Every finding on record at Bay Ridge Healthcare Center

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 5 resident reviewed for notification of changes. RN A failed to notify CR #1's physician immediately when at approximately 6:30 am on [DATE], CR # 1 was delusional and looked pale yellowish. RN A failed to consult with CR #1's physician immediately for medical guidance when at approximately 8:00 am on [DATE], CR #1's oxygen saturation level was 84%. RN A waited until 12:30 pm to notify CR #1's physician regarding CR #1's change in condition after CR #1 became minimally responsive. On [DATE] at approximately 1:00 pm, CR #1 was sent to the hospital due to low oxygen saturation level. CR #1 was admitted to ICU with respiratory distress and hypotension. During ICU evaluation CR #1 experienced pulselessness prompting resuscitative efforts. After about 20 minutes of resuscitative efforts, CPR was terminated per daughter's request, and CR #1 was pronounced deceased at 8:53 pm on [DATE]. On [DATE] at 5:49 pm, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the residents' condition, and /or sepsis, stroke, or death. Record review of CR #1's face sheet, dated [DATE], revealed a [AGE] year-old female readmitted to the facility on [DATE] after an extended stay in an LTAC. CR #1's admitting diagnoses on [DATE] included: acute gastric ulcer with perforation (an open sore in the stomach lining that eats completely through the stomach wall creating a hole), UTI (an infection caused by bacteria entering the urinary system), acute respiratory failure with hypoxia (when lungs suddenly stop working properly, leaving blood dangerously low on oxygen), sepsis (body's extreme life-threatening response to an infection) and atelectasis (partial or complete collapse of the lung). Record review of CR #1's quarterly MDS assessment, dated [DATE], revealed a BIMS of 15 indicating intact cognition and memory. Record review of CR #1's Care Plan dated [DATE], indicated CR #1 had Emphysema/COPD with interventions to monitor for difficulty breathing on exertion and to monitor for s/s of acute respiratory insufficiency: anxiety, confusion, restlessness. Record review of CR #1's active physician's order summary for [DATE] indicated an order for Bipap (a machine that pumps pressurized air through a mask to keep airways open, giving higher pressure when breathing in and lower pressure when breathing out) with settings: (16/8, 40% FiO2 (fraction of inspired oxygen) nightly and 3Liters O2 via nasal canula related to Chronic Obstructive Pulmonary disease and Acute Respiratory failure with Hypoxia. An order for Ipratropium-albuterol inhalation solution (a prescription liquid medication that is vaporized into a mist and breathed in to open up the airways) 0.5-2.5 (3) mg/3ml inhale orally to be given every 6 hours as needed for shortness of breath. Further record review on CR #1's physician order revealed there was no monitoring in place for CR #1's O2 saturation level. During an interview on [DATE] at 1:09 pm, MA B said she made it to CR #1's room around 7:15 am on [DATE] to administer morning medications. MA B stated she got all her medications ready, but when she approached CR #1, she observed CR #1 was out of it. MA B said CR#1 was mumbling, seemed confused, and was saying things that could not be understood. MA B stated that she could not understand CR #1 and notified RN A to come assess her immediately. MA B stated she informed RN A that she was not comfortable administering medications to CR #1 and RN A instructed MA B to hold CR #1's morning medication. MA B stated she did not know what interventions were provided to CR #1 after she reported to RN A at 7:30 am and continued with her medication pass. MA B stated when she asked RN A if CR #1 was going to be sent to the hospital, RN A said that she was not sure. MA B stated she continued to pass medications on other halls and was not aware of any updates about CR #1 until she saw EMS leave with CR #1 around lunch time. MA B stated when she asked RN A, RN A told her CR #1's oxygen saturation level was not increasing. Record review of Resident #1's progress notes, dated [DATE] at 11:27 am, revealed that CR #1's oral medication was held due to lethargy, confusion, and she was considered a high aspiration risk. During an interview on [DATE] at 1:35 pm, RN A stated on the morning of [DATE], after getting shift report from the night nurse, she made her rounds to CR #1's room around 6:30 am. RN A stated she noticed CR #1 was mumbling to herself like she was delusional which was unusual for CR #1. RN A stated CR #1 had her nasal canula on at 4 LPM and looked pale and yellowish. RN A stated she continued to finish her rounds. RN A stated MA B notified her that she was not comfortable to administer medications to CR #1 and asked RN A to assess CR #1. During RN A's assessment, she noticed CR #1 taking deep breaths through her mouth although she wore her nasal canula and she notified the DON. RN A said the DON and RN A obtained CR#1's O2 saturation at 84%. RN A stated that the DON said the O2 saturation of 84% was CR #1's baseline and suggested to put the Bipap on since resident had her nasal canula on and was breathing through her mouth RN A stated on [DATE] around 11am, she reassessed CR #1 after putting the Bipap on. RN A stated she could not get an oxygen saturation level (the percentage of red blood cells carrying oxygen compared to the total amount of oxygen in blood). RN A stated she tried 2 different pulse oximeters and was still unable to get an O2 level reading. RN A stated she tried the pulse oximeter on her own hands and was able to get a reading immediately. RN A stated one minute CR #1 was talking, mumbling and confused and then CR #1 had stopped talking and color had changed. RN A stated she notified MD at 12:30 pm who gave orders to send CR #1 out to the hospital. RN A stated she called 911 who arrived immediately. RN A stated EMS took CR #1's O2 level, and it was 82%. RN A stated CR #1 was moaning and mumbling when EMS was wheeling her out of the facility at 1:00 pm. RN A stated the interventions she implemented were changing the oxygen to Bipap and making sure the Bipap was on properly. RN A stated she did not feel CR #1 was sent out late and she did not notify MD sooner because she wanted to collect data and present a case to the MD. RN A stated when she realized she could not do anything to bring CR #1's O2 saturation up, she asked for help from other staff on the procedure to send a resident out. She stated she felt that an 84% O2 saturation was a concern and that was why she got the DON. RN A stated she followed the DON's instructions to keep CR #1 in the facility and monitor her with the Bipap being on. During an interview on [DATE] at 2:35 pm, CNA C stated that while completing her round on [DATE] at 6:15 am, CR#1 did not have her Bipap on and she checked to make sure she was breathing. CNA C stated when she tried to feed CR #1 breakfast, CR#1 had her eyes closed and was talking to herself. CNA C stated CR#1 said that she did not want to eat and CNA C stopped because she did not feel it was safe in her current state. CNA C stated CR #1 told her that she did not want to eat breakfast and that she was tired. CNA C stated RN A was notified. CNA C stated she checked on CR #1 at least 3 times before she was transferred. CNA C stated each time she saw her, CR #1 denied being wet and had her eyes closed talking to herself. CNA C stated no Bipap was observed during each check-in. During an interview on [DATE] at 2:59 pm, the DON stated CR #1 was non-compliant with using the Bipap. The DON stated when she checked at 11:00 am, CR #1'soxygen was on at 4 LPM via nasal canula and O2 saturation level were at 93%. The DON stated for an obese woman, 4 LPM was ok and her order was for 02 sats to be kept over 90%. The DON stated she then left CR #1's room and RN A was in the room. DON stated at 12:30 pm, RN A informed her that CR #1 had a change in condition and had order from the MD to send her out. DON stated the change in condition was that CR #1 was not as responsive and the O2 saturation had dropped. DON stated after RN A informed her of CR #1's condition that morning, she instructed RN A to put CR #1's Bipap mask on if CR #1 allowed it, but she did not return to monitor CR #1 because other staff were doing so. The DON stated when she left the room RN A was putting the Bipap mask on for CR #1. DON stated that if CR #1's O2 saturation levels were below 90% or 83%, she would have notified the MD and would have gotten an order to send CR #1 out. The DON stated she was not aware that CR #1's O2 sats were below 90% for a long period of time. DON stated that if the O2 sats were low, it was better to send CR #1 out sooner than later for further evaluation. DON stated CR #1 was already on 4LPM NC and on Bipap but had a bad lung disease that had declined. DON stated her expectation was for nurses to notify the MD, herself, and Administrator immediately if there was a change in condition. DON stated the only thing that could have been done for intervention was to send CR #1 sooner to the hospital. Record review of CR #1's progress notes for Change in Condition note on [DATE] at 12:30 pm documented CR #1 had an O2 saturation of 80% on a nasal canula, breathed through her mouth, and appeared pale with yellow-gray coloration. CR #1 was minimally responsive with no response to verbal stimuli. She had an altered mental status with delusions, indicated by her speaking to her mother who was not present in the room. CR #1 refused breakfast and lunch. CR#1's responsiveness and oxygenation continued to decline during shift. CR #1 was ordered to be sent to the hospital by MD and left via EMS at 1:00 pm. During an interview on [DATE] at 12:37 pm, the MD stated he was notified by RN A that CR # 1 was not as responsive as usual and that her 02 level was low. The MD stated he instructed RN A to send CR #1 to the hospital. The MD stated he did not remember receiving any other vital signs other than CR #1's 02 level. The MD stated he was not aware that CR #1 had other changes in condition going on at the same time. The MD stated the facility should notify him immediately if there was a significant change. The MD stated in CR # 1's case the risk of not receiving appropriate assessment sooner was catastrophic. The MD stated CR #1 had the worst outcome, death. The MD stated the risk of receiving delayed emergency care would result in worsening symptoms and harder to treat conditions. Record review of the facility's policy titled, Condition & MD-Family Notification, revised [DATE] and reviewed [DATE], read in part, .PROCEDURE: The physician will be contacted immediately for any emergencies irrespective of the time of day.Each attempt will be charted as to the time the call was made, who was spoken to and what information was given to the physician. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:49 pm. The Administrator and DON were notified. The Administrator and DON were provided with the IJ templated [DATE] at 5:49pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:11pm. It was documented as follows:F580 Notify of ChangesThe facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).Situation: CR#1 passed away at the hospital. Charge Nurse removed from the schedule by DON on [DATE].The Director of Nursing (or designee) reviewed all current residents who had experienced a significant change in condition and those currently exhibiting a significant change in condition to verify that physician notification had occurred timely, physician orders had been received and implemented as appropriate, and no residents remained at risk due to delayed physician notification. Any identified concerns were immediately addressed. No residents identified having concerns with change of condition.Completed [DATE].All licensed nurses received immediate education regarding the facility's expectations for timely physician notification whenever a resident experiences a significant change in condition. Education included recognizing changes that require immediate physician notification, communicating pertinent clinical information to the physician, documenting the notification, physician response, and implementation of any resulting orders. Staff will not be allowed to provide direct resident care until training was completed.The Director of Nursing reinforced the expectation that physician notification will occur immediately upon identification of a significant change in condition and will not be delayed while additional information is gathered if the resident's condition warrants prompt medical evaluation.QAPI committee reviewed its policies and procedures related to change in condition and physician notification to ensure compliance. No updates made to policy reviewed [DATE].Completed [DATE]. Director of Nursing/Regional Nurse provided immediate re-education to all licensed nurses on the following: The expected process for: 1. Immediately evaluating/assessing resident upon a suspected or identified change in condition noted. 2. Documenting nursing findings to include but not limited to evaluation of vital signs and utilizing the appropriate Change in Condition User Defined Assessment and/or Nursing Progress Note to ensure proper documentation is noted within the medical record. 3. Nurse to promptly report the identified change in condition (exception of usual baseline status) to the Medical Provider in order to ensure appropriate interventions are provided and carried out as ordered/recommended. 4. Nurse to ensure that appropriate notification is made to the resident's representative. 5. The Nurse should review the vital sign form to ensure that any abnormal vital signs have been reviewed by the nurse with appropriate re-assessment and interventions to include the licensed nurse conducting the evaluation/assessment, notification to the Medical Provider, carrying out any recommended or prescribed medical interventions and notification to the resident's representative promptly, and ensuring all is documented within the electronic health record. 6. The nurse will ensure that all identified changes in condition or suspected changes in condition will be reported to the on-coming nurse to ensure appropriate 24-hour reporting at change of shift as per usual hand-off process.Director of Nursing Services/Regional Nurse completed a 100% audit on all residents in the community to identify any residents with a change in condition. Outcome: 0 of 33 active residents were noted with no identified change in condition.Completed [DATE] Monitoring/Verification of Plan of removal: [DATE] Record review reflected that facility-wide in-services and a quiz conducted between [DATE], [DATE] and [DATE] were completed across all shifts under the direction of clinical leadership. Thirteen Licensed Nurses were educated to notify physicians of changes in conditions promptly to ensure timely assessment, treatment, and resident safety. Upon completion of this in-service, licensed nurses will be able to: recognize what constitutes a significant change in condition, notify the physician promptly when a significant change occurs, provide accurate clinical information during physician notification, implement physician orders immediately, document the notification, physician response, and interventions accurately. Review of in-service reflected Licensed nurses were in-serviced on identifying a significant change in condition which was defined as a decline or improvement in a resident's physical, mental, or psychosocial status that requires physician evaluation or intervention. Examples of significant change in condition included: change in level of consciousness, respiratory distress or oxygen desaturation, chest pain, acute change in blood pressure, pulse, respirations, or temperature, new onset confusion or altered mental status, falls with injury or suspected injury, uncontrolled pain, new bleeding, significant change in blood glucose and any condition requiring possible transfer to a higher level of care. Review of the in-service reflected when a change in condition was identified licensed nurses were expected to:- Assess the resident immediately, Obtain pertinent vital signs and clinical information, Notify the physician without delay, Do not wait to gather additional information if the resident's condition warrants immediate medical evaluation, Receive and accurately read back physician orders, Implement orders promptly, Continue monitoring the resident and document the response, Notify the resident representative as appropriate per facility policy. Review of the in-service reflected licensed nurses are to document the following: - Time the change in condition was identified, Assessment findings, Time physician was notified, Physician name, information communicated, Orders received, Time orders were implemented, Resident response, Notification of resident representative when applicable. Review of the facility's Change in Condition audit tool reflected daily audits were conducted.On [DATE], all 33 residents were reviewed with compliance noted for all residents.On [DATE], 34 residents were reviewed with 1 resident identified with a change in condition that occurred at the time the audit was being conducted. The resident was on end-of-life care (hospice care). Nurses conducted appropriate assessments, communication with the Medical Provider, orders received, change in