignity. In an interview on 04/14/2026 at 11:28am with the DON, who said that training supplies should not be stored in a room that was occupied by a resident. She said that the training mannequin was usually stored in her office or in an empty room when not being used for training. She said that she did not know who placed the mannequin in the room of Resident#43, why the mannequin was placed in the room, or how long the mannequin had been in the room. She said that she did not know how Resident#43 felt about the mannequin being in the room. She said that if Resident #43 asked for the mannequin to be moved it should have been done immediately. She said that the facility was Resident #43's home and he had the right to be treated with dignity. Record review of the policy titled, Resident Rights, with a revised date February 2021 read in part, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: a. a dignified existence; b. be treated with respect, kindness, and dignity;.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Resident #3, Resident #9, and Resident #12) reviewed for comprehensive care plans. 1. The facility failed to provide Resident #3 with comprehensive per-centered care plan to address Activities of Daily Living (ADL). 2. The facility failed to provide Resident #9 with comprehensive per-centered care to address her Contact isolation or Urinary Tract Infection. 3. The facility failed to provide Resident #12 with a comprehensive care plan to address her Contact isolation or Urinary Tract Infection. This failure could place residents at risk of not having personalized plans developed to address their specific care needs.Findings included:1. Record review of Resident #3's face sheet revealed a [AGE] year old female, with an admission date 08/31/2023, and primary diagnosis of left vertebral artery occlusion and stenosis (blockages or narrowing in this artery, which supplies blood to parts of the brain).Record review of Resident #3's Quarterly MDS dated [DATE] revealed BIMS 09, indicating a moderate cognitive impairment status in section C. In section GG revealed that Resident #3 was triggered as dependent for bathing/showering, partial/moderate assistance for bed mobility, substantial/maximal assistance for dressing, partial/moderate assistance for personal hygiene, substantial/maximal assistance for toilet use, and substantial/maximal assistance for transfers. Record review of Resident #3's undated care plan revealed no focus, goal, or interventions for ADL's to address bathing/showering, bed mobility, dressing, personal hygiene, toilet use, and transfers.In an interview on 04/16/2026 at 2:25pm Resident #3 said that she as able to stand with little assistance from staff, and there was usually one aide in the room when she needed help with transfers, repositioning, toileting, and hygiene. 2. Record review of Resident #9's face sheet revealed she was a [AGE] year old female with an admission date 03/27/2026 with a primary diagnosis of wedge compression fracture of second lumbar vertebra (fracture to spine in the lower back), subsequent encounter for fracture with routine healing.Record review of Resident #9's Quarterly MDS dated [DATE] revealed BIMS 15, indicating a cognitively intactstatus in section C. In section I revealed that Resident #9 was triggered for Urinary Tract Infection as an active diagnosis. Record review of Resident #9's care plan dated 04/01/2026 revealed the following: The resident was not care-planned for Urinary Tract Infection or Contact Isolation. In an interview on 04/15/2026 at 3:15PM with Resident #9, (prior to entering the room there was signage outside of the room indicating the resident was on contact isolation). The resident stated she was on contact isolation for a Urinary Tract Infection. Resident stated she had started her medication on 4/14/26 and stated her antibiotics would be complete on 4/17/26. Resident #9 reported she had been having issues with UTI prior to being admitted into the facility. 3. Record review of Resident #12's undated face sheet revealed she was an [AGE] year old female who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by underlying systemic illnesses), hypertension (high blood pressure), cirrhosis (scarring of the liver), heart failure (heart does not pump effectively), chronic kidney disease (kidneys are not filtering), acute cystitis (bladder infection with blood in the urine) with hematuria, and asthma.Record review of Resident #12's admission MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, which indicated moderately impaired cognition. The assessment revealed the resident was always incontinent of bowel and bladder.Record review of Resident #12's Care Plan dated 1/13/26 did not mention her UTI, contact isolation, or antibiotics.Record review on 4/14/26 of Resident #12's April 2026 Physician Orders revealed the following orders from MD R:- Contact Isolation: DX VRE (antibiotic resistant bacteria)/UTI, every shift for 14 days. Recollect UA C&S 48hr after antibiotics complete. Ordered on 4/1/26.In an observation and interview on 4/14/26 at 9:48am, Resident #12 had a sign on her door that said she was on contact isolation. Resident #12 said she was on isolation for a urine infection.Record review of Resident #12's Progress Notes revealed a note from 4/15/26 at 8:35am from MD R that said, .She has completed her antibiotic course, and a follow-up urine culture is pending results.VRE UTI was diagnosed and treated with Macrobid 100 mg (antibiotic) BID, which she completed on 04/12/2026. Her past medical history revealed she had recurrent urinary tract infections and VRE UTI. Under Care Coordination it said, .Continue contact isolation for VRE.In an observation on 4/16/26 at 1:35pm, Resident #12 had a sign on her door that said she was on contact isolation. Resident #12 said no one had mentioned anything to her about discontinuing the isolation.In an interview on 4/16/26 at 3:10pm, MD R said Resident #12 should still be on isolation and it should not have been discontinued. She said she was waiting for the resident's urine culture results to come back to see whether the resident could come off of isolation or not.In an interview on 4/17/26 at 9:55am, the DON said the IDT team updated the care plan. The IDT Team consisted of the MDS Coordinator, SW, Dietary Manager, AD, and the DOR. The DON said the MDS Coordinator did the clinical portion of the care plan. She said acute changes were talked about in the morning meeting and the MDS Coordinator updated the care plan then. The DON said if the care plan was not comprehensive care could be missed.In an interview on 04/17/2026 at 10:58am with MDS Coordinator, she said that all residents should have a comprehensive person centered care plan. She said that without a comprehensive person centered care plan residents may not receive the appropriate care needed. She said that she was a part of the facilities Interdisciplinary Team (IDT), an after the completion of the MDS she is responsible for updating care plan. She said the care-planned could be updated by all clinical staff. She said she was not aware Resident #9's diagnosis had updated but that the resident should be care planned for UTI and Contact isolation. She said that she was not aware that Resident #3's care plan did not include a focus, goal, or interventions for ADL's. She said that any clinical staff that reviewed the care plan could have caught the errors and it was an oversight. In an interview on 04/18/2026 at 3:54pm with the DON, she said residents should have a comprehensive person-centered care plan. She stated when residents' diagnosis were updated it should have been reflected on the resident's care plan. She stated the risk of the resident's care plan not being updated could cause the resident not to receive proper care. Record review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date March 2022 read in part, 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. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally- competent and trauma-informed. 7. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals, and preferences for 1 (Resident #4) of 24 residents reviewed for parenteral fluids. Resident #4 had an IV in her L hand that was tender to touch, had redness, and evidence of prurial leakage. IV had not been flushed for 7 days and was not removed per physician's orders. This failure placed residents at risk for a delay in treatment, pain, and hospitalization. Findings Include: Record review of Resident #4's face sheet revealed a [AGE] year-old woman originally admitted on [DATE]. Admitting diagnoses were COPD (ongoing lung condition caused by damage to the lungs), generalized anxiety disorder (overlay anxious), morbid (severe) obesity due to excess calories, need for assistance with personal care, post-traumatic stress disorder (mental health condition triggered by experiencing or witnessing terrifying events), mood disorder with depressive features (persistent sadness, loss of interest, and low energy) and moderate major depressive disorder (persistent daily feelings of sadness, low energy, and loss of interest). Record review of Resident #4's MDS dated [DATE], under Section C- Cognitive patterns revealed a BIMS score of 12 (moderate cognitive impairment, suggesting occasional mistakes in daily routine). Record review of Resident #4's care plan date initiated 4/27/23 revealed that she received psychology/psychiatry services in the facility. Activities care planned on 7/6/21 that she enjoyed word finds, watching TV, talking on the phone and crocheting. Resident #4 had a history or depression and was at risk for poor mood stability, increased depression, and poor quality of life. Intervention documented to assist with developing a program of activities that were meaningful and of interest and she should be encouraged to engage in activities (crocheting, completing puzzles, reading, and watching tv) frequently to increase mood and cognitive stimulation. Resident #4 also could not bear weight, was incontinent of bowels and bladder, and had an altered respiratory status related to sleep apnea. Record review of Resident #4's orders for April 2026revealed that she on 4/2/26, she was ordered to receive normal saline flush intravenous solution 0.9 % (sodium chloride flush) for 1 liter intravenously. On 4/7/26, a new order was implemented to receive normal saline flush intravenous solution 0.9 % (sodium chloride flush) for 70 milliliters intravenously and was discontinued on 4/10/26. Resident #4 was ordered to drink 2 liters of fluid daily starting on 4/10/26. Record review of Resident #4's NMAR for April 2026 revealed that Resident #4 was ordered to receive Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) with 1 liter intravenously every shift for hyperkalemia (high potassium), until MD reviewed BMP results 4/6/26. The order was started on 4/4/26 and discharged [DATE]. The order was documented as completed for both day shift (6 a.m.) and night shift (6 p.m.). It was last completed by RN G on 4/10/26. Record review of Resident #4's NMAR for April 2026 revealed that Resident #4 was ordered to receive Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) with 70 milters intravenously every day and night shift for abnormal lab fluids continuously until doctor discharged the order. The order was started on 4/7/26 and discharged [DATE]. The order was documented as completed for both day shift (6 a.m.) and night shift (6 p.m.). Record review of Resident #4's progress notes dated 4/9/26 at 10:30 a.m. by the MD revealed staff reported no concerns and noted she ate a lot of fast food and did drink fluids. Resident #4 denied cough, shortness of breath, chest pain, or palpitations. She reported she drank about 1 liter of fluid per day. The patient was instructed that she continued with acute kidney injury due to poor fluid intake. The plan was to continue with normal saline IV fluid hydration; however, the patient preferred to do oral fluid intake. She was encouraged to have at least 2 liters of fluid daily. Given that she was able to drink, will hold off on continuing the normal saline and would repeat a BMP (a blood test that checks the levels of different substances in your blood)in the morning to monitor her acute kidney injury. eGFR (is a measure of how well your kidneys are filtering waste from your blood) has shown improvement, increasing from 17 to 20 in the last 3 days. Record review of Resident #4's progress note on 4/11/26 at 1:13 a.m. by LVN L revealed that IV normal saline remained on hold at that time. In an observation and interview 4/14/26 at 9:10 a.m., revealed Resident #4 was lying in bed with the covers pulled up to her chin. She held up her left hand and showed the surveyor that she currently had an IV line in her hand. She stated she was given an IV so that she could get extra fluids and she could not get it wet, so she had been getting bed baths instead of showers. In an interview on 4/16/26 at 12:15 p.m. with the MD, she stated that she placed an IV line in Resident #4 about a week ago because she had been having acute and chronic hypokalemia (low potassium in blood serum) and dehydration. The MD stated that reviewing lab work, her kidney function had dropped around 15 which was very low. The MD stated that Resident #4 and herself had a long discussion about her hydration and she stated that she needed more fluids although Resident #4 did not believe the lab results. Resident #4 was started with normal saline and potassium and she let her know she either tried the IV to receive additional fluids or her next step would be to the ER. The MD stated since then her kidneys and potassium levels had been stable and Resident #4 recently stated she wanted to try receiving more fluids orally instead of using the IV. In a follow up observation and interview on 4/17/26 at 10:30 a.m. Resident #4 stated that her IV was changed on 4/10/26 but it had not been changed or flushed since then. She said that the nurse (name unknown) told her that they were keeping the IV line in her hand because they may need to put the IV bag back up so she could get extra fluids but the IV site was a little tender. Observation of the IV revealed that it was inserted in the left hand and was secured with a transparent Tegaderm dressing. At the insertion site, there was visible dried blood beneath the dressing and with noted redness. The surrounding skin also had a yellow discoloration. No date was documented on the bandage. In an interview on 4/17/26 at 11:05 a.m. with LVN D, he stated that he was currently working Hall B and was familiar with Resident #4. He stated that he had not been at work since 4/13/26 and today was his first day back. LVN D stated that during morning assessments, he would assess the residents when he arrived to work at 6 a.m. to check if they were alert, oriented, and aware and he was required to check IV's every day. When asked about Resident #4's IV, he stated that he didn't know if she had an IV because it might have been discharged pending lab work. He stated when checking IV's, he was required to check the date on the bandage to see the last time it was changed, and check for redness, swelling, and infiltration (occurs when intravenous fluid or medication leaks into surrounding tissue instead of the vein, causing swelling, discomfort, and potential tissue damage He stated that IV dressings were typically changed every 7 days or as needed and if the IV was not running, nursing would flush it and ask the doctor if she wanted to discharge it. LVN D stated that flushing the IV should be done once daily and the adverse effects of not flushing the IV could be the risk of it getting clogged, increase risk for infection, a delay in flushing could potentially clot into the body and possibly cause a pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). During the interview, LVN D was asked to join the surveyor in Resident #4's room to observe the IV line. He stated that he saw redness and evidence of prurial leakage (means that the intravenous fluid or medication has escaped from the vein into the surrounding tissue). In a follow up observation and interview on 4/17/26 at 12:47 p.m., revealed Resident #4 had gauze on her left hand that was secured with paper tape where the IV once was. She stated that nursing removed the IV from her hand a few minutes ago. In an interview on 4/17/26 at 2:15 p.m. with the MD, she stated that she knew Resident #4 still had an IV in her hand because she was dehydrated and had been getting IV fluids so she wanted it to stay in. The surveyor asked her if the IV was infiltrated because Resident #4 had complaints of pain, the injection site was red, warm, tender to touch, and bruised. The MD stated that those symptoms did not mean that the IV was infiltrated and she did not know that Resident #4 had complained of pain. The MD stated she did not know that the IV line had not been flushed since 4/10/26. She stated she did not know why the IV line was still in Resident #4's arm because she verbally informed RN G to remove the IV line on 4/16/26 (not documented in progress note). The MD stated that when she saw Resident #4 the morning of 4/17/26, the IV site was not warm and she did not have any complaints of pain. In an interview on 4/18/26 at 4:15 p.m., the DON stated that the IV for fluids for Resident #4 had been placed on hold while the MD was waiting on lab work. She stated that although the order was discontinued, the IV should have been flushed daily while they awaited orders from the MD. The DON stated that the harm in leaving an IV in Resident #4's arm without flushing could be irritation and infection. In an interview on 4/18/26 at 4:48 p.m. with RN G, she stated that the last time she worked with Resident #4 was on 4/16/26 and she remembered seeing an IV line in her left hand. She stated that there was an order the previous week to receive fluids by IV but the fluids were to be held. She stated that on 4/16/26, the MD told her to remove the IV but she forgot because there was a lot going on. The DON called her on 4/17/26 and gave her the education on following physician's orders and was told that she needed to have a better system going forward and she should write things down so she would not forget. She stated that she was a new nurse and she took full accountability for what happened and stated that it would not happen again. She stated that she believed she flushed it after 4/10/26, but she did not document it and could not recall if she updated the NMAR. Record review of the facility's policy and procedures on Change in Resident's Condition or Status (revised April 2025) revealed in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition. The nurse will notify the resident's attending physician or physician on call when there has been a(an):.discovery of injuries of an unknown source.significant change in the resident's physical/emotional/mental condition.need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting).Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.Unless otherwise instructed by the resident, a nurse will notify the resident's representative. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. No policy was requested or attained from the facility on the use or Parenteral Fluids.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 1 medication storage rooms and 3 of 6 (Nurse 100 hall, Nurse 200 hall, and Med Aide 200 hall) medication carts, reviewed for pharmacy services.The facility failed to ensure expired medications were not stored with current medications on the 100 hall Nurse medication cart,200 hall Nurse medication cart, 200 hall Med Aide medication cart, and medication storage room.These failures could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns.Findings included: 1. In an observation on 4/17/26 at 11:20am, there were 5 bottles of expired medications found in the 100 hall nurse medication cart. The expired medications were as follows:- Glucose Control Strips Opened 3/2/26 Expired 4/2/26- Calamine Lotion 6oz Mulit-use bottle Expired March 2026- Sodium Chloride Tablets 1 gm Mulit-use bottle Expired March 2026- Bisacodyl Suppository 10mg Expired 4/1/26In an interview on 4/17/26 at 11:20am, LVN O said the medications in the 100 hall nurse medication cart should be checked for expiration at the beginning of the shift. He said expired medication was a medication error and the medications could be less effective. 2. In an observation on 4/17/26 at 11:24am, there was one bottle of expired Saline Nasal Spray 1.5oz found on the 200 hall nurse medication cart. It was opened on 3/9/26 and expired on 4/9/26.In an interview on 4/17/26 at 11:24am, LVN D said he tried to check the 200 hall nurse medication cart every shift, but that did not always happen. He said the expired medication could be less effective. 3. In an observation on 4/17/26 at 12:04pm, there were 10 bottles of expired eye drops, ranging in expiration dates from January 2026 to April 20226 on the 200 hall med aide cart.In an interview on 4/17/26 at 12:15pm, Med Aide F said she checked her 200 hall med aide cart once a month. She said eye drops were good for 30 days after opening. The Med Aide said expired eye drops could cause an eye infection or not be as effective. 4. In an observation on 4/17/26 at 11:45am, one bottle of Insulin Lispro 100u/ml was found expired in the medication storage room refrigerator. The Insulin had been opened on 2/8/26 and expired on 3/8/26.In an interview on 4/17/26 at 11:42am, the DON said she expected staff to check the cart at the beginning of their shift for expired medications and the medication storage room should be checked daily as well. She said opened eye drops, nose sprays, and Insulin were only good for 30 days after opening because bacteria could get inside and they could be less effective.Record review of the facility's policy and procedure on Medication Labeling and Storage (revised February 2023) read in part: .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Number of residents sampled: Number of residents cited: Based on observations, interviews and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (Resident #80) of 24 residents whose records were reviewed for advance directives.- The facility failed to have Resident #80's code status on file from admission ([DATE]) through [DATE].This failure could place residents at risk for not having their end of life wishes honored. The findings included:Record review of Resident #80's undated face sheet revealed she was an [AGE] year old female who admitted to the facility on [DATE] with diagnoses of injury of right lower leg, orthostatic hypotension (blood pressure drops when standing), pain in right ankle and joints of right foot, dementia (progressive decline in memory), anemia (low iron), chronic kidney disease (kidneys do not filter), afib (irregular heart rate), rheumatoid arthritis (autoimmune disease of joints), acute kidney failure, and fracture of right lower leg. The code status was blank on the face sheet.Record review of Resident #80's Baseline Care Plan dated [DATE] revealed the code status was blank.Record review of Resident #80's admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, which indicated normal cognition.Record review of Resident #80's Care Plan dated [DATE] revealed a Focus: Resident #80 desires to have a full code status (Initiated: [DATE]). The interventions included ensuring the staff were aware of the resident's advanced care planning decisions and keeping the face sheet, order, and profile information updated as needed.Record review performed on [DATE] of Resident #80's [DATE] Physician Orders revealed no advanced directives ordered or code status anywhere in the resident's chart.In an observation on [DATE] at 3:00pm, the code cart did not have a code book.In an interview on [DATE] at 3:04pm, CNA M said they did not have a code book. The code status of residents was only listed in the EMR.In an interview on [DATE] at 3:10pm, MD R said if there was not a code status listed on a resident and the resident suddenly was unresponsive, the staff would perform a full code until they could find out what the code status was.In an interview on [DATE] at 8:53am, Med Aide F said the code status was if the resident was going to be resuscitated or not. She said she would look on the resident's orders to see what the code status was. Med Aide F said if the code status was not in the orders she would look in the resident's physical chart that was at the nurse's station. She said if the order was not located anywhere, then she would call the MD for an order. She said if a resident became unresponsive and there was no code status, she would perform CPR until further notice.In an interview on [DATE] at 8:55am, LVN D said he would check the resident's orders or face sheet for the code status order. He said the admitting nurse put the code status in and got the information from the medical records. LVN D said the code status was usually on the first pages of the medical records. He said if he had a new resident, he would look to see what their code status was but otherwise he only kept track of the DNRs. The nurse looked in the orders for Resident #80 and saw an order for the code status that was entered on [DATE]. He said if a resident became unresponsive and he did not see a code status on them he would perform CPR until further notice.In an interview on [DATE] at 10:01am, the DON said a code status told them if the resident wishes were to have CPR or be a DNR. She said she would look in the orders to find the resident's code status, and the code status was only in the orders. The DON said the code status was entered by the admitting nurse. She said if a resident became unresponsive staff checked the EMR for their code status and then either performed CPR or not. The DON said if there was not a code status, staff would perform CPR until a code status could be determined. She said the admission nurse probably forgot to put the code status in, and said it could cause a delay in the care. The DON said either she or the IDT team reviewed admission checklists for completeness so she was unsure how that happened.In an interview on [DATE] at 2:45pm the MDS Coordinator said they got information for resident's care plans from their charts. She said if the code status was not in the chart, she would ask around to see where the order was. She said she was not the one who entered Resident #80's code status on her Care Plan, and it was her co-worker that came in the evenings. The MDS Coordinator said when she looked for the code status of residents she looked in the EMR, the medical records, and the physical chart.Record review of the facility's policy and procedure on admission Assessment and Follow Up: Role of the Nurse (revised [DATE]) read in part: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS.Determine if the resident has existing advance directives. If so, initiate the process of obtaining a copy for the medical record. If not, provide the resident with information on his/her rights to have advance directives and initiate the process of establishing them. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The following information should be recorded in the resident's medical record.Orders obtained from the physician.Record review of the facility's policy and procedure on Advance Directives (revised [DATE]) read in part: The resident has the right to formulate advance directives to convey decisions about end-of-life ahead of time. Advance directives are honored in accordance with state law and facility policy. Advance directives include the following documents: Directive to Physicians & Family or Surrogates; Medical Power of Attorney; Out of Hospital- Do Not Resuscitate (OOH-DNR); Statutory Durable Power of Attorney; and Declaration for Mental Health Treatment. Upon admission the Social Service Director/designee will determine if the resident has any advance directives in place and will provide the residents and/or the resident representative (RP) with written information regarding advance directives. Advance 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 advance directive. The admitting charge nurse will obtain an order for code status. In the absence of an OOH-DNR, the nurse will obtain an order for a Full Code Status and enter into the EHR. If OOH-DNR is present, the charge nurse will obtain an order for Do Not Resuscitate (DNR) and will enter the order into the EHR. Social Service Director/designee will meet with the newly admitted resident or RP within 72 hours of admission to orally review and discuss the written information referenced above.and to verify the code status of the resident.The Social Service Director (SSD)/designee will complete an Advance Care Planning plan of care and indicate the resident's choice regarding advance directives and code status. The social worker/designee will also ensure that.An order for code status is reflected in the EHR which will read either Full Code or Do Not Resuscitate based on the resident's advance directives. SSD/designee will review all advance directives in the quarterly care plan meetings.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 (Resident #85) of 22 residents reviewed for sanitary conditions. The facility failed to clean and disinfect a mud brown smudge with a solid consistency from the wall inside of Resident #85's room for 3 days. The failure could place residents at risk of sickness and infection. Findings included: Record review of Resident #85's face sheet revealed an [AGE] year-old man was initially admitted on [DATE]. Admitting diagnoses were diverticulosis of the large intestine, COPD (ongoing lung condition caused by damage to the lungs), Crohn's Disease of large intestine (is a chronic inflammatory bowel disease that affects the gastrointestinal tract), hemorrhage (bleeding from a damaged blood vessel) of anus and rectum, hemorrhoids (swollen veins in the anus and lower rectum), and slow transit constipation. His face sheet revealed a Full code status. Record review of Resident #85's MDS dated [DATE], under Section C- Cognitive patterns revealed a BIMS score of 9 (moderate cognitive impairment, suggesting occasional mistakes in daily routine). Record review of Resident #85's care plan initiated on 8/20/23 revealed that he required assistance with ADL's and his functional abilities due to impaired cognitive cognition and he was incontinent of bowels and bladder. On 4/18/26, the care plan was updated to include Resident #85 had a behavior problem of smearing BM everywhere on his side of his room and would try to clean it up at times but would still smear it everywhere. In an observation and interview on 4/14/26 at 9:20 a.m., Resident #85 was observed standing on his side of the room near the wall next to a window. He wore a t-shirt and an adult brief that appeared full by the way the brief drooped and swayed when he moved. Upon entry, the room had a very pungent smell of BM. When the surveyor entered the room, Resident #85 turned from the wall and walked toward the right side of the bed to sit. On the wall where he was standing was a mud brown smudge of a thick consistency that looked about 8 inches long. The smudge did not have any drip lines and looked raised on the left side and thinned out towards the right. During the interview, Resident #85 stated that he was doing alright and had no concerns regarding staff coming when he pressed his call light. He stated that he used the restroom on his own, but staff would assist him as needed. On his bed, there were brown stains of what appeared to be BM that appeared to be coming from the side of his brief. When asked about the stains on his linen, he stated that the aides changed his linen and housekeeping cleaned his room daily. Two flies buzzed around his room and he stated that he did not know where they came from but maintenance would come in and spray the room periodically and had set traps in the past to catch any pests. In a follow up interview on 4/15/26 at 9:47 a.m., Resident #85 stated that he had hemorrhoids and he told the nurses, but there was nothing they could do about it. When asked a follow up question regarding his linen, he stated that the stains on his sheets were given to him when he got them and the machine could not get everything out. During the interview, Resident #85 began to stare past the surveyor for a period of time. In the room, a strong smell of BM materialized. In an interview on 4/15/26 at 9:56 a.m. with CNA G, she stated that Resident #85 required assistance with getting dressed and undressed and he was able to feed himself. She stated that sometimes he would go to the restroom because he was able to walk around by himself but he would need follow-up assistance after to ensure cleanliness. When asked about the flies, CNA G stated that Resident #85 had a condition and she was unsure what it was but it caused him to go #2 frequently. She stated they could provide care for him, but he would go again. She stated that the aide that tended to Resident #85 on that hall was in his room almost every 30 minutes to an hour providing care and housekeeping would go all over to make sure the room was cleaned. In an interview on 4/15/26 at 10:03 a.m. with CNA R, she stated that she had first noticed the flies in Resident #85's room on 4/14/26 and she believed it was due to his incontinence and that housekeeping probably had not cleaned the room yet. She stated that Resident #85 would not let the aides know when he used the bathroom and he did not use his call light. She stated that she would know that he needed incontinent care because there would be a noticeable smell and by the way his brief looked because he did not like to wear bottoms unless he left his room. She stated when she provided care, she would normally clean, wipe, and put him in a new brief. She stated he sometimes would have a loose stool and because he did not wear bottoms, the stool would leak out on his sheets so she regularly would have to change his linen but had not gotten to his room to repeat care at that time. When asked about the mud brown smudge on the wall, she stated she did not know what it was and could not speak to it. In an observation on 4/17/26 at 10:45 a.m., revealed the mud brown smudge on Resident #85's wall was still there. Flies were no longer present at the time. In an interview on 4/17/26 at 10:58 a.m. with HK A, she stated that she had worked at the facility for over 10 years and she normally worked on hall B where Resident #85 was housed. She stated that she had not gotten to his room yet because she was clearing the room across the hall from his for new admits but she would be there shortly. HK A was directed to the mud brown smudge on the wall of Resident #85's wall and she stated that perhaps the smudge was from his coffee. The surveyor pointed out how thick the smudge was and that there was no drip marks indicating that it was thin liquid. HK A said that she had been off for 2 days but she was not sure what it was but she would make sure the entire room was cleaned up. She followed up with the surveyor and stated that the room and the wall had been cleaned. In an interview on 4/17/26 at 11:02 a.m. with the EVS Director, he stated that he oversaw all maintenance responsibilities and housekeeping. He explained that housekeeping was supposed to dust, clean door knobs, wipe down beds, clean restrooms, floors, wipe down walls, and any and everything inside of a resident's room. He stated that harm in keeping the mud brown smudge on the wall could be sickness and he expected the rooms to be cleaned throughout every day. In an interview on 4/18/26 at 4:15 p.m., the DON stated that the harm in leaving substances like the mud brown smudge on the wall would be the potential for infections. She stated that sometimes Resident #85 would smear BM everywhere and if he had an incident, the facility staff was supposed to go behind him frequently. Record review of the facility's policy titled Homelike Environment revised February 2021, policy statement revealed that residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. In that: 1. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment;b. clean bed and bath linens that are in good conditionc. pleasant, neutral scents