condition was documented within the electronic health record and appropriate notifications to RP were made and the nursing 24-hour communication report was updated accordingly. The resident returned from hospital to facility on the same day ([DATE]).On [DATE], all 34 residents were reviewed with compliance noted for all residents.Review of the facility's vital signs monitoring audit tool reflected all residents' vital signs were completed daily from [DATE] to [DATE] with no abnormalities. Staff interviews:During interview conducted on [DATE] between 4:00pm to 4:30pm, LVN D and RN B, who worked the 6:00 am to 6:00 pm shift, stated they were agency nurses. They said they were in-serviced the morning of [DATE] prior to start of shift on identifying changes in condition with residents and promptly notifying physicians. LVN D and RN B stated that changes in condition were identified as deviations from baseline (altered mental status, abnormal vital signs) and required completion of CIC assessments, documentation in progress notes, and family and physician notification. LVN D and RN B stated they completed 2 quizzes as part of the in-services. On [DATE] at 6:45pm, an attempt was made to interview nurses from the evening shift from 6:00pm to 6:00am but nurse had not arrived and another nurse was not available. The Administrator and DON were informed the Immediate Jeopardy was removed on [DATE] at 7:22 p.m. The facility remained out of compliance at a severity level of minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview, and record review, the facility failed to ensure 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 (CR#1) of 5 resident reviewed for quality care. The facility failed to ensure CR #1 received treatment and care promptly when CR #1 experienced a change in condition of altered mental status and respiratory decline with low Oxygen saturation level. The facility failed to obtain an order for interventions including order to send CR#1 to hospital for further evaluation and treatment when CR #1's altered mental status was first identified around 6:30am on [DATE] and a decline in respiratory status with low oxygen saturation level identified around morning med pass on [DATE]. The facility failed to properly assess CR#1 or obtain vital signs after a change in condition of altered mental status and respiratory decline was identified. CR # 1 was not administered breathing treatment for shortness of breath as per physician order. The facility waited approximately 4-5 hours to notify CR #1's physician after observing the change in condition. On [DATE] at 5:48pm, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated and due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the residents' condition and /or sepsis, stroke, or death. Findings included: - Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old female readmitted to the facility on [DATE] after an extended stay in an LTAC. CR #1's admitting diagnoses on [DATE] included:- acute gastric ulcer with perforation (an open sore in the stomach lining that eats completely through the stomach wall creating a hole), UTI (an infection caused by bacteria entering the urinary system), acute respiratory failure with hypoxia (when lungs suddenly stop working properly, leaving blood dangerously low on oxygen), sepsis (body's extreme life-threatening response to an infection) and atelectasis (partial or complete collapse of the lung). Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS of 15 indicating intact cognition and memory. Record review of CR #1's Care Plan indicated CR #1 had Emphysema / COPD with interventions to monitor for difficulty breathing on exertion and to monitor for s/s of acute respiratory insufficiency: anxiety, confusion, restlessness. Record review of CR #1's active physician's order summary for [DATE] indicated an order for Bipap with settings: (16/8, 40% Fio2(fraction of inspired oxygen) nightly and 3Liters O2 via nasal canula related to Chronic Obstructive Pulmonary disease and Acute Respiratory failure with Hypoxia. An order for Ipratropium-albuterol inhalation solution (a prescription liquid medication that is vaporized into a mist and breathed in to open up the airways) 0.5-2.5 (3) mg/3ml inhale orally to be given every 6 hours as needed for shortness of breath. Further record review on CR #1 physician order revealed there was no monitoring in place for CR #1's O2 saturation level. Record review of CR #1's vital signs documentation record revealed no vital signs were obtained for CR #1 on [DATE]. Record review of CR #1's SBAR 3.0 assessment with effective date [DATE] at 1:00 pm indicated the most recent blood pressure reading was 128/76 obtained on [DATE] at 8:24pm; the most recent pulse was 86 obtained on [DATE] at 8:24pm; the most recent respiration was 16 obtained on [DATE] at 8:53am; the most recent temperature was 98.1 degrees obtained on [DATE] at 7:50pm and the most recent O2 sats were 93% via nasal canula obtained on [DATE] at 7:40am. Further review revealed CR #1 was on oxygen at 4 liters and the most recent blood glucose was 158 mg/dl obtained on [DATE] at 7:39 am. During an interview on [DATE] at 1:35 pm, RN A stated on the morning of [DATE], after getting shift report from the night nurse, she made her rounds to CR #1's room around 6:30 am. RN A stated she noticed CR #1 was mumbling to herself like she was delusional which was unusual for CR #1. RN A stated CR #1 had her nasal canula on at 4 LPM and looked pale and yellowish. RN A stated she continued to finish her rounds. RN A stated MA B notified her that she was not comfortable to administer medications to CR #1 and asked RN A to assess CR #1. During RN A's assessment, she noticed CR #1 taking deep breaths through her mouth although she wore her nasal canula and she notified the DON. RN A said the DON and RN A obtained CR#1's O2 saturation at 84%. RN A stated that the DON said the O2 saturation of 84% was CR #1's baseline and suggested to put the Bipap on since resident had her nasal canula on and was breathing through her mouth RN A stated on [DATE] around 11am, she reassessed CR #1 after putting the Bipap on. RN A stated she could not get an oxygen saturation level (the percentage of red blood cells carrying oxygen compared to the total amount of oxygen in blood). RN A stated she tried 2 different pulse oximeters and was still unable to get an O2 level reading. RN A stated she tried the pulse oximeter on her own hands and was able to get a reading immediately. RN A stated one minute CR #1 was talking, mumbling and confused and then CR #1 had stopped talking and color had changed. RN A stated she notified MD at 12:30 pm who gave orders to send CR #1 out to the hospital. RN A stated she called 911 who arrived immediately. RN A stated EMS took CR #1's O2 level, and it was 82%. RN A stated CR #1 was moaning and mumbling when EMS was wheeling her out of the facility at 1:00 pm. RN A stated the interventions she implemented were changing the oxygen to Bipap and making sure the Bipap was on properly. RN A stated she did not feel CR #1 was sent out late and she did not notify MD sooner because she wanted to collect data and present a case to the MD. RN A stated when she realized she could not do anything to bring CR #1's O2 saturation up, she asked for help from other staff on the procedure to send a resident out. She stated she felt that an 84% O2 saturation was a concern and that was why she got the DON. RN A stated she followed the DON's instructions to keep CR #1 in the facility and monitor her with the Bipap being on. Record review of CR #1's MAR for [DATE] revealed CR#1 was not administered Ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml inhale orally every 6 hours as needed for shortness of breath as per physician's order when Cr #1 was having respiratory issues on [DATE]. During an interview on [DATE] at 2:59 pm, the DON stated CR #1 was non-compliant with using the Bipap. The DON stated when she checked at 11:00 am, CR #1'soxygen was on at 4 LPM via nasal canula and O2 saturation level were at 93%. The DON stated for an obese woman, 4 LPM was ok and her order was for 02 sats to be kept over 90%. The DON stated she then left CR #1's room and RN A was in the room. DON stated at 12:30 pm, RN A informed her that CR #1 had a change in condition and had order from the MD to send her out. DON stated the change in condition was that CR #1 was not as responsive and the O2 saturation had dropped. DON stated after RN A informed her of CR #1's condition that morning, she instructed RN A to put CR #1's Bipap mask on if CR #1 allowed it, but she did not return to monitor CR #1 because other staff were doing so. The DON stated when she left the room RN A was putting the Bipap mask on for CR #1. DON stated that if CR #1's O2 saturation levels were below 90% or 83%, she would have notified the MD and would have gotten an order to send CR #1 out. The DON stated she was not aware that CR #1's O2 sats were below 90% for a long period of time. DON stated that if the O2 sats were low, it was better to send CR #1 out sooner than later for further evaluation. DON stated CR #1 was already on 4LPM NC and on Bipap but had a bad lung disease that had declined. DON stated her expectation was for nurses to notify the MD, herself, and Administrator immediately if there was a change in condition. DON stated the only thing that could have been done for intervention was to send CR #1 sooner to the hospital. Record review of CR #1's progress notes for Change in Condition note on [DATE] at 12:30 pm documented CR #1 had an O2 saturation of 80% on a nasal canula, breathed through her mouth, and appeared pale with yellow-gray coloration. CR #1 was minimally responsive with no response to verbal stimuli. She had an altered mental status with delusions, indicated by her speaking to her mother who was not present in the room. CR #1 refused breakfast and lunch. CR#1's responsiveness and oxygenation continued to decline during shift. CR #1 was ordered to be sent to the hospital by MD and left via EMS at 1:00 pm. During an interview on [DATE] at 12:37 pm, the MD stated he was notified by RN A that CR # 1 was not as responsive as usual and that her 02 level was low. The MD stated he instructed RN A to send CR #1 to the hospital. The MD stated he did not remember receiving any other vital signs other than CR #1's 02 level. The MD stated he was not aware that CR #1 had other changes in condition going on at the same time. The MD stated the facility should notify him immediately if there was a significant change. The MD stated in CR # 1's case the risk of not receiving appropriate assessment sooner was catastrophic. The MD stated CR #1 had the worst outcome, death. The MD stated the risk of receiving delayed emergency care would result in worsening symptoms and harder to treat conditions. During an interview with the HRN on [DATE], she stated that CR #1 arrived at the hospital with shortness of breath, hypoxia and low blood pressure at 83/45. HRN stated EMS administered breathing treatment x1. HRN stated ER triage physical exam indicated CR#1 had a temperature 99.1; Pulse 107, Respiration 24, BP 87/28, O2 sat 91%. HRN stated CR#1 was intubated and within 20 minutes CR# lost pulse. CR#1 was treated with IV fluid and antibiotics and was transferred to ICU. HRN stated at approximately 8:00 pm CR#1 became pulseless and CPR was initiated. CR#1's RP requested to stop CPR after numerous attempts. CR# 1 was pronounced deceased at 8:53pm on [DATE]. Record review of facility's policy titled, Resident Examination and Assessment, read in part, . Purpose: The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan.Physical exam: #1. Vital Signs: blood pressure (standing and sitting); pulse (carotid); respirations; and temperature. #3. Respiratory: lung sounds (upper and lower lobes) for wheezing, rales, rhonchi, or crackles; irregular or labored respirations; cough (productive or nonproductive); and consistency and color of sputum.Reporting: #2. Notify the physician of any abnormalities such as, but not limited to abnormal vital signs; labored breathing; breath sounds that are not clear; or cough, productive or nonproductive; change in cognitive, behavioral or neurological status from baseline. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:48 p.m. The Administrator, DON, and ADON were notified. The Administrator and DON were provided with the IJ templated [DATE] at 5:48 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:11pm. It was documented as follows: F684 Quality of Care The facility failed to ensure CR #1 received treatment and care promptly in accordance with professional standards of practice who experienced a change in condition of altered mental status and respiratory decline with low Oxygen saturation level of 84%.Situation: CR#1 passed away at the hospital. Charge Nurse removed from the schedule by DON on [DATE]. The Director of Nursing (or designee) conducted a review of all current residents receiving oxygen therapy, BiPAP/CPAP, respiratory treatments, and/or those with significant respiratory diagnoses or documented changes in condition to ensure: A current nursing assessment had been completed; Vital signs and oxygen saturation had been obtained as clinically indicated; Physician notification had occurred when warranted; Physician orders had been implemented timely; and No resident was experiencing an unaddressed change in condition requiring immediate intervention. Any concerns identified during these reviews were addressed immediately. No Concerns were identified in audit completed [DATE].Completed date: [DATE] DON/Designee in serviced all licensed nurses on [DATE] and educated regarding the facility's expectations for: Prompt recognition and assessment of a significant change in condition; Completion of an appropriate nursing assessment, including obtaining pertinent vital signs and clinical information; Immediate physician notification when a significant change in condition is identified; Timely implementation of physician orders; and Accurate and timely documentation of assessments, physician notification, interventions, and resident response.The Director of Nursing also reinforced with licensed nursing staff the expectation that residents demonstrating a significant change in condition are assessed promptly and that physician notification occurs without unnecessary delay to ensure timely intervention. Staff will not be allowed to provide direct resident care until training has been completed.In addition to licensed nursing staff, all direct care staff were educated on [DATE], regarding recognition of changes in resident condition and the expectation to immediately report any observed change to the licensed nurse for prompt assessment and physician notification. Staff will not be allowed to provide direct resident care until training has been completed.Completed date: [DATE] QAPI committee reviewed its policies and procedures related to change in condition and physician notification to ensure compliance. No updates made to policy was reviewed [DATE].Completed date: [DATE] To ensure the deficient practice has been corrected and does not recur, the Director of Nursing or designee will review all documented significant changes in condition daily for seven (7) days including afterhours and weekends, then 3x a week for 4 weeks and then weekly thereafter to verify: Appropriate nursing assessment was completed; Physician notification occurred timely; Physician orders were implemented promptly; and Documentation accurately reflects the assessment, notification, interventions, and resident response. Any identified concerns will be addressed immediately through corrective coaching and follow-up as appropriate.Completed date: [DATE], [DATE], [DATE] and ongoing. Director of Nursing Services/Regional Nurse completed a 100% audit on all residents in the community to identify any residents with a change in condition. Outcome: 0 of 33 active residents were noted with no identified change in condition.Completed [DATE] Risk Response:All residents who are currently reside in the community with a change in condition have the potential to be affected by the deficient practice. Systemic Response:Director of Nursing / Regional Nurse provided immediate re- education to all nursing staff on the following: The expected process for: 1. Immediately evaluating/assessing resident upon a suspected or identified change in condition is noted. 2. Documenting nursing findings to include but not limited to evaluation of vital signs and utilizing the appropriate Change in Condition User Defined Assessment and/or Nursing Progress Note to ensure proper documentation is noted within the medical record. 3. Nurse to ensure that appropriate notification is made to the resident's representative. 4. The Nurse should review the vital sign form to ensure that any abnormal vital signs have been reviewed by the nurse with appropriate re-assessment and interventions to include the licensed nurse conducting the evaluation/assessment, notification to the Medical Provider, carrying out any recommended or prescribed medical interventions and notification to the resident's representative promptly, and ensuring all is documented within the electronic health record. 5. The nurse will ensure that all identified changes in condition or suspected changes in condition will be reported to the on-coming nurse to ensure appropriate 24-hour reporting at change of shift as per usual hand-off process. Monitoring/Verification of Plan of removal: [DATE] Review reflected that facility-wide in-services and quizzes conducted between [DATE], [DATE] and [DATE] were completed across all shifts under the direction of clinical leadership. Licensed nursing staff were educated on the following expectations: Recognition of Significant Change in Condition; A significant change in condition includes, but is not limited to: Shortness of breath or respiratory distress, Oxygen saturation below ordered parameters, Changes in respiratory rate or effort, Altered mental status, Chest pain, Fever with declining condition ,Hypotension or hypertension, Acute pain, Any change from the resident's baseline requiring nursing intervention Review of the in-service reflected that licensed nurses are to provide Immediate Nursing Assessment. When a significant change occurs, the nurse must immediately: Assess the resident. Obtain complete vital signs, including oxygen saturation when indicated. Perform a focused assessment related to the resident's symptoms. Compare findings to the resident's baseline. Continue monitoring while awaiting further instructions. The physician or practitioner must be notified immediately when assessment findings indicate a significant change in condition or when required by facility policy. The nurse must communicate: Assessment findings, Current vital signs, Oxygen saturation, Resident symptoms, Interventions already performed, Relevant clinical history, Recommendation or request for further orders. Review of the in-service reflected All physician orders must be implemented promptly, including Oxygen therapy adjustments, Respiratory treatments, Laboratory testing, Diagnostic testing, Medication changes, EMS activation or hospital transfer when indicated. The nurse must reassess the resident following interventions and document the resident's response. The expectation was that Every nurse was responsible for: Recognizing changes promptly, never delaying physician notification, Escalating concerns when the resident's condition worsens, following physician orders without unnecessary delay, asking for assistance when needed, providing accurate and timely documentation and Resident safety was always the priority. Review of facility wide in-services and quiz conducted across all shifts for non-licensed staff reflected the responsibility of all non-licensed staff to promptly recognize and report any change in a resident's condition to the licensed nurse to ensure timely assessment, intervention, and quality resident care. All non-licensed staff will be able to: Recognize common signs and symptoms of a change in condition, understand their role in observing and reporting resident concerns, identify situations that require immediate notification of the licensed nurse and explain why timely reporting is essential to resident safety. Review of in-service reflected identifying changes in condition that may include:- Increased confusion or change in mental status, Lethargy or difficulty waking the resident, Shortness of breath or increased work of breathing, Low oxygen saturation (if observed or reported), Chest pain or complaints of not feeling well, New weakness or inability to perform usual activities, Changes in skin color (blue, gray, pale), Fever or chills, Sudden swelling, Falls or suspected injuries, Refusal to eat, drink, or take medications when this is unusual for the resident and Any behavior or physical change that is not normal for that resident. Expected responsibility of non-licensed staff member was to Observe residents during every interaction, know what is normal for each resident, Report concerns immediately to the licensed nurse, continue to monitor the resident until relieved by the nurse if instructed, Document care according to facility policy. Review of in-service reflected non-licensed staff were educated not to Wait until the end of the shift to report, assume someone else has already reported it, attempt to diagnose or treat the resident independently and to Delay reporting because the resident says they are fine. Examples Requiring Immediate Nurse Notification were Resident is more confused than normal, Resident is difficult to wake, Resident has trouble breathing, Resident's oxygen or BiPAP is not being used as ordered, Resident suddenly becomes weak or cannot [NAME], .Resident complains of chest pain, Resident experiences a fall, Resident's condition simply doesn't seem right. Review of the facility's Change in Condition audit tool reflected daily audits were conducted.- On [DATE], all 33 residents were reviewed with compliance noted for all residents.- On [DATE], 34 residents were reviewed with 1 resident identified with a change in condition that occurred at the time the audit was being conducted. The resident was on end-of-life care (hospice care). Nurses conducted appropriate assessments, communication with the Medical Provider, orders received, change in condition was documented within the electronic health record and appropriate notifications to RP were made and the nursing 24-hour communication report was updated accordingly. The resident returned from hospital to facility on the same day.- On [DATE], all 34 residents were reviewed with compliance noted for all residents. Review of the facility's vital signs monitoring audit tool reflected that all residents' vital signs were completed daily from [DATE] to [DATE] with no abnormalities. Staff interviews: During staff interview conducted on [DATE] between 3:50pm to 6:20pm, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J and CNA K who worked from 6:00 am to 6:00pm and 6:00pm to 6:00am shifts stated they were in-serviced and took a quiz on the importance of identifying any changes in residents and notifying their nurses immediately when a change in condition was identified. They reported that changes such as decreased intake, altered behavior, lethargy, abnormal vital signs, or skin changes were some of the symptoms that they should look for when providing care to their residents. During an interview on [DATE] at 4:26pm with MA L who worked the 6:00am to 6:00pm shift, stated she would notify her nurse immediately if she observed her residents had a change in condition like vital signs were not stable or if the residents were refusing to take their medication. During interview conducted on [DATE] between 4:00pm to 4:30pm, LVN D and RN B, who worked the 6:00 am to 6:00 pm shift, stated they were agency nurses. They said they were in-serviced the morning of [DATE] prior to start of shift on identifying changes in condition with residents and promptly notifying physicians. LVN D and RN B stated that changes in condition were identified as deviations from baseline (altered mental status, abnormal vital signs) and required completion of CIC assessments, documentation in progress notes, and family and physician notification. LVN D and RN B stated they completed 2 quizzes as part of the in-services. On [DATE] at 6:45pm, an attempt was made to interview nurses from the evening shift from 6:00pm to 6:00am but nurse had not arrived and another nurse was not available. The Administrator and DON were informed the Immediate Jeopardy was removed on [DATE] at 7:22 p.m. The facility remained out of compliance at a severity level of minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure and provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 for 1 of 1 medication rooms reviewed for labeling and storage. -Facility failed to ensure Emergency Narcotic Kit kept in the facility medication room was permanently affixed on 4/29/2026. This failure could place residents at risk for misappropriation of property, and exploitation related to drug diversion.Findings: Observation and interview with DON on 04/29/2026 at 11:46 AM of facility's only medication room that was key locked and secured, located off of the main facility lobby corridor. There was a small approximately 10 cm X 10cm X 10 cm bright red metal box with a keypad coded front, which was closed and sealed, located on an upper cabinet shelf. The box had 1 small hole on the back side of the box and had a thin silver metal chain hanging from the cabinet shelf that was not attached to the box. The top of the box had a white sticker tag with the number 15 written on it and another white sticker that read Exp 6/26. There was still another laminated white sticker that had a list of 23 narcotic medication names listed as being contained inside the box and a number amount of each. The DON said staff had not told her that the narcotic box had come loose from the chain permanently affixing it to the shelf. The DON said the box was changed weekly by Pharmacy usually on Tuesday's and the number 15 was most likely how the pharmacy numbered the boxes they delivered. The DON said the list of medications on the top of the box were medication inside the box, and that only licensed nursing staff had keys and access to the medication room. She said in the event emergency-controlled medications were ordered; the charge nurse would have to contact the pharmacy for a code to access the ordered medication inside the box and sign a narcotic reconciliation sheet which the pharmacy kept and was included in the facility pharmacy review when used. She said the box was removable from the shelf and could be picked up easily and held by hand. The DON demonstrated holding the box freely in both hands and replaced the box back on the upper shelf. She said to her knowledge there had never been any issue with the box being removed or missing from the medication room. The DON said she would immediately get the issue resolved because she understood how easily the narcotic box could be stolen or drug diverted from the medication room. Record review on 04/29/2026 at 11:48 AM of white laminated sticker on top of narcotic E-kit box revealed the following: Drug.Acetaminophen-Cod #3 Tab . Alternate Name.Tylenol #3.QTY.10Acetaminophen-Cod #4 Tab. Alternate Name.Tylenol #4.QTY.10Alprazolam 0.25 MG . Alternate Name.Xanax.QTY.10Clonazepam 0.5 MG. Alternate Name.Klonopin.QTY.10Diazepam 5 MG. Alternate Name.Valium.QTY.10Fentanyl 12 MCG/HR Patch. Alternate Name.Duragesic.QTY.2Fentanyl 25 MCG/HR Patch. Alternate Name.Duragesic.QTY.2Fentanyl 50 MCG/HR Patch. Alternate Name.Duragesic.QTY.2Hydrocodon-Acetamin 5-325 MG . Alternate Name.Norco.QTY.10Hydrocodon-Acetamin 10-325 MG . Alternate Name.Norco.QTY.10Hydrocodon-Acetamin 7.5-325 MG . Alternate Name.Norco.QTY.10Lorazepam 0.5 MG. Alternate Name.Ativan.QTY.10Morphine Sulf 20 MG/ML Soln 30 ML. Alternate Name.Roxanol.QTY.1Oxycodone HCL 5 MG Tab.Alterate Name.OxylR.QTY.10Oxycodon-Acetamin 5-325 MG.Alternate Name.Percocet.QTY.10Oxycodon-Acetamin 7.5-325 MG.Alternate Name.Percocet.QTY.10Oxycodon-Acetamin 10-325 MG.Alternate Name.Percocet.QTY.10Pregabalin 25 MG.Alternate Name.Lyrica.QTY.10Pregabalin 50 MG.Alternate Name.Lyrica.QTY.10Temazepam 15 MG.Alternate Name.Restoril.QTY.10Temazepam 7.5 MG.Alternate Name.Restoril.QTY.10Tramadol 50 MG.Alternate Name.Ultram.QTY.10Zolpidem 5 MG.Alternate Name.Ambien.QTY.10 Observation and interview with DON on 04/29/2026 at 12:28 PM, of the medication room which was locked and secured. The small approximately 10cm X10cm X 10cm bright red metal box with a keypad coded front, was closed and sealed and chained and anchored, to the secured, permanently affixed to medication room cubicle shelf. The red box had a key and keypad code entry system to access it. The DON said the pharmacy would continue to manage the smaller red narcotic E-kit box. The top of the box had a white sticker tag with the number 15 written on it and another white sticker that read Exp 6/26. There was still another laminated white sticker that had a list of 23 controlled medication names listed as being contained inside the box and a number amount of each. Record review of facility policy procedure titled Storage of Medications: reviewed 6/24/2025 revealed, 13. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments.

Based on interviews and record review, the facility failed to accurately assess each resident's status for 1 (Resident #4) of 5 residents reviewed for accuracy of assessments. -The facility failed to ensure Resident #4's Quarterly MDS assessment dated [DATE] accurately reflected the resident's hypoglycemic medication use and incorrectly coded the resident for insulin medication use. This failure could place residents at risk for inaccurate assessments, inaccurate care plans, inadequate care, diminished quality of life and decline in health. Findings include: Record review of Resident #4's Clinical Resident Profile revealed a [AGE] year-old male who admitted to the facility on [DATE]. Diagnoses included diastolic heart failure (a condition that occurs when the heart's main pumping chamber (left ventricle) becomes too stiff or thick to relax and fill properly with blood between beats), dysphagia (difficulty or discomfort in swallowing), edema (swelling caused by excess fluid trapped in the body's tissues), Morbid (severe) obesity due to excess calories, and schizoaffective disorder bipolar type (a chronic mental health condition combining primary symptoms of schizophrenia [hallucinations, delusions] with significant mood episodes, specifically mania). Record review on 04/29/2026 at 1:22 PM of Resident #4's Quarterly MDS assessment dated [DATE] revealed his BIMS score was 13 out of 15 indicating his cognition was intact, and he was coded in Section N Medications as taking Insulin injection medication. Section N was signed as completed by MDS Coordinator A on 03/30/2026 and verified as completed by the Consultant Nurse on 04/03/2026. Record review on 04/29/2026 at 1:57 PM of Resident #4's physician order summary recap report dated Active Orders as of 03/01/2026 through 04/29/2026 revealed Resident #4 had no order for any insulin (hormone preparations used to treat diabetes by managing high blood sugar). Continued record review also revealed Resident #4 had the following order: Wegovy subcutaneous solution auto-injector 1 MG/0.5 ML.Inject 1 MG subcutaneously one time a day every (sic)Sun for weight loss.Verbal Order.Order Status discontinued.03/26/2026.Order Date.01/02/2026. Record review and interview with MDS Coordinator A on 04/29/25 at 1:39 PM said Resident #4 was taking Wegovy (Brand Name)/Semaglutide. The MDS Coordinator A said Wegovy was not and then said she thought Wegovy was an insulin and she would have to check and get back with the surveyor. When asked what was coded on Resident #4's Q MDS dated [DATE] the MDS Coordinator said they coded for insulin injection medication. Interview on 04/29/2026 at 2:02 PM with MDS Coordinator A said she checked with the pharmacist who explained to her and confirmed with her that Wegovy/semaglutide was not insulin and mimicked a hormone called GLP-1 (glucagon-like[hormone produced by the pancreas] peptide-1)to suppress appetite and reduce hunger). MDS Coordinator A said it was an error on her part in coding the Q MDS for Resident #4 and it was incorrect. MDS Coordinator A said they would correct the MDS assessment by modifying it. MDS Coordinator A said they worked as an MDS Coordinator at the facility for a few months and the MDS Consultant was the oversight person over the MDS Department. MDS Coordinator A said they had been trained by Regional MDS and used the RAI manual as the policy and procedure for MDS completion and accuracy. Interview with DON on 04/29/2026 at 4:33 PM, the DON said they did not sign Resident #4's Q MDS dated [DATE] and was new to her role as the DON and had only been the DON for about 1 month. The DON was not 100 percent sure who trained MDS Coordinator A but said Regional MDS most likely trained MDS Coordinator A and would be the person over the MDS department. The DON said she expected that resident assessments were accurate because if the assessments were incorrect, it could affect reimbursement and cause delays or confusion with resident care and treatments. Record review of Resident #4's Q MDS dated [DATE] on 05/01/2026 at 4:10 PM revealed in Section N Medication Resident #4 was no longer coded as receiving insulin injection.Section X. Correction revealed: Reasons for Modification.D.Item Coding Error. Section Z Assessment Administration Signature of Persons Completing the Assessment of Entry/Death Reporting, was signed by DON with Date Section Completed, dated 04/30/2026. Telephone interview with the Regional MDS on 05/01/2026 at 4:20 PM, said they did some training with MDS Coordinator A and was over the MDS department. The Regional MDS said MDS Coordinator A did have virtual training, that included meetings, and audits. The Regional MDS said his last audit was on PASSRs about a month ago, and not on accuracy of medications. When asked if MDS Coordinator A had been trained on how to code an insulin versus a GLP-1 medication, the Regional MDS said Wegovy was not an insulin medication, and he said MDS Coordinator A called him on 04/29/2026 and they discussed it. The Regional MDS said the facility did not have a separate MDS accuracy policy or procedure and used the RAI manual. The Regional MDS said inaccurate MDS assessments could affect reimbursement and could lead to residents having inaccurate information in their medical records. Record review of CMS's RAI Version 3.0 Manual dated October 2025, read in part. the assessment accurately reflects the resident's status.