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #44) of 24 residents reviewed for PASRR.The facility failed to perform a new PASRR level 1 assessment on Resident #44 due to diagnoses, of major depressive disorder (persistent, intense, low mood, or a loss of interest), generalized anxiety disorder (persistent, excessive, and uncontrollable worry), mood disorder due to known physiological condition with mixed features (mania/hypomania and depression occur together), and adjustment disorder with mixed disturbance (emotional issues and behavioral problems after a stressor).This failure could place residents at risk of not receiving the services and support needed.Findings Included:Record review of Resident #44's undated face sheet revealed he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses of mood affective disorder (long-term emotional disturbances) , recurrent major depressive disorder, adjustment disorder with disturbance of conduct, generalized anxiety disorder, and mood disorder due to known physiological condition with manic features.Record review of Resident #44's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, which indicated severely impaired cognition. The resident had impairment on one side of his upper extremities and impairment of both sides of his lower extremities. He used a wheelchair for mobility. The resident was dependent for all ADLs and was always incontinent of bowel and bladder. The assessment revealed resident #44 was diagnosed with anxiety disorder, depression, and bipolar disorder and was taking antianxiety and antidepressant medications.Record review of Resident #44's Care Plan dated 12/16/23 revealed a Focus: Resident #44 was receiving psychology/psychiatry services in the facility. Interventions included communicating with Resident #44 his progress of the psychology/psychiatry services and notifying provider and family of any changes in resident's condition. Focus: Resident #44 was using anti-anxiety medication r/t anxiety disorder. Interventions included administering anti-anxiety medications as ordered, monitoring for side effects and effectiveness, and educating resident/family about risks and benefits. Focus: Resident #44 was using antidepressant medication r/t depression. Interventions included administering antidepressant medications as ordered, monitoring for side effects and effectiveness, and educating resident/family about risks and benefits.Record review of Resident #44's PASRR Level 1 Screening performed 12/6/23 by MDS N, revealed the resident the resident did not have evidence of dementia as the primary diagnosis, he did not have evidence of mental illness, he did not have evidence of an intellectual disability, and he did not have evidence of a developmental disability.Record review of Resident #44's Progress Notes revealed an H&P dated 12/11/23 from NP A that said, .past medical history of TBI, anxiety, depression.Record review of Resident #44's medical record revealed a Psychiatric Initial assessment dated [DATE] from MHNP F revealed that he was diagnosed with recurrent major depressive disorder and was being treated with Bupropion, generalized anxiety disorder and being treated with lorazepam, mood disorder due to known physiological condition with mixed features and being treated with Depakote, and adjustment disorder with mixed disturbance of conduct.Record review of Resident #44's Progress Notes revealed a note dated 4/9/26 from LCSW Z that revealed the resident was being treated for generalized anxiety disorder, recurrent major depressive disorder, and mood disorder due to known physiological condition with manic features.Record review on 4/16/26 of Resident #44's April 2026 Physician Orders revealed the following orders from MD R:- VPA (Depakote) Level Q6 months. Ordered 5/23/24.- Antidepressant monitoring for sertraline and bupropion every shift for side effects, every shift. Ordered 5/23/24.- Behavior Monitoring - Antidepressant Behavior (Escitalopram), every shift. Ordered 4/14/26.- Behavior Monitoring - Antidepressant Behavior (Trazodone), every shift. Ordered 4/13/26.- Behavior Monitoring - Anxiolytic Behavior (Lorazepam), every shift. Ordered 4/6/26.- Behavior Monitoring for antidepressant medication: sertraline and bupropion, every shift document resident outcome following intervention. Ordered 5/23/24.- Behavior Monitoring for antipsychotic medication: depakote, every shift document resident outcome following intervention. Ordered 5/23/24.- Deer Oaks may provide psychiatry/psychology services and medication management as needed. Ordered 12/13/23.- Side effects - antidepressant: chart all appropriate codes, every shift. Ordered 4/14/26.- Side effects - anxiolytics: monitor every shift, document code and notify provider, every shift. Ordered 4/6/26.- Bupropion HCl ER (XL) Oral Tablet Extended Release 24 hour 150mg, 1 PO QD for depression. Ordered 12/6/23.- Depakote Oral Tablet Delayed Release 250mg, 1 PO BID for mood disorder. Ordered 5/28/24.- Lorazepam Oral Tablet 0.5mg, 1 PO TID for anxiety. Ordered 12/6/23.- Sertraline HCl Oral Tablet 50mg, 1 PO QD for recurrent major depressive disorder. Ordered 2/21/24.In an interview on 4/17/26 at 9:01am, the MDS Coordinator said she remembered Resident #44 being negative for the PE when he was first admitted , then he was diagnosed with other medical conditions and she did not submit a new PE because she knew he was not going to qualify since he had not been in any psychiatric facilities. She said since she did not do a PE the resident could be losing out on possible services.Record review of the facility's policy and procedure on PASRR (dated 1/20/26) read in part: The aim of the PAS RR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed , whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD.The PASRR Level 1 Screen (PL 1) The facility Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL 1 upon admission.When it is determined that a PL 1 was filled out incorrectly, the MDS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form. If the referring case worker is unwilling/unable to correct the PL 1 that contains a potential error, the social worker or designee will complete and submit a form 1012 (MI) or new PL 1 (ID/DD). A subsequent positive PL 1 will be entered according to 1012 findings (MI). When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL 1 was incorrect, the social worker or designee will complete and submit a form 1012 (MI) or new PL 1 (ID/DD). A subsequent positive PL 1 will be entered according to 1012 findings.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 1 out of 24 residents (Resident #12) reviewed for ADLs.- The facility failed to shower/bathe Resident #12 for a week (from 4/9/26-4/16/26) when she was scheduled to have one three times a week on Tue/Thu/Sat.This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth.Findings included:Record review of Resident #12's undated face sheet revealed she was an [AGE] year old female who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, hypertension, cirrhosis, heart failure, chronic kidney disease, acute cystitis with hematuria, and asthma.Record review of Resident #12's admission MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, which indicated moderately impaired cognition. The MDS revealed the resident was substantial/max assistance (helper does more than half the effort) with showers/baths. Resident #12 was always incontinent of bowel and bladder and had shortness of breath when lying flat. The resident took diuretics (medication that increased urination) and was on oxygen.Record review of Resident #12's Care Plan dated 1/13/26 revealed a Focus: Resident #12 had an ADL self-care performance deficit r/t weakness. The interventions included PT/OT evaluation and treatment and encouraging the resident to participate to the fullest extent possible. Focus: Resident #12 was at risk for skin breakdown due to incontinence. Interventions included keeping skin clean and dry.Record review of Resident #12's April 2026 Physician Orders as of 4/14/26 revealed the following orders from MD R:- Contact Isolation Dx VRE/UTI, every shift for 14 days. Recollect UA C&S 48hr after antibiotics complete. Ordered 4/1/26.- Healing Partners to consult for skin and wound conditions/prevention. Ordered 2/15/26.- Calamine External Lotion, Apply to affected area topically Q6hr PRN for itching. Ordered 4/2/26.- Lubriderm External Lotion, Apply to trunk and BLE topically QAM and QHS for dry skin. Ordered 4/2/26.- Nystatin External Powder 100000 unit/gm, Apply to abdominal folds topically QAM and QHS for erythema intertrigo (rash caused by skin-on-skin friction, heat, and moisture). Ordered 2/20/26.In an interview and observation on 4/14/26 at 9:48am, Resident #12 was in a room with contact isolation. She was sitting up in bed and had brown, dirty looking nails. Resident #12 said she was in contact isolation for bacteria in her urine. She said she was moved to the 400 hall from the 100 hall and she had not had a bath/shower since she moved there. She said she had no problems with showers/baths on the 100 hall. Resident #12 said it had been almost 2wks since she had a bath/shower.Record review on 4/16/26 of Resident #12's April 2026 Shower/Bathing Task, revealed she was scheduled for Tuesdays, Thursdays, Saturdays on the 2pm-10pm shift. The task revealed her last shower/bath was on 4/9/26 at 3:14pm.In an interview on 4/16/26 at 11:58am, CNA M said she gave showers to all of the residents in A beds, except for the residents on the 300 hall. She said the 2pm-10pm shift gave showers to the B beds. CNA M said she documented the showers and refusals in the POC under the shower/bath task. She said she thought she had given Resident #12 a shower the previous week but was not sure. The CNA said if she was unable to give a shower/bath it was because she was pulled to the floor to work as a CNA, and in that case the CNAs for that hall were responsible for giving their own showers/baths. CNA M said if residents did not get showers/baths they could stink and could have skin breakdown.In an interview on 4/16/26 at 1:35pm, Resident #12 said she had not received a shower/bath yet.In an interview on 4/17/26 at 10:01am, the DON said she expected residents to get their scheduled showers/baths and whenever they needed them. She said they had enough help that every resident should get theirs. The DON said if a resident did not get their shower/bath they could have dignity issues or could have skin breakdown. She said the IDT Team talked about the POCs in the morning meetings.Record review of the facility's policy and procedure on Activities of Daily Living (ADL), Supporting (revised February 2025) read in part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

Based on record review and staff interview, the facility failed to ensure radiology services were obtained and reported in a timely manner for 1 of 8 residents (Resident #14) reviewed for radiology services.-The facility failed to ensure Resident #14 received a STAT ( immediately or without delay) chest x-ray as ordered on 04/13/2026 which delayed further medical assessment and treatment until 04/14/2026.This failure placed residents at risk of experiencing delays in clinical decision-making and treatment.Finding included:Record review of the face sheet for Resident #14 dated 04/14/2026 revealed an [AGE] year-old female admitted to the facility on [DATE] with principal diagnoses of other specified chronic obstructive pulmonary disease (COPD progressive and lifelong respiratory disorder that leads to an abnormal inflammatory response in the lungs).Record review of Resident #14's undated care plan revealed the following:Focus: Resident #14 is at risk for having altered respiratory status/difficulty breathing due to her COPD, she does require the use of oxygen.Goal: Resident #14's will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Resident #14 will have no complications related to her COPD though the review date.Intervention: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Assist resident/family/ caregiver in learning signs of respiratory compromise. Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to yawn. Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for s/sx (sign and symptoms) of respiratory distress and report to MD(Doctor of Medicine) PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia);Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. O2 as indicated by the MD. Pace and schedule activities providing adequate rest periods.Record Review of Resident #14's Quarterly MDS dated [DATE] revealed a BIMS score 12 of 15; indicating Resident #14's had cognition that was moderately impaired. In section I Resident#14 was triggered for Asthma, Chronic Obstructive Pulmonary Disease), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung diseases such as asbestosis) in section I. In Section O Resident #14 was triggered for oxygen therapy in respiratory treatments. Record Review of Resident#14's progress note dated 04/13/2026 at 09:13am by LVN G read in part, Resident c/o(complaints of) increasing aching chest pain upon exhalation. Resident did not appear to be in any respiratory distress. v/s (vital signs) obtained BP(blood pressure 135/64 HR(heart rate) 80, RR(respiration rate) 18 T (temperature)97.7 O2(oxygen) 97% on 2L(liters) NC(nasal cannula) 6 out of 10 on a 0-10 pain scale. Nitroglycerin(used to treat chest pain) administered, resident requested PRN(as needed) Pain medication, nurse administered, On call notified, new order for STAT CXR (chest x-ray) ordered. @ 2040 (8:40pm) resident stated chest pain had subsided. Will continue to monitor throughout shift for coc[sic].Record Review of Resident #14's physician order dated 04/13/2026 at 08:47pm for a STAT chest x-ray. Record Review of Resident #14's chest x-ray dated 04/14/2026 with no abnormal results.In an interview and observation on 04/14/2026 at 9:39am LVN H was observed to enter/exit the room of Resident#14 responding to the call light. She said that Resident#14 requested an update on when she would receive a chest x-ray that was order on the night shift on 04/13/2026 after she experienced chest pain. She said that she completed an assessment of Resident#14 with vitals within normal limits and no complaints of pain. She said that the resident expressed she was upset that she had not got the x-ray because the night nurse (LVN G) told her that it would be completed the same night. She said that she asked the resident if she wanted to go to the hospital to complete the x-ray but the resident declined. She said that she told Resident #14 to give her some time to research because she was not aware of the order. In an interview on 04/14/2026 at 9:42am Resident#14, said that sometime after lunch on 04/13/2026 she started to have chest pains, but she did not alert the day nurse. She said that the pain worsened, and she told the night nurse(LVN G). She said that the night nurse (LVN G) called the nurse practitioner who ordered medication and a chest x-ray. She said that the night nurse (LVN G) told her that she would get the x-ray the night of 04/13/2026, but she had not received the x-ray. She said that she was not currently in pain, the nurse(LVN H) had assessed her and asked if she wanted to go to the hospital. She said that she declined going to the hospital.In a follow up interview on 04/14/2026 at 10:32am LVN H said that LVN G received orders from the on-call nurse practitioner for Resident#14 to receive a STAT chest x-ray. She said that she confirmed with laboratory company that the x-ray had not been completed and they could send a technician between 5:00pm-6:00pm on 04/14/2026. She said that she provided the information to Resident#14's primary physician who was present in the building and agreed to reassess Resident #14 for a need for a STAT chest x-ray. She said that she did not see that LVN G followed up with the on-call nurse practitioner after the x-ray was not completed the night of 04/13/2026. She said that LVN G did not give her information to follow up on a chest x-ray for Resident#14 during shift change. She said that when a STAT order was given the expectation was that it was completed within 2-4 hours. She said that if the order can not be completed in the four-hour window contact should be made with the physician or nurse practitioner immediately. She said that if the physician or nurse practitioner are not notified, they are not able to make changes to the treatment plan, it could cause a delay in treatment, and the residents condition could worsen.In a follow up interview on 04/14/2026 at 11:33pm with Resident #14, she said that LVN H told her that the x-ray technician should arrived around 5:00pm, and her primary physician will come see her that same day. She said that LVN H asked if she wanted to go the hospital again and she declined. In an interview on 04/14/2026 at 11:45am with MD R, who said that LVN H came to her and asked if Resident#14 could be assessed after a STAT Chest X-ray was not completed the night of 04/13/2026 after complaint of chest pain. She said that LVN H told her that the residents vitals were within normal limits, the resident was not currently in pain, and Resident #14 was offered transfer to the hospital and declined. She said that she had been made aware that a technician was expected at the facility by 5pm to complete the order.In a follow up interview on 04/14/2026 at 1:38pm with MD R, who said she assessed Resident #14, to have no pain, normal vital signs, and clear lungs. She said that the lab technician will arrive by 6:00pm to complete the chest x-ray. She said that STAT labs should be completed within 2-4 hours. She said that staff should notify the physician if the lab can not be completed, to assess the need to send to the hospital or remain at the facility and wait. She said that if the task is not completed it could cause a delay in treatment. She said that when she reviewed the order for Resident#14 she did not see that the order was STAT.In a interview on 04/15/2026 at 12:44pm with NP A, who said that STAT labs should be completed within 2-4 hours. She said that staff should notify the physician if the lab can not be completed, to assess the need to send to the hospital, remain at the facility and wait, or additional orders could be given. She said that if the task were not completed it could cause a delay in treatment. She reviewed the electronic medical records of Resident# 14. She said that that the on call nurse practitioner ordered a STAT chest x-ray for Resident #14 on 04/13/2026 at 8:00pm. She said that that the chest x-ray was not completed until 04/14/2026 at 5:00pm with no abnormal results. She said that there was a delay in treatment for Residenet#14. In a phone interview on 04/16/2026 at 12:16pm LVN G said that stat labs should be completed within 3-5 hours. She said that if a technician does not arrive to the facility within the window notification should be made to the physician or nurse practitioner for additional orders or interventions. She said that if the physician or nurse practitioner are not notified it could cause as delay in treatment. She said that she worked the 6:00pm to 6:00am shift on 04/13/2026. She said that during her shift Resident #14 complained of chest pains, and she notified the on-call nurse practitioner who order Nitroglycerin and a STAT chest x-ray. She said that at the end of the shift the lab company had not arrived, and she gave the information to LVN H on the next shift to follow up as the lab company were still in the 3-5 hour window. She said that if LVN H did not follow up on the 6:00am-6:00pm shift on 04/14/2026 it would have been a delay in treatment. In a follow up interview on 04/16/2026 at 12:35 pm with MD R, who said after reviewing the electronic medical records for Resident #14 she confirm that the order for the chest x-ray was given as STAT. She said that the x-ray was completed outside of the 2-4 hour window, and notification should have been made to physician or nurse practitioner. She said that Resident#14 had a delay in treatment with no negative impact because the x-ray was completed on 04/14/2026 with no abnormal results.In an interview on 04/16/2026 at 1:08pm with the DON who said that a stat lab order should be completed within 3-5 hours, with notification made to the physician or nurse practitioner if a technician does not arrive during the time frame. She said that if notification was not made it could cause a delay in treatment. She said that she would provide a copy of the contract with the lab company to confirm the response time for STAT lab services. In an interview on 04/17/2026 at 9:35am with the DON. She said that STAT lab orders should be completed within 4-6 hours. She said that she reviewed the electronic medical records for Resident #14. She said that LVN G should have notified the on call nurse practitioner during her shift when a technician did not come to complete the chest x-ray for Resident#14. She said that the LVN G should could have notified the ADON, DON, or given LVN H the information during report that the order had not been completed. She said that there was a delay in treatment. She said that she would provide a copy of the contract with the lab company to confirm the response time for STAT lab services due to inconsistencies provided multiple interviews.An email was sent 04/16/2026 at 11:44am to the Administrator and DON for the following policies, laboratory services and stat labs policy and procedures. An email was sent 04/17/2026 at 3:42pm to the Administrator and DON for the following policies, STAT labs, incomplete labs, notifying physician of incomplete labs, and a copy of the lab contract with stat lab response times.An email was sent 04/18/2026 at 1:27pm to the Administrator and DON for the following policies, Labs (a policy that addresses the time frame for stat labs) -incomplete labs, notifying the physician of incomplete labs, and Quality and/or timeliness of providing laboratory services.A policy was requested for STAT Laboratory Services policy from both the Administrator and DON was not received prior to exit.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. -The facility failed to ensure food was discarded from the refrigerator prior to the use by date.-The facility failed to ensure food was labeled with a discard or use by date.-Dietary Staff A used an object to prop open the kitchen door allowing two flies to enter the kitchen. These failures could place residents at risk of foodborne illness and disease.Findings include:1.Observation on 04/14/2026 at 8:40am with the Food Service Director of the refrigerator located in the kitchen revealed the following:*an open bag of shredded lettuce secured with a clip to be brown with a brown liquid at the bottom of the bag. Observation of the bag of shredded lettuce to have no manufacture package date, with a handwritten date of 03/29/2026, and no use by/discard date written on the package. *an unopened bag of mozzarella cheese to have a manufacture package date of 02/25/2026, with a handwritten date of 03/26/2026, and no use by/discard date written on the package.In an interview observation on 04/14/2026 at 8:45am with the Food Service Director, who said that food items in the refrigerator should be labeled with a delivery date if a manufacture date does not exit, open date, and use by date. She said that food items that are not labeled appropriately in the refrigerator are at risk of being consumed after it was no longer safe. She said that if a resident consumed expired food, it could cause food borne illness. She said that the dates written on the package were use by date, but it was not indicated on the package. She said that the mozzarella cheese and shredded lettuce should have been thrown out. She said that staff should check at the start of each shift that all expired foods had been thrown out and it was an oversight. The Food Service Director disposed both food items in the garbage. In an interview on 04/14/2026 at 9:15am with the Administrator, DON, and RNC B, all said that expired food should not be stored in the kitchen. All said that food should be discarded before the use by date or manufacture expiration date. All said that dietary staff should ensure food products are labeled to ensure that expired food was not stored in the kitchen. All said that the risk of consuming expired food was food borne illness.2.Observation on 04/15/2026 at 10:50am Dietary Staff A used a cardboard box to prop the door to the kitchen open while taking the trash out. Two flies entered the kitchen. [NAME] A used a towel to swat the flies, removing them from the kitchen and closing the door A sign was posted on the door, to keep it closed. In an interview on 04/15/2026 at 10:55am [NAME] A said the kitchen door should be closed immediately when exiting and entering in effort to keep pest out. She said that pests can cause cross contamination and food borne illness. In an interview on 04/15/2026 at 11:00am Dietary Staff A said the kitchen door should be closed immediately when exiting and entering in effort to keep pest out. She said that pests can cause cross contamination and food borne illness. She said that she used the cardboard box to prop the door when she should not have done so because she was going to make multiple trips to the dumpster. In an interview on 04/15/2026 at 11:05 am with the Food Service Director, who said the kitchen door should be closed immediately when exiting and entering in effort to keep pest out. She said that pests can cause cross contamination and food borne illness.In an interview on 04/15/2026 at 11:10am with the Administrator, who said that dietary staff should follow guidelines in place to prevent concerns with pest control. She said that if there was a sign posted to keep the door closed in the kitchen, staff should not have prop open the door for any reason. She said that pests can cause cross contamination and food borne illness. Record review of the policy titled, Food Receiving and Storage, revised date November 2022 read in part, . Policy Statement.Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation.Refrigerated/Frozen Storage 1. All foods stored in a refrigerator or freezer are covered, labeled and dated ( use by date).7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 8 residents (Resident #69 and Resident #109) reviewed for call systems. The facility failed to provide a functioning call light system in the rooms of Resident #69 and Resident #109. This failure could place residents at risk for a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life. Finding included: 1.Record review of the face sheet for Resident #69 dated 04/16/2026 revealed an [AGE] year-old female admitted to the facility on [DATE], with principal diagnoses of Alzheimer's Disease, Unspecified (brain condition that slowly damages memory, thinking, learning, and organizing skills). Record Review of Resident #69's Quarterly MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score 0 out of 15; indicating Resident #69's cognition was severely impaired. In Section GG Resident# 69 required substantial/maximal ( Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) assistance for rolling to left to right, moving from sitting on the side of the bed to lying, when standing, being transferred form the chair, bed, and shower. Record review of Resident #69's undated care plan revealed the following:Focus: Resident #69 has impaired cognition and poor safety awareness , she does require assistance with all her transfer, she is at risk for falls.Goal: Resident #69's risk for falls will be reduced through the next review date.Intervention: Assist with all transfers. Keep call light within reach. Monitor for changes in condition that may warrant increased assistance and notify the physician. Refer to physical therapy for evaluation. Remind resident to ask staff for assistance with all transfers. 2.Record review of the face sheet for Resident #109 dated 04/16/2026 revealed an [AGE] year-old female admitted to the facility on [DATE], with principal diagnoses of Hypertensive Chronic Kidney Disease (condition where high blood pressure both causes and worsens kidney damage,). Record Review of Resident #109's Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score 7 of 15; indicating Resident #109's cognition was severely impaired. In Section GG Resident# 109 was dependent ( Helper does ALL of the effort. Resident does none of the effort to complete the activity. or, the assistance of 2 or more helpers is required for the resident to complete the activity.) with assistance for rolling to left to right, moving from sitting on the side of the bed to lying, when standing, being transferred from the chair, bed, and shower. Record review of Resident #109's undated care plan revealed the following:Focus: Resident #109 has poor balance and weakness putting her at risk for falls, she does require assistance with all transfers.Goal: Resident #109's risk for falls will be reduced through the next review date.Intervention: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Follow facility fall protocol. Pt evaluate and treat as ordered or PRN. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. In an interview and observation on 04/14/2026 at 9:57 am with Resident #109 in room [ROOM NUMBER]B, she said that she wanted to be repositioned in the bed, she pressed the call light but no one had come. She said that she could not recall how long ago she had pressed the call light. Observation at this time of Resident #109 to have pressed the call light, the indicator light did not flash on the wall at the bedside, and the indicator light did not come on in the hallway outside of the room. She said that she was not aware that the call light was not functioning and she thought it had worked on 04/13/2026. In an interview and observation on 04/14/2026 at 10:10am with LVN H, who pressed Resident #109's call light and stated the indicator light did not flash on the wall at the bedside, and the indicator light did not come on in the hallway outside of the room. She was not sure of how long the call light had not functioned. LVN H said that residents had a right to a functioning call light at all times. She said that residents without a functioning call light were not able to alert staff of care needs, incidents, accidents, or changes in conditions. She said that she would report the issues to the EVS Director immediately. Observation on 04/14/2026 at 10:12am LVN H reported the issue of the call light not functioning to the EVS Director who was on the 400 hall In an interview and observation on 04/14/2026 at 10:14am with EVS Director, who said that he was responsible for ensuring that call lights functioned in the facility. He said that he did weekly documented testing to catch any call lights that may not be functioning, and staff should alert him immediately if they identify a call that was not functioning. He said that residents needs to have a functioning call light to alert staff when they need something, and without a functioning call light staff will not know what the residents may need. He was observed to pressed Resident #109's (room [ROOM NUMBER]B) call light and stated the indicator light did not flash on the wall at the bedside, the indicator light did not come on in the hallway outside of the room, and he said that he would repair it immediately. Observation on 04/14/2026 at 10:16am Resident #69's call light was pressed on the wall at the bedside in room [ROOM NUMBER]A, and the indicator light did not come on in the hallway outside of the room. Resident#69 was not present in the room during the observation. In an interview and observation on 04/14/2026 at 10:21am with CNA P, who pressed Resident #69's call light and confirmed the indicator light did not flash on the wall at the bedside, and the indicator light did not come on in the hallway outside of the room. She was not sure of how long the call light had not functioned. CNA P said that residents had a right to a functioning call light at all times. She said that residents without a functioning call light were not able to alert staff of care needs, incidents, or changes in conditions. She said that she would report the issue to the EVS Director immediately. In an interview on 04/14/2026 at 10:38am with the DON and Administrator, both said that residents should have functioning call lights. Both said that Residents need call lights to alert staff for care needs, change in condition, and incidents/accidents. Both said that without a functioning call light care needs, change in condition, and incidents/accidents could be missed by staff. Both said that staff should alert the EVS Director when a call light was observed not functioning. The Administrator said that the EVS Director should test call lights functioning routinely in effort to ensure all resident have call that function. Efforts to interview Resident #69 on 04/14/2026 at 10:50am were not successful as the resident was not interviewable. Record review of electronic work orders from January 2026-April 2026 with no outstanding repair request for call light malfunction for Resident #69 or #109. Record review of electronic work orders report for conducting a test of the nurse call system dated 01/30/2026. The report revealed that only rooms 102, 104, 105, 112, 205, 209, 210, 212, 216, 402,404,410, and 418 were tested for functioning call lights. Record review of electronic work orders report for conducting a test of the nurse call system dated 02/27/2026. The report revealed that only rooms 201, 202, 204, 205, 206, 207, 208, 209, 210, 211,212,213, 214, 215, and 216 were tested for functioning call lights. Record review of electronic work orders report for conducting a test of the nurse call system dated 03/13/2026. The report revealed that only rooms 301, 302, 304, 305, 306, 307, 308, 309, 310, 311, 312,313, 314, 315, and 316 were tested for functioning call lights. Record review of electronic work orders report for conducting a test of the nurse call system dated 04/15/2026. The report revealed that only rooms 109, 114, 115, 203, 207, 214, 215,306, 310, 312, 402,404, 407, 416, and 418 were tested for functioning call lights. Record review of the policy titled, Call System, Resident, and updated January 2025 read in part, . Policy Statement.Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation. 1.Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.3.The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional.5.The resident call system is routinely maintained and tested by the maintenance department.