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 (Kitchen #1) reviewed for food safety. -The facility failed to ensure that drinks were covered.-The facility failed to keep a personal, opened beverage out of the food storage area. These failures could place residents at risk of foodborne illness and disease.Findings included: During an observation and interview with the Dietary Manager on 4/29/26 at 10:27 am, inside the walk-in-refrigerator, 3 cups of milk were not covered completely with a plastic lid. The Dietary Manager said the cups of milk were going out for lunch and the importance for milks to be covered was so nothing could get into the milk. She said possible harm was the residents could get sick with due to cross contamination. During an observation and interview with the Dietary Manager on 4/29/26 at 11:23 am, indicated an open soda can by the menus and above the dry storage bins that held sugar, flour, and corn meal. The Dietary Manager said the area was for dry storage and the area was not a preparation area. Observation indicated the Dietary Manager removed the can of soda, crushed, threw the soda can away and washed her hands. The Dietary Manager said the soda could waste spill but that it could not do any harm because the lids were on the dry goods. During an interview on 4/29/25 at 12:40 pm, with the Assistant Administrator and DON they both said the expectation was for foods to be covered to prevent cross-contamination and the potential for harm was a resident getting sick. Record review of the facility policy and procedure entitled Food Preparation and Service, dated revised 3/5/2026, read in part. Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Appropriate measures are used to prevent cross-contamination. These include. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for two (Resident #1 and Resident #11) of nine residents reviewed for physical environment. The facility failed to maintain an appropriate physical environment as evidenced by holes in the wall of resident rooms and no grab bars, soiled towels and a smell of urine in the shower area. This failure could place residents at risk of exposure to pests, falls, infections and injury. Findings included: During an observation on 04/28/2026 at 9:38 AM, Resident #11's room was observed with a door handle sized hole on the wall and exposed wiring hanging from the room's vent. During an observation on 04/30/2026 at 10:52 AM, staff moved the bed of Resident #1 away from the wall. Observation indicated the right side of the electrical outlet behind the bed had a palm sized hole exposing the sheetrock. During an interview on 04/30/2026 at 10:55 AM, Resident #1 said she told maintenance about the hole in the wall behind her bed. She said she went to the other hall for a shower because there were no grab bars in the shower across the hall from her room. During an observation on 04/30/2026 at 11:05 AM, one bathroom near the front exit was observed with no grab bars around the shower area. The path to get to the shower was slightly inclined. A damp, soiled towel was observed in the corner of the room, and a strong smell of urine was noted. During an interview on 05/01/2026 at 12:30 PM, the Maintenance Director said he was in charge of anything maintenance related in the facility. He said he was the only person who did maintenance for the building. He said he did not conduct routine inspections of resident rooms. He said the management team did neighbor rounds and if they saw anything wrong, they reported it to him. He said residents also reported any concerns directly to him. He said staff either verbally or digitally reported, needed repairs. He said there were a lot of cosmetic issues within the facility like exposed dry wall. He said he was not aware there were no handrails in one of the bathrooms. He said he thought residents were reluctant to use that bathroom due to it causing water to leak into the next-door resident's room. He said the lack of handrails in the shower area could be a slip hazard. He said holes in the wall could expose the residents to pests. During an interview on 05/01/2026 at 1:30 PM, the DON said the Administrator, DON, and ADON conducted neighborhood rounds daily to ensure appropriate physical environment conditions in the facility. She said she was not aware of any holes in the wall of Resident 11's room. She said she was also not aware until yesterday of the lack of grab bars in one of the bathrooms. She said aides were responsible for cleaning up the bathrooms after every resident shower. During an interview on 05/01/2026 at 2:44 PM, the Assistant Administrator said the physical environment of the facility and resident rooms were observed through neighborhood rounding. She said this was supposed to be done every day. She stated staff completed a checklist to ensure neighborhood rounds were done. She said if there was an issue, staff should put in a work order. She said she was not aware of the holes in the walls in resident rooms, lack of grab bars in the shower area and soiled towels in the bathroom. She said the aides were responsible for cleaning the bathrooms after residents used them. She said a negative effect of holes in the walls could be bugs or other pests coming into resident rooms. She said the soiled towels could present an infection control problem and the lack of grab bars could be a safety hazard to residents while showering. A record review of the facility's policy titled, Homelike Environment dated February 2021, revealed. Residents are provided with a safe, clean, comfortable and homelike environment. Policy implementation stated, the facility staff and management maximizes.the characteristics of the facility that reflect a personal homelike setting. These characteristics include a clean, sanitary and orderly environment and pleasant, neutral scents.

Based on interview and record review, the facility failed to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation was in progress for two (Resident #1 and Resident #7) out of two residents reviewed for abuse. The facility failed to demonstrate protection measures for Resident #1 by not completing assessments in a timely manner and failed to prevent further alleged abuse by not maintaining appropriate interventions for Resident #7. This failure could place residents at risk of further physical and mental harm. Findings included: A record review of facility self-reported incident, dated 12/31/2026 at 2:40 PM, revealed conflicting dates and times for an incident occurring on or around the morning of 12/30/2025 or 12/31/2025 involving Resident #1 and Resident #7. The self-report indicated Resident #1 stated Resident #7 pulled out his penis in front of her in her room. Provider response noted Resident #7 removed from Resident #1's doorway, psychiatric evaluation requested for Resident #7, trauma assessment done for Resident #1 and safe survey done for Resident #7. RP, Administrator and Medical Director were listed as notified parties. Provider action post investigation detailed abuse and neglect in-service was initiated and police were called. Investigation findings were documented as unfounded. A record review of Resident #1's Trauma Informed PRN Assessment revealed an effective date of 01/09/2026. A record review of Resident #1's Senior Psych Care referral revealed a date of 01/13/2026. A record review of the facility timeline for the self-report incident revealed:- 12/30/25 Incident occurred - 12/31/25 Knowledge of incident- 12/31/25 Resident #7 placed on 1:1 supervision, assessed by physician/medication review- 01/01/26 Ongoing 1:1 supervision for Resident #7- 01/01/26 1:1 supervision ended at 2 PM due to going home with family member- 01/01/26 Resident #7 returned to facility, 1:1 supervision discontinued- 01/02/26 Resident #7 follow up visit with physician- 01/02/26 Life Satisfaction Rounds- 01/08/26 Care Plan meeting for Resident #7 with family member- 01/09/26 Another incident of sexually inappropriate behavior by Resident #7 towards another resident- 01/09/26 Trauma Informed Assessment of Resident #1 completed A record review of Resident 1's care plan, dated 03/16/2026, revealed a female with a diagnosis of Chronic Obstructive Pulmonary Disease, Epilepsy, Type 2 Diabetes, Repeated Falls and Lack of Coordination. The resident's care plan referenced a known incidence of sexual harassment by a resident (who) exposed himself to her and asked her to perform a sexual act on him. A record review of Resident 7's care plan, dated 04/21/2026 revealed a male with a diagnosis of Anxiety Disorder, Insomnia, Anoxic Brain Damage, Mild Neurocognitive Disorder, Cognitive Communication Deficit, Major Depressive Disorder and Schizoaffective Disorder. The resident's care plan referenced the resident having a behavior problem.related to exposing himself in common areas, making sexual comments to others and being physically aggressive towards others. A record review of Resident #7's order summary report, dated 04/11/2026. revealed:- order on 11/25/2025 for Wander Bracelet- order on 01/09/2026 for referral to a psychiatric hospital for evaluation and treatment - order on 02/06/2026 for 1:1 supervision until further notice- order on 04/10/2026 for referral to UT Health Houston Behavioral Sciences Campus for evaluation and treatment During an interview on 05/01/2026 at 11:40 AM, Resident #1 said she recalled an incident in which Resident #7 went into her room and laid in her bed. She said she was not in her bed when Resident #7 got in it. She denied any sexually inappropriate behavior towards her by Resident #7. She said she was aware of another incident with Resident #7 going into someone's room but she's not sure exactly what happened. She denied any feelings of discomfort or fear related to Resident #7. She said that was just how Resident #7 acted. During an attempted interview on 05/01/2026 at 11:47 AM with Resident #7, he was unable to answer any questions related to the alleged incidents. Resident #7 was walking down the hall with his aide. During an interview on 05/01/2026 at 12:18 PM, the Social Worker said she was responsible for trauma assessments, psychosocial notes, and referrals to psych services. She said she provides emotional support to residents. She said Trauma Informed Assessments were done when a resident was alleged to have been abused or neglected at the facility and psych services were offered following alleged incidents. She said this was typically done right away or within twenty-four hours of an alleged incident occurring. The Social Worker said if the alleged incident occurred on a weekend, it would be completed on the next business day. She said the Administrator normally handled ANE investigations. She stated she doesn't know much about the process. She said the Abuse Coordinator for the facility was the Administrator. She said she found out about the alleged incident between Resident 1 and Resident #7 on 01/09/2026 (in conjunction with a new and similar incident on another resident involving Resident #7) from the previous Administrator. She said she was told there were sexual allegations made against Resident #7 towards Resident #1. She denied the incident was discussed with her previous to this date. She said once she was informed of the incident, she completed the Trauma Informed Assessment of Resident #1 and a referral to Senior Psych Care. She said to ensure residents were protected and further abuse was prevented, residents were separated from each other, and family and psych services were notified. She stated a sexually inappropriate encounter could leave a resident feeling uncomfortable and not safe. During an interview on 05/01/2026 at 1:30 PM, the DON said alleged incidents were typically conveyed during the morning meeting. She stated facility investigations started with staff education and in-service. She said management developed a timeline of what happened. She said within five days the Administrator concluded the investigation based on statements from staff. She said psych services were typically provided to residents if needed. She advised a head-to-toe assessment was also completed depending on the allegations. She said assessments were expected to be done immediately following an incident or within twenty-four hours. She said it was the Administrator's responsibility to ensure that assessments were done in a timely manner. During an interview on 05/01/2026 at 2:44 PM, the Assistant Administrator said she was not employed at the facility when the alleged incident occurred. She said facility investigations involved talking to residents and gathering information. She said management gathered statements from those involved. She said communication was made with RP, doctor and Ombudsman. She said if there was a concern, they investigated further. She said head to toe assessments were conducted on those involved. She said a report was made to the state within two hours of the alleged incident and the police were contacted if necessary. She said facility investigations were completed within five days following an alleged incident. She said she understood how a lapse in response to alleged abuse could lead to further ANE incidents. A record review of the facility policy titled, Abuse Prohibition, dated 05/01/01 included the following components screening, prevention, identification, investigation and protection. The policy stated, facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring. The investigation component detailed examination of the resident alleged to have been abused for appropriate interventions (medical, psychosocial, etc.) and measures to prevent repeat incidents. Protections described all residents will be immediately protected from harm.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, mental, and psychosocial needs for 1 resident (Resident #6,) of 5 residents reviewed for comprehensive care plans. - Resident #6 did not have a comprehensive care plan in place with interventions to address any of his health care diagnoses or needs . This failure could place residents at risk of their needs not being monitored and cared for met at the facility.Findings included: Resident # 6:Record review of Resident #6' s facility admission record, dated 4/29/26, revealed a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included end stage renal disease(also called end-stage kidney disease or kidney failure, occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state. In end-stage renal disease, your kidneys no longer work as they should to meet your body's needs) and type II diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication). Record review of Resident #6's admission MDS assessment, dated 3/14/26, revealed a BIMS score of 8 out of 15 indicating that moderately impaired cognitively. He was severely impaired with vision. Resident #6 required partial to moderate assistance with ADL's and was occasionally incontinent with bladder, frequently incontinent with bowels. Record review of Section O-Special Treatments revealed that dialysis services was not triggered. Record review of Resident #6's baseline care plan, dated 3/5/26, revealed there were care plans to address vison impairment, ADL's, advanced directives, dialysis, medications, diet, and cognition. Record review of Resident #6's care plan, undated, provided revealed there was no comprehensive care plans in place with interventions to address any diagnoses or health care needs. During an interview at 2:00 pm on 4/28/26 with the MDS Coordinator, she said she was working on all the care plans and thought Resident #6's baseline was completed and was working on the comprehensive care plan. The MDS Coordinator said she used the RAI Manual and, that she was responsible for completing care plans and MDS assessments. During an interview on 5/1/26 at 2:29 pm, the Corporate Nurse/RN, said typically the DON or a RN would review the comprehensive care plans. The MDS Coordinator was responsible for creating them. She said that the importance of comprehensive care plans was that they provided a residents specific level of needs and without a care plan those needs may not be addressed. During an interview on 5/1/26 at 2:30 pm, the Assistant Administrator said that care plans were important because they let the person providing care know what the residents needs were and possible harm could be not providing those needs. During an interview on 5/1/26 at 2:37 pm, the DON said that care plans were important to provide care for the resident and possible harm could be not providing those needs. During an interview on 5/1/26 at 4:25 pm, the Corporate MDS said that he was not aware that Resident #6 did not have a comprehensive care plan until the date it was updated (he did not provide a date). The Corporate MDS said comprehensive care plans were important because they provided the type and level of care a resident required and this was important to be communicated to the team. He said the facility used the RAI Manual for the policy for resident assessments and care plans. Record review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered, dated reviewed: 06/02/2025 read in part. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: Include measurable objectives and timeframes; Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; Incorporate identified problem areas.