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards.The facility failed to ensure CNA A, on 10/07/25, had a 2nd staff member assisting her when transferring Resident #1 from her bed to her wheelchair and failed to ensure the mechanical lift sling was free from defects. Resident #1 fell from her bed to the floor and sustained lacerations to her head resulting in 7 stitches to her left forehead and 5 staples to her posterior scalp.The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 10/07/25 and ended on 10/08/25. The facility had corrected the noncompliance before the survey began.This deficient practice placed residents at risk of pain, injury, and hospitalization.Findings included:Review of Resident #1's face sheet dated 10/29/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including other epilepsy, not intractable, without status epilepticus (a form of epilepsy (a chronic neurological disorder characterized by recurrent seizures caused by abnormal electrical activity in the brain) where seizures are not considered difficult to control with treatment), contracture, left knee (limiting movement and causing pain, stiffness, and an inability to fully extend the leg), and dementia in other diseases classified elsewhere, unspecified severity with agitation (dementia (a general term for a decline in mental ability that affects memory, thinking, and daily life) caused by another disease (like Alzheimer's or Parkinson's) who also exhibit agitation, such as restlessness, shouting, or aggression, and the severity of the dementia has not been specified). Review of Resident #1's care plan initiated on 03/18/21 and revised on 10/07/25 reflected Resident #1 had very limited mobility and required total assistance with all transfers via mechanical lift, putting her at risk for falls. Review of Resident #1's Quarterly MDS dated [DATE], reflected a BIMS score of 04 indicating severe cognitive impairment. Observation on 10/29/25 at 9:47 am of transfer by mechanical lift of Resident #1 from her bed to her wheelchair by CNA C and CNA D. Surveyor observed safe transfer and mechanical lift sling in good condition. During the observation of Resident #1 being transferred, Resident #1 told CNA C and CNA D, don't hurt me like you did the other day. Review of facility investigation statement dated 10/07/25 of CNA A reflected she was preparing to transfer [Resident #1] to her chair using a [mechanical lift] and sling. I positioned the sling under the resident while waiting on my coworker to assist with the transfer. As I set the resident in the sling above her bed the sling broke. She fell off the bed onto the floor. The incident happened before my coworker arrived. I immediately notified the nurse. Review of facility Accident/Incident Investigation Statement of CNA B dated 10/07/25 reflected on 10/07/25 at about 7:35 am CNA B was in the shower room assisting another resident when CNA A called and asked her to go help with a mechanical transfer. CNA B said she was finishing up with the shower and would come as soon as she could. When CNA B got to the room to help with Resident #1, Resident #1 was already on the floor. CNA A told CNA B that the sling had broken when she was waiting for help. The nurse was called right away and CNA A and CNA B stayed with Resident #1 until the nurse arrived. Review of facility investigation statement dated 10/07/25 of DON reflected at approximately 7:55 am she was called to Resident #1's room by CNA A who stated Resident #1 was on the floor at bedside. Resident #1 was on her back with a laceration above her left eyebrow and back of her head. Staff at bedside applied pressure. Resident #1 remained in the same position as when she fell from the mechanical lift. Vitals were taken and Resident #1 complained of pain to her bilateral lower extremity at a level of 4 out of 10 (Moderate pain, manageable). RP and MD notified, and orders received for emergency medical services transport for evaluation and treatment. Record review of hospital records dated 10/07/25 reflected [AGE] year-old female arrived by emergency medical service from nursing facility status post fall approximately 3 - 4 feet as patient was being carried over on a lift. Patient sustained left forehead laceration as well as posterior scalp not on any anticoagulation. Patient was at her baseline since the fall. No bruising to the rest of her body. Vital signs were stable per emergency medical services. Record review of TULIP (an online system used by the Texas Health and Human Services Commission for long-term care licensing, applications, and reporting) facility self-report dated 10/07/25 reflected Resident #1 had an observed fall. CNA A said as she was waiting for CNA B to come into Resident #1's room to assist CNA A with transferring Resident #1 from her bed to her wheelchair. While CNA A was waiting for CNA B to come, CNA A positioned the resident in the sling to get ready for CNA B to come and CNA A lifted the resident up about an inch above the bed, then she heard a pop, she noted the sling hooks on the side she was on had come undone, and the resident landed on the bed, then the resident rolled off the bed onto the floor. CNA B came into Resident #1's room when Resident #1 was on the floor and CNA B called for a nurse. When the nurse entered the room, she saw Resident #1 on her back with a laceration above her left eyebrow and the back of her head. When Resident #1 asked what happened, Resident #1 said she fell. Resident #1 was left in the same position as when she fell, her vitals were taken, her pain level was assessed, and emergency medical services were called. Resident #1 was transferred by emergency medical services to the hospital. CNA A was suspended pending the outcome of the investigation. Resident #1 received 7 stitches to her left forehead and 5 staples to her posterior scalp. Resident #1 returned to the facility the same day and was seen by the facility MD the following day. Resident #1 denied pain and was at her baseline. Resident #1 was monitored post fall. The facility conducted a life satisfaction survey regarding CNA A and survey revealed no negative statements from residents. The facility re-educated staff on facility abuse and neglect and activities of daily living transfer policies, audited mechanical lift slings, conducted activities of daily living transfer competencies, and terminated CNA A for not adhering to facility activities of daily living transfer procedures. Record review of in-service for mechanical lift sling audit beginning 10/08/25 reflected the ADON and DON will alternate inspection of all facility mechanical lift slings to confirm reliability and safety every 3 (three) months ongoing. Record review of mechanical lift sling audit signed by either the ADON or DON beginning 10/8/25 reflected audit will be conducted every 3 months ending indefinitely.Interview on 10/29/25 at 9:47 am with Resident #1 revealed shoot, yea it hurt when she fell out of bed the other day. Interview on 10/29/25 at 11:35 am with the DON reflected when CNA A was transferring Resident #1 from her bed to her wheelchair on 10/07/25, CNA A loaded [Resident #1] up into the mechanical lift without another person in the room. After Resident #1 was in the sling connected to the mechanical lift the straps came loose on both sides of the sling closest to the floor and Resident #1 hit the bed then fell to the floor. The DON said mechanical lifts were a 2-person process and their nurses and CNAs were re-educated that you cannot begin to load a resident onto a mechanical lift without a second person. She said they did a competency demonstration on how to safely operate and what to check when you are transferring a resident by mechanical lift. She said during the competency demonstration, all CNAs and nurses had to demonstrate using a dummy as a substitute resident how to properly check the sling and conduct a safe transfer. The DON said she and the ADON looked at every mechanical lift sling in the building, gathering slings from resident rooms, the laundry, and storage, and inspected them for defects or concerns that they could not bear the weight of any resident. Any slings that were found deficient were disposed of. Interview on 10/29/25 at 11:53 am with CNA B reflected on the day Resident #1 fell from the mechanical lift, CNA A asked for her help and CNA B told CNA A she was with another resident and to give her a minute. CNA B said CNA A began lifting the mechanical lift before CNA B got to the room. When CNA B entered the room Resident #1 was on the floor crying and shaking like Resident #1 was nervous. CNA B said there was blood on Resident #1's forehead. She said the nurse came in and applied pressure to Resident #1's forehead and checked Resident #1's vital signs. CNA B said staff were not supposed to start any part of a mechanical lift transfer by themselves and it took 2 (two) people all the time to transfer a resident by mechanical lift. She said she was re-inserviced the day after the incident on safe mechanical lifting. She said they did competency training using a dummy as a resident to demonstrate proper mechanical lift transfers. CNA B said she felt confident in conducting mechanical lift transfers. CNA B said during her in-service staff were taught to always have two people when you put the resident in a sling and to check the equipment before beginning the mechanical lift transfer. She said they were in-serviced to make sure the sling was in good condition and did not have any tears or fraying. She said if the sling did not look like it was in good condition staff were to throw it away and inform the ADON or DON. Interview on 10/29/25 at 1:43 pm with the Administrator reflected CNA A told CNA B she needed assistance to transfer Resident #1 and CNA B said she would be right there, but CNA A went ahead and put Resident #1 in the mechanical lift sling. The Administrator said CNA A told her Resident #1 was about 1 (one) inch off the bed and CNA A was holding Resident #1 steady over her bed and CNA A heard a pop and Resident #1 fell onto the bed then onto the floor. The Administrator said CNA A told her she knew she needed 2 (two) people for a mechanical lift transfer. She said CNA A was suspended pending investigation and after the investigation CNA A's employment was terminated. She said all the mechanical lift slings were pulled from residents' room and the laundry rooms and all areas of the building and the ADON and DON inspected them for defects. She said any sling that looked like the loops were loose or torn or frayed were disposed of and 72 new slings in different sizes were ordered. Attempted interview via phone of CNA A on 10/30/25 at 8:45 am. Surveyor left CNA A a voice mail and sent a text message to her cell phone. No response from CNA A was received. Interview on 10/30/25 at 2:34 pm with the DON reflected it was her expectation that the staff followed the facility mechanical lift policy and made sure it was a 2 (two) person process because the policy was there for the residents' safety. She said CNA A was not following facility policy when she began the transfer without the other CNA. She said it was the responsibility of the Administrator, ADON and DON to make sure that the staff were following safe procedures when staff were transferring a resident who required a mechanical lift. She said the possible negative effects of not following facility policy for resident transfer using a mechanical lift were resident injury. Interview on 10/30/25 at 4:45 pm with the ADON reflected it was her expectation that when residents were being transferred using a mechanical lift, staff use 2 (two) people for safety measures. She said the sling needed to be inspected before being used to make sure it was in good condition and if it was not in good condition, to take it off the floor and give it to her or the DON. She said it was the responsibility of the DON, ADON, and charges nurses to make sure that staff were operating the mechanical lifts safely and with 2 (two) people. She said the possible negative effect of not having 2 (two) people was a resident could get injured; it could be a bad situation. A possible negative effect if there was something wrong with the sling was that the sling would break and the resident could fall and get hurt.Interview on 10/30/25 at 5:09 pm with the Administrator reflected it was her expectation for the staff to follow the facility mechanical lift policy that always required 2 (two) people when transferring a resident who needed a mechanical lift. Staff should have inspected the sling before using it to make sure it was in operable order with no fraying and no parts that were not connected completely. If staff needed assistance or had questions they should talk to the charge nurse. It was the responsibility of the individual staff members and leadership to make sure residents were transferred safely following facility policy when the mechanical lift was used to transfer residents. Record review of facility policy Safe Lifting and Movement of Residents Policy Statement dated July 2017 reflected in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Policy Interpretation and Implementation1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisionsregarding the safe lifting and moving of residents.2. Manual lifting of residents shall be eliminated when feasible.3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs fortransfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in thecare plan. Such assessment shall include the following:a. Resident's preferences for assistance;b. Resident's mobility (degree of dependency);c. Resident's size;d. Weight-bearing ability;e. Cognitive status;f. Whether the resident is usually cooperative with staff; andg. The resident's goals for rehabilitation, including restoring or maintaining functional abilities.4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateralboards) and mechanical lifting devices.5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents.7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged.9. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings.10. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.11. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints.12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which:a. involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies;b. addresses reports of workplace injuries;c. provides training on safety, ergonomics and proper use of equipment; andd. continually evaluates the effectiveness of workplace safety and injury-prevention strategies.Review of facility policy Lifting Machine, Using a Mechanical July 2017 reflected the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device.It is not a substitute for manufacturer's training or instructions.General Guidelines1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.2. Mechanical lifts may be used for tasks that require:a. Lifting a resident from the floor;b. Transferring a resident from bed to chair;c. Lateral transfers;d. Lifting limbs;e. Toileting or bathing; [NAME]. Repositioning.3. Types of lifts that may be available in the facility are:a. Floor-based full body sling lifts;b. Overhead full body sling lifts; andc. Sit-to-stand lifts.4. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competencyusing the specific machines or devices utilized in the facility.Steps in the Procedure1. Before using a lifting device, assess the resident's current condition, including:a. Physical:(1) Can the resident assist with transfer?(2) Is the resident's weight and medical condition appropriate for the use of a lift?b. Cognitive/Emotional:(1) Can the resident understand and follow instructions?(2) Does the resident express fear or appear anxious about the use of a lift?(3) Is the resident agitated, resistant, or combative?2. Measure the resident for proper sling size and purpose, according to manufacturer's instructions.3. Select a sling bar that is appropriate for the resident's size and the task.4. Prepare the environment:a. Clear an unobstructed path for the lift machine;b. Ensure there is enough room to pivot;c. Position the lift near the receiving surface; andd. Place the lift at the correct height.5. Make sure the battery is charged.6. Test the lift controls. Ensure the emergency release feature works.7. Make sure the lift is stable and locked.8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in goodcondition.9. Double check the sling and machine's weight limits against the resident's weight.10. Place the sling under the resident. Visually check the size to ensure it is not too large or too small.11. Lower the sling bar closer to the resident.12. Attach sling straps to sling bar, according to manufacturer's instructions.a. Make sure the sling is securely attached to the clips and that it is properly balanced.b. Check to make sure the resident's head, neck and back are supported.c. Before resident is lifted, double check the security of the sling attachment.d. Examine all hooks, clips or fasteners.e. Check the stability of the straps.f. Ensure that the sling bar is securely attached and sound.Observation on 10/29/25 at 2:46 pm of transfer by mechanical lift of Resident #2 from her wheelchair to her bed by CNA E and CNA F. Surveyor observed safe transfer and observed mechanical lift sling in good condition.Observation on 10/29/25 from 12:39 pm until 2:45 pm of 10 mechanical lift slings located in resident beds or on resident wheelchair revealed all slings free of defects and appeared brand newRecord review of CNA A's Record of Employee Counseling dated 10/07/25 revealed CNA A's suspension for failure to follow policy related to use of mechanical lift, employee used [mechanical lift] unassisted.Record review of CNA A's Record of Employee Counseling dated 10/20/25 revealed that CNA A's employment was terminated via phone and reflected reason for termination improper use of equipment.Record review of facility Life Satisfaction Survey regarding CNA A for 5 (five) residents reflected CNA A never responded to residents in a negative manner, CNA A never made a resident feel as if their needs were not acknowledged, CNA A never provided activities of daily living care incorrectly, and CNA A never ignored residents' activities of daily living care or stated that she would not do their activities of daily living care.Record review of facility in-service training from the ADON on 10/07/25 revealed CNAs and nurses received in-servicing on facility Abuse and Neglect Policy and Procedures Record review of facility in-service training from the ADON on 10/07/25 revealed CNAs and nurses received in-servicing on staff should always operate mechanical lift with 2 (two) staff members and staff should verify mechanical lift if is fully functional and operating proper. If the mechanical lift is not functioning properly staff are to pull it off the floor, notify management/maintenance director and put a work order in TELS (a service request platform used by facilities for maintenance and operations) from the facility ADON.Record review of facility in-service training from the ADON on 10/07/25 revealed CNAs and nurses received in-servicing on staff are to check gait belts and slings daily every shift for any tears, holes, or thread unraveling. If any defects are noted to equipment staff are to pull it from the floor and notify DON/ADON immediately. Shower (mesh) slings are only to be used for residents when giving showers. They are not to be used for everyday get up to participate in daily activities. Staff to ensure batteries sufficiently charged before each use of mechanical lift/sit to stand before use to ensure they are functioning properly. Record review of facility competency transferring the resident using mechanical lift given to nursing and CNA staff for technique and safety beginning 10/07/25. Competency documentation showed that over 80% of the staff completed the training by 10/08/25. During interviews on 10/29/25 from 2:27 pm - 10/31/25 at 10:25 am, four LVNs, 1 LPN, and 10 CNAs from different shifts all stated they were in-serviced by the ADON and DON on 1. facility Abuse and Neglect Policy and Procedures2. always operate mechanical lift with 2 (two) staff members and staff should verify mechanical lift is fully functional and operating properly. If the mechanical lift is not functioning properly staff are to pull it off the floor, notify management/maintenance director and put a work order in TELS (a service request platform used by facilities for maintenance and operations).3. to check gait belts and slings daily every shift for any tears, holes, or thread unraveling. If any defects are noted to equipment staff are to pull it from the floor and notify DON/ADON immediately. Shower (mesh) slings are only to be used for residents when giving showers. They are not to be used for everyday get up to participate in daily activities. Staff to ensure batteries sufficiently charged before each use of mechanical lift/sit to stand before use to ensure they are functioning properly.

Based on observations, interviews, and record review, the facility failed to ensure that residents receive parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one resident (Resident #3) of 5 residents reviewed for treatments. The facility failed to follow facility protocol of cleaning and changing of the PICC line dressing for Resident #3, since his return from the hospital on [DATE] until he was readmitted to the hospital on [DATE]. This failure could lead to infections and related complications. Findings included:Record review of Resident #3's face sheet dated 10/30/25 revealed a [AGE] year-old male initially admitted on [DATE] and re admitted to the facility on [DATE]. His diagnoses included cellulitis (skin infections), dysphagia (difficulty to swallow) , type 2 diabetes, hemiplegia and hemiparesis (paralysis of one side), pain, muscle weakness, lack of coordination and reduced mobility.Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 8 indicating his cognition was moderately impaired.Record review of Resident #3's care plan dated 04/11/25 reflected Resident #3 was recently in the hospital and had a UTI and Sepsis[KS3] putting him at risk for having a recurrent UTI. The relevant intervention was giving antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. Record review of the facility reported incident dated 07/16/25 revealed, on 07/14/25 Resident #3 was noted with an elevated temperature and was sent to the emergency room for evaluation. Upon examination Resident #3 was observed with an outdated dressing at IV site to right arm.Record review of progress notes in the E HR revealed Resident #3 was admitted to the hospital on [DATE] for UTI and discharged on 6/13/25 with PICC line[KS4] in place, after a course of IV antibiotics. He was readmitted to hospital on [DATE] as he was febrile (had a fever) and returned to facility on 7/21/25. On 07/14/25 at the hospital it was noticed that the date on the PICC line dressing was 06/11/25.Observation of the photograph of the PICC line dressing provided by FM revealed it was taken on 07/14/25. The date printed on the PICC line dressing was 06/11/25 .Record review of the MAR of June 2025 reflected:1. No order for changing the PICC line dressing.2. Imipenem/Cilastatin (Primaxin) 500mg/100ml ns injectable, 500mg/100ml mg/ml (Imipenem, Cilastatin) : Use 33.3 ml intravenously three times a day for IV ABT Therapy for 36 Administrations over 3 hours. -Start Date- 06/14/2025.Record review of the MAR for July 2025 reflected:1. PICC line dressing and cap change weekly using sterile technique per protocol: At bedtime every Sunday. -Start Date-07/27/2025 -D/C Date-08/21/2025.2. DAPTOmycin Intravenous Solution Reconstituted 500 MG(Daptomycin):Use 372 mg intravenously one time a day for Cellulitis/MRSA until 08/15/2025. Infuse 372mg q 24hrs. Original order: Daptomycin 6mg/kg q 24hr. Patient weighs 62kg (136lb). -Start Date- 07/22/2025 During an interview on 10/30/25 at 3:02pm the FM stated on 07/14/25 he had noticed the date on the PICC line dressing on Resident #3, and it was 06/11/25. He stated Resident #3 was in the hospital for IV antibiotic treatment and returned to the facility on [DATE] with the PICC line on him. The FM continued, this means the dressing was not changed at the facility ever since his return from the hospital. He stated he took a photo of the dressing, on 07/14/25 and showed it to DON. The FM stated he was not happy with this neglect from the facility side.During a telephone interview on 10/30/25 at 3:20pm LVN A stated she was the nurse who readmitted Resident #3 from hospital on 6/13/25 and probably had forgotten to get an order for changing PICC line dressing every week. She stated she was aware of the importance of changing the dressing to minimize infection. She stated, at the facility the PICC line dressing changes were scheduled every Sunday in the afternoon shift and were performed by the nurse in charge on that day. She stated she was not sure why she had forgotten to organize the order with the physician on duty on that day. She stated she attended an in service on IV care and monitoring sometime in July 2025 and did not remember the exact day.During a phone interview on 10/30/25 at 3:43pm LVN B stated she was not working in hall 400 where Resident #3 was admitted on [DATE]. She said she worked with Resident #3 afterwards however in the weekdays and had not noticed the date on the PICC line dressing. LVN B said the PICC line dressing changes were scheduled at the facility weekly on Sundays and completed by the respective nurses on that day. LVN B stated changing the PICC line dressing once a week or PRN when it is dirty is crucial to minimize infection. LVN B stated it was the responsibility of the nurse who admitted the resident to the facility to get the dressing order from the NP.During an interview on 10/30/25 at 1:38pm LVN C stated she was the wound nurse at the facility and worked Monday to Friday in the day shift. She stated she did not attend PICC line dressing changes unless there was any infection or skin complications. She stated PICC line dressing changes were the responsibility of the nurse in charge in the hall and generally conducted once a week every Sunday. She stated changing PICC line dressing routinely would minimize the risk of infection at the site.During an interview on 10/30/25 at 2:18pm, LVN D stated she was a PRN nurse at the facility since August 2023 and worked in all the halls from time to time. She stated she worked with Resident #3 in the past. LVN D stated, PICC line site should be assessed every shift for signs of infection and the dressing was to be changed once a week as per facility protocol. She stated she believed the dressing was changed every Sunday and did not look for the date on the dressing on Resident #3. During an interview on 10/30/25 at 12:10pm the MD stated, on 07/14/25 Resident #3 was sent out to the hospital due to high temperature and returned on 07/26/25 after being treated for sepsis. She stated as per the hospital records the cause of sepsis was unknown, however she believed it was most likely from his recurrent UTI as he had a long history of sepsis from UTI. She stated, Resident #3 was admitted to the hospital in the 1st week of June 2025 for IV antibiotic treatment for UTI and returned to the facility on [DATE] with PICC line in place. She stated Resident #3 continued with the IV antibiotic treatment at the facility until 06/28/25. She stated the family complained the PICC line was still on Resident #3 even after the IV antibiotic treatment completed and the dressing on it was not changed after returning from the hospital. The MD stated the PICC line could remain on the body for a month however the dressing should be changed frequently as per the protocol to minimize the chances of infection at the insertion site.During an interview on 10/30/25 at 1:10pm the DON stated Resident #3 went out to the hospital on [DATE] and was diagnosed and treated for sepsis. She stated he came back on 06/13/25 with a PICC line to continue with antibiotic treatment at the facility. She said Resident #3 was sent out to hospital again on resident's family's request on 07/14/25. She said while at the hospital the family had noticed the PICC line dressing was not changed at all at the facility. The DON stated on 07/14/25 the FM sent her the photo of the PICC line dressing while he was at the hospital with the resident. She said the date printed on the PICC line dressing was 06/11/25. The DON stated the dressing was not changed at the facility after Resident #3 was returned from the facility on 06/13/25 until he readmitted to the hospital on [DATE]. The DON stated the expectation was, changing the dressing at least once a week and inspecting the insertion site every day for infection. She stated this was a neglect from the nursing staff and she conducted an in-service with the nurses. She said, as per facility protocol all the PICC line and midline dressings were changed every Sunday by the nurses who worked in the afternoon shift. The DON stated the admitting nurse on 06/13/25 did not initiate to get an order for changing the dressing and later days no other nurses on duty had noticed that there was no order for dressing changes. She stated the nursing staff did not make the same mistake when he returned to the facility on [DATE]. She said she verified that the staff initiated and followed the PICC line dressing changes after his return from the hospital with another PICC line, on 07/21/25.Record review of the in-service file revealed on 07/16/25 the facility conducted an in service on IV care and Monitoring. The staff were educated on the following1. IVs are to be flushed Q shift as well as before and after med administration2. IV site to be cleaned and dressing changed Q Sunday and PRN3. IV site to be monitored Q shift and PRN for patency , infiltration, phlebitis [bleeding] and infection.4. Any and all change in condition to be reported to nurse management immediately and documentation completed . Record review of facility policy Midline Dressing Changes revised in April 2016 reflected: The purpose of this procedure is to prevent catheter related infections associated with contaminated , loosened or soiled catheter site dressings.1. Change midline catheter dressing 24hours after catheter insertion and every 5-7days , or if it is wet, dirty, not intact or compromised in any way .

Based on interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 (Resident #4, Resident #5, Resident #6, and Resident #7) of ten residents.The facility failed to ensure CNA G did not make Resident #4 feel threatened, make Resident #5 feel like a child, hurt Resident #6's feelings, and make Resident #7 feel not like a human.This deficient practice placed residents at risk of mental harm, anxiety and depression.Findings included:Review of Resident #4's face sheet dated 10/30/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side (paralysis (hemiplegia) or weakness (hemiparesis) on the right side of the body due to an unspecified cerebrovascular disease affecting the left side of the brain), Type 2 Diabetes Mellitus, and chronic kidney disease stage 3 (moderate kidney damage where the kidneys are not functioning optimally).Record review of Resident #4's care plan reflected a problem dated 09/20/23 of Resident #4 continued to use profanity as his way of communicating towards others. Resident #4 would at times refuse care. Resident #4 continued to do what he wanted and would joke with staff in an inappropriate manner. Review of Resident #4's Quarterly MDS dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Review of Resident #5's face sheet dated 10/31/25 reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] and 01/17/24 with diagnoses including Parkinson's disease without dyskinesia (neurodegenerative disorder characterized by tremors, rigidity, slowness of movement (bradykinesia), and balance problems), bipolar disorder (a mental health condition characterized by extreme mood swings between periods of high energy (mania or hypomania) and low energy (depression), and anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss).Record review of Resident #5's care plan reflected a problem dated 07/21/23 of psychological well-being due to her history of depression and bipolar with intervention dated 05/09/25 of encourage participation from resident who depends on others to make decisions. Review of Resident #5's Quarterly MDS dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #6's face sheet dated 10/31/25 reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses including Dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, problem-solving, and language), chronic obstructive pulmonary disease with acute exacerbation (a long-term lung condition characterized by airflow obstruction and inflammation) and morbid severe obesity (a severe form of obesity characterized by a body mass index (BMI) of 40 or higher).Record review of Resident #6's care plan reflected a problem dated 07/21/21 of Resident #6 has a history of depression and is at risk for poor mood stability, increased depression, and poor quality of life with an intervention dated 08/20/25 discuss with the resident any concerns or issues regarding health and/or emotional well-being.Review of Resident #6's Quarterly MDS dated [DATE], reflected a BIMS score of 13 indicating no cognitive impairment.Review of Resident #7's face sheet dated 10/31/25 reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with diagnoses including Dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, problem-solving, and language), anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and epilepsy (a chronic neurological disorder characterized by recurrent seizures, which are sudden, uncontrolled electrical discharges in the brain). Record review of Resident #7's care plan reflected a problem dated 06/21/22 of Resident #7has a history of depression, bipolar disorder (a mental health condition characterized by extreme mood swings between periods of high energy (mania or hypomania) and low energy (depression) and psychosis (mental health condition characterized by a loss of touch with reality). Review of Resident #7's Quarterly MDS dated [DATE], reflected a BIMS score of 09 indicating moderate cognitive impairment. Record review of TULIP (an online system used by the Texas Health and Human Services Commission for long-term care licensing, applications, and reporting) facility self-report dated 07/09/25 reflected that on 07/09/25 Resident #4 told a staff member (name of staff member not listed) that about a week prior to this date CNA G told him he would she would, take him outside on the grass and whoop his butt. CNA G was suspended pending the outcome of the investigation. CNA G submitted her resignation prior to the investigation being completed. Facility conducted resident life satisfaction rounds regarding care provided by CNA G and facility revealed that, the results weren't favorable regarding [CNA G's] attitude.Record review of facility resident Life Satisfaction Rounds dated 07/10/25 and 07/11/25 for investigation involving CNA G reflected:Resident #4 said, I Don't want her as my CNAResident #5 said, She is very abrupt. In the morning she states its too early to be asking her questionsResident #6 She has a rude approach. For example: she tells me Im getting in the shower instead of asking meRecord review of email dated 07/09/25 from CNA G to the Administrator reflected CNA G said what Resident #4 said about her was not true and she would never say anything like taking somebody to the grass and CNA G and Resident #4 clowned and joked and laughed when she passed trays. Review of statement dated 07/10/25 by the SSA reflected on 07/08/25 she asked Resident #4 if the staff treated him and he said, That [CNA G] is no good, I don't want her as my CNA. SSA said she asked him what he meant by that, and he stated she made the comment about him getting out of bed and told SSA that CNA G told him, you better get out of bed before I whoop your butt. SSA asked him if he thought CNA G would hurt him and he said he did not know but did not want her as his CNA. SSA asked him if he felt threatened by that comment and he said he was not threatened as in harm for his life but threatened as in that comment rubbed him the wrong way because he did not want to get up and she kept making comments to get out of the bed. Resident #4 said CNA G had never tried to harm him, but he did not want her as his CNA.Record review of an email dated 07/14/25 from CNA G to the Administrator revealed she was resigning from her employment with the facility. Interview on 10/30/25 at 8:17 am with Resident #4 reflected he had a problem with CNA G and CNA G said she wanted to fight him, and a family member came to the facility to tell the facility about it. He did not have a problem with any more staff members. Attempted to contact CNA G on 10/30/25 at 5:32 pm. Left CNA G a telephone voice mail message and a text message and received no response.Interview on 10/30/25 at 5:36 pm with Resident #7 reflected the staff treated him respectfully now that [CNA G] was gone. He said CNA G did not treat him respectfully and did not treat him like a human. Resident #7 said she hurt his feelings. Resident #7 said he could not remember what CNA G said but he remembered how she made him feel. He said CNA G spoke to him in a mean manner and he felt like she was verbally abusive. Interview on 10/30/25 at 5:39 pm with Resident #6 reflected CNA G did not treat her respectfully and said she would get mad when Resident #6 asked about anything and seemed not to like people to ask her things. She said CNA G hurt her feelings and her feelings were easy to hurt because she was bipolar. She said she told a person who was a psychiatrist about how CNA G spoke with her, but that psychiatrist was no longer at the facility. She said CNA G's tone when she talked was boisterous and she would talk roughly. She said CNA G, when she spoke with you, she sounded like she did not want to do whatever you asked her to do. She said the sound of CNA G's voice when she was speaking with her was explosive and made Resident #6 feel bad. Interview on 10/31/25 at 9:42 am with Resident #5 reflected CNA G was really rough and she did not like for you to ask any questions. She said that CNA G kind of hurt her feelings, and CNA G more or less treated her like she was a child. She said CNA G did not physically hurt her, but she was never able to tell her she liked something one way or another way. She said CNA G was abrupt and Resident #5 did not like CNA G's attitude. She said she did not tell anyone about it and just learned to put up with it. Resident #5 said CNA G did not have to be so rough and CNA G was kind of hateful. Resident #5 did not like CNA G's attitude. Interview on 10/31/25 at 9:56 am with SSA reflected that she did the Life Satisfaction Rounds dated 07/10/25 and 07/11/25 for investigation involving CNA G and most residents did not know CNA G, but she had 2 (two) residents, she did not remember their names, who said CNA G was very abrupt with her approach to them. SSA said CNA G was not the most professional and had a strong accent that did not come off as pleasant. One resident stated CNA G just came in and said we are going to give you a shower and the resident said it was the way that CNA G spoke to her that the resident did not like. SSA said she spoke with the Administrator about the comments made in the Life Satisfaction rounds and the Administrator said she was doing an investigation. SSA said the Administrator was a little upset about the comments and was going to get with the DON. SSA said an example of verbal abuse would be to say derogatory statements to a resident. Interview on 10/31/25 at 10:32 am with CNA H reflected she did not work with CNA G. CNA H said residents have the right to say no to any kind of care, they have a right to feel safe, they have the right to be treated as adults, and they have a right to ask questions. She said if she worked with someone who she felt was unkind or hurt residents' feelings she would report this to the Administrator. She said residents have the right to feel safe. She said she was trained in resident rights when she was hired, and resident rights were highly important because the facility was their home. She said she felt residents should be treated like she would like someone to treat her loved one. She said it was the responsibility of everyone to protect resident rights and if there is a problem they take it to their Administrator.Interview on 10/31/25 at 10:36 am with CNA I reflected she worked with CNA G and did not hear CNA G speak unkindly to residents. She said she was trained in resident rights when she was hired at the facility. She said some examples of resident rights were the right to refuse care, the right to privacy, the right to speak about their concerns and choose what they ate. She said residents have the right to ask questions and not to be treated as children. She said if a resident's rights were violated, she would take a report and go straight to the nurse or the ADON. Interview on 10/31/25 at 10:56 am with LVN E reflected he had not heard that any staff member had been unkind to any residents, and he did not know CNA G. He said he was trained in resident rights when he was hired at the facility. He said when you speak with residents, you should speak to them respectfully and it would violate resident rights if a resident felt their feelings here hurt. He said it was not right for residents not to be able to ask questions about their care. He said residents have a right to feel like they are humans, and it was the responsibility of all staff to make sure that resident rights were protected. He said he would report to the Administrator if a resident's rights were not respected. He said a negative effect of not respecting resident rights might be that residents were affected emotionally. He said residents have the same rights as any other person.Interview on 10/31/25 at 11:02 am with LVN F reflected he worked with CNA G, and he felt like she was respectful to residents and no residents complained about the way she treated them. He said he was trained in resident rights when he was hired at the facility, and it was the responsibility of everyone to protect resident rights. He said examples of resident rights were the right to privacy, to be treated fairly and respectfully and to make decisions of their own choices. If a staff member did not allow a resident to ask questions that would be inconsiderate and disrespectful and was a violation of resident rights and borderline abusive. LVN F said if he felt a resident's rights were being disrespected, he would talk to the staff member who was not respecting the resident's rights then speak to the resident then let the ADON or DON know. Allegations of abuse and neglect were reported to the Administrator first and foremost and he would also report resident rights issues to the Administrator.Interview on 10/31/25 at 11:13 am with the DON reflected resident rights involved honoring residents' likes and dislikes and respecting and honoring residents' wishes. The DON said this included making sure Residents' feelings were not hurt and they were respected. She said residents have the right to know they have a say and for their voice to be heard. She said that after the SSA brought the Life Satisfaction results involving CNA G to her attention and the Administrator, they talked with the residents and let them know CNA G would not be back. She said it was the responsibility of everyone to protect the residents' rights, from the nurses to the CNAs to the dietary staff, everyone. Interview on 10/31/25 at 11:11 am with the Administrator reflected after the life satisfaction surveys were reported to her, she would have terminated CNA G's employment, but CNA G already resigned. She said, after hearing what Residents #4, #5, #6, and #7 felt about how CNA G made them feel, it was possible she violated their rights. She said the staff were trained in resident rights when they were hired and it was the responsibility of everyone to make sure residents had their rights protected. It was her expectation that staff reported to her any knowledge of resident rights violation. She said the possible negative effect of resident's having their resident rights violated would be residents could regress and not feel they have rights in their living space. Review of facility Resident Right's Policy dated February 2021 reflected employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: 1. a dignified existence;2. be treated with respect, kindness, and dignity;3. be free from abuse, neglect, misappropriation of property 4. communication with and access to people and services, both inside and outside the facility;exercise his or her rights as a resident

Based on observation, interview and record review, the facility failed to implement their policies and procedures that prohibited neglect to 1 of 15 residents (Resident CR#1) reviewed for neglect. -Resident CR#1 was identified as high risk for aspiration and was not provided the honey thickened liquids recommended by the speech pathologist following a swallowing study. CR #1 was admitted to the hospital with [REDACTED]. This deficient practice affected one former resident and placed 8 current residents who require thickened liquids of not receiving appropriate consistency of liquids, aspiration, pneumonia, decline in medical condition and death. Findings include: Complaint # 1 Record review of Resident CR #1's admission Face Sheet revealed he was [AGE] years of age and initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. CR #1 was discharged on [DATE]. Record review of CR#1 ' s care plan dated 6/9/16 read in part; Problem /need: (CR #1) has impaired swallowing as evidenced by resident being unable to tolerate regular consistency foods or liquids; Goal: the resident will receive the appropriate fluid/food consistence during the facility stay as evidenced by no episodes of aspiration occurring through the next 90 days; Approaches: -Initiate speech therapy as ordered to address appropriate diet/fluid consistence need; -Observe resident during meals for changes or complications with tolerance to current diet/fluid consistency orders; -Review X-Rays as ordered to evaluate possible aspiration occurrences. Record review of Resident CR#1 ' s annual MDS dated [DATE] revealed he required limited assistance of one staff for the following activities of daily living: bed mobility, transfer, dressing, eating and toilet use and he required extensive assistance from one staff for personal hygiene. The resident did not have any functional limitations in his range of motion and he was always incontinent of bowel and bladder. The resident's BIMS was not able to be scored. His cognitive skills for daily decision making was three which indicated his cognition was severely impaired. Record review of CR#1 ' s consolidated physician orders dated July 2016 revealed the resident ' s diet was regular pureed diet and nectar thick liquid consistency. Record review of CR#1 ' s electronic Physician Evaluation and Management Report dated 7/1/16 from an outside imaging center for a modified [MEDICATION NAME] swallow study (MBSS) (a clinical swallowing examination in that the patient is presented with various food items and observed during swallowing to evaluate the risk of aspiration) revealed the indications for the evaluation requested-life limiting or threatening dysphagia disorder with feeding difficulties and risk of aspiration were positive. Continued review revealed the resident was required to go to the physician's office and imaging center because of an emergent request resulting from an elevated aspiration risk. The report ' s examination of CR#1 revealed he was chronically ill with evidence of chronic distress as indicated by: wheelchair bound, drooling thin unable to hold head erect or with difficulty. The resident ' s respiratory evaluation revealed no coordination of breathing and swallowing when chewing. The conclusion revealed CR#1 was at high risk for aspiration pneumonia and choking episodes. Recommendation was honey thickened liquids. Record review of CR#1 ' s electronic MBSS after visit summary dated 7/1/16 revealed the reason for the visit was problems with eating and drinking. The diet recommendations/care options revealed honey thick liquids based on the performance during this evaluation. Continued review of the summary revealed the MBSS results delivered to the nursing staff and referring physician by addition to the chart. Record review of CR#1 ' s electronic nurses notes dated 7/25/16 revealed resident was observed drooling from the mouth and nose. Physician notified, laboratory blood work, X-Ray and electrocardiogram (EKG) ordered. Record review of CR#1 ' s electronic nurses notes dated 7/25/16 revealed chest X-Ray results given to physician which indicated possible early inflammation or pneumonia lateral right upper lung. Orders received for antibiotic. Resident ' s temperature was 99.1 degrees Tylenol given. Resident ate 25% of dinner. Record review of CR#1 ' s nurse ' s notes revealed a physician notification of resident changes form from the nurse (SBAR) dated 7/26/16 revealed the resident ' s temperature was 101.6 degrees, his heart rate was 107 beats/minute. The resident was drooling more than usual, he was lethargic and not eating well since yesterday. Record review of CR#1 ' s physician telephone orders dated 7/26/16 revealed an order to send the resident to the hospital. Record review of the electronic records from a local hospital for CR#1 revealed he was admitted on [DATE] with the [DIAGNOSES REDACTED]. Continued review of the hospital record revealed the resident was discharged from the hospital on [DATE] and was transferred to hospice care. Record review of CR#1 ' s clinical record did not reveal a physician ' s order for honey thick liquids or a communication form for a diet change. In an interview on 9/22/16 at 10:25 am with the facility ' s speech language pathologist (SLP), she stated when a MBSS was done at the imaging center there was a nurse, SLP and physician present during the examination. After the test the SLP writes the report with the findings and the recommendations. The testing center will notify the nursing staff the report was ready, they leave it with the nurse for review, and the nurse notifies the physician and writes the order change from the physician. When there is a diet change the communication form is completed one page was put in the clinical record and the copy given to dietary. The SLP stated CR#1 had been seen by her in 2015 but he was not able to continue because he could not participate in the program. After the SLP reviewed the electronic MBSS Report /Nursing summary she stated CR#1 aspirated the nectar and honey thick liquids but honey thick was the best choice because he did not cough with it and he did cough with the nectar thick liquids. The SLP stated a cough was an indication of aspiration. In an interview on 9/22/16 at 10:56 am, the DON stated when a MBSS was done at the imaging center they mail the findings and recommendations to the facility and they are sent to the DON. Once we received the recommendation the physician would be notified and the order and communication form for any diet change will be written in the clinical record. The DON stated she had not received any MBSS results for CR #1. She stated she did not know what happened to the results between the test on 7/1/16 and present. Record review of the facility policy and procedure titled Abuse and Neglect Clinical Protocol dated 2005 and revised April 2007 revealed . Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .Along with other staff and management, the medical director will help identify situations that might constitute or could be construed as neglect . The facility identified 8 current residents on thickened liquids.