Based on observation, interviews and record review the facility failed to ensure that residents receive and consume foods in the appropriate form in accordance with the residents physician order, care plan and dietary recommendationsfor 1 resident (Resident #16) out of 7 residents reviewed for therapeutic diets. -The facility failed to ensure that Resident #16 did not receive a peanut butter and jelly sandwich during lunch on 4/28/26. This failure could place residents at potential choking hazard, aspiration, or death. Findings included: Resident #16 Record review of Resident #16' s facility admission record dated 4/29/26 revealed that Resident #16 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paranoid schizophrenia (mental health disorder that changes how you think, feel and act. It can cause delusions, hallucinations and disorganized thinking), dysphagia(occurs when there is a problem with the muscles, nerves, or structures involved in swallowing, affecting the movement of food or liquids from the mouth to the stomach), and Alzheimer's Disease(is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia). Record review of Resident #16's Discharge MDS dated [DATE] Resident #16 was moderately impaired cognitively in section C1000. She required set-up or clean-up assistance with eating and required substantial to partial assistance with ADL's, had a catheter and was always incontinent of bowels. Record review of Resident #16's comprehensive care plan updated 4/20/26 read in part.The resident has potential nutritional problem Unplanned weight loss/gain r/t Dysphagia, Protein-Calorie-Malnutrition: ENHANCED PUREED NAS THIN CONSISTENCY. Record review of Resident #16's physician orders dated 4/20/26 revealed a physician order: Enhanced Diet, Pureed texture, thin consistency, NAS Active 04/20/2026. Record Review of the Dietician recommendations dated 4/28/26 revealed Resident #16's diet/nutrition plan was Enhanced diet, purred texture, thin consistency, NAS. Record review of the Diet Type Report dated 4/28/26 revealed that Resident #16 was on an Enhanced diet, purred texture, thin consistency, NAS. Record review of nursing progress note dated 4/28/2026 at 1:09 pm: Note Text : Resident was observed during lunch taking a bite of regular-texture food. CNA immediately intervened and stopped the resident, as the resident is on a puree diet. Writer assessed the resident; lung sounds were clear upon auscultation, and oxygen saturation was 96% on air room. No signs of distress noted at this time. Team Health was notified. The on-call physician was contacted and gave no new orders, as the resident showed no signs of aspiration. Responsible party and DON were notified. Will continue to monitor closely. Observation and interview on 4/28/26 at 12:11 pm, Resident #16 had not received her lunch while all other residents had received their lunch. The Agency CNA said that Resident #16 asked for a sandwich. Observation at this time of the Agency CNA, she went to the kitchen door and brought Resident #16 a peanut butter and jelly sandwich, unwrapped the sandwich from plastic and set it in front of Resident #16. CNA J approached the table and sat a puree texture tray in front of Resident #16. The Agency CNA removed the sandwich , and acknowledged that Resident #16 had taken one bite, she said she had training on purees diets, but when they said Resident #16, got her mixed up with someone else, she did not say source of training. On 4/28/26 at 12:11 pm, an interview on with CNA J, said that Resident #16 was on a puree diet. When asked about Resident #16 receiving the peanut butter and jelly sandwich, she said that Resident #16 could have choked and they checked resident tickets prior to giving the resident their tray, she acknowledge stated she receiving received training on diets, choking and aspiration. The Agency CNA said that I know that it is dangerous for a resident not to get their diet. She said I mean it's soft (touching the sandwich), but I understand it's not her diet. During an interview on 4/28/26 at 12:30 pm [NAME] A said that someone just came up and took the peanut butter and jelly sandwich, . He said that they did not give him the name of who the sandwich was for, he said he thought the sandwich was for a different resident that requested peanut butter and jelly sandwiches often. He said the process was that the person requested the sandwich, kitchen staff checked the diet and would give the item if it was on the residents diet. He said that dietary staff always cross-checked therapeutic diets for allergies, choking, dislikes, preferences. Interview on 4/28/26 at 1:10 pm, the Assistant Administrator and DON shared said that Agency CNA gave Resident #16 a peanut butter sandwich, she was not aware that Resident #16 was on a pureed diet and the resident took 1 to 2 bites of the sandwich. The Agency CNA removed the sandwich when CNA J returned with a pureed diet tray, the agency CNA then began to assist Resident #16 with the pureed diet tray . The Assistant Administrator and DON both said that the agency CNA had worked there before and they would go address the issue immediately. The DON and the Administrator said possible harm could be aspiration, choking and their expectation was for therapeutic diets to be followed. Interview on 4/29/26 at 12:33 pm, with the Dietary Manager she said Resident #16 receiving the sandwich while on a puree diet, at the same time that Resident #16 wanted the sandwich, a different resident that always request sandwiches requested one and the sandwich ended up going to the wrong resident. She said Dietary staff always checked the resident's diet tickets and made sure the resident receives the correct meal. She said she understood therapeutic diets and knew that Resident #16 required a pureed diet, . She said the facility had 2 residents that were currently on pureed diets. Interview on 4/28/26 at 1:30 pm, with the Dietician she heard about Resident #16, that she was given a peanut butter and jelly sandwich, . She said that would have been be fine if it were pureed ,but she could have choked with a full piece of bread. On 4/28/26, 4/29,26 and 4/30/26 at various times the surveyor requested facility policies and procedures to address physician orders, therapeutic diets, dietician recommendations and never received the policies and procedures.

Based on interview and record review, the facility failed to ensure the resident's discharge summary included an accurate reconciliation of all pre-discharge medications with post-discharge medication for 1 of 1 Residents reviewed for discharge medication reconciliation. The facility failed to complete an accurate reconciliation of medications for Resident #1 when he was discharged home on 1/31/2026. This failure could place residents at risk for discontinuity of care after being discharged from the facility to their home. Findings include:Record review of Resident #1's face sheet dated 2/2/2026 showed a [AGE] year old male was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (a medical condition where a patient experiences complete paralysis or weakness on the left side of the body because of a cerebral infarction, commonly known as a stroke, affecting the non-dominant hemisphere of the brain), bipolar disorder (a condition characterized by extreme mood swings including periods of mania and depression), type 2 diabetes mellitus (a chronic disease that is characterized by high levels of sugar in the blood), and cognitive communication deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech). Record review of progress notes showed that Resident#1 was discharged from the facility to his responsible party's home on 1/31/2026. There was a physician order to discharge Resident#1 received by the facility on 1/30/2026 that read, may discharge home with sister POA with scheduled medications no narcotics and all other belongings. Record review of a document titled Medications Released on Leave of Absence that was saved in Resident #1's electronic record as discharge medication list and signed on 1/31/2026 by the DON and resident's responsible party did not list insulin as a medication sent home with Resident #1. Record review of Resident #1's active orders at the date and time of discharge on [DATE] indicated the following orders for insulin:1. Humalog injection solution (Insulin Lispro). Inject 5 IU subcutaneously two times a day for DM. Hold for BS less than 100. Order date 1/23/2026. Discontinue date 2/2/2026.2. Insulin Glargine Solution 100 unit/ml. Inject 30 units subcutaneously two times a day for diabetes. Hold for BS less than 80. Order date 1/23/2026. Discontinue date 2/2/2026.Record review of Resident #1's care plan with an initiation date of 10/27/2025, listed DM as a focus with interventions that included to monitor and document for side effects and effectiveness of diabetic medication as ordered and listed Insulin Glargine as a medication that Resident #1 is receiving.Interview with the DON on 2/4/2026 at 10:40 am revealed she had been working as the DON since April 2024 and worked the shift when Resident #1 was discharged from the facility. The DON stated that she gathered Resident #1's scheduled medications except his narcotics and gave them to Resident #1's responsible party and they both signed a discharge medication list. She stated she didn't think Resident #1 had insulin prescribed, and if he did, she would have sent home the insulin as well.Interview with LVN A on 2/4/2026 at 1:47 pm revealed she was working on the day Resident #1 was discharged and was his nurse. She stated that the DON said she was going to take care of Resident #1's discharge medications which included gathering them and getting the responsible party to sign the discharge medication form. LVN A stated that insulin should be sent home with a resident who is being discharged home along with any other scheduled medications except narcotics.Interview with the DON on 2/4/2026 at 2:06 pm revealed that Resident #1 did have active orders for insulin at the time of discharge. The DON stated that insulin should have gone home with Resident #1. When asked why it didn't, the DON stated she was helping the nurse on duty and listed the medication that was handed to her. The DON stated that she overlooked it. The DON stated neither Resident #1 nor his responsible party mentioned anything about the insulin. The DON stated that she assumed what she was handed by LVN A was all the medications that were ordered for Resident #1. The DON stated that Resident #1's insulin was in a separate area in the nurse's medication cart, and the medications that were handed to her were in the Medication aide's cart. The DON also stated that she was the nurse who signed off on the discharge summary which stated on page 2-part B under drug therapy to see MAR. The DON was able to point out insulin on the MAR that Resident #1 had two insulin orders. The DON stated that the risk of not sending home insulin with the resident included hyperglycemia that could lead to hospitalization or even death. Interview with Regional Senior Administrator on 2/4/2026 at 3:00 pm revealed from her understanding, narcotics are the only medications not sent home with residents when discharged . She stated insulin usually goes home with residents. She stated she was in the facility because the current Administrator had only been in her role for two days and was new to the facility and new to the role of an administrator. The former Administrator who was employed during the time Resident #1 was discharged was no longer employed at the facility. When asked what kind of training nurses receive for discharging a resident, she stated that it is covered during a nurse's orientation on the floor. She stated that there was no written policy for specific actions for nurses to take in regard to discharging a resident. Record review of the facility guide that was not dated and read Planned Discharge Documentation read in part .send medication with exception of discontinued medications and/or narcotics, with Resident and/or RP. Provide education on medications and administration to Resident and/or RP and have Resident and RP sign verification of any medications received upon discharge as applicable .

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy. Resident #1's October 2025 MARs did not reflect documentation that Diclofenac three times a day was done as ordered. Resident #2's October 2025 MARs did not document Accu-check as done on 10/2/2025. This deficient practice could place residents at risk for errors in their care and treatment. Record review of Resident #1's admission face sheet, dated 10/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia (a condition were the body does not enough red blood cells), heart failure (when the heart muscle does not pump blood as well as it should), hyperlipidemia(high levels of fat in the blood), hemiplegia/hemiparesis, depression(mental health condition characterized by feelings of sadness and loss of interest in activities), malnutrition (a condition where the body does not have adequate calories such as vitamin, protein and minerals), morbid obesity(sever form of obesity characterized by an high body mass index), chronic diastolic heart failure (a condition where the heart muscle is unable to relax properly) and osteoarthritis (common joint disease that causes pain and stiffness and swelling in the joints). Review of Resident #1's initial MDS, dated [DATE], revealed a BIMS score of 11, indicating Resident #1's cognitive skills for decision making were intact. For functional abilities he was coded: for eating, oral hygiene as set up assistance, for toileting and putting and taking off footwear, he was coded as dependent on staff for assistance, for shower/bathe self, upper/lower body dressing he was coded as needing substantial/maximal assist and for personal hygiene he was partial/moderate assist, for bowel and bladder, he was coded as always incontinent. Record review of Resident #1's physician's order, dated 08/31/2025 and discontinued on 10/13/2025, revealed: Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical), apply to 2g to left knee topically three times a day for pain apply 2g to affected area. Record review of Resident #1's MAR dated 10/2025 revealed:Record review of the MAR dated 10/02/2025 revealed no documentation that Diclofenac Sodium External Gel 1% was administered 5:00pm. There was a blank on the MARS for Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical), apply to 2g to left knee topically three times a day for pain. Record review of Resident #1's nurse's progress notes, dated 10/02/2025 written by, revealed no documentation as to why the treatment was not done Record review of Resident #2's admission face sheet, dated 10/24/2025, revealed Resident #2 was an [AGE] year-old female admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), hyperlipidemia (high level of fat in the blood), malnutrition (when the body does not get enough calories, vitamin , minerals and protein), schizophrenia (a chronic mental health condition that impacts a person's thoughts, feeling and behaviors), anxiety disorder (mental health condition characterized by worry, fear and nervousness), depression (mental health condition characterized by feelings of sadness and loss of interest in activities), muscle weakness (loss of muscle strength), and dysphagia (difficulty swallowing). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 02, indicating Resident #2 was cognitively impaired, indicating skills for decision making were not intact. For Functional abilities, she was coded: for eating - supervision assistance, for toileting - putting on and taking off footwear, shower/bathe self, upper/lower body dressing, and for personal hygiene she was coded as partial/moderate assist, and for bowel and bladder, she was coded as always incontinent. Record review of Resident #2's physician's order summary report revealed an order for Accu-Chek twicedaily, in: AM and PM (Report result over >300 to NP/MD). two times a day related to DM Type 2. Record review of Resident #2's TAR for October 2025 revealed the Accu-Chek was not documented as checked on 10/02/2025 at 5:00pm. Further record review of the TAR revealed there were blanks on the treatment administration records. Record review of Resident #2's nurse's progress notes, dated 10/02/2025, revealed no documentation as to why the Accu Check was not done. Observation on 10/24/2025 at 11:45 am revealed Resident #2 was lying in bed resting. Resident #2 was alert and oriented with confusion. She was clean, well-groomed with no offensive odor, and the call light was observed to be within reached. interview on 10/28/2025 at 4:00 p.m., LVN C said she was not the one who provided treatment to Resident #1. She said there should be no blanks on the MARs/TARs. She said if there were blanks on the MARs/TARs it would be difficult to determine if the medication was given or not given. She said if the treatment or medication was not done there should be a check stating why it was not done but there should be no blanks on the MARs. In an interview on 10/28/2025 at 5:00 p.m., RN A said there should be no blanks on the MARs /TARs. She said whether the treatment was done, or not, it should be documented. She said she must pay more attention and always document when medications were given and or not given. She said blanks on the MARs could indicate the medication was given or not given. She said this should be a learning experience for the nurses to always document and ensure that no blanks were on the MARs. In an interview on 10/28/2025 at 5:30pm, the Administrator said the resident record should be complete and accurate. She said they were going to do a complete audit of resident's medical records. She said the nursing staff would be in-serviced on documentation regarding physician's orders, medication administration and the adverse effect of not documenting could influence resident's care. She said her expectations of the staff were to ensure the physician's orders were followed and documented in the clinical records. She said the plan going forward was to ensure that staff were documenting accurately in resident clinical records. Record review of the facility's policies and procedures dated July 2017 titled Charting and Documentation read in part.Policy StatementAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.Policy Interpretation and Implementation2. The following information is to be documented in the resident medical record:b. Medications administered;c. Treatments or services performed;3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the residents' medical chart as permitted by facility policy.6. To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.7. Documentation of procedures and treatments will include care-specific details, including:a. the date and time the procedure/treatment was provided;b. the name and title of the individual(s) who provided the care;e. whether the resident refused the procedure/treatment;f. notification of family, physician, or other staff, if indicated; andg. the signature and title of the individual documenting.