Based on observation, interview and record review, the facility failed to provide necessary care and services to 1 of 4 residents (Resident #1) who were unable to carry out activities of daily living reviewed for ADL care, as evidenced by: -The facility staff failed to provide timely incontinent care to Resident #1 and she had an open area on her sacral area that was not identified by the staff. The open area was exposed to bacteria from the stool and urine. This failure affected 1 resident and could place an additional 58 residents who were occasionally or frequently incontinent of bladder and the 40 residents who were occasionally or frequently incontinent of bowel at risk for not receiving care and assistance when needed. Findings included: Intake # 0 and # 8 Record reviewed of Resident # 1's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE], [DIAGNOSES REDACTED]. She was [AGE] years old. Observation on 11/10/2015 at 12:07 p.m. revealed Resident #1 in bed lying on her back on a regular mattress with the head of the bed elevated at 45 degrees and she had a pillow under her right upper arm and both of her knees. Further observation revealed there was a strong odor of stool and urine upon entrance to her room and she had an untouched lunch tray in front of her. Continued observation and interview, when surveyor asked Resident #1 how she was doing, Resident #1 stated I am doing really bad, I have a pressure sore on my tail bone that has been bleeding, I am hurting, my tail bone is hurting and my diaper has been wet all morning. I wear diapers and they haven't changed it since last night, it's been wet. Resident #1 continued saying C.N.A. A is my aide, but she hasn't come at all, I heard she had been busy giving showers to other people but she hasn't come to help me. I have my lunch tray here but I don't want to eat, I want to be changed. Continued observation at that time, Resident #1 pressed her call bell. Observation on 11/10/2015 at 12:17 p.m. during incontinent care of Resident #1 revealed that her brief was heavily saturated with dark brown urine up to her waist front and back and had dry bowel movement covering her buttocks. Further observation and interview at that time, C.N.A. A stated that she had just provided incontinent care to Resident #1 at 9:00 a.m. At that time, Resident #1 replied loudly No, is not true, you did not come to clean me today, it was the night shift staff that cleaned me last, not you. Continued observation during incontinent care revealed that Resident #1 had a circular open area to her sacrum that was covered with dry bowel movement . When asked C.N.A. A if Resident #1 had the open area before, she replied will call the treatment nurse. C.N.A. A continued saying I am not sure if the wound care nurse knows about it but the charge nurse gave me a cream to put on her buttocks, the charge nurse knows about it already. Record review of Resident #1's undated care plan revealed in part: .Resident #1 has incontinent of bowel and bladder episodes. - Goal: Resident #1 will remain clean, dry and odor free and no occurrences of skin breakdown will occur over next 90 days. Record review of Resident #1's Braden scale for prediction of pressure sore risk assessment dated [DATE] revealed a score of scored 15, indicating risk for pressure sores. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 12 out of a possible 15 (indicating little to no cognitive impairment) and required extensive assistance for bed mobility, transfers, toilet use, personal hygiene and bathing. She was occasionally incontinent of bowel and bladder. Resident #1 was not identified with pressure ulcers. Record reviewed of Resident #1's shower assessment form dated 11/9/2015 revealed no concerns with her skin. Further interview at that time, C.N.A. A stated that she provided incontinent care to Resident #1 at 9:00a.m. and that residents are supposed to get incontinent care every 2 hours. In an interview on 11/10/2015 at 12:36 p.m. with Resident #1, she stated that Wound care nurse B has only treated her upper back area rash but not her pressure sore and further said he only comes and put the cream to my upper back but has not looked at my sore area, my tail bone has been hurting for 2 weeks already and I told them already. She continued saying that usually takes long time to get help with incontinent care and that having a wet brief made her tail bone burn in pain. In an interview on 11/10/2015 at 3:20 p.m. with the DON, he stated that incontinent care is supposed to be done every 2 hours and as needed and that Resident #1's open area was a new concern. Record review of the facility's Clinical Protocol for urinary incontinence revised April 2007 revealed no information of monitoring and providing incontinent care to residents. Based on the facility CMS form 672 there were 41 residents occasionally or frequently incontinent of bowel and 59 residents occasionally or frequently incontinent of bladder.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident and hazards on 3 of 3 resident halls (Halls 200, 300, and 400), 1 of 2 shower rooms (Hall 300/400) and for 4 residents (Residents #32, #68, #1, and #2) and 5 confidential residents, who were reviewed for a safe living environment. IMMEDIATE JEOPARDY The facility failed to maintain hot water temperatures within a safe temperature range on 3 of 3 halls in resident's bathrooms and the shower room between hall 300 and 400. Hot water temperatures ranged from 120 to 149 degrees Fahrenheit. Residents #32, #68, #1, #2 and 5 confidential residents expressed concerns about the hot water temperatures being so hot they were fearful of burns. Staff members who were responsible for assuming the Maintenance Directors responsibilities were not trained on how the monitoring of the hot water temperatures in resident care areas. NON-IMMEDIATE JEOPARDY The facility failed to maintain mechanical lift slings that were safe and would not rip causing falls for 2 of 12 residents (#43 and #37) who required mechanical lifts for transfers. Residents #43 and #37 both were dropped suddenly from the mechanical lift when the slings on the lift ripped during transfers. An immediate jeopardy (IJ) was identified on 7/21/14 at 2:40 P.M. The IJ was removed on 7/23/14 at 11:50 A.M. however the facility remained out of compliance at a scope of wide spread and a severity level of No Actual Harm with the Potential for more than Minimal Harm that is not an Immediate Jeopardy. All staff had not been trained on policies and procedures concerning safe hot water temperatures. Hot water temperatures were lowered into a safe range but all parts required to repair the hot water at the facility had not been installed. These failures affected 11 residents and placed 64 residents on 3 of 3 halls at risk of accidents and injuries related to hot water temperatures and transfers with faulty mechanical lift equipment. Findings include: IMMEDIATE JEOPARDY Hall 300: The following observations were made on 7/21/14 on 300 hall during initial tour per the surveyor's thermometers: In room 301 at 8:49 A.M., Resident ' s bathroom hot water temperature was turned on and hot water was noted steaming, temperature was 135 degrees F. (Fahrenheit). In room 302 at 8:51 A.M., Resident ' s bathroom hot water temperature was 130 degrees F. In room 303 at 9:04 A.M., Resident ' s bathroom hot water temperature was 132 degrees F. In room 304 at 9:20 A.M., Resident ' s bathroom hot water temperature was 135 degrees F. In room 306 at 9:31 A.M., Resident ' s bathroom hot water temperature was 132 degrees F. Interview on 7/21/2014 at 9:01 A.M., Resident # 32 said the hot water was just too hot. She said she had to be careful not to burn herself. In room 307 at 9:48 A.M., Resident ' s bathroom hot water temperature was 130 degrees F. In room 311 at 10:03 A.M., Resident ' s bathroom hot water temperature was 135 degrees F. On 7/21/2014 at 12:10 P.M. floor tech #2 and surveyor took the hot water temperatures in the following rooms. Floor Tech thermometer 312 - 120 degrees F. 313 122 degrees F. 314 122 degrees F. 315 132 degrees F. 316 122 degrees F. Surveyor thermometer 312 - 149 degrees F. 313 - 144 degrees F. 314 - 145 degrees F. 315 - 146 degrees F. 316 - 144 degrees F. 300 Shower Room Floor Tech thermometer 128 degrees F. Surveyor thermometer 124 degrees F Hall 400: Observation on 7/21/2014 during initial tour between 8:30 A.M. and 10:30 A.M. of hallway 400 revealed the hot water temperatures in the following rooms: 402 130 degrees F. 406 135 degrees F. 408 135 degrees F. 412 130 degrees F 413 120 degrees F. 414 130 degrees F. 415 120 degrees F. 420 120 degrees F. 422 120 degrees F. In room 401 at 12:25 P.M., on 7/21/2014 Resident ' s bathroom hot water temperature was 132 degrees F.; the resident ' s family member said " the hot water was really hot. " In room 403 at 12:28 P.M., on 7/21/2014 Resident ' s bathroom water temperature was 132 degrees F. On 7/21/2014 at 12:20 P.M. Floor Tech #2 and surveyor took the hot water temperatures in the following rooms. Floor Tech thermometer 402 118 degrees F. 406 118 degrees F. 408 110 degrees F. 412 110 degrees F. 414 112 degrees F Surveyor thermometer 402 130 degrees F. 406 135 degrees F. 408 135 degrees F. 412 130 degrees F. 414 130 degrees F. Interview on 7/21/2014 at 12:20 P.M. Floor Tech #2 stated he had never taken water temperatures before. He said he did not know when the thermometer was last calibrated or how to calibrate a thermometer. He agreed the hot water was steamy and too hot too touch. Interview on 7/21/2014 at 12:45 P.M. Resident #68 from room 414 stated he was blind but able to get around and use the bathroom sink independently. He stated the water in his sink was very hot and it was a concern for him. He stated he had neuropathy (nerve damage/nerve pain) in his hands and he could not feel. He said he was concerned his hands could get burnt from the hot water. He stated he had to be very careful and conscious to be sure not to use only hot water and to turn on more cold water than hot. Hall 200: Observation on 7/21/2014 during initial tour between 8:30 A.M. and 10:30 A.M. of hallway 200 revealed the hot water temperatures in the following rooms: 201 135 degrees F. 202 135 degrees F. 205 129 degrees F. 210 130 degrees F. 214 133 degrees F. Interview on 7/21/2014 at 8:45 A.M. Residents #1 and #2 said the hot water temperature in the bathroom gets too hot. They stated they had not received any burns from using the water nor had they told staff about the water temperatures because they always forgot to mention it to them. They both stated they were just careful when using the hot water. On 7/22/2014 at 3:30 P.M. hot water temperatures in the following rooms were: 204 121 degrees F. 207 121 degrees F. 210 121 degrees F. 214 121 degrees F. 301 121 degrees F. 306 121 degrees F. 316 121 degrees F. On 7/22/2014 at 4:00 P.M. Corporate Maintenance Director and surveyor took the hot water temperatures in the following rooms: Floor Tech thermometer Surveyor thermometer 204 120 degrees F. 120 degrees F. 214 120 degrees F. 120 degrees F. 306 120 degrees F. 120 degrees F. On 7/23/2014 at 9:00 A.M. Floor Tech #1 and surveyor took the hot water temperatures in the following rooms: Floor Tech thermometer Surveyor thermometer 204 101 degrees F. 101 degrees F. 215 101 degrees F. 101 degrees F. 406 101 degrees F. 101 degrees F. In a confidential group meeting on 7/23/2014 at 9:00 A.M. 5 of 5 residents stated the water temperatures in the bathrooms were very hot. Record review of the facility ' s Maintenance Weekly Hot Water Temperature Check Records revealed the previous Maintenance Director documented these readings: 6/23/14 Shower Hall 200 - 115 degrees F. No resident rooms were checked 7/1/14 Shower Room (unknown hall) - 110 degrees F. No resident rooms were checked 7/9/14 Shower Hall 200 115 degrees F. Shower Hall 300 110 degrees F. No resident rooms were checked. Interview on 7/21/14 at 2:45 PM, the DON stated the water temperatures in the front hallway bathroom that residents, staff, and visitors used was really hot. Interview on 7/23/14 at 11:42 AM, the contracted plumber stated the facility was safe, but he had to order 2 valves that would be delivered on 7/24/14. He stated once the parts arrived, he would come back to the facility and install. He stated this was a temporary fix, but the residents were safe. Interview on 7/24/14 at 12:25 PM, the Administrator stated he was not aware there was a problem involving hot water temperatures prior to survey. He stated there had been a high turnover in the maintenance department and this was the 3rd Director this year. He stated the facility had been without a Maintenance Director for a week and the floor techs were responsible for handling the maintenance problems, until a new Maintenance Director was hired. He further stated the water temperatures needed to be maintained between 100 and 110 degrees F. Record review of the facility ' s Water Temperatures policy, dated 12/2007 revealed the water heaters that serviced the resident rooms, bathrooms, common areas, and tub/shower areas should be " set to temperatures of no more than (BLANK) F, or the maximum allowable temperatures per state regulation " . It further read " ... Direct care staff shall be informed of risk factors for scalding/burns that are more common in the elderly, such as; decreased skin thickness, sensitivity, peripheral neuropathy, reduced reaction time, decreased cognition, mobility, and communication " . An immediate jeopardy (IJ) was identified on 7/21/14 at 2:40 P.M. and the Administrator was informed at that time. A Plan of Removal (POR) of the IJ was submitted and accepted on 7/23/2014 at 11:50 A.M. The POR included: On 7/21/2014 water temperatures were changed in the mechanical rooms behind the nurses station, the kitchen and laundry areas. On 7/21/2014 2 P.M. - 10 P.M. staff were inserviced about hot water temperatures and to use caution when showering residents and alert residents if hot water temperatures are to hot. A contract plumber was called to investigate the problem at 5:06 P.M. on 7/21/2013. At 7:30 A.M. on 7/22/2013 the plumber arrived and diagnosed the problem that the water temp at the mixing valve was set to high. The facility has designated the morning floor tech and the evening floor tech to take water temperatures daily. Staff will take temperatures from 4 resident rooms on each hall and the shower rooms. If any temperatures rise above 113 degrees or fall below 97 degrees, the staff have been instructed to call the Administrator and the charge nurse. The charge nurse will then alert the floor staff about the unsafe water temperatures and they will notify the residents. The floor techs would be trained by the Administrator on how to take the water temperatures. The process included: turn on the faucet on to hot water and let it run for 2 minutes, fill a cup full of hot water that is tilted to the side, and while the water is running to stick the thermostat into the cup and to get a reading. Once the needle on the thermostat stops moving the temperature is recorded. The results of these readings will be turned into the Administrator daily and the readings over the weekend will be reviewed on Mondays. If any temperatures rise over 113 degrees or fall below 97 degrees the staff have been instructed to call the Administrator. The facility would in-service all staff on what to do if hot water temperatures were identified beginning 7/22/14 and monitoring would begin on 7/22/14. The kitchen staff has been in-service. The morning cook and the evening cook will monitor the temperatures of both the faucets and the dish machine to be within compliance. The results of these temperatures taken will be reported to the dietary manager and the results of the weekend readings will be reviewed on Monday. The dietary manager will turn the results into the administrator. If any variance is noted they are to report them to the dietary manager who will alert the administrator. The in-services will be started on 7/22/2014 and we will begin recording on 7/22/2014. The survey team confirmed the POR had been implemented sufficiently to remove the IJ by: Record review of the facility ' s In-service form, dated 7/21/14 revealed 71 staff members had been trained, representing, nursing, administration, dietary, housekeeping, therapy, and laundry on all three shifts had been in-serviced on hot water temperatures in the resident rooms and showers. Record review of the contracted plumber ' s report, dated 7/22/14, revealed a service complaint of water too hot. After [DIAGNOSES REDACTED]. The parts would be shipped overnight and once they received the parts, the contracted plumber would install. Record review of the facility ' s provided receipt, dated 7/22/14, revealed 4 thermometers were purchased. Interviews on 7/22/14 and 7/23/14, revealed the majority of nursing staff representing all three shifts revealed staff were competent in identifying when water temperatures were too hot, whom to notify, and what to do with the residents. Monitoring of numerous resident rooms on all three halls and both shower rooms by staff and surveyors on 7/23/14 revealed water temperatures were less than 115 degrees F. A notice was posted in all the shower rooms, notifying staff what to do in case of hot water. A review of the facility log showing random water temps taken over the past twenty-four hours revealed water temps within normal limits. The IJ was lifted on 7/23/14 at 11:50 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 7/23/14 the facility remained out of compliance at a scope of wide spread and a severity level of No Actual Harm that is not Immediate Jeopardy because all staff had not been trained on the policies and procedures concerning unsafe water temperatures. NON IMMEDIATE JEOPARDY Resident #43 Record review of Resident #43 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Record review of Resident #43 ' s Care Plan, dated 5/27/14, revealed the resident was at risk for falls due to a history of recent falls. The care plan did not address Resident #43 ' s actual fall on 7/6/14 and no new interventions were implemented. Record review of Resident #43 ' s Progress Notes, dated 7/6/14, revealed she had an actual fall when the mechanical lift strap had ripped and the resident landed on the floor. It was documented three staff members were transferring Resident #43 with the mechanical lift. The lift ' s sling was torn and the resident landed on the floor. Record review of Incident/ Accidents Log, revealed there was no incident/accident report completed for Resident #43 ' s fall after the Mechanical lift strap had ripped and the resident had fell to the floor on 7/6/2014. Interview on 7/22/14 at 2:45 PM, LVN #4 stated she was not aware that Resident #43 had fallen and there was no incident report. She further stated if the resident had fallen, then an incident report should have been completed, and the family, and physician needed to be notified. Interview on 7/24/14 at 8:30 AM, CNA #9 stated she helped assist Resident #43 using the mechanical lift on 7/6/2014 when she fell . She stated the resident fell from the mechanical lift when the strap broke. She stated the sling that was used was not a new sling, but an older one. She stated the resident fell and began to cry. She stated the resident was scared. The nurse came and assessed the resident and then the 3 CNAs helped to get Resident #43 back into the lift, using a new sling, and was able to put her into the bed. She further stated the broken sling was then thrown away. Interview on 7/24/14 at 8:50 AM, CNA #16 stated she was helping assist Resident #43 to bed using the mechanical lift when the 2 foot straps broke and the resident fell to the floor. She stated the resident was scared and started crying. She stated the other CNA went to get the nurse while the other CNAs stayed with the resident. She stated the resident calmed down and the nurse assessed the resident. She stated Resident #43 did not complain of any pain and had no bruising or swelling. She stated the staff got another mechanical lift sling and were able to get Resident #43 off the floor and into the bed. She stated the staff threw the broken sling away. She further stated the straps that broke were from an older sling. She stated the older slings were different in color and were faded and frayed. Resident #37 Record review of Resident #37 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Record review of Resident #37 ' s Incident/Accident, dated 6/4/14, revealed when the CNAs were using the mechanical lift to put the resident in the bed, the sling strap broke. The resident was assessed to have no injuries and the resident ' s family and physician were both notified. Record review of the facility ' s Invoice, dated 5/28/14, revealed 6 large full body, 450 lb, large, sling mesh were delivered. Observation on 7/22/14 at 11:57 PM, revealed inside the laundry room/closet were 2 different mechanical lift slings. One sling was frayed and the material was coming apart from the sling. The strap colors were green, yellow, and red. Another sling was located inside the laundry room and it appeared to be newer and had a purple strap. Interview on 7/22/14 at 11:57 PM CNA #31 stated the sling with the purple strap was a newer strap. She stated the other strap was frayed and coming apart, and did not appear to be as strong. Further observation revealed CNA #31 took the frayed sling and placed it on top of the cabinet. She did not throw the frayed sling away. Interview on 7/23/14 at 9:10 AM, the Corporate Nurse stated the facility had completed an incident report late on 7/22/14 for Resident #43. She stated the facility was going to be completing in-services concerning mechanical lift transfers. Record review of the facility ' s Accidents and Incidents Policy, dated 12/2007, revealed all accidents or incidents involving residents ...occurring on the premises shall be investigated and reported to the Administrator. The facility provided a list of 12 residents that required mechanical lift for transfers. The facility's CMS form 672 revealed a census of 75 residents with no residents being bedfast all or most of the time. The same form listed 52 residents with Dementia: multi-infarct, senile, and Alzheimer's.

Based on observation, interview, and record review, the facility's Administration failed to manage the facility by not appointing a staff member to maintain hot water temperatures when there was no Maintenance Director, and by not monitoring the water temperatures for 9 residents (Residents #32, #68, #1, and #2), and 5 confidential residents, on 3 of 3 resident Halls (Hall 200, 300, and 400), who were reviewed for a safe living environment. The Administrator did not appoint a staff member, when there was no Maintenance Director employeed at the faciltiy, to maintain the water temperatures in a safe temperature range. Hot water temperatures in resident care areas ranged between 120 to 149 degrees F. The Administrator did not monitor water temperatures for 3 of 3 resident halls. An immediate jeopardy (IJ) was identified on 7/21/14 at 2:40 P.M. The IJ was removed on 7/23/14 at 11:50 A.M. however the facility remained out of compliance at a scope of wide spread and a severity level of No Actual Harm with the Potential for more than Minimal Harm that is not an Immediate Jeopardy because all staff had not been trained on policies and procedures concerning safe hot water temperatures and even though hot water temperatures were within a safe range all parts required to repair the hot water at the facility had not been installed. This failure affected 9 residents and placed 66 other residents on 3 of 3 halls at risk of accidents and injuries related to hot water temperatures. Findings include: Record review of the facility ' s Maintenance Weekly Hot Water Temperature Check Records revealed the previous Maintenance Director had recorded: 6/23/14 Shower Hall 200 - 115 degrees F. No resident rooms were checked 7/1/14 Shower Room (unknown hall) - 110 degrees F. No resident rooms were checked 7/9/14 Shower Hall 200 - 115 degrees F. Shower Hall 300 - 110 degrees F. No resident rooms were checked. Hall 200: Observation on 7/21/2014 during initial tour between 8:30 A.M. and 10:30 A.M. of hallway 200 revealed the hot water temperatures in the following rooms: 201 135 degrees F. 202 135 degrees F. 205 129 degrees F. 210 130 degrees F. 214 133 degrees F. Interview on 7/21/2014 at 8:45 A.M. Residents #1 and #2 said the hot water temperature in the bathroom gets too hot. They stated they had not received [MEDICAL CONDITION] using the water nor had they told staff about the water temperatures because they always forgot to mention it to them. They both stated they were just careful when using the hot water. On 7/22/2014 at 3:30 P.M. hot water temperatures in the following rooms were: 204 121 degrees F. 207 121 degrees F. 210 121 degrees F. 214 121 degrees F. Hall 300: The following observations were made on 7/21/14 on 300 hall during initial tour: In room [ROOM NUMBER] at 8:49 A.M., Resident ' s bathroom hot water temperature was turned on and hot water was noted steaming, temperature was 135 degrees F. (Fahrenheit). In room [ROOM NUMBER] at 8:51 A.M., Resident ' s bathroom hot water temperature was 130 degrees F. In room [ROOM NUMBER] at 9:04 A.M., Resident ' s bathroom hot water temperature was 132 degrees F. In room [ROOM NUMBER] at 9:20 A.M., Resident ' s bathroom hot water temperature was 135 degrees F. In room [ROOM NUMBER] at 9:31 A.M., Resident ' s bathroom hot water temperature was 132 degrees F. Interview on 7/21/2014 at 9:01 A.M., Resident # 32 said the hot water was just too hot. She said she had to be careful not to burn herself. In room [ROOM NUMBER] at 9:48 A.M., Resident ' s bathroom hot water temperature was 130 degrees F. In room [ROOM NUMBER] at 10:03 A.M., Resident ' s bathroom hot water temperature was 135 degrees F. On 7/21/2014 at 12:10 P.M. floor tech #2 and surveyor took the hot water temperatures in the following rooms. Floor Tech thermometer 312 - 120 degrees F. 313 - 122 degrees F. 314 - 122 degrees F. 315 - 132 degrees F. 316 - 122 degrees F. Surveyor thermometer 312 - 149 degrees F. 313 - 144 degrees F. 314 - 145 degrees F. 315 - 146 degrees F. 316 - 144 degrees F. 300/400 Shower Room Floor Tech thermometer - 128 degrees F. Surveyor thermometer - 124 degrees F. On 7/22/2014 at 3:30 P.M. hot water temperatures in the following rooms were: Room 301 121 degrees F. room [ROOM NUMBER] 121 degrees F. room [ROOM NUMBER] 121 degrees F. Hall 400: Observation on 7/21/2014 during initial tour between 8:30 A.M. and 10:30 A.M. of hallway 400 revealed the hot water temperatures in the following rooms: 402 130 degrees F. 406 135 degrees F. 408 135 degrees F. 412 130 degrees F 413 120 degrees F. 414 130 degrees F. 415 120 degrees F. 420 120 degrees F. 422 120 degrees F. In room [ROOM NUMBER] at 12:25 P.M., on 7/21/2014 Resident ' s bathroom hot water temperature was 132 degrees F.; the resident ' s family member said " the hot water was really hot. " In room [ROOM NUMBER] at 12:28 P.M., on 7/21/2014 Resident ' s bathroom water temperature was 132 degrees F. On 7/21/2014 at 12:20 P.M. Floor Tech #2 and surveyor took the hot water temperatures in the following rooms. Floor Tech thermometer 402 118 degrees F. 406 118 degrees F. 408 110 degrees F. 412 110 degrees F. 414 112 degrees F Surveyor thermometer 402 - 130 degrees F. 406 - 135 degrees F. 408 - 135 degrees F. 412 - 130 degrees F. 414 - 130 degrees F. Interview on 7/21/2014 at 12:20 P.M. Floor Tech #2 stated he had never taken water temperatures before. He said he did not know when the thermometer was last calibrated or how to calibrate a thermometer. He agreed the hot water was steamy and too hot too touch. Interview on 7/21/2014 at 12:45 P.M. Resident #68 from room [ROOM NUMBER] stated he was blind but able to get around and use the bathroom sink independently. He stated the water in his sink was very hot and it was a concern for him. He stated he had [MEDICAL CONDITION] (nerve damage/nerve pain) in his hands and he could not feel. He said he was concerned his hands could get burnt from the hot water. He stated he had to be very careful and conscious to be sure not to use only hot water and to turn on more cold water than hot. On 7/22/2014 at 4:00 P.M. Corporate Maintenance Director and surveyor took the hot water temperatures in the following rooms: Floor Tech thermometer 204 120 degrees F. 214 120 degrees F. 306 120 degrees F. Surveyor thermometer 204 - 120 degrees F. 214 - 120 degrees F. 306 - 120 degrees F. On 7/23/2014 at 9:00 A.M. Floor Tech #1 and surveyor took the hot water temperatures in the following rooms: Floor Tech thermometer 204 101 degrees F. 215 101 degrees F. 406 101 degrees F. Surveyor thermometer 204 - 101 degrees F. 215 - 101 degrees F. 406 - 101 degrees F. Confidential Group: In a confidential group meeting on 7/23/2014 at 9:00 A.M. 5 of 5 residents stated the water temperatures in the bathrooms were very hot. Interview on 7/21/14 at 2:45 PM, the DON stated the water temperatures in the front hall bathroom that residents, staff, and visitors used was really hot. Interview on 7/23/14 at 11:42 AM, the contracted plumber stated the facility was safe, but he had to order 2 valves that would be delivered on 7/24/14. He stated once the parts arrived, he would come back to the facility and install them. He stated what he had done was a temporary fix, but the residents were safe. Interview on 7/24/14 at 12:25 PM, the Administrator stated he was not aware there was a problem involving hot water temperatures prior to survey. He stated the Maintenance Department and the Director had very high turnover. He stated the facility had three different Maintenance Directors so far this year (2014). He stated he had not hired another Maintenance Director, and had been without one for over a week. He further stated the floor techs were responsible for handling the maintenance problems, until a new Maintenance Director was hired. He further stated the water temperatures needed to be maintained between 100 and 110 degrees F. Record review of the facility ' s Water Temperatures, dated 12/2007 revealed the water heaters that serviced the resident rooms, bathrooms, common areas, and tub/shower areas should be " set to temperatures of no more than (BLANK) F, or the maximum allowable temperatures per state regulation " . It further read " ... Direct care staff shall be informed of risk factors for scalding/burns that are more common in the elderly, such as; decreased skin thickness, sensitivity, [MEDICAL CONDITION], reduced reaction time, decreased cognition, mobility, and communication " . An immediate jeopardy (IJ) was identified on 7/21/14 at 2:40 P.M. and the Administrator was informed at that time. A Plan of Removal (POR) of the IJ was submitted and accepted on 7/22/2014 at 12:48 P.M. The POR included: On 7/21/2014 water temperatures were changed in the mechanical rooms behind the nurses station, the kitchen and laundry areas. On 7/21/2014 2 P.M. - 10 P.M. staff were inserviced about hot water temperatures and to use caution when showering residents and alert residents if hot water temperatures are to hot. A contract plumber was called to investigate the problem at 5:06 P.M. on 7/21/2013. At 7:30 A.M. on 7/22/2013 the plumber arrived and diagnosed the problem that the water temp at the mixing valve was set to high. The facility has designated the morning floor tech and the evening floor tech to take water temperatures daily. Staff will take temperatures from 4 resident rooms on each hall and the shower rooms. If any temperatures rise above 113 degrees or fall below 97 degrees, the staff have been instructed to call the Administrator and the charge nurse. The charge nurse will then alert the floor staff about the unsafe water temperatures and they will notify the residents. The floor techs would be trained by the Administrator on how to take the water temperatures. The process included: turn on the faucet on to hot water and let it run for 2 minutes, fill a cup full of hot water that is tilted to the side, and while the water is running to stick the thermostat into the cup and to get a reading. Once the needle on the thermostat stops moving the temperature is recorded. The results of these readings will be turned into the Administrator daily and the readings over the weekend will be reviewed on Mondays. If any temperatures rise over 113 degrees or fall below 97 degrees the staff have been instructed to call the Administrator. The facility would in-service all staff on what to do if hot water temperatures were identified beginning 7/22/14 and monitoring would begin on 7/22/14. The kitchen staff has been in-serviced. The morning cook and the evening cook will monitor the temperatures of both the faucets and the dish machine to be within compliance. The results of these temperatures taken will be reported to the dietary manager and the results of the weekend readings will be reviewed on Monday. The dietary manager will turn the results into the administrator. If any variance is noted they are to report them to the dietary manager who will alert the administrator. The in-services will be started on 7/22/2014 and we will begin recording on 7/22/2014. The survey team confirmed the POR had been implemented sufficiently to remove the IJ by: Record review of the facility ' s In-service form, dated 7/21/14 revealed 71 staff members had been trained, representing, nursing, administration, dietary, housekeeping, therapy, and laundry on all three shifts had been in-serviced on hot water temperatures in the resident rooms and showers. Record review of the contracted plumber ' s report, dated 7/22/14, revealed a service complaint of water too hot. After [DIAGNOSES REDACTED]. The parts would be shipped overnight and once they received the parts, the contracted plumber would install. Record review of the facility ' s provided receipt, dated 7/22/14, revealed 4 thermometers were purchased. Interviews on 7/22/14 and 7/23/14, revealed the majority of nursing staff representing all three shifts revealed staff were competent in identifying when water temperatures were too hot, whom to notify, and what to do with the residents. Monitoring of numerous resident rooms on all three halls and both shower rooms by staff and surveyors on 7/23/14 revealed water temperatures were less than 115 degrees F. A notice was posted in all the shower rooms, notifying staff what to do in case of hot water. A review of the facility log showing random water temps taken over the past twenty-four hours revealed water temps within normal limits. The IJ was lifted on 7/23/14 at 11:50 A.M. and the Administrator was notified after verification of the plan implementation had occurred. However while the IJ was removed on 7/23/14 the facility remained out of compliance at a scope of wide spread and a severity level of No Actual Harm that is not Immediate Jeopardy because all staff had not been trained on the policies and procedures concerning unsafe water temperatures. The facility provided a list of 12 residents that required mechanical lift for transfers. The facility's CMS form 672 revealed a census of 75 residents with no residents being bedfast all or most of the time. The same form listed 52 residents with Dementia: multi-infarct, senile, and Alzheimer's.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment to attain or maintain the highest practicable physical and mental well-being for 3 of 13 residents (Resident #32, #34 and #5) reviewed for pain management. Resident # 32 who was constipated for a week, with nausea and vomiting was not promptly assisted to get alternate medical help when all plans and care provided were ineffective. The resident was discharged to the hospital on [DATE]. Resident # 34 ' s pain was not effectively managed. Resident # 34 constantly complained of pain. Resident # 5 ' s pain was not effectively managed. These failures affected 3 residents whose pain/condition were not maintained, with one requiring hospitalization and placed 16 residents on pain management at risk of unmanaged pain which could lead to a decline in both physical abilities and psychosocial well-being. Findings included: Resident # 32 Record review of Resident # 32 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident # 32 ' s MDS dated [DATE] revealed he was moderately impaired for cognition. The resident required extensive assistance with most ADLs, was frequently incontinent of bladder and always continent of bowel. Record review of Resident #32 ' s care plan dated 7/1/14 revealed Resident #32 was noted to experience incontinence of bowel and bladder. Record review of Resident #32 ' s care plan, not dated, revealed Resident #32 had a history of [REDACTED]. The goal with a target date of 7/15/14 was resident will have bowel movement at least every three days and will have no signs and symptoms of impaction or bowel obstruction over the next 90 days. Approaches included -encourage oral fluid intake within dietary limits, encourage to be out of bed daily and exercise as tolerated, give medication per order. Record review of Resident #32 ' s X-ray results dated 7/18/14 revealed constipation. Record review of Resident #32 ' s nurse ' s notes dated 7/18/14 at 10:00 A.M., revealed the resident had complained of not feeling well and was nauseated. Further review of the same notes at 10:24 A.M., revealed Resident #32 vomited all her medications. X-ray was ordered on [DATE], MD contacted at 11:17 P.M., new order was received for magnesium [MEDICATION NAME], one dose now and [MEDICATION NAME] 17 gram twice daily. Record review of Resident # 32 ' s Nurse Notes dated 7/19/14 at 10:00 A.M., revealed no bowel movement. No evidence the resident ' s physician was notified of no bowel movement on 7/19/14. Record review of Resident # 32 ' s Nurse Notes dated 7/20/14 at 9:55 A.M., revealed Resident # 32 complained of no bowel movement for 5 days. The resident was crying and asking for help. The physician was contacted and he ordered to give magnesium [MEDICATION NAME] stat and if patient does not have bowel movement within 2 hours, give her enema, then repeat magnesium [MEDICATION NAME] and enema as above as needed. Further review of notes at 10:25 A.M., revealed enema was given, rechecked after 15 minutes, she had a small amount of bowel movement solid, ball shaped feces-resident showing signs of happiness of being able to have some bowel out. Record review of Resident #32's nurse's notes dated 7/20/2014 at 12:30 P.M. revealed the resident was able to have a lot of bowel movement after taking enema after 2 hours. Observation and interview on 7/21/14 at 9:31 A.M., revealed Resident # 32 in bed holding her stomach. The resident stated she had been throwing up and had not had a bowel movement since Tuesday of last week. Resident #32 said she had been taking medication to help her move her bowels but it had not worked well and she still felt constipated. She stated she now started vomiting and had been afraid to eat. Resident # 32 said she did not want to continue to eat since she could not have a bowel movement and was very afraid of throwing up her feces. Resident stated she was very miserable and did not like the way she felt. Resident # 32 said the facility was being very helpful but all the medication she had been given seemed not to be effective. Resident # 32 said she had an X-ray which showed she had constipation. She said her stomach was hurting. Observation and interview on 7/21/14 at 2:50 P.M., revealed Resident # 32 sitting on the toilet. She said she had some bowel movement but still felt very constipated. She said she was still throwing up and unable to eat. Resident #32 said her feces was very strong smelling and coming out very little in ball like shapes. Observation and interviews on 7/22/14 at 8:50 A.M., revealed Resident # 32 in her room with a family member at her bedside. Resident #32 appeared frustrated and verbalized she was still miserable. She said she felt horrible and wanted to get well. The family member reported the resident needed to go to the hospital since she still felt bad after all the facility had done. Resident #32 ' s physician walked into the room and examined the resident, he reported the resident felt better yesterday and had a lot of bowel movement. The physician said he would change her nausea medication. Resident #32 verbalized she was not feeling well to the physician and the physician told her he was going to send her to the hospital. Interview on 7/22/14 at 9:00 A.M., the DON said the resident ' s physician had been involved with the resident's care. She said the facility did an X-ray and had given the medications as ordered by the physician. The DON said she was not aware the resident was throwing up. She said the resident was to be sent out according to the Physician this morning. The DON said she thought about sending the resident to the hospital since she still felt constipated; with complaints of pain to the stomach, nausea and vomiting. Record review of Resident # 32 ' s nurse ' s notes dated 7/22/14 at 9:21 A.M., resident in bed complaining of nausea and vomiting, MD notified. At 10:13 A.M., the resident left the facility for hospital. Record review of Resident #32 ' s physician order [REDACTED]. Resident # 34 Record review of Resident #34 ' s Face Sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 34 ' s admission MDS dated [DATE] revealed a BIMs cognition score of " 00 " and no staff assessment for mental status was conducted. Record review of Resident # 34 ' s care plan dated 5/3/14 revealed the resident was at risk of chronic pain. It was documented the resident complained of back pain at times. Goal was the pain would be in an acceptable level for the resident over the next quarter. Approaches included: assess for pain on each contact, routine pain treatment, as needed pain treatment and use medications and non-pharmacological interventions. Record review of resident #34 ' s June 2014 pain management flow sheet revealed: 6/10/14 pain rating was 8 of 10 ( with 10 being the most severe) , resident behavior was restless, and she was medicated with [MEDICATION NAME] 5/325 mg-effective. 6/12/14, pain rating was 8 of 10, resident behavior was restless, and she was medicated with [MEDICATION NAME] 5/325 mg-effective. 6/20/14, pain rating was 6 of 10 as verbalized by the resident; she was medicated with [MEDICATION NAME] 5/325 mg-effective. 6/26/14, pain rating was 7 of 10; she was medicated with [MEDICATION NAME] 50 mg-effective. Record review of Resident # 34 ' s June 2014 MAR indicated [REDACTED]. Medication was given 6 times in the month of June. Record review of Resident# 34 ' s June 2014 MAR indicated [REDACTED]. Record review of Resident # 34 ' s record revealed no pain assessment for both June and July 2014. Resident # 34' s pain was only assessed prior to pain medication administration. Record review of Resident # 34 ' s pain assessment flow sheet dated July 2014 revealed [MEDICATION NAME] 50 mg was given 5 times on: 7/1/14 pain level was 6 of 10. 7/3/14 pain level was 7 of 10. 7/6/14 pain level of 6 of 10. 7/12/14 pain level of 7 of 10. 7/17/14 pain level of 7 of 10. [MEDICATION NAME] -[MEDICATION NAME] 5/325 mg was given on: 7/8/14 -pain level of 7 of 10. 7/9/14- pain level of 6 of 10. 7/13/14- pain level of 6 of 10. Further review of the Resident #34' s July 2014 MAR indicated [REDACTED]. No [MEDICATION NAME]- [MEDICATION NAME] was documented as administered for the month. [MEDICATION NAME] 50 mg, give one tablet by, mouth every 6 hours as needed for pain was given 4 times -7/1, 7/2, 7/6, and 7/17/14. The resident received [MEDICATION NAME] 650 mg by mouth every 4 hours daily. Record review of Resident # 34 ' s record did not reveal any evidence that the resident ' s physician was contacted for review of pain medication or that resident's pain was assessed and treated effectively. Observation and interview of Resident # 34 on 7/21/14 at 9:50 A.M., during initial tour revealed the resident sitting in her wheelchair, alert and requested to go back to bed. The resident stated she was hurting, when asked what was hurting she said her hemorrhoids. LVN # 19 said the resident always complained of pain most times to her back. Interview on 7/22/14 at 3:00 P.M., Resident # 34 complained of pain, she said her pain was all over. Resident requested to be repositioned to her left side because she was sitting on her right side and she was in pain. Observation on 7/23/14 at 1:00 P.M., revealed the Resident was noted by the dining area during lunch. She was alert and somewhat disoriented. She was assisting herself with her meal. The resident was able to make some needs known and complained of pain. Interview on 7/24/14 at 4:40 P.M., the DON said the resident received routine pain medication and as well as some as needed medications. She said the resident still complained of pain very often and agreed a review would be necessary to see what would be effective. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Record review of Resident #5' s physician's order [REDACTED]. Record review of Resident #5' s Medication Administration Record [REDACTED]. The PRN [MEDICATION NAME] HCI 50 mg was given 7/17/2014 and the PRN Tylenol 500 mg/15 ml was not given in the month of July 2014. Record review of Resident #5's Pain Management form revealed documentation of the nurse's assessment of the resident's pain and the administration of pain medications for July 2014. The forms last entry was dated 7/13/2014. Observation and Interview of Resident #5 on 7/21/2014 at 9:00 A.M. revealed the resident in bed laying down. Resident #5 stated she was waiting for her incontinent care to be performed. She stated she was in pain because she had a stage IV pressure ulcer in her perineal area and if she was not changed in time, it started to affect her pressure ulcer. She stated she sat in pain for long periods of times while waiting for incontinent care. She also revealed that she was in pain several times a day due to her pressure ulcer but endured the pain because she felt it was part of the healing process. She stated she was given pain medications but not before she received incontinent care. She stated she gets pain medication regularly but the medicine did not help her pain. She stated she had told her nurse but nothing had been done or changed to help her pain. Interview on 7/23/2014 at 10:00 A.M. the DON said Resident #5 had PRN pain medications that were given to her during the month of July. She stated she was not aware the resident was in a great deal of pain. She stated the resident ' s Pain management form reflected the nurse assessing the resident ' s pain but the documentation stopped on 7/13/2014. Interview on 7/23/2014 at 10:30 A.M. LVN #18 said the pain management form ran out of space to put more information in regards to the resident receiving PRN pain medication. She stated if it was not documented on the form, it would be documented in the resident ' s nurse ' s notes. Record Review of Resident ' s nurse ' s notes dated 7/13/2014-7/23/2014 revealed the resident received [MEDICATION NAME]-APAP 10/325 on 7/19/2014. There was no documentation of the resident receiving any other pain medications between the dates of 7/13/2014 and 7/23/2014 in the nurse ' s notes or assessments of pain. A policy was requested concerning pain management but was not provided for review prior to exit. Facility CMS Form 672 dated 7/24/14 listed 75 residents, with 19 residents on pain management.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibited misappropriation of property for 1 of 8 residents (CR#1) reviewed for exploitation. CR#1 ' s money from his bank account ($2880.00) was taken by the BOM (Business Office Manager), without his consent, and was applied to the resident ' s facility bill. CR#1 ' s cash ($450.00), that was given to the front office for safe keeping, was taken by the BOM, without the resident ' s consent, and was applied to his facility bill. This affected 1 discharged resident and caused the resident stress, anxiety and loss of appetite, and placed 74 residents at risk for misappropriations of personal funds, over-drafted accounts, fees, and financial distress. Findings include: Intake # 5 and # 3 CR#1 Record review of CR#1 ' s face sheet revealed he was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE]. He was [AGE] years old and was diagnosed with [REDACTED]. Record review of CR#1 ' s financial record, revealed the facility ' s Admission Agreement was signed by the resident ' s family member on 2/21/14, but was not signed by a facility representative. Further review of his financial record revealed a form titled Inquiry Record, no date that identified CR #1 as needing " long term " care. It further revealed CR#1 needed Medicare/Medicaid services. Record review of CR#1 ' s personal bank statements (that was attached to his Medicaid Application), dated 3/19/14, revealed the resident had $1,920.94 in his checking account and $1074.54 in his savings account. Further review revealed the resident received $682.00 monthly from social security and he had monthly bills that were automatically drafted from his accounts. Record review of CR#1 ' s most recent Transaction History, revealed on 3/27/14 a payment of $2880.00 was applied to CR#1 ' s bill. On 4/22/14, a payment of $450.00 was applied to his bill. Further review revealed the resident had a credit balance currently with the total due to the resident being $3,330.00. Record review of the facility ' s charge receipt (two different receipts), revealed on 3/27/14 at 10:44 AM, CR#1 was debited $1820.00 from his checking account. At 10:46 AM, CR#1 was debited $1060.00 from his savings account. The total charges were $2880.00. Both receipts were not signed by CR#1, his family member, or any facility representative. Record review of CR#1 ' s financial statement, dated 6/1/14, revealed the facility owed the resident $3,330.00. He did not have a balance due to the facility and the facility owed him a refund. Interview on 6/4/14 at 8:34 AM, CR#1 ' s family member stated she was the resident ' s responsible party and the resident was diagnosed with [REDACTED].#1 had $450.00 cash on him at the time of his admission. She stated the facility staff did not contact her about the cash. She stated when she came to visit CR#1, he had asked her about his $450.00 cash and she had contacted the BOM concerning CR#1 ' s $450.00 cash. She stated the BOM informed her the cash had been applied to CR#1 ' s bill. She stated the facility took his money and she wanted to get his money back. She stated the facility did not ask her or CR#1 ' s permission to apply the $450.00 towards CR#1 ' s bill. She further stated the resident had approximately $2,900 in his bank accounts and the BOM took all his money and applied it to his bill. She further stated the resident was declining medically and physically and CR#1 was admitted to the hospital on [DATE] due to him not eating. She stated CR#1 had stopped eating and the hospital was going to insert a feeding tube. She stated she was concerned and worried about CR#1 ' s health. She stated it was not right for the facility to empty his bank account and to keep the cash that belonged to CR#1. Interview on 6/4/14 at 12:20 PM, the BOM stated the facility was not a Medicaid pending facility, but accepted Medicare and Medicaid as a payer source. She stated the residents ' who were admitted under Medicare were covered at 100% for days 1-20. If the resident did not have a secondary insurance, then the resident would be responsible for paying a co-pay of $152.00 per day. She stated CR#1 was admitted to the facility under Medicare and did not have a secondary insurance. She stated CR#1 was responsible for paying $152.00 per day for the co-payment. She further stated CR#1 applied for Medicaid on 3/27/14. On 3/27/14, she withdrew $2,880.00 from his bank accounts and applied it to his bill. She stated CR#1 had too much money in his accounts and would not qualify for Medicaid, so she applied $2880.00 from his accounts towards his outstanding bill. She stated she received a verbal consent from CR#1 to withdraw from his checking and savings account. She further stated on an unknown date, RN#1 had brought her cash that belonged to CR#1. She stated she kept the cash in the safe for a few days and then deposited it into the facility ' s account. She stated she did not contact the family or CR#1 to get permission to apply the $450.00 towards CR#1 ' s bill. Observation on 6/5/14 at 11:25 AM, revealed CR#1 in the hospital, lying in bed. The resident had missing teeth, and he was very thin. He was alert and interviewable. Interview on 6/5/14 at 11:25 AM, CR#1 stated the facility " stole his money " and " cleaned out his bank account " . He stated he had $450.00 cash and nearly $3,000.00 in his bank account. He stated he never gave permission for anyone to take his money and he wanted the money back. He stated he needed that money for bills, personal items, spending money, and food. He stated he had a house and was still responsible for paying some bills. He stated that was all the money he had, it was his savings, and the facility " stole his money " . He stated the cash came from his home and he brought the money with him when he was admitted to the facility. He stated a staff member had encouraged him to give the $450.00 cash to the front office for safe keeping. He stated he gave the cash to an unidentified nurse and she assured him the money would be safe. He further stated he was not eating well anymore because he was stressed over not having any money. He stated he did not usually eat 3 meals a day, but would snack throughout the day. He said he enjoyed eating hamburgers, chocolate milkshakes, snack foods, and would often get items out of the vending machines. Record review of the facility ' s New Admission Paperwork in-service, dated 6/5/14, revealed all new admission ' s paperwork had to be completed prior to admission and the forms needed to be signed by a facility representative and the responsible party. Interview on 6/6/14 at 11:30 AM, RN#1 stated she had found an envelope in the medication ' s secured lock box, with CR#1 ' s name on it. She found the envelope had cash inside. She took the cash to the BOM. She stated she was unsure how much money was in the envelope. She stated on an unknown date, CR#1 ' s family member asked her about $450.00 cash that CR#1 had on him. RN#1 stated she escorted the family member to the business office and did not follow-up with the family or business office. She further stated CR#1 would snack throughout the day. She stated CR#1 always had money on him and would get snacks out of the snack machine. Interview on 6/9/14 at 11:39 AM, LVN#2 stated on 5/9/14 at 2:00 PM, CR#1 ' s personal items were all packed up when she came to work. She stated the resident was very upset about his cash being gone. She stated the resident was alert and interviewable. She stated he had asked about his $450.00 cash and he wanted it before he left the facility. She stated she went to the BOM and asked about his $450.00 cash and was told the cash was applied towards his bill. She stated she told the resident what the BOM said, and he became even more upset. She further stated CR#1 would snack on food throughout the day. She stated he had snacks in his room and would get snacks out of the vending machine. Record review of the facility ' s Abuse Prevention Program policy, dated 8/2006, revealed the residents have the right to be free from abuse, neglect, misappropriation of resident ' s property. It further revealed comprehensive policies and procedures have been developed to aid the facility in preventing abuse. Investigative protocols had been developed concerning resident abuse, theft/misappropriations of resident property. Record review of the facility ' s Abuse and Neglect policy, dated 10/2009, revealed misappropriation of resident ' s property was defined as the deliberate use of a resident ' s money without the resident ' s consent. Record review of the facility ' s Resident Rights policy, no date, revealed the residents have the right to expect all facility personnel to carefully handle and safeguard their personal property and to manage their financial affairs. The facility ' s roster listed a census of 74 residents.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibited misappropriation of property for 1 of 8 residents (CR#1) reviewed for exploitation. CR#1 ' s money from his bank account ($2880.00) was taken by the BOM (Business Office Manager), without his consent, and was applied to the resident ' s facility bill. CR#1 ' s cash ($450.00), that was given to the front office for safe keeping, was taken by the BOM, without the resident ' s consent, and was applied to his facility bill. This affected 1 discharged resident and caused the resident stress, anxiety and loss of appetite, and placed 74 residents at risk for misappropriations of personal funds, over-drafted accounts, fees, and financial distress. Findings include: Intake # 5 and # 3 Record review of the facility ' s Abuse Prevention Program policy, dated 8/2006, revealed the residents have the right to be free from abuse, neglect, misappropriation of resident ' s property. It further revealed comprehensive policies and procedures have been developed to aid the facility in preventing abuse. Investigative protocols had been developed concerning resident abuse, theft/misappropriations of resident property. Record review of the facility ' s Abuse and Neglect policy, dated 10/2009, revealed misappropriation of resident ' s property was defined as the deliberate use of a resident's money without the resident ' s consent. Record review of the facility ' s Resident Rights policy, no date, revealed the residents have the right to expect all facility personnel to carefully handle and safeguard their personal property and to manage their financial affairs. CR#1 Record review of CR#1 ' s face sheet revealed he was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE]. He was [AGE] years old and was diagnosed with [REDACTED]. Record review of CR#1 ' s financial record, revealed the facility ' s Admission Agreement was signed by the resident ' s family member on 2/21/14, but was not signed by a facility representative. Further review of his financial record revealed a form titled Inquiry Record, no date that identified CR #1 as needing " long term " care. It further revealed CR#1 needed Medicare/Medicaid services. Record review of CR#1 ' s personal bank statements (that was attached to his Medicaid Application), dated 3/19/14, revealed the resident had $1,920.94 in his checking account and $1074.54 in his savings account. Further review revealed the resident received $682.00 monthly from social security and he had monthly bills that were automatically drafted from his accounts. Record review of CR#1 ' s Transaction History, revealed on 3/27/14 a payment of $2880.00 was applied to CR#1 ' s bill. On 4/22/14, a payment of $450.00 was applied to his bill. Further review revealed the resident now had a credit balance with the total due to the resident being $3,330.00. Record review of the facility ' s charge receipt (two different receipts), revealed on 3/27/14 at 10:44 AM, CR#1 was debited $1820.00 from his checking account. At 10:46 AM, CR#1 was debited $1060.00 from his savings account. The total charges were $2880.00. Both receipts were not signed by CR#1, his family member, or any facility representative. Record review of CR#1 ' s financial statement, dated 6/1/14, revealed the facility owed the resident $3,330.00. He did not have a balance due to the facility and the facility owed him a refund. Interview on 6/4/14 at 8:34 AM, CR#1 ' s family member stated she was the resident ' s responsible party and the resident was diagnosed with [REDACTED].#1 had $450.00 cash on him at the time of his admission. She stated the facility staff did not contact her about the cash. She stated when she came to visit CR#1, he had asked her about his $450.00 cash and she had contacted the BOM concerning CR#1 ' s $450.00 cash. She stated the BOM informed her the money had been applied to CR#1 ' s bill. She stated the facility took his money and she wanted to get his money back. She stated the facility did not ask her or CR#1 ' s permission to apply the $450.00 towards CR#1 ' s bill. She further stated the resident had approximately $2,900 in his bank accounts and the BOM took all his money and applied it to his facility bill. She further stated the resident was declining medically and physically and CR#1 was admitted to the hospital on [DATE] due to him not eating. She stated CR#1 had stopped eating and the hospital was going to insert a feeding tube. She stated she was concerned and worried about CR#1 ' s health. She stated it was not right for the facility to empty his bank account and to keep the cash that belonged to CR#1. Interview on 6/4/14 at 12:20 PM, the BOM stated the facility was not a Medicaid pending facility, but accepted Medicare and Medicaid as a payer source. She stated the residents ' who were admitted under Medicare were covered at 100% for days 1-20. If the resident did not have a secondary insurance, then the resident would be responsible for paying a co-pay of $152.00 per day. She stated CR#1 was admitted to the facility under Medicare and did not have a secondary insurance. She stated CR#1 was responsible for paying $152.00 per day for the co-payment. She further stated CR#1 applied for Medicaid on 3/27/14. On 3/27/14, she withdrew $2,880.00 from his bank accounts and applied it to his bill. She stated CR#1 had too much money in his accounts and would not qualify for Medicaid, so she applied $2880.00 from his accounts towards his outstanding bill. She stated she received a verbal consent from CR#1 to withdraw from his checking and savings account. She further stated on an unknown date, RN#1 had brought her cash that belonged to CR#1. She stated she kept the cash in the safe for a few days and then deposited it into the facility ' s account. She stated she did not contact the family or CR#1 to get permission to apply the $450.00 towards CR#1 ' s bill. Observation on 6/5/14 at 11:25 AM, revealed CR#1 in the hospital, lying in bed. The resident had missing teeth, and he was very thin. He was alert and interviewable. Interview on 6/5/14 at 11:25 AM, CR#1 stated the facility " stole his money " and " cleaned out his bank account " . He stated he had $450.00 cash and nearly $3,000.00 in his bank account. He stated he never gave permission for anyone to take his money and he wanted the money back. He stated he needed that money for bills, personal items, spending money, and food. He stated he had a house and was still responsible for paying some bills. He stated that was all the money he had, it was his savings, and the facility " stole his money " . He stated the cash came from his home and he brought the money with him when he was admitted to the facility. He stated a staff member had encouraged him to give the $450.00 cash to the front office for safe keeping. He stated he gave the money to an unidentified nurse and she assured him the money would be safe. He further stated he was not eating well anymore because he was stressed over not having any money. He stated he did not usually eat 3 meals a day, but would snack throughout the day. He said he enjoyed eating hamburgers, chocolate milkshakes, snack foods, and would often get items out of the vending machines. Record review of the facility ' s New Admission Paperwork in-service, dated 6/5/14, revealed all new admission ' s paperwork had to be completed prior to admission and the forms needed to be signed by a facility representative and the responsible party. Interview on 6/6/14 at 11:30 AM, RN#1 stated she had found an envelope in the medication ' s secured lock box, with CR#1 ' s name on it. She found the envelope had cash inside. She took the cash to the BOM. She stated she was unsure how much money was in the envelope. She stated on an unknown date, CR#1 ' s family member asked her about $450.00 cash that CR#1 had on him. RN#1 stated she escorted the family member to the business office and did not follow-up with the family or business office. She further stated CR#1 would snack throughout the day. She stated CR#1 always had money on him and would get snacks out of the snack machine. Interview on 6/9/14 at 11:39 AM, LVN#2 stated on 5/9/14 at 2:00 PM, CR#1 ' s personal items were all packed up when she came to work. She stated the resident was very upset about his cash money. She stated the resident was alert and interviewable. She stated he had asked about his $450.00 cash and he wanted it before he left the facility. She stated she went to the BOM and asked about his $450.00 cash and was told that money was applied towards his bill. She stated she told the resident what the BOM said, and he became even more upset. She further stated CR#1 would snack on food throughout the day. She stated he had snacks in his room and would get snacks out of the vending machine. Interview on 6/9/14 at 11:55 AM, the Administrator stated he was not aware that the BOM applied CR#1's cash money of $450.00 or the money from CR#1's personal account of $2880.00 towards his bill. He stated the BOM was responsible for collecting money from residents and was responsible for keeping money in the trust fund for residents. The facility ' s roster listed a census of 74 residents.