Based on observation, record review and interview, the facility failed to ensure that residents were free of medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. Resident #1's October 2025 MARs did not reflect documentation that Diclofenac three times a day was done as ordered. This failure could place residents at risk of not getting their medications as ordered, which could result in residents not receiving the therapeutic benefits of the medication including increased pain and decreased quality of life.Record review of Resident #1's admission face sheet, dated 10/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia (a condition were the body does not enough red blood cells), heart failure (when the heart muscle does not pump blood as well as it should), hyperlipidemia(high levels of fat in the blood), hemiplegia/hemiparesis, depression(mental health condition characterized by feelings of sadness and loss of interest in activities), malnutrition (a condition where the body does not have adequate calories such as vitamin, protein and minerals), morbid obesity(sever form of obesity characterized by an high body mass index), chronic diastolic heart failure (a condition where the heart muscle is unable to relax properly) and osteoarthritis (common joint disease that causes pain and stiffness and swelling in the joints). Review of Resident #1's initial MDS, dated [DATE], revealed a BIMS score of 11, indicating Resident #1's cognitive skills for decision making were intact. for functional abilities he was coded: for eating, oral hygiene as set up assistance, for toileting and putting and taking off footwear, he was coded as dependent on staff for assistance, for shower/bathe self, upper/lower body dressing he was coded as needing substantial/maximal assist and for personal hygiene he was partial/moderate assist, for bowel and bladder, he was coded as always incontinent. Record review of Resident #1's physician's order, dated 08/31/2025 and discontinued on 10/13/2025, revealed: Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical), apply to 2g to left knee topically three times a day for pain apply 2g to affected area. Record review of Resident #1's Medication Administration Record for 10/2025 revealed:MAR dated 10/02/2025 in the PM revealed no documentation that the treatment was administered 5:00pm. There was a blank on the MARS for Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical), apply to 2g to left knee topically three times a day for pain apply to affected area. Record review of Resident #1's nurse's progress notes dated 10/02/2025, revealed no documentation as to why Diclofenac Sodium External Gel 1% (topical) for pain was not done. During an observation on 10/24/2025 at 11:55 a.m., Resident #1 was lying in bed resting. Resident #1 was alert and oriented and could make his needs known. He was clean, well-groomed with no offensive odor, and the call light was observed to be within reach. In an interview on 10/24/2025 at 11:55 a.m., Resident #1 said he was not abused or neglected by staff. He said sometimes, he did not get what he ordered to eat. He said he was getting routine pain medication for his knee but now he gets his pain medication when he complained of pain, and they always give it to him. In an interview on 10/28/2025 at 4:00 p.m., LVN C said she was not the one who provided treatment to Resident #1. She said there should be no blanks on the MARs/TARs. She said if there were blanks on the MARs/TARs it would be difficult to determine if the medication was given or not given. She said if the treatment or medication was not done there should be a check stating why it was not done but there should be no blanks on the MARs. In an interview on 10/28/2025 at 5:00 p.m., RN A said there should be no blanks on the MARs /TARs. She said whether the treatment was done, or not, it should be documented. She said she must pay more attention and always document when medications were given and or not given. She said blanks on the MARs could indicate the medication was given or not given. She said this should be a learning experience for the nurses to always document and ensure that no blanks were on the MARs. In an interview on 10/28/2025 at 5:30pm, the Administrator said the resident record should be complete and accurate. She said they were going to do a complete audit of resident's medical records. She said the nursing staff would would be in-serviced on documentation regarding physician's orders, medication administration and the adverse effect of not documenting could influence resident's care. She said her expectations of the staff were to ensure the physician's orders were followed and documented in the clinical records. She said the plan going forward was to ensure that staff were documenting accurately in resident clinical records. Record review of the facility policy titled, Medication Administration, dated 07/2025, revealed .21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered.b. the dosage.c. the route of administration.g. the signature and title of the person administering the drug.24. Topical medications used in treatments are recorded on the resident's treatment record (TAR).25. Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, Enhanced Barrier Precautions etc.) for the administration of medications, as applicable.

Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency for Resident #2. - The facility failed to investigate and report (within 2 hours or 24 hours) an incident involving an unwitnessed fall in which Resident #2 sustained a hematoma to the forehead and skin tear to the eyebrow. This failure could place residents at risk of falls not investigated to prevent abuse and neglect.Record review of Resident #2's admission face sheet, dated 10/24/2025, revealed Resident #2 was an [AGE] year-old female admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), hyperlipidemia (high level of fat in the blood), malnutrition (when the body does not get enough calories, vitamin , minerals and protein), schizophrenia (a chronic mental health condition that impacts a person's thoughts, feeling and behaviors), anxiety disorder (mental health condition characterized by worry, fear and nervousness), depression (mental health condition characterized by feelings of sadness and loss of interest in activities), muscle weakness (loss of muscle strength), and dysphagia (difficulty swallowing). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 02, indicating Resident #2 was cognitively impaired, indicating the resident's skills for decision making were not intact. For Functional abilities, she was coded: for eating - supervision assistance, for toileting - putting on and taking off footwear, shower/bathe self, upper/lower body dressing, and for personal hygiene she was coded as needing partial/moderate assist, and for bowel and bladder, she was coded as always incontinent. Record review of nurse's notes, dated 10/1/2025, written by LVN B, revealed, .resident found on floor on left side yelling for help. Resident had bleeding under her left side at temple. Resident was assisted to sitting position - vitals taken BP 105/71 P 80 T97.3 Pulse Ox 98 on room air resident assisted to W/C for further evaluation. Hematoma noted to left forehead with small skin tear on left forehead in center of hematoma. Team health notified - spoke with MD- ordered to send to hospital - family notified. 911 called to transport to nearest hospital. Record review of nurses' notes, dated 10/01/2025, written by LVN B, documented. Received resident from hospital on stretcher with two EMTs-BP 105/58-P65-R 14-T 97.3-Noted on forehead a few abrasions on left side of forehead, no active bleeding, scratched over-Resident alert knows where she was at this time. Bed low position and call light within reach-Educated resident to use call light when she attention -Place call to RP will call back again this shift. During an interview on 10/24/2025 at 12:15 pm. the Administrator was asked if there was an incident report for Resident #2, she said she was going to look for it. The Administrator was informed by the surveyor Resident #2 had an unwitnessed fall with hematoma and was sent to the hospital. At that point she said she was going to look for the incident report. In an interview on 10/24/2025 at 2:42 pm with the DON regarding reporting incidents, she said the staff usually reported incidents to her and the Administrator. She said when incidents were reported to her, she would inform the Administrator. She said the Administrator would investigate and report it to the state. She said unwitnessed falls should be investigated and reported if there were injuries and if the resident was unable to say what caused the fall. Further interview on 10/28/2025 at 10:30 am with the Administrator she said the incident was not investigated and reported. She said she took full responsibility for not investigating and reporting the incident in the 2 hours or 24 hours' time frame for reporting and investigating abuse and neglect. She said the day they told her about the incident she had intended to investigate and report it but did not get a chance. She said she had missed it. In an interview on 10/28/2025 at 3:50pm LVN B said she was the nurse working at the time the incident occurred. She said it was around dinnertime and Resident #2 was in bed, the bed was in the lowest position, and she heard her yelling and when she got to the room the resident was at the door on the floor on her left side and bleeding. She said Resident #2 had a skin tear with blood and hematoma to the forehead. She said she immediately checked her vitals, called the MD, DON, 911, cleaned the area to the forehead and Resident #2 was sent out 911 to the nearest hospital. She said Resident #2 returned from the hospital the same day with no stitches, bleeding, or fracture. In an interview on 10/28/2025 at 5:14pm, the Administrator said usually when there was an incident regarding abuse, neglect or exploitation they would report to the administrator. She said if it were nursing issues then the staff would report to the DON or Charge nurse, and they would inform her. She said she was informed about Resident #2's fall and had got written up because it was not investigated and reported within the reporting time frame. She said she will ensure that all incidents regarding abuse, neglect and exploitation would be investigated and reported in the timely reporting manner. Record review of the facility's Abuse Prohibition Policy, dated 06/02/2025, revealed.INTENT:This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property.Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.POLICY:2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations.3.The facility will designate a qualified staff member to oversee the abuse prohibition program.4. The facility will post the Abuse Prohibition poster in the facility easily visible to residents, families, significant others and staff. Abuse Prohibition Program:The facility's abuse prevention program includes the following components: Screening Training Prevention Identification Investigation Protection Reporting/ Response Investigation:1.The facility will thoroughly investigate all alleged violations and take appropriate actions.2.The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation. 3. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state survey and certification agency.5.Investigations will be prompt, comprehensive and responsive not involves serious bodily injury.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 out of 3 residents (Resident #1) reviewed for adequate supervision.The facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidentsThis noncompliance was identified as Past Non-Compliance Immediate Jeopardy (IJ). The IJ began on 8/21/25 and ended on 8/31/25. The facility corrected the noncompliance by having implemented actions that corrected the non-compliance prior to surveyor entrance. This failure could expose residents living in the facility to safety and accident hazards.Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that include Anoxic Brain Damage (a brain injury that occurs when the brain is deprived of oxygen, which can lead to confusion, speech and vision problems, loss of consciousness, and long-term issues like tremors, memory loss, and difficulty with motor skills) Schizoaffective (a severe mental health condition that combines symptoms of schizophrenia, such as hallucinations and delusions, with a mood disorder like bipolar disorder or depression) and Anxiety Disorder (any of a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIM score of 2 which indicated severe cognitive impairment. Resident #1 could ambulate without assistance with any mobility devices. Resident #1 uses a Wander/elopement alarm daily. Record review of Resident #1's care plan dated 8/7/24 revised on 8/25/25 addressed wandering, read I have been evaluated as a wandering risk r/t decreased safety awareness, confusion and wandering behavior and require the use of a wander guard for safety. Interventions included: I will remain free of injuries associated with wandering behaviors through this review period and check my location frequently. Resident #1's initial wandering evaluation conducted on 8/5/24 indicated he was not a wandering risk. Record review of Resident #1's nursing progress note dated 8/21/25 written by (staff ID) read @ (at) or around 2300 {11:00 PM}, [city] Police knocked on the door and informed this writer that a young male was looking around and messing with the neighbor's belongings and asked if he is a resident of the facility. This writer informed them yes and returned inside the facility with the resident. Upon assessing resident, no injuries were noted and no s/s of pain and/or distress noted at present time. This writer notified RP and DON. Will cont. to monitor. Record review of the facility incident report dated 8/21/25 read in part.Brief narrative summary of the reportable incident: During night shift rounds resident was observed in bed sleeping at 10:15pm. At 11:05pm resident was at front door awaiting to be let in. Resident had wander guard on at time of incident. Resident returned by the local police was found across the street away from the facility for approximately 20 minutes. Resident assessed and no injuries were noted. Resident #1 placed on one-on-one monitoring. RP DON, Administrator notified. Elopement in-service started immediatelySide Door Code changed immediately. Smoking policy and instruction to ensure door security. Interview on 11/6/25 at 9:57 am with Resident #1's Family Member said was notified that Resident #1 eloped. She said the facility had suggested a transfer to a secure location after the elopement, but she did not want the transfer. Observation and interview on 11/6/25 at 10:40 a.m., Resident #1 lying in his bed awake, groomed and presenting no odors or visible injuries. When asked how he was doing, he said fine. No additional questions, including questions about the elopement, were not answered. Observation and Interview on 11/6/25 at 9:25 a.m., the DON said that through the facility investigation, they found that Resident #1 eloped due to Resident #2 propping the door open when she went out to smoke. She said there was no police report filed that the police officer just brought him back to the facility and the police were contacted by a household across the street. She added that Resident #1 was assessed and had no injuries. She said they placed him on one-on-one monitoring. Educated Resident #2 on propping the doors open and performed audit checks on all residents with wander guards. All staff were in-services on elopements, supervision, and smoking rules. She said that the facility had a meeting and believed there was a PIP but would wait for the Administrator to provide that information. The DON was asked to show the area and route Resident #1 eloped to and the door that was propped open at the time was observed, the route and house that Resident #1 eloped to was directly across the street. Interview with the Administrator on 11/6/25 at 11:15 am, she stated that through the facility investigation, they found that Resident #1 eloped due to Resident #2 propping the door open when she went out to smoke. She said Resident #1 was assessed and had no injuries no police report was filed the police officer returned the Resident #1. She said they placed him on one-on-one monitoring. Educated Resident #2 on propping the doors open and performed audit checks on all residents with wander guards. All staff were in-serviced on elopements, supervision, and smoking rules. She said they checked all doors for malfunctioning alarms and there were no issues found, she said the facility hired a new maintenance director, but that person had not started yet. She said that the facility also changed codes to all doors with keypads, in-serviced staff on entry and exit to the facility, making sure the door was completely closed and the staff would have to punch a key code in to allow entrance back into the facility. She said that the facility performed a PIP and would provide the surveyor with all documentation. Observation and interview on 11/13/25 at 11:45 a.m. Resident #2 was in her room, sitting in bed eating dry cereal. She said that she was trained in safe smoking including propping doors. She denied doing propping the door open and said that she remembered something about Resident #1 eloping but did not remember the details. Interview on 11/13/25 at 1:21 p.m., with the Administrator and Director of Clinical Operations added to the interview via telephone at 1:38 pm confirming Performance Improvement Plan on 8/23/25 8/31/25 to ongoing which was attended by the Administrator, DON, and Medical Director. Record review of facility's elopement policy dated revised 1.17.18, 6/23/25; 7/1/25, entitled Wanderer Management, Monitoring System & Resident Elopement Protocol read in part. Purpose:To monitor safety of residents at risk for elopement.to provide a system to alert staff that a resident may be attempting to leave the facility.Policy.It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.Responsibility.All staff is responsible to ensure resident safety. On 11/13/25 at 1:21 p.m., the Administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided on 11/13/25 at 1:21 pm to the administrator in person and via email with signature requested. The facility implemented the following interventions prior to the surveyor : Record review of the facility completed a Performance Improvement Plan dated 8/23/25 to 8/31/25 to which was attended by the Administrator, DON, and Medical Director indicated the following topics were discussed:1. Elopement wandering/leaving the facility training.2. Abuse/neglect training,3. Resident right rights training4. Updated the elopement book and care plans.5. Audit and maintenance check of all residents with wander guards Performance improvement plan with immediate intervention which included:1. Head count,2. Resident returned to facility within 20 minutes and immediately placed on one-on one monitoring by staff.3. Medical Director/RP notified4. Head to assessment completed5. Wandering/elopement evaluation for resident #1-updated.6. Audit on all residents to identify residents at risk for elopement. 7. All smokers re-trained about smoking policy including not to prop doors open. 8. All staff trained on monitoring/supervision and assuring doors are not ajar when smokers go out to smoke. Record review of one-on-one monitoring dated 8/22/25 through 8/25/25 revealed Resident #1 received one-one monitoring from 8/22/25 through 8/25/25. Record review of the Elopement wandering/leaving the facility training in-services dated 8/23/25-8/25 indicated all staff attended the in-services indicated they were in-serviced on abuse and neglect, monitoring/supervision residents, responsibilities to monitor doors on both shifts to insure they are closed, the change of codes to doors and that no one other than staff are allowed to have the codes to doors, elopement policy and procedure, supervision or residents who smoke, wander guard residents monitoring and procedures. Interviews conducted on 11/6/25, 11/12-11/13/25 from various times throughout the investigation the Administrator, AIT, DON, Director of Clinical Operations, the Activity Director, The Social Worker, LVN A, LVN B, RN A, CNA B, CNA C, Med Aide A, The Shower Aide, The Dietary Manager, [NAME] and Kitchen Aide with indicated they were in-serviced on abuse and neglect, resident rights, monitoring/supervision residents, responsibilities to monitor doors on both shifts to insure they are closed, the change of codes to doors and that no one other than staff are allowed to have the codes to doors, elopement policy and procedure, supervision or residents who smoke, wander guard residents monitoring and procedures. Record review of the Abuse/neglect training in-service dated 8/22/25-8/26/25 revealed all staff received in-services on Abuse and Neglect. Interviews conducted on 11/6/25, 11/12-11/13/25 from various times throughout the investigation the Administrator, AIT, DON, Director of Clinical Operations, the Activity Director, The Social Worker, LVN A, LVN B, RN A, CNA B, CNA C, Med Aide A, The Shower Aide, The Dietary Manager, [NAME] and Kitchen Aide with indicated they were in-serviced on abuse and neglect, resident Rights monitoring/supervision residents, responsibilities to monitor doors on both shifts to insure they are closed, the change of codes to doors and that no one other than staff are allowed to have the codes to doors, elopement policy and procedure, supervision or residents who smoke, wander guard residents monitoring and procedures. Record review of the facility elopement book revealed all residents with wander guards had been re-assessed and had measures in place to prevent elopement. Record review of the care plans indicated Resident #1 care plans were revised on 8/25/25 to address the actual elopement. Record review of the Audit and maintenance check of all residents with wander guards indicated there were no issues. Record review of Resident #1's clinical record revealed a Head to assessment was completed on 8/21/25 . Record review of the Wandering/elopement evaluation for Resident #1 was updated on 8/22/25. Record review the facility Audit on all residents to identify residents at risk for elopement was completed on 8/21/25-8/22/25. Record review of the facility documentation of All smokers re-trained on smoking policy including not to prop doors open was completed on 8/25/25. Record review of the monitoring/supervision/redirecting of residents and assuring doors are not ajar when residents that smoke go out in-service dated 8/22/25-8/23/25 indicated all staff were trained. This noncompliance was identified as Past Non-Compliance Immediate Jeopardy (IJ) . The IJ began on 8/21/25 and ended on 8/31/25. The facility corrected the noncompliance by having implemented actions that corrected the non-compliance prior to surveyor entrance.

51036 Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person- centered care plan that included measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 3 of 12 residents reviewed for care plan accuracy (Residents #38, #17, #19), in that: 1. The facility failed to ensure the care plan for Resident #38's Hospice included a focus, goals, or interventions. 2. Facility failed to provide a care plan for Resident # 17's Dialysis. 3. Facility failed to document cerebral vascular accident affecting left side documented on Resident 19's care plan when they have right sided weakness. These failures placed residents at risk of not receiving needed services due to inaccurate comprehensive care plans. Findings include: Resident #38 Record review of Resident #38's face sheet revealed a [AGE] year-old female with admitted [DATE] and diagnoses including Hemiplegia and hemiparesis following cerebrovascular disease (weakness and paralysis on one side of the body), chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), anxiety disorder (feelings of worry, anxiety, fear interfering with daily activities), dementia (neurological condition affecting the brain), major depressive disorder (depression or loss of interest for at least 2 weeks), and chronic kidney disease(gradual loss of kidney function over time). Record review of Resident #38's Significant Change MDS assessment dated [DATE] revealed BIMS score of 07 out of 15 which indicated impaired cognitive skills for daily decision making, unclear speech, sometimes being understood, sometimes understands others, moderate to maximum assistance for ADLs, and dependent for toileting and receiving Hospice care. Record review of Resident #38's undated comprehensive care plan contained no focus, goals, or interventions for Hospice care. Record review of Resident #38's physician orders dated for 2/2025 revealed: Admit to [Hospice Company] (Dx: Cerebral Infarction) 1/11/2025. Record review of Hospice Company contract revealed home health aide, nurses, social work, and chaplain would be provided, with daily care to be provided by the nursing facility. l Observation and attempted interview with Resident #38 on 2/18/25 revealed she was in bed, awake, clean, and was not responding to questions. Resident #17 Record review of Resident #17's face sheet revealed a [AGE] year-old male with admitted [DATE] and diagnoses including end stage renal disease (loss of kidneys to remove waste and balance fluids), Diabetes (inability of the body to control glucose in the blood), vascular dementia (decline in thinking skills), major depressive disorder (persistent depressed mood or loss of interest), peripheral vascular disease (poor circulation due to narrow blood vessels in legs), acquired absence of left leg below knee. Record review of Resident #17's physician orders dated for 2/2025 revealed: Resident to receive dialysis 3 days a week MWF . chair time 11:00a.m. Record review of Resident 17's Significant Change MDS dated [DATE] revealed BIMS 13 out of 15 which indicated modified independence in cognitive skills for decision making, usually understood and understands, moderate to maximum assistance for ADLs, and Dialysis. Record review of Resident #17's undated comprehensive care plan revealed no focus, goals, or interventions for Dialysis. Observation and interview with Resident #17 on 2/18/25 at 10:15am revealed he was sitting in his wheelchair outside the nurses' station. He had a warm coat and a scarf across his shoulders and told surveyor he was going outside and to Dialysis and wanted to be warm. In an interview with MDS nurse on 2/20/25 at 2:30pm revealed if the resident just got on hospice, it would not be on the care plan for 90 days since she does care plans every 90 days. She said the risk of having inaccurate care plans would be they would not get the right care. In an interview with the DON on 2/20/25 at 2:40pm, she said she did not know why the Hospice or Dialysis were missed on the care plan. She said the nurses have input into the care plans and they let the MDS nurse know of any changes, and the MDS nurse would incorporate it into the comprehensive care plan. She said the risk of having inaccurate care plans would be things would not get done for the resident, and it would not be on the Kardex. Resident #19 Record Review of Resident #19's face sheet dated 2/20/25, revealed resident is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, and Hemiplegia (One-Sided Paralysis or Weakness of the Face, Arm and Leg) and Hemiparesis (One-Sided Muscle Weakness caused by Brain, Spinal Cord or Nerve Problems) Following Cerebrovascular Disease (Disorders that affect blood flow to the brain) Affecting Left Dominant Side. Record review of Resident's #19's quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. Record review of Resident #19's care plan revealed that The resident had a cerebral vascular accident (CVA/Stroke) affecting left side which is not correct as Resident 19 has had a cerebral vascular accident (CVA/Stroke) affecting her right side. Record review of Resident #19's occupational therapy notes for certification period of 11/9/24 to 1/7/25 revealed that resident had impaired right upper extremity strength and left upper extremity strength was within functional limits. Record review of Resident #19's doctor's progress note dated 2/14/2025 revealed that Resident #19 had an old CVA (Stroke) with right hemiparesis (One-Sided Muscle Weakness caused by Brain, Spinal Cord or Nerve Problems) listed under the past medical history section. Observation and Interview on 2/18/25 at 11:33 a.m. revealed that Resident #19 could not move her right arm during observation of 10 minutes while initial pool questions were being asked by surveyor. Resident #19 said she had done physical therapy but not in the last couple of months. During an interview on 2/19/25 at 11:31 a.m., the Director of Rehab said that Resident #19 was on physical therapy at the time of the interview. During an interview on 2/19/25 at 2:12 p.m., LVN G said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 2:12 p.m., CMA G said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 2:13 p.m., the DON said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 2:13 p.m., the ADON said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 3:45 p.m., Resident #19 said her right arm had been affected by a stroke in 2019, and she was unable to move her right arm. Resident #19 denied ever having any deficit in her left arm as was documented in Resident #19's care plan. During an interview on 2/19/25 at 3:45 p.m., Resident #18 Family said that Resident #19 had difficulty moving her right arm, and it occurred when she had a stroke in 2019. During an interview on 2/20/25 at 8:49 a.m., the ADON said the MDS nurse entered information into the residents' care plans. During an interview on 2/20/25 at 8:50 a.m., the DON said the MDS nurse entered information into the resident's care plans. During an interview on 2/20/25 at 9:19 a.m., Casemix Specialist A said she was the MDS nurse, but her title was Casemix Specialist. Casemix Specialist A said that care plan information was entered by the MDS nurse. Casemix Specialist A said that the information for left hemiplegia on Resident 19's care plan was initially entered by Casemix Specialist B who was the Casemix Specialist at the time. Casemix Specialist A said that she reviewed the resident's care plans every 90 days but generally reviewed things that were acute and going to change. Casemix Specialist A said she was familiar with Resident #19 and that her right side was affected. Record review of the facility's policy Care Plans, Comprehensive Person Centered revealed, in part: Care plans describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being .to identify professional services responsible for each resident's care . and Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Also, assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Care Plans, Comprehensive Person-Centered policy was reviewed November 2024.

Based on interview and record review the facility failed to coordinate the assessments with the pre admission screening and resident review (PASARR program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort which includes incorporating the recommendations from the PASRR level II determination and the PASARR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 4 residents Resident #1 reviewed for PASARR. Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The Facility failed to provide Resident #1 specialized services of PT, OT, and ST. Based on record review November 15, 2022 was the date listed in Simple LTC PASARR Portal. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident#1's OT, PT, and ST specialized services by a specific deadline. This failure could place residents at risk for not receiving specialized PASARR services which could contribute to a decline in physical, [NAME] psychosocial well-being and quality of life. Findings include: Record review of Resident #1's electronic face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, intellectual disability, Mood disorder, (bipolar disorder and Major depression (A serious mental illness characterized by extreme mood swings, panic, or other severe anxiety disorder.) Record review of Resident #1'sAnnual MDS assessment, dated 01/25/24, reflected Resident #1 was positive for intellectual disability and other related condition. Her cognitive patterns Brief Interview for Mental Status (BIMs ) were coded as 13 out of possible 15, which reflected she was cognitively intact. Record review of Resident #1 care plan, updated on 4/25/24, reflected the resident had a positive PASARR Level II for developmental Disability. Goal Resident #1 will receive all specialized services related to positive PASARR through the next 92 days target date of 05/27/24. Record review of the undated Simple LTC PASARR NFSS Activity Portal History, for Resident #1, reflected the NFSS form was completed and submitted for PT\OT and ST on 06/28/2019 but was rejected. Reason was wrong therapy services such as PT, OT and SP. During interview with the Rehab Director, on 8/6/24 at 12:00 PM, she stated the PASARR was just approved on 7/26/2024 and Resident #1 was currently receiving PT only for the next 6 months. The Rehab Director stated she was not aware who submitted the PASARR form, but she recalled it being rejected due to doctor signature. The Rehab Director stated she would enter the Resident's information for specialized services into the system once she got the ok from the MDS coordinator. The Rehab Director stated she had been employed at the facility for 3 years. During an interview with the MDS Coordinator on 08/06/24 at 1:00 PM, she said she did not complete the forms and corporate would complete the form and send it to the facility and was not sure why Resident #1's PASARR was not completed. The MDS Coordinator stated she just started in April of this year. She said the therapy department was supposed to complete the NFSS forms and send them in through the LTC online portal. Record review of a statement from the PASARR Unit Program Specialist of IDD Services reflected as discussed on the phone, you will need to submit a NFSS request forms for PASARR Specialized Services (Therapies and Assessments PT) by 6/10/2024 and customized manual wheelchair by 6/12/2024 through the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Portal. The resident has not received a Medicaid service because of the following: The nursing facility administrator and MDS nurse was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal by the nursing facility was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASARR for the residents. Based on interview with MDS nurse on 08/06/24 at 2:00pm she stated that she could not give me an answer to why the NFSS form was not completed. She also stated that the facility corporation handle all PASARR information. She also stated she started in April and can not say to why or why not the previous MDS nurse did or not did. MDS nurse stated she was made aware as of today that Resident#1 was not receiving services. She also stated that she understands that is important for all Residents to receive the services they deserve to have because this would improve their quality of life. Record review of PASARR requirement, dated 11/10/2023, Titled Companion Guide for Completing the Authorization Request for PASARR Nursing Facility Specialized Services (NFSS) Form, Page 9, read in part . NFSS Request More Than 30-Calendar Days After IDT Meeting If the nursing facility is submitting the NFSS request more than 20 business days (Approximately, 30 calendar days) after the initial IDT or annual specialized services. meeting, the nursing facility submitters will receive an error message to this effect. This is to notify the nursing facility submitters that they are out of compliance with the requirements in rule and may be subject to a follow-up visit by regulatory staff.