Based on observation, record review and interviews the facility failed to provide the necessary care and services for 2 of 13 residents ( #1 and CR#1 ) reviewed for care and services provided to residents with diabetes to attain or maintain their highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to prevent complications for residents with diabetes.. The facility failed to ensure the licensed nursing staff were knowledgeable in the assessing of changes in condition to residents with diabetes. The facility staff did not accurately assess ? Resident CR#1's change in condition when she became lethargic and required hospitalization . The facility staff assessed Resident #1's blood sugar as 110 and at the hospital her blood sugar was 33. ? Resident #1 when he experienced a change of condition and required hospitalization . The facility staff assessed Resident #1's blood sugar as 76 and the ambulance technicians assessed the resident's blood sugar as 43 when he was assessed for transport. The staff did not report to the physician when the resident's blood sugar registered over 300 on two separate days after his return from the hospital or when it dropped to 39 on one day. An IJ was identified on 5-31-2012 at 12:02 P.M. While the IJ was removed on 6-4-2012 at 12:09 P.M., the facility remained out of compliance at a scope of patterned and a severity level of actual harm that is not immediate jeopardy because all staff had not been trained on the usage and calibration of glucose monitoring machines and the signs and symptoms of hypo or [MEDICAL CONDITION]. This failure of not accurately assessing diabetic residents blood sugars affected 2 residents and placed 44 residents at risk of having abnormal blood sugars go undetected, untreated and unreported to the physician which could cause serious health decline, coma or death. Findings include: CR#1 Record review of Resident CR#1 ' s admission information revealed she was [AGE] years old and admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. Record review of Resident CR#1's admission MDS dated [DATE] revealed the following: ? BIM score of 3 (which meant the resident had severe impairment) ? The resident was totally dependent on staff for all areas of care and required a feeding tube to maintain an adequate nutritional status ? The resident was an insulin dependent diabetic. Record review of Resident CR#1's care plans revealed no documented care plan to address diabetes, [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. Record review of Resident CR#1's physician's orders dated 3/1/12 revealed the following: Accucheck BID (twice a day) with Regular Insulin on a Sliding Scale ? 150-200= 0 ? 201-250= 2 units ? 251-300= 4 units ? 301-350= 6 units ? 351-400= 8 units ? >400 call MD Record review of the facility Weights and Vitals Summary revealed Resident CR#1's blood sugar result on 4/14/12 at 8:42 P.M. was 110. Record review of the resident's nursing progress notes dated 4/14/2012 revealed at 8:43 P.M. Resident CR#1's vital signs were as follows: Blood pressure 90/58, heart rate 94, respirations 12, and axillary temperature 91.9 The Physician was notified and an order was received to transfer the resident to the local hospital by ambulance. The resident was discharged on [DATE] to the hospital due to lethargy and a blood sugar of 33. Record review of the resident's discharge summary dated 4/14/12 revealed the following documentation: " Brief history ...Patient found in bed by nursing with lethargy " . Record review of the Encounter Summary from the local hospital revealed Resident CR#1 arrived at the emergency room at 10:09 P.M. on 4/14/12. Record review of the first lab test form completed at the local hospital dated 4/14/2012 at 11:16 P.M. revealed the following: Glucose 33 (normal ranges documented on lab form were 65-99) Record review of the hospital Physician note dated 4/14/2012 at 11:59 P.M. revealed: " ...glucose 30s, will give D50"( D50 given for [DIAGNOSES REDACTED]). Record review of the hospital Discharge Summary dated 4/20/2012 revealed: " ...she was brought in to the emergency room after she was found unresponsive at around 11 P.M. The patient had been lethargic all day, less responsive and was not eating. Blood sugar was low at 33 and she was given D50 with significant improvement ... " The summary listed as a principal discharge [DIAGNOSES REDACTED]. The blood sugar affects the function of neurons, and alters brain function and behavior.) . Resident #1 Record review of Resident # 1's admission information revealed he was [AGE] years old and admitted to the facility on [DATE]. His medical [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS dated [DATE] revealed the following: ? BIM score of 2 (which meant the resident was severely impaired) ? The resident required extensive assistance in all areas of care ? The resident was an insulin dependent diabetic. Record review of Resident #1's care plan on Diabetes Mellitus revealed the following interventions: Monitor/document/report to MD as needed (prn) signs/symptoms (s/sx) of [DIAGNOSES REDACTED] ... Date initiated:1/10/2012. Record review of Resident #1's Physician's orders for April and May 2012 revealed the following order: " Blood sugar before meals and bedtime. [MEDICATION NAME]per sliding scale ...blood sugar >(greater than) 300=10 units of [MEDICATION NAME]and call MD. " Record review of the resident's nursing progress notes revealed the last entry before the resident was transferred to the local hospital was dated 4/12/2012 at 21:47 (9:47 P.M.) with the following notation: "the resident had an order to change the FSBS (fasting blood sugar) to twice a day". Record review of Resident # 1's MAR for April 2012 revealed the following physician's order for the resident's routine dose of insulin: ? Blood sugar before breakfast daily ? [MEDICATION NAME] N Insulin subcutaneous 15 units every morning ? Give meal within 15 minutes of administering insulin Record review of the same MAR for Resident #1 revealed the following documentation: ? Blood glucose documented on 4/13/12 at 6:30 A.M. was 118. Interview on 6/1/2012 at 2:55 P.M. LVN # 2 stated she could not remember why Resident #1 went to the hospital. LVN # 2 searched the nurse's notes in the computer for documentation on 4/13/12 related to the resident going to the hospital and there was no documentation related to the incident. LVN #2 was the resident's assigned nurse on 4/13/2012. Record review of Resident #1's nurse's notes from the local medical center dated 4/13/2012 revealed the following presenting information: " ...at 0941 (9:41 A.M.) call to EMS from Fallbrook Nursing Home due to patient was not acting appropriately at 0630 (6:30 A.M.) when she went in to check on patient. States that he did not eat his breakfast and his blood sugar was 76. Per EMS upon their arrival patient's blood sugar was 43. EMS gave oral glucose and now blood sugar 94 ... " Review of Resident #1's MAR for April and May revealed the following blood sugar results: On 4/24/12 at 11:30 A.M. blood sugar 312 On 5/3/12 at 4:30 P.M. blood sugar 360 Record review of the resident's nursing progress notes for 4/24/12 and 5/3/12 revealed no documentation the physician was notified of the blood sugar results Record review of Resident #1's care plan on Diabetes Mellitus revealed the following interventions: Monitor/document/report to MD prn for s/sx of [MEDICAL CONDITION] ... Date initiated 4/25/2012. [MEDICATION NAME] (Insulin [MEDICATION NAME]) 100 unit/ml blood sugar per sliding scale ...> 300=10 units and call MD Date initiated 4/25/2012. Record review of Resident #1's nursing progress notes dated 5/19/12 at 21:20 (9:20 P.M.) revealed the following documentation: " ...Accucheck done. Blood sugar 39". Continued review revealed no documentation of notification to the physician of the resident's low blood sugar results.. Interview on 5/30/12 at 10:05 A.M. RN #1 stated if the resident's blood sugar was low she would administer [MEDICATION NAME] or call the physician to get an order to administer medication. She also stated if she was unable to contact the physician and she knew the blood sugar was low she would give the [MEDICATION NAME] anyway and keep trying to reach the physician and call 911 if there was no improvement noted in the resident Interview on 5/30/12 at 11:15 A.M. LVN #2 stated if she was caring for a resident with a low blood sugar and the resident was unresponsive she would call the medical director and give [MEDICATION NAME] if the resident could swallow. LVN # 2 stated she would call 911 if the physician ordered it or if there was no improvement in the resident's condition. Interview on 5/30/12 at 11:30 A.M. LVN #2 stated it was important to know how to perform a quality control check on the glucose monitoring machine to determine accuracy of the monitor if the blood glucose results were questionable. Observation at the same time as the above interview revealed LVN # 2 gathered the glucose monitoring machine used to check blood sugars on the 200 hall residents, test strips and control solution to perform a random QC (quality control) check on the glucose monitoring machine. She also obtained the QC log control book to record the results. LVN #2 discovered the control solution was not dated as to when it was opened. She discarded the solution since it was not dated and was unable to locate another bottle of control solution in the facility to perform a QC check. LVN # 2 stated she had performed several blood sugar tests earlier in the day. Observation on 5/30/12 at 11:45 A.M. revealed RN # 1 was unable to perform a quality control test on the glucose monitoring machine used to check blood sugars on the 100 hall residents due to the unavailability of control solution. Interview on 5/30/12 at 12:00 P.M., by phone, a representative at the customer care center for the manufacturer of the glucose monitoring machine stated the control solution was good for 90 days once opened. Interview on 5/30/12 at 12:10 P.M. the DON stated the control solution used to calibrate the glucose monitoring machines was good until the expiration date on the bottle. She also stated during the interview she had reviewed the literature and was aware of the correct range for the control solution. The DON stated the staff received instruction through a formal process during new hire orientation on the use of the glucose monitoring machine as well as a 3-day orientation on the floor with return demonstration on glucometer usage. She also stated the night nurses knew how to perform the quality control on the glucose monitoring machine since it was done on the 10 PM to 6 AM shift and she had no expectations of staff on the other 2 shifts being knowledgeable on performing the quality control check. Interview on 5/30/12 at 12:39 P.M., the DON made available the glucose monitor's manufacture ' s leaflet/information for review. The information was written in Spanish. She was unable to explain how non-Spanish speaking staff used the instructions written in Spanish. It was not clear where the information came from but when asked, she said it was in the nurses ' medication records. She stated at this time she had sent a facility staff to go to a local company and purchase two new glucose monitoring machines . Interview on 5/30/2012 at approximately 3:00 P.M. the ADON stated she was in-servicing the licensed staff on the new glucose monitoring machines. Observation at this same time revealed the new glucose monitoring machines were a different brand then the previously used machines at the facility Observation on 5/31/12 at 5:28 A.M., LVN # 6 was working on the 300 and 400 halls for the night shift. LVN # 6 was unable to calibrate the glucose monitoring machine when asked. Interview on 5/31/12 at 5:35 A.M., LVN # 6 said she tried to calibrate the machine earlier during her shift but was not familiar with the machine and so could not calibrate it. She said she got out of range readings in low control mode but she did not know what to do or how to fix the problem. She said she was to report this to the on-coming nurse for follow up. She said the evening nurse told her how to do the calibration of the new machine but she did not understand it and the nurse had to go home. She said she had not used that kind of machine and needed to be shown how to use it. When asked if she checked resident's blood sugars during the night shift, she said yes. She also said some residents were given insulin because their blood sugar levels registered high on the glucose machine. Observation on 5/31/12 at 5:30 A.M. revealed LVN #7 performed a quality control check on the glucose monitoring machine by applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The low range expected as printed on the bottle of test strips was 37 to 67. The low result obtained by LVN #7 was 72. She then checked the glucose monitoring machine by removing and replacing the batteries " as she was instructed " . LVN #7 repeated the quality control test for the low control by again applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The low result reading was 71 which was still out of range. LVN #7 did not attempt another QC check. Interview at the same time LVN #7 stated she would not perform another QC (Quality control) check since the machine was not working and she would notify the DON and not use the machine until the problem could be corrected. LVN #1 did not recognize a possible cause for the erroneous reading. She stated she had been in-serviced on the glucose monitoring machine at the beginning of her shift on 5/30/12. Observation on 5/31/12 at 5:50 A.M. revealed LVN #6 performed a quality control check on the glucose monitoring machine by applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The low range expected as printed on the bottle of test strips was 46 to 76. The low result obtained by LVN #6 was 71. Interview at the same time LVN #6 stated the low control was out of range and the meter should not be used. She stated she had been in-serviced on 5/30/12 at the beginning of the 10:00 P.M.-6:00 A.M. shift on the use of the new glucose monitoring machine. Observation on 5/31/12 at 6:30 A.M. revealed RN #1 performed a quality control check on the glucose monitoring machine by applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The results were as follows: 72 for the low control and 254 for the high control. The expected control ranges on the bottle of test strips was as follows: Low range 46-76 and High range 189-255. RN #1 performed blood glucose tests on 3 residents after performing the quality control tests. Interview at the same time as the above observation revealed RN #1 did not recognize the glucose monitoring machine was not in control mode and the control solution should not be applied directly to the tip of the strip in the machine. She stated she had received an in-service on the use of the glucose monitoring machine on 5/30/12. Observation on 5/31/12 at 7:15 A.M. on the day shift revealed LVN # 3 performed a calibration of the glucose monitoring machine with the low control number registering outside of the normal control range. Normal range was documented to be 46 to 76. The low number registered 79. LVN # 3 did not perform any additional checks on the glucose monitoring machine but just continued to use the machine to check other resident's blood sugars on the 400 hall. Interview on 5/31/12 at 7:17 A.M., LVN # 3 said she did not know what to do when the glucose monitoring machine had an out of range control number. She stated " that one is just a little off. " She said she did not have to do the calibration because it had already been done by the night shift nurses. She said she could not recall receiving any kind of training on how to calibrate the glucose monitoring machine. Interview on 5/31/12 at 11:48 P.M., the DON said she expected a glucose monitoring machine to be in all nursing carts in the facility and also to have control solution accessible to all staff. She said the licensed staff were given orientation before they started work and all nursing staff were given an in-service before the new glucose monitoring machine was given to the staff for use. The DON said the use and calibration of the glucose monitoring machine was part of the new hire orientation. She said according to the glucose control solution manufacturer, the expiration was 10/2012 on the control solution. Interview on 6/1/12 at 2:55 P.M. at the same time as above, LVN # 2 stated she had been at the facility for 2 years and did not recall receiving any training or in-services on diabetes or glucose monitoring machine usage. Interview on 6/1/12 at 3:15 P.M. RN # 1 stated she had been at the facility for a year and 7 months and did not recall receiving any in-service training on diabetes or glucose monitoring machine usage. Interview on 6/1/12 at 3:30 P.M. the DON stated she had instructed staff not to ask for permission to call 911 but if the situation was not life threatening she would prefer staff call her first to determine course of action before calling 911. Record review of the facility policy titled Blood Sugar Monitoring Procedure 220 dated 2006 Documentation Guidelines. Documentation may include " ...If blood glucose level is above or below normal range, document the time the physician was notified. " Plan to remove the immediate jeopardy A. DON and/or designee will in-service License Nurses on the change of condition related to blood sugars. The Licensed Nurses will be in-serviced on the manufacture recommendation of recalibrating for unusual results. The physician and all appropriate parties will be notified of blood glucose out of range. This will begin on May 31, 2012. B. Don and/or designee will in-service Licensed Nurses on the glucose monitoring machine related to high and low calibration and utilization of the meter. The Licensed Nurses will be instructed to availability of additional glucometer's as well as control solutions (if glucose monitoring machine does not calibrate). This will begin on May 31, 2012 and end on June 1, 2012. C. The DON, ADONs, and/or designee will review Diabetic Control Logs; calibration for accuracy of equipment and glucose monitoring machine once each shift. This will be completed until each nurse demonstrates proficiency. This will begin on May 31, 2012 and end June 1 2012. D. All diabetic residents will have a baseline blood sugar completed on May 31, 2012 E. The DON, ADON and/or designee will monitor the availability of Control Solution weekly to ensure adequate supply is in the facility. An additional supply of control solution will be maintained in the facility. This will begin May 31, 2012. F. All Licensed Nurses will be in=-service on hypoglycemic and hyperglycemic as well as what to report to the physician or other parties for appropriate action. This will begin on May 31, 2012. And end June 1, 2012. The DON and ADON will complete Blood Glucose Monitoring Skills Demonstration for all Licensed Nurses. (See attached for details of training) This will begin on May 31, 2012. All Licensed Nurses will receive skill sets prior to working a shift to ensure competency. These in-services will begin May 31, 2012 and end on June 1, 2012. All nurses on duty will be required to attend the in-service prior to the beginning of the shift. Any nurse unable to attend training will not be allowed to work. Monitoring of the plan The Monitoring of the plan began on 6-1-2012. In-service training had begun to all Licensed Nurses to include the use of the new glucometer's purchased by the facility and signs of hypo and hyper glycemia. Various shifts over the weekend and during the weekdays between 6-1-2012 and 6-4-2012 were monitored. Due to the machines being new to the staff competency was not clearly demonstrated to the surveyors until 6-4-201. By this time staff had been observed on the weekends and weekdays. All shifts had been monitored. Numerous staff had been interviewed concerning changes in conditions, reporting to physicians, calibrating glucometer's and back up supplies. While the IJ was removed on 6-4-2012 at 12:09 P.M., the facility remained out of compliance at a scope of patterned and a severity level of actual harm that is not immediate jeopardy because all staff had not been trained on the usage and calibration of glucose monitoring machines and the signs and symptoms of hypo or [MEDICAL CONDITION]. The facility reported there were 46 diabetic residents in the facility with 21 residents requiring daily/or more often blood glucose monitoring.

Based on observation, interview, and record review the facility failed to provide pharmacy services to ensure the accurate calibration, monitoring, and training of staff on 2 of 2 glucose monitoring machines (A machine used in monitoring blood sugars) to ensure 2 of 13 diabetic residents(CR#1 and #1) reviewed for diabetic monitoring, received services to accurately assess their blood sugars. The facility failed to ensure ? Staff were able to accurately obtain a blood sugar when Residents CR #1 and #1 were experiencing a change in condition. Staff recorded CR#1's blood sugar as 110 and the hospital recorded the residents blood sugar as 33 (low) less then two hours later. Staff recorded Resident #1's blood sugar as 118 . The ambulance attendants recorded the resident's blood sugar as 43 (low). ? Staff were able to identify if a glucose machine was calibrated accurately and ready for use. Two of 2 glucose monitoring machine's monthly control logs did not have high/low ranges documented and staff were unable to verbalize what the high/low ranges were to be on the glucose monitoring machines to ensure the quality control checks of the machines were within normal range prior to performing a blood sugar test. ? Staff were able to identify if the glucose monitoring machines control solution used to calibrate the machine was not expired. One of 2 bottles of control solution, which per manufacturers recommendation expired 90 days after opening, was dated 8/18/11 and was still being used by staff in the quality control checks for the glucose monitoring machine on hall 300. and one bottle of control was opened and not dated. This bottle was being used by the staff in the quality control checks for the glucose monitoring machine on hall 200. ? Eight Nurses (LVNs #1, 2, 3, 4, 5, 6, 7 and RN #1) on 3 of 3 shifts were able to check/calibrate glucose monitoring machines before using the machine to monitor a resident's blood sugar. An IJ was identified on 5-31-2012 at 12:02 P.M. While the IJ was removed on 6-4-2012 at 12:09 P.M., the facility remained out of compliance at a scope of patterned and a severity level of actual harm that is not immediate jeopardy because all staff had not been trained on the usage and calibration of glucose monitoring machines and the signs and symptoms of hypo or hyperglycemia. These failures affected 2 residents and placed 45 residents at risk of not having their obtained blood sugars being accurate and their medications dispensed in the appropriate dosages based on the blood sugar tests which could cause health risks, coma and/or death. Findings include: Intake # 3. Record review of Resident CR#1 ' s admission information revealed she was [AGE] years old and admitted to the facility on [DATE]. The resident was discharged on [DATE] to the hospital lethargic with a blood sugar of 33. Her medical [DIAGNOSES REDACTED]. Record review of Resident CR#1 ' s physician's order [REDACTED]. ? 150-200= 0 ? 201-250= 2 units ? 251-300= 4 units ? 301-350= 6 units ? 351-400= 8 units ? >400 call MD Record review of the facility Weights and Vitals Summary revealed Resident CR#1 ' s blood sugar result on 4/14/12 at 8:42 P.M. was 110. Record review of the resident ' s nursing progress notes dated 4/14/2012 revealed at 8:43 P.M. Resident CR#1 ' s vital signs were as follows: blood pressure 90/58, heart rate 94, respirations 12, and axillary temperature 91.9. The Physician was notified and order was received to transfer the resident to the local hospital by ambulance. Record review of the Encounter Summary from the local hospital revealed Resident # CR#1 arrived at the emergency room at 10:09 P.M. on 4/14/12. Record review of the first lab test completed at the local hospital dated 4/14/2012 at 11:16 P.M. revealed the following: Glucose 33 normal ranges were from 65-99. Record review of the hospital Physician note dated 4/14/2012 at 11:59 P.M. revealed " ...glucose 30s, will give D50 ... D50 given for [DIAGNOSES REDACTED]. " Record review of the hospital Discharge Summary dated 4/20/2012 revealed " ...she was brought in to the emergency room after she was found unresponsive at around 11 P.M. The patient had been lethargic all day, less responsive and was not eating. Blood sugar was low at 33 and she was given D50 with significant improvement ... " The summary listed as a principal discharge [DIAGNOSES REDACTED]. Resident #1 Record review of Resident # 1's admission information revealed he was [AGE] years old and admitted to the facility on [DATE]. His medical [DIAGNOSES REDACTED]. Record review of Resident #1's physician's orders [REDACTED].>(greater than) 300=10 units of NovoLog insulin and call MD. " Record review of the resident ' s nursing progress notes revealed the last entry dated 4/12/2012 at 21:47 (9:47 P.M.) the resident had an order to change the resident ' s FSBS (fasting blood sugar) to twice a day. Record review of Resident # 1's MAR for April 2012 revealed blood glucose documented on 4/13/12 at 6:30 A.M. was 118. Record review of Resident #1 ' s nurse ' s notes from the local medical center dated 4/13/2012 revealed the following presenting information: " ...at 0941 (9:41 A.M,) call to EMS from Fallbrook Nursing Home due to patient was not acting appropriately at 0630 (6:30 A.M.) when she went in to check on patient. States that he did not eat his breakfast and his blood sugar was 76. Per EMS upon their arrival patient ' s blood sugar was 43. EMS gave oral glucose and now blood sugar 94 ... " Review of Resident # 1's clinical record revealed the resident returned to the facility on ,[DATE]. Review of Resident #1 ' s MAR for April and May revealed the following blood sugar results: On 4/24/12 at 11:30 A.M. blood sugar 312 On 5/3/12 at 4:30 P.M. blood sugar 360 Record review of nursing progress notes for 4/24/12 and 5/3/12 revealed no documentation the physician was notified of the blood sugar results. Record review of Resident # 1 ' s nursing progress notes dated 5/19/12 at 21:20 revealed the following documentation: " ...Accucheck done. Blood sugar 39. " Continued review revealed no notification to the physician. Observation on 5/30/12 at 10:51 A.M., on the day shift, during calibration of the glucose monitoring machine on 300 hall revealed LVN # 1 did not know how to calibrate the glucose monitoring machines . LVN #1 applied the control solution onto the glucose monitoring machine's testing stripe. When the machine displayed a number, LVN #1 did not know what the numbers meant and what to do with them. LVN #1 did not know where to locate information concerning the calibration of the glucose monitoring machine to determine what the normal control range should be for the glucose monitoring machine. Interview on 5/30/12 at 10:58 A.M., LVN # 1 was asked how she would determine if the glucose monitoring machine was in a good working condition, she stated " I really don ' t know. " She said she did not know the glucose machine calibration range and she also did not know how long glucose control solution was good for once opened. LVN # 1 read the expiration on the package and then said the solution would expire 10/2012. There was no manufacture leaflet/information in package. Observation on 5/30/12 at 11:10 A.M., revealed a package of glucose control solution which had two small plastic bottles containing 4 mls of glucose control solution. One bottle was identified for low control and the other bottle for high control which were hand dated 8/18/11 (when opened by staff),with the manufacturers expiration date stamped 10/2012. Neither the bottles or the package had any identifying information concerning what the normal high/low control ranges were. There was no package leaflet/information inside the package. Observation on 5/30/12 at 11:45 A.M. revealed RN # 1 was unable to perform a quality control test on the glucose monitoring machine due to the unavailability of control solution. Interview on 5/30/12 at 12:00 P.M. by phone with a representative at the customer care center for the manufacturer of the glucose monitoring machine stated the control solution was good for 90 days once opened. Observation on 5/30/12 at 12:05 P.M., revealed there was no glucose monitoring machine and no glucose control solution in 400 hall nurses cart. Interview on 5/30/12 at 12:10 P.M. the DON stated the control solution used to calibrate the glucose monitoring machine's was good until the expiration date on the bottle. She also stated during the interview she had reviewed the literature and was aware of the correct range for the control solution. The DON stated the staff received instruction through a formal process during orientation on the use of the glucose monitoring machine as well as a 3-day orientation on the floor with return demonstration on glucose monitoring machine's usage. She also stated the night nurses knew how to perform the quality control on the glucometer since it was done on the 10 PM to 6 AM shift and she had no expectations of staff on the other 2 shifts being knowledgeable on performing the quality control check. The DON said she expected the nursing staff to read the manufacturer ' s instructions on how to calibrate the glucose monitoring machines. She said she would expect them to check the package to find the control range. She said every manufacturer was different in their instructions. She also said she had called the company representative and was awaiting a return call from them. Record review of the facility ' s glucose monitoring machine's control log revealed no control range parameters listed on the log for halls 100, 200, 300 and 400. There was no information provided by staff to identify the glucose control range for the glucose monitoring machines in use. Surveyor was unable to determine what staff used as parameters for the controls when calibrating the glucose monitoring machines. At this time staff had no information as to where to get the information requested. Record review of ( ) leaflet provided by the DON upon surveyor's request revealed " expected result for use with ( ) Control Solution: Low: 25- 56 mg/dl, 1.4- 3.1 mol/l. Mid: 63-119 mg/dl, 3.5-6.6 mol/l. High: 214-364mg/dl, 11.9-20.2 mol/l. " Record review of facility ' s form tilted blood glucose equipment check dated April 2012 for halls 100, 200, 300 and 400 revealed the form had spaces for the following information: device used, serial #, test strip #, calibration range, low glucose control range, normal glucose control range and Hi glucose control range. Further review revealed there were 4 recorded ranges outside of the parameters recommended by the manufacturer. Documented under " action taken for readings outside of control range " revealed no actions were taken. Record review of facility ' s form tilted blood glucose equipment check dated May 2012 for halls 100, 200, 300 and 400 revealed the form had the same spaces as the April 2012 form. Further review revealed there were 11 recorded ranges outside of the parameters of the manufactured recommended ranges with no documented action taken from the staff as to addressing the machine's ranges being abnormal. Interview on 5/30/12 at 12:39 P.M., the DON made available the glucose monitor's manufacture ' s leaflet/information for review. Information was written in Spanish. She was unable to explain how non-Spanish speaking staff used the instructions written in Spanish. It was not clear where the information came from but when asked, she said it was in the nurses ' medication records. She stated at this time she had sent a facility staff to go to a local company and purchase two new glucose monitoring machines . Interview on 5/30/2012 at approximately 3:00 P.M. the ADON stated she was in-servicing the licensed staff on the new glucose monitoring machines. Observation at this same time revealed the new glucose monitoring machines were a different brand then the previously used machines at the facility Observation and interview on 5/30/12 at 4:23 P.M. on the evening shift, LVN # 4 was observed administrating insulin to a resident on hall 400. LVN #4 stated she had just checked the resident's blood sugar and was about to administer the resident's insulin based on the blood sugar level and the sliding scale orders. She said she calibrated the glucose machine before checking the blood sugar. When asked to calibrate the glucose monitoring machine , LVN # 4 did not know what to do but just stared at the machine. Interview on 5/30/12 at 4:28 P.M., LVN # 4 said she was not familiar with the machine. She stated " we just got this machine today and I honestly do not know how to calibrate it. " She said she was not given any training on how to use the new glucose machine. Observation on 5/30/12 at 4:30 P.M., on the evening shift, LVN # 5 used the new glucose monitoring machine to check the resident's blood sugars on hall 300 for the evening shift. This new machine was a different brand then the former glucose machine. LVN # 5 calibrated the glucose machine and had the Hi control number reading of 262 while the Low control number read 77. The control range for the machine was documented as 189-255 for the Hi and 46-76 for the Low control range. Four residents had their blood sugars checked with this glucose machine which was recording out of normal calibration ranges. Two of these 4 residents were given insulin based on the results of their blood sugar readings with this glucose machine. Interview on 5/30/12 at 5:00 P.M., LVN # 5 said the numbers were slightly out of range. She said she was not to do anything because it was just a slight difference. She explained the reason the numbers were out of range was because she applied too much control solution on the strips and that made the numbers higher than normal. She said the machine was new to staff in the facility but not to her because she had used it in the past. She said she was not provided any kind of training about the new machine. Observation on 5/31/12 at 5:28 A.M.,LVN # 6 was working on the 300 and 400 halls for the night shift. LVN # 6 was unable to calibrate the glucose monitoring machine when asked. Interview on 5/31/12 at 5:35 A.M., LVN # 6 said she tried to calibrate the machine earlier during her shift but was not familiar with the machine and so could not calibrate it. She said she got out of range readings in low control mode but she did not know what to do or how to fix the problem. She said she was to report this to the on-coming nurse for follow up. She said the evening nurse told her how to do the calibration of the new machine but she did not understand it and the nurse had to go home. She said she had not used that kind of machine and needed to be shown how to use it. When asked if she checked resident's blood sugars during the night shift, she said yes. She also said some residents were given insulin because their blood sugar levels registered high on the glucose machine. Observation on 5/31/12 at 5:30 A.M. revealed LVN #7 performed a quality control check on the glucose monitoring machine by applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The low range expected as printed on the bottle of test strips was 37 to 67. The low result obtained by LVN #7 was 72. She then checked the glucose monitoring machine by removing and replacing the batteries " as she was instructed " . LVN #7 repeated the quality control test for the low control by again applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The low result reading was 71 which was still out of range. LVN #7 did not attempt another QC check. Interview at the same time LVN #7 stated she would not perform another QC (Quality control) check since the machine was not working and she would notify the DON and not use the machine until the problem could be corrected. LVN #1 did not recognize a possible cause for the erroneous reading. She stated she had been in-serviced on the glucose monitoring machine at the beginning of her shift on 5/30/12. Observation on 5/31/12 at 5:50 A.M. revealed LVN #6 performed a quality control check on the glucose monitoring machine by applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The low range expected as printed on the bottle of test strips was 46 to 76. The low result obtained by LVN #6 was 71. Interview at the same time LVN #6 stated the low control was out of range and the meter should not be used. She stated she had been in-serviced on 5/30/12 at the beginning of the 10:00 P.M.-6:00 A.M. shift on the use of the new glucose monitoring machine. Observation on 5/31/12 at 6:30 A.M. revealed RN #1 performed a quality control check on the glucose monitoring machine by applying the drop of control solution from the bottle directly on the tip of the test strip in the machine and did not ensure the machine was in control mode. The results were as follows: 72 for the low control and 254 for the high control. The control ranges on the bottle of test strips was as follows: Low range 46-76 and High range 189-255. RN #1 performed blood glucose tests on 3 residents after performing the quality control tests. Interview at the same time as the above observation revalued RN #1 did not recognize the glucometer was not in control mode and the control solution should not be applied directly to the tip of the strip in the machine. She stated she had received an in-service on the use of the glucose monitoring machine on 5/30/12. Observation on 5/31/12 at 7:15 A.M. on the day shift, LVN # 3 during a glucose monitoring machine calibration revealed the low control number was outside the normal control range. Normal range was documented to be 46 to 76. The low number registered 79. LVN # 3 did not perform any additional checks on the glucose monitoring machine but just continued to use the machine to check other resident's blood sugars on the 400 hall. Interview on 5/31/12 at 7:17 A.M., LVN # 3 said she did not know what to do when the glucose monitoring machine had an out of range control number. She stated " that one is just a little off. " She said she did not have to do the calibration because it had already been done by the night shift nurses. She said she could not recall receiving any kind of training on how to calibrate the glucose machine. Interview on 5/31/12 at 11:48 P.M., the DON said she expected a glucose monitoring machine to be in all nursing carts in the facility and also to have control solution assessable to all staff. She said the licensed staff were given orientation before they start work and all nursing staff were given an in-service before the new glucose machine was given to the staff for use. The DON said the use and calibration of glucose monitoring machine was part of the new hire orientation. She said according to the glucose control solution manufacturer, the expiration was 10/2012. Interview on 6/1/12 at 2:55 P.M. LVN # 2 stated she had been at the facility for 2 years and did not recall receiving any training or in-services on diabetes or glucose monitoring machine usage. Interview on 6/1/12 at 3:15 P.M. RN # 1 stated she had been at the facility for a year and 7 months and did not recall receiving any in-service training on diabetes or glucose monitoring machine usage. Record review of facility's policy on blood sugar monitoring dated 2006 revealed " ...follow the manufacturer ' s instruction for the type of equipment used in the facility... Procedure # 3: follow manufacturer ' s direction for the use and care of the equipment used in the facility..." A plan to remove the Immediate Jeopardy was submitted by the facility and after corrections was accepted on 6-1-12 at 11:01 A.M. Pharmacy Services Plan of action to remove the immediate jeopardy A. Don and/or designee will in-service Licensed Nurses on the glucometer related to high and low calibration and utilization of the meter. The Licensed Nurses will be instructed to availability of additional glucometer (s) as well as control solutions (if glucometer does not calibrate). A back up glucometer and control solution will be available at the nurse station and DON ' s office. This will begin on May 31, 2012 and end on June 1 2012. B. Medical Supply Vendor will in-service management nurse and Licensed Nurses (as appropriate) on the use of glucometer related to high and low calibration. This will begin on May 31 2012 and end on June 1, 2012. C. Control solutions will be available in the facility for all machines on May 31, 2012. The date opened will be noted on the bottles and item discarded as appropriate. The DON, ADON will monitor for compliance. D. The DON, ADONs and/or designee will review Diabetic Control Logs every shift and the calibration to ensure the accuracy of the equipment. This will be completed until each nurse demonstrates proficiency. This will begin on May 31, 2012 and end on June 1, 2012. E. All diabetic residents will have a baseline blood sugar completed on May 31, 2012. This will be completed by the Licensed Nurses that demonstrated competency. F. The DON, ADON and/or designee will monitor the availability of Control Solution weekly to ensure adequate supply is in the facility. An additional supply of control solution will be maintained in the facility. This will begin May 31, 2012. G. The DON, ADON and/or designee will monitor to ensure Licensed Nurses check glucometer's daily for calibrations and the equipment is in good working conditions. The DON, ADON and/or Designee will in-service on the policies and procedures for Diabetics/Blood Glucose. This will include ranges out of parameters that would relate to the manufactures guidelines (recalibrating as appropriate). Also included in the training are instructions on what actions should be taken related to hypoglycemic and hyperglycemic results as necessary i.e. assessment; notification to physician as condition warns; recheck blood glucose; administer medication; follow up on the next shift; etc ... The results may take one and/or a combination of approaches to stabilize. This will begin May 31, 2012 H. The DON and ADON will complete Blood Glucose Monitoring Skills Demonstration for all licensed nurses. This will begin on May 31, 2012. All Licensed Nurses will receive skill sets prior to working a shift to ensure competency. These in-services will begin May 31, 2012 and end on June 1, 2012. All nurses on duty will be required to attend the in-service prior to the beginning of the shift. Any nurse unable to attend training will not be allowed to work. Monitoring of the plan The Monitoring of the plan began on 6-1-2012. In-service training had begun to all Licensed Nurses to include the use of the new glucometer's purchased by the facility and signs of hypo and hyper glycemia. Various shifts over the weekend and during the weekdays between 6-1-2012 and 6-4-2012 were monitored. Due to the machines being new to the staff competency was not clearly demonstrated to the surveyors until 6-4-201. By this time staff had been observed on the weekends and weekdays. All shifts had been monitored. Numerous staff had been interviewed concerning changes in conditions, reporting to physicians, calibrating glucometer's and back up supplies. While the IJ was removed on 6-4-2012 at 12:09 P.M., the facility remained out of compliance at a scope of patterned and a severity level of actual harm that is not immediate jeopardy because all staff had not been trained on the usage and calibration of glucose monitoring machines and the signs and symptoms of hypo or hyperglycemia. The facility reported there were 46 diabetic residents in the facility with 21 residents requiring daily/or more often blood glucose monitoring.

Based on observation, interview, and record review, the facility failed to ensure that 2 of 11 sampled residents (Resident # 54 and Resident # 40) received care and services to prevent decrease in their range of motion. The facility failed to: place Resident # 54 on a Restorative Program and apply bilateral knee orthoses (splints) and hand rolls. provide splints, palm guard, or passive ROM for Resident # 40. This failure caused one resident's contractures to worsen to the point that he could no longer stand at his bedside or sit in a chair and one resident to develop a hand contracture. This failure placed 30 residents at risk of having existing contractures worsen and 56 residents at risk of developing contractures causing pain and a decrease in functionable ability. Findings include: Resident # 54 Review of Resident # 54 ' s admission information revealed he was [AGE] years old and admitted to the facility on [DATE]. His medical history included the following: Joint Contractures, [MEDICAL CONDITION], [MEDICAL CONDITIONS], Anxiety, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Heart Valve Replacement, and [MEDICAL CONDITION] Fibrillation. Observation on 06-28-11 at 10:10 A.M. during initial tour of the facility revealed Resident #54 lying in bed on his right side. Resident # 54 was awake with his eyes open but was non-verbal. He was clean, dressed in a hospital gown, and was receiving [MEDICATION NAME] 1.5 liquid nutritional supplement at 60 cc hour per enteral feeding pump. Further observation revealed Resident # 54 had bilateral flexion contractures of his hands and knees. Review of a physician order [REDACTED]." Review of physical therapy progress notes revealed knee orthoses were ordered and obtained on 05-11-11. Interview on 06-30-11 at 9 A.M. with RPT revealed Resident # 54 was fitted with the orthoses to both knees and tolerated them well. The RPT went on to say the purpose of the orthoses was to stretch the tendons to improve joint movement and prevent further flexion contracture. The RPT said the angle of the "stretcher orthoses" was gradually increased over time, as well as the time the resident wore the orthoses. She went on to say that by the time Resident # 54 was discharged from Physical Therapy Services, he was wearing the knee orthoses from 4 to 6 hours daily and had shown much improvement. The RPT said that when Resident # 54 was discharged from Physical Therapy on 05-21-11, he was referred to the nursing Restorative Program. The restorative aides were instructed on the application of the knee orthoses. Observation on the following dates and times failed to reveal knee orthoses on either of Resident # 54's knees or hand rolls in either hand: 06-28-11 at 12:10 P.M. 06-28-11 at 1:55 P.M. 06-29-11 at 8:15 A.M. 06-29-11 at 11:30 A.M. 06-29-11 at 5:00 P.M. 06-30-11 at 9:00 A.M. 06-30-11 at 1:15 P.M. Observation on 06-30-11 at 8:25 A.M. revealed two (2) " knee corrective orthosis / static " and two (2) padded/Velcro hand rolls located in the bottom of Resident # 54 ' s wardrobe closet under several pillows and other items. Review of " Therapy (Physical Therapy) Discharge Note " dated 05-21-11 revealed: " right knee ext to 90 degrees, ...left knee ext to 95 degrees.. " " care givers to continue ROM and apply splints. " It was further documented the CNAs were educated. Review of " Interdisciplinary Communication Memo " dated 05-23-11 revealed " patient discharged from skilled physical therapy referred to restorative for ROM and daily splint placement.. " The memo was signed by RPT. Review of Resident # 54' s clinical record failed to reveal any restorative nursing notes " or any documentation that ROM had been done, or that the knee orthoses and hand rolls had been placed on Resident # 54. Interview on 06-29-11 at 1:40 P.M. CNA# 6 (restorative aide), she stated Resident # 54 had never been placed on the Restorative Nursing Program after he had been discharged from Physical Therapy. Interview on 06-29-11 at 5::00 P.M., Resident # 54 ' s family at his bedside. The family member stated that in April (2011) at the facility he was at prior to this one, the resident was able to sit up in a Geri-Chair but this facility did not have Geri-chairs. " She went on to say that " all I want is for him to be able to sit up in a chair. " She said that the PT department at this facility had worked with his legs and even had him sitting at the bedside. She said now his legs were worse; " it seemed after he finished physical therapy, everyone just gave up on him. " Observation of Resident # 54 on 06-30-11 at 9 A.M. revealed RPT performed a physical examination of the resident ' s upper and lower extremities per request. The RPT stated at the time of discharge from Physical Therapy on 05-21-11, Resident ' s 54 ' s right knee contracture was at 90 degrees and at present it had worsened to 110 degrees. His left knee contracture at time of discharge was 95 degrees and had worsened at present to 100 degrees. The RPT went on to say Resident # 54 had flexion contractures of the 3,4, 5th digits of the right hand that measured 130 degrees and flexion contractures on the left hand that measured 90 degrees. The RPT stated Resident # 54 ' s family had brought hand rolls to the facility but she had not seen them used by staff after he was discharged from physical therapy. Interview on 06-29-11 at 1:35 P.M. the DON stated Resident # 54 had bilateral upper and lower extremity contractures upon admission. She went on to say he should have received restorative services and been wearing the knee orthoses. The DON was unable to explain the reason these interventions had not occurred. Resident # 40 Record review of Resident # 40 ' s Face Sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident # 40 on 6/28/11 at 9:07 a.m. revealed she was seated in her wheelchair, with no splints or braces on, unable to use her left arm, and with a right hand that was bent at the wrist, fingers digging into her palm, with no hand roll. She was not able to open her hand when requested. Subsequent observations made throughout the days on 6/29/11 and 6/30/11 during the morning, afternoon and early evening revealed the resident was not wearing a splint, brace or hand roll. Interview on 6/28/11 at 9:07 a.m. Resident # 40 stated she was unable to open her hand up, did not wear a splint, and did not use a hand rolls. Review of Admission MDS dated [DATE] revealed: ? Section G0400 Functional Limitation in Range of Motion coded no Impairment to either upper or lower extremities; ? Section O0400 B. Occupational Therapy coded 113 minutes of services in 3 days; and ? Section O0400 C. Physical Therapy coded 189 minutes of services in 5 days. Review of Quarterly MDS dated [DATE], revealed: ? Section G0400 Functional Limitation in Range of Motion coded Impairment on one side of the upper extremity and no Impairment to the lower extremities; and ? Section O0500 Restorative Nursing Programs indicated Resident # 40 received no passive range of motion, active range of motion, and did not wear a splint or brace or receive assistance with one. Review of Nursing Restorative Care Program data dated 2/21/2011 through 6/9/2011 revealed Resident # 40 wore a left-hand palm guard 8 hours daily. Review of Care Plan, not dated failed to identify whether the resident's contractures/limited range of motion to her upper extremities. It also failed to identify the use of a splint or brace. Interview on 6/28/11 at 9:07 a.m. LVN # 4 stated Resident # 40 developed the contracture while in the nursing home. She said the resident did not wear a splint, brace, or use hand rolls. In an interview with the DON on 6/29/11 at 5:05 p.m. she stated residents' MDS should reflected limited range of motion and/or contractures. She was not sure whether Resident # 40 wore a palm protector or not. The DON said the resident was on the restorative nursing program and they should be using the protector. CMS form 672 revealed 32 residents with contractures leaving the remaining 56 residents without contractures.

Based on observation, interview, and record review, the facility failed to provide assistance devices and supervision to prevent falls for 2 of 4 sampled residents (Resident # 48 and Resident # 9) and failed to ensure 2 of 4 hallways ( 300 and 400 halls) were free of hazards. The facility failed to: implement additional fall precautions for Resident # 48 when she was assessed at a higher risk for falls. Resident # 48 fell out of bed and sustained serious injury, ensure Resident # 9 had her call light in reach, a " fall risk " sign posted on her door and floor mats next to her bed after the resident had sustained 2 falls within the last week, ensure the proper storage of hazards in a common shower room located between the 300 and 400 hallways These failures caused one resident to sustain lacerations and bruising to her face and to be transferred to the hospital for treatments, one resident to sustain two falls causing pain and knee injury and placed 5 residents at risk of injury from falls and 55 residents at risk of being exposed to hazardous products. Findings include: Resident # 48 Record Review of Resident # 48 ' s admission face sheet revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Admission MDS dated [DATE], revealed severely impaired cognition, altered level of consciousness, and total dependence on staff for care. Record review of the Hospice Nursing assessment dated [DATE] found in the front of her clinical record revealed: " Fall risk assessment-score 13 Medium Risk. " Record review of Hospice Nursing assessment dated [DATE] found in the front of the resident's clinical record revealed her fall risk score changed to a 19 and was considered at " very high risk " . It was documented the reason for the change in her fall risk was due to her decrease in level of consciousness and mental status. Review of Care Plan dated 6/25/11 revealed " the resident is High risk for falls r/t Confusion... " . The interventions included were provide " safe environment ...follow facility fall protocol. " Review of the " Call Don' t Fall Program " Nursing Interventions revealed interventions to be used to reduce the risk and/or impact of falls. The interventions listed revealed: safe environment when resident ambulates, assess for bed rails, non-slip foot wear, call lights with in reach, safety checks every two hours, night lights, bed pans within easy reach, alarm devices to alert staff, and reorientation of resident. Most of these interventions were not applicable to Resident # 48 due to her level of consciousness, cognition and physical status. Record review of the nursing documentation failed to reveal any new interventions implemented to reduce the risk of falls or to reduce the severity of consequences of a fall. Review of an Incident Report dated 6/30/11 revealed that same date at 7:57 a.m. , " cna notified desk nurse that she observed patient on floor face down with head turned to right side with left arm under her stomach and right arm along beside her body (sic) also noted patient to have a bleeding laceration to forehead above right eyebrow also noted to have a quarter size hematoma to forehead at side of laceration and a 5 x 5 cm superficial skin tear to left elbow." The report revealed she was transported to the hospital. Observation of Resident # 48 on 6/30/11 around 12:00 p.m., after her return from the hospital, revealed considerable bruising to face, cut to forehead and lip, bruising to neck and chest. Resident was in a bed in a low position and call light was next to her. Observation revealed no additional fall precautions were implemented upon the resident ' s return. Interview on 6/30/11 at 12:05 p.m. CNA # 3 stated she did not know what happened to Resident # 48 and did not know her history because she had not worked with this resident before. The CNA stated she knew that she had fallen. When asked what fall prevention interventions had been put into place, the CNA said she did not know of any. CNA #3 stated she was going to go get a fall mat and place it by the bed because she did not want the resident further injured. Observation approximately 15 minutes later revealed the CNA walking down the hall towards the resident ' s room with a fall mat in her hand. Interview on 6/30/11 at 1:30 p.m. LVN # 1 stated she was unaware that Resident # 48 was at Risk for Falls. She said she was not aware of hospice reassessing the resident ' s fall status or of the increased risk. She stated the facility had not implement anything new as a result of her fall that morning. Review of Nursing Services Policy and Procedure Manual " Functional Impairment-Clinical Protocol " revealed, " . . . at any time a significant change of condition occurs, and periodically during a resident ' s stay, the physician and staff will assess the resident ' s physical condition and functional status " . It further revealed, " As appropriate, the physician and other staff will identify and evaluate the individual ' s co-morbidities, conditions causing functional decline, symptoms, risks, impairments, and disabilities, and investigate their causes " . The nursing facility should " review(ed) the results and implications of these evaluations and use them to guide subsequent care planning " . Resident # 9 Review of Resident # 9's admission information revealed she was [AGE] years old and admitted to the facility on [DATE]. Her medical history included the following: Intracranial Hemorrhage, Hypertension, Muscle Wasting, and Hematuria. Observation on 06-28-11 at 9:30 A.M. during initial tour of the facility revealed Resident # 9 sitting in her wheelchair in the Physical Therapy Department. She was clean, well-groomed, alert and oriented. Interview with Resident # 9 at this time she stated her left knee " hurt a lot. " At the time of this observation, RN # 1 reported that Resident # 9 had fallen from her bed the night before and an x-ray had been ordered. Review of Resident # 9 ' s Nurses Notes for June 2011 revealed the resident had fallen twice out of her bed within the last week: on 06-22-11 at 5:20 P.M. and again on 06-27-11 at 9:35 P.M. Call light: Observations on the following dates and times revealed Resident # 9 lying in her bed with her call light not within reach: 06-29-11 at 1:00 P.M. : Resident # 9 ' s call light was observed on the floor, CNA # 3 entered the room and clipped the bed alarm to the pillowcase; failed to notice the call light on the floor. After surveyor intervention, CNA # 5 retrieved the call light from the floor, sanitized it and gave it to Resident # 9. CNA# 5 stated Resident # 9 was able to use the call light and asked the resident to demonstrate. Resident # 9 complied and pushed the call light. 06-29-11 at 4:50 P.M.: Resident # 9 ' s call light was observed on the floor. CNA # 2 retrieved the call light from the floor and gave it to Resident # 9. Fall Risk sign: Observation of Resident # 9 ' s room during initial tour on 06-28-11 at 9:30 A..M. failed to reveal a " fall risk " sign posted on her doorframe. Floor mats: Observation on 06-29-11 AT 1:00 P.M. revealed Resident # 9 lying in bed; there were no floor mats on the floor next to the bed at this time. Interview on 06-30-11 at 2:15 P.M. the DON stated the facility's fall protocol consisted of 3 levels with different fall prevention interventions. The first level was used for the first fall and the interventions were call light in reach, fall-risk sign outside door, and a fall-risk bracelet. Level 2 was instituted if a 2nd fall occurred. Level 2 interventions were the same as level one, but /floor mats were added. The DON went on to say that Level 3 was put in place if a resident had additional falls and it consisted of all of the interventions of Levels 1 and 2 plus a bed /chair alarm. The DON stated because Resident #9 experienced a 2nd fall, she was considered Level 2. The DON provided an Interim Plan of Care for Resident # 9 that documented " fall risk/ floor mats." Review of the facility ' s policy titled " Call Don ' t Fall Program, " undated, read: Level 1: call light in reach -teach resident to use-answer promptly ... " Observation on 6/28/2011 during initial tour at approximately 9:00 A.M. revealed on Hall 400 Resident #78 in the hallway. Interview at this same time the DON stated that Resident #78 had a mental illness and wandered. Observation of the shower room between Halls 300 and 400, on 6/28/11 at 2:15 P.M., revealed a double door cabinet with a lock on each side. The left side of the cabinet was unlocked and contained 2 disposable razors and a half bottle of body wash with a label that read "keep out of the reach of children." Observation of the same shower room on 6/29/11 at 12:45 P.M., revealed the left side of the cabinet was again unlocked and contained the same contents. Interview on 6/30/11 at 12:45 P.M. the DON stated the cabinet in the shower area should be locked. According to the facility 802 form there were 5 residents who had falls or fractures. According to the facility census roster, there were 55 residents on the 300 and 400 hallways.