Based on observations, interviews, and records reviewed, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 of 1 kitchen reviewed for dietary services. -The facility failed to provide sufficient dietary staffing for breakfast on 03/29/24. This failure could place residents at risk of not receiving meals at designated mealtimes and a diminished quality of life. The findings included: Observation and interview on 04/01/24 at 11:41 a.m., revealed Resident #3 was lying in bed. She said last Saturday, 03/30/24, or Friday, 03/29/24, they had kolaches and donuts for breakfast. She said she usually ate cereal for breakfast, but it was something she could eat and did not have any concerns about what was served. Observation and interview on 04/03/24 at 3:49 p.m., revealed Resident #6 was lying in bed. She said she had been feeling under the weather since she had returned from the hospital. She said the facility served donuts and kolaches last Friday, 03/29/24, for breakfast and she had enough to eat. She said it was an isolated incident, the Dietary Manager was on suspension, and it was corrected the next day. She said she asked questions about it because she was the Resident Counsel President. In an interview on 04/01/24 at 2:40 p.m., CNA B said she worked 6:00 a.m. to 3:00 p.m. on Friday 03/29/24. She said she believed that was the day they had to order breakfast for the residents. She said she texted the Administrator, DON, and ADON at 7:19 a.m. to let them know there was no one in the kitchen. She said she told the Charge Nurse there was no dietary staff at the facility and said the Charge Nurse called the DON. She said kolaches and donuts were ordered for the residents. In an interview on 04/01/24 at 4:02 p.m., the ADON, said there was no dietary staff on 03/29/24 to make breakfast. She said the facility ordered kolaches and donuts for the residents to eat. She said she was not notified about the dietary staff not showing up and found out that morning when she arrived to work at 8:07 a.m. She said she did not know what happened to the dietary staff. In an interview on 04/03/24 at 9:06 a.m., the DON said she was notified by telephone and text message, a little before 7:30 a.m. on 3/29/24 by the Charge Nurse, telling her that no one had shown up in the kitchen yet. She said after she was notified, she called the Administrator, and the Administrator called the Corporate Regional Nurse to let her know. She said the Corporate Regional Nurse said to go ahead and order breakfast. She said breakfast was ordered and delivered to the building. She said she was told they had delivered donuts, kolaches, oatmeal, and did not remember if they ordered cereal or got the cereal from the kitchen. She said the only conclusion she could come to about the dietary staff was there was a no call, no show. She said from there the dietary staff was called. She said if dietary staff were not at the facility to make breakfast, then it was not prepared on time and could come out late. In an interview on 04/03/24 at 9:13 a.m., Dietary Aide A said she was scheduled to work on Friday, 03/29/24, in the afternoon from 1:00 p.m. to 7:30 p.m. She said the Administrator called her first, between 7:00 a.m. and 7:30 a.m., but she did not answer the call. She said CNA A then called her at approximately at 8:00 a.m. and asked her to come in to work because there was no cook or tray aide at the facility. She said she told CNA A she would call [NAME] A so someone could be there to cook. She said she called [NAME] A right after she was called and asked her to come to work because there were no workers in the kitchen that showed up. She said she arrived at the facility at approximately 9:00 a.m. She said when she arrived at the facility [NAME] A was already there. She said they did not have to make breakfast that morning because she thinks they bought breakfast for the residents. She said she did not know what happened to the morning kitchen staff and that Dietary Aide B was scheduled to work that morning in the kitchen. A telephone interview on 04/03/24 at 9:51 a.m., with Dietary Aide B was attempted. The call was answered but then disconnected. A text message was sent at 9:52 a.m. requesting a return phone call. In an interview on 04/03/24 at 9:58 a.m., the Dietary Manager said she worked Monday through Friday, from 6:00 a.m. to 2:00 p.m. and was responsible for making the dietary aide schedule. She said on Thursday, 03/28/24, at approximately 2:25 p.m. she was placed on a 3-day suspension. She said the dietary staff schedule for that week had already been made. She said [NAME] A told her she could not work on Fridays, and some other days, on the previous day, Thursday, 03/28/24, between 2:00 p.m. and 2:30 p.m. She said Dietary Aide B was supposed to work Friday, 03/29/24, from 6:00 a.m. to 1:30 p.m., and on Saturday and Sunday from 6:00 a.m. to 7:30 p.m. She said Dietary Aide B sent her a text message Friday morning, 3/29/24, at approximately 8:00 a.m. telling her that she quit. She said she did not let management, or the workers know because she was on suspension. In an interview on 04/03/24 at 11:10 a.m., the Administrator said the dietary manager had been suspended on Thursday, 03/28/24, late in the afternoon and realized then that the Dietary Manager and Dietary Aide B was scheduled to work on Friday, 03/29/24. She said she called the Dietary Manager to let her know that she noticed they were scheduled to work. She said the Dietary Manager said not to worry, that she already notified her staff, and people would be in place. She said the Charge Nurse called the DON around 7:20 a.m. but she was not reached until around 7:40 a.m. She said she immediately tried to call [NAME] B but was unable to reach her. She said she then called the Corporate Regional Nurse at approximately 7:46 a.m. who told her to order food for residents. She said food was ordered at approximately 7:57 a.m. She said kolaches, donuts, and a separate order of apple juice, orange juice, and oatmeal was made. She said Dietary Aide B was a no call/no show and was terminated. She said she was told by the Dietary Manager, yesterday, 04/02/24 that Dietary Aide B notified her that she quit but she did not know what day she told the Dietary Manager. Interview on 04/03/24 at 3:33 p.m., revealed Resident #4 said he was doing pretty good. He said he was able to eat the donuts and kolaches that were served this past week for breakfast and did not have any trouble eating. Interview on 04/03/24 at 3:38 p.m., revealed Resident #5 said she was doing okay. She said they served donuts and kolaches this past week, 03/29/24, because there was no staff in the kitchen to make breakfast, because no one showed up. She said she was able to eat the food without difficulty and that it was enough for her. In an interview on 04/15/24 at 10:55 a.m., [NAME] A said she was not scheduled to work on Friday, 03/29/24. She said she was off that day, but Dietary Aide A called her at approximately 8:00 a.m. and asked her if she could come to work and mentioned to her that no one showed up to work in the kitchen. She said she arrived at the facility at approximately 9:00 a.m. She said she was the first kitchen staff to arrive. She said she did not have to make breakfast that morning. Record review of time punch cards for all of the dietary staff on 03/29/24, revealed [NAME] A clocked in at 9:07 a.m., [NAME] B clocked in at 1:13 p.m., and Dietary Aide A clocked in at 9:28 a.m. Record review of the facility's policy titled Staffing, revised October 2017, read in part .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .3. Other support services (e.g., dietary .) are also staffed to ensure that resident needs are met .

Based on interview and record review, the facility failed to ensure each resident received and was provided food prepared in a form designed to meet individual needs for 2 (Resident #1 and Resident #2) of 5 residents reviewed for food preparation. -The facility failed to ensure Resident #1 and #2 received a pureed diet as ordered by the physician. This failure could place residents at risk for poor intake, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs). The findings included: Record review of Resident #1's Admission Record, dated 04/05/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included neuroleptic induced parkinsonism (condition where parkinsonian symptoms occur as a side effect of taking neuroleptic drugs), dysphagia (difficulty in swallowing) following unspecified cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain), dysphagia oropharyngeal phase (first stage of swallowing), and other dysphagia. Record review of Resident #1's physician orders, undated, read in part .enhanced diet, pureed texture, thin consistency, fortified meal plan, ordered 12/29/23, start 12/29/23 . Record review of Resident #1's Quarterly MDS assessment, dated 03/06/24, revealed the BIMS was not completed as resident was rarely/never understood. Further review revealed he required substantial/maximal assistance with feeding. Section K0520, 3. While a Resident, C. Mechanical altered diet and D. Therapeutic diet were checked. Record review of Resident #1's, undated, care plan revealed he had an ADL self-care performance deficit and required extensive assistance with eating. The resident was on aspiration precautions related to history of Dysphagia and interventions included diet to be followed as prescribed. Record review of Resident #2's Admission Record, dated 04/05/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (type of dementia that effects memory, thinking, and behavior) with early onset, Wernicke's encephalopathy (type of brain injury that occurs due to a thiamine deficiency), hypertensive heart disease (group of heart conditions caused by high blood pressure), and increased secretion of gastrin (production and release of hormone made by digestive system). Record review of Resident #2's physician orders, undated, read in part .NAS diet, pureed texture, nectar thickened consistency, pleasure feed only for dysphasia, ordered 03/03/24, start 03/03/24 . Record review of Resident #1's Quarterly MDS assessment, dated 02/15/24, revealed the BIMS was not completed as resident was rarely/never understood. Further review revealed he was dependent with feeding. Section K0520, 3. While a Resident, C. Mechanical altered diet and D. Therapeutic diet were checked. Record review of Resident #2's, undated, care plan revealed he had an ADL self-care performance deficit and required extensive one-person assistance with eating. Further review revealed he required a NAS, mechanical soft texture, nectar thickened consistency diet for dysphagia and interventions included to provide and serve diet as ordered and RD to evaluate and make diet change recommendations PRN, date initiated/created: 05/10/23 and revision on 08/08/23. Observation and interview on 04/01/24 at 12:47 a.m., revealed smothered chicken, lemon rice, chateau vegetables, dinner roll, whole milk, water, and bread pudding was on the lunch menu. Residents #1 and #2 ate their meal in the dining room. Both residents were served the correct pureed food items. Observation and interview on 04/03/24 at 10:50 a.m., revealed Resident #1 was lying in bed watching television. He said he was doing alright. He said he did not remember having oatmeal for breakfast or if they ordered donuts and kolaches this past week on Friday, 03/29/24. In an interview on 04/01/24 at 2:40 p.m., CNA B said she worked 6:00 a.m. to 3:00 p.m. on Friday, 03/29/24. She said she believed that was the day they had to order breakfast for the residents. She said she texted the Administrator, DON, and ADON at 7:19 a.m. to let them know that there was no one in the kitchen. She said she also told the Charge Nurse that there was no dietary staff at the facility and said the Charge Nurse called the DON. She said kolaches and donuts were ordered for the residents and a resident's family member brought a jug of apple and orange juice. She said she believed the ADON arrived at approximately 8 a.m. and opened the kitchen door. She said kolaches and donuts were served to the residents who were not on a special diet. She said nothing was ordered for the residents who were on a pureed diet. She said as far as she remembered, Residents #1 and #2 were the only residents who were on a pureed diet. She said she went to the kitchen and made 6 bowls of oatmeal and grabbed some pre-made orange juice, milk, and water. She said she asked the Charge Nurse if Residents #1 and #2 could have the oatmeal to eat and the orange juice, milk, and water to drink and she said yes. She said she stayed in the dining room during breakfast time and fed Resident #1. She said residents on a pureed diet who received the wrong type of foods to eat could aspirate, have a hard time chewing, and/or difficulty swallowing. In an interview on 04/01/24 at 3:39 p.m., Nurse A said she worked 6:00 a.m. to 6:00 p.m. on 03/29/24. She said kolaches and donuts were ordered for breakfast. She said oatmeal, cold cereal, milk, and juice was also available for the residents. She said the kitchen staff arrived after they finished with breakfast and said she did not know what happened with them. She said the Administrator and DON were notified, she did not know by whom, but said she was going to call them, but was told they already called. She said she did not pass breakfast that morning. She said she was given 2 bowls of oatmeal, thickened juice, a thickened strawberry health shake, and thickened water for Resident #2. She said the residents who were on a mechanical soft diet got cereal and oatmeal. She said the oatmeal was already in a pureed consistency just the way it was made. She said she knew this from her [AGE] years of nursing and looking at a pureed consistency. She said the oatmeal was really, really, soft, and easy for the residents to swallow. She said if a resident was on a pureed diet and got the wrong foods to eat, they could choke if it they were on the diet for chewing and/or swallowing. In an interview on 04/01/24 at 4:02 p.m., ADON, said there was no dietary staff on 03/29/24 to make breakfast. She said the facility ordered kolaches and donuts for the residents to eat. She said apple juice oatmeal, cream of wheat, dry cereal, and premade water, milk, orange juice, thickened liquids, and some kind of custard was provided to the residents who were on a pureed diet. She said CNA B made the oatmeal that morning. She said Residents #1 and #2 were on a pureed diet. She said those 2 residents may have been served oatmeal, custard, and their liquid drinks. She said Resident #1 was on thin liquids and Resident #2 was on nectar thickened. She said she did not know what happened to the dietary staff. She said Resident #2 got 2 bowls of oatmeal. She said she believed everyone got everything they were supposed to. She said if a resident was given the wrong food to eat, they could aspirate. In an interview on 04/03/24 at 9:06 a.m., the DON said she was notified by telephone and text message a little before 7:30 a.m. on 3/29/24 by the Charge Nurse telling her that no one had shown up in the kitchen yet. She said after she was notified, she called the Administrator, and the Administrator called the Regional Nurse [NAME] to let her know. She said [NAME] said to go ahead and order breakfast. She said breakfast was ordered and delivered to the building. She said she was told they had delivered donuts, kolaches, oatmeal, and did not remember if they ordered cereal or got the cereal from the kitchen. She said Residents #1 and #2 were on a pureed diet. She said she did not know what they were served and did not ask. In an interview on 04/03/24 at 9:58 a.m., the Dietary Manager said she worked Monday through Friday, from 6:00 a.m. to 2:00 p.m. and was responsible for making the dietary aide schedule. She said on Thursday, 03/28/24, at approximately 2:25 p.m. she was placed on a 3-day suspension. She said the dietary staff schedule for that week had already been made. She said [NAME] A told her she could not work on Fridays, and some other days, on the previous day, Thursday, 03/28/24, between 2:00 p.m. and 2:30 p.m. She said Dietary Aide B was supposed to work Friday, 03/29/24, from 6:00 a.m. to 1:30 p.m., and on Saturday and Sunday from 6:00 a.m. to 7:30 p.m. She said Dietary Aide B sent her a text message Friday morning, 3/29/24, at approximately 8:00 a.m. telling her that she quit. She said she did not let management, or the workers know because she was on suspension. She said oatmeal did not need to be pureed. She said it was all about preparation. She said by preparation she meant that the box directions needed to be followed to a T. She said Residents #1 and #2 were on a pureed diet. In a telephone interview on 04/03/24 at 10:35 a.m., the Dietician said she had been contracted since November 2023 and spent 10 hours per month at the facility. She said she would not think oatmeal was in its pureed form. She said it should be put into a blender and water should be added until it formed the right consistency that the resident needed. She said Residents # 1 and #2 should be eating pureed oatmeal because regular oatmeal was too thick. She said eating regular oatmeal could lead to choking, food getting into their lungs, and/or more significant food scenarios. Record review of the facility's policy titled Therapeutic Diets, reviewed [DATE], read in part . a therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet or to alter the texture of a diet . Record review of the facility's policy titled Food and Nutrition Services, dated October 2022, read in part . each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .

Based on interview and record review, the facility failed to ensure each resident was free from abuse for one (Resident #1) of fifty- one residents reviewed for abuse. The facility failed to prevent the AD from verbally abusing Resident #1. The AD made the statement where I come form snitches get stitches and end up in ditches. This failure could place 51 residents who participate in activities at risk of verbal abuse and decreased quality of life. Findings Included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a cerebral infraction (area of tissue death to the brain), cognitive communication deficit (difficulty with thinking and using language), depression, and COPD (lung disease). Record review of Resident #1's MDS completed [DATE], revealed a BIMS (interview to determine a resident's mental status) score of 14 (cognitively intact). Record review of Resident #2's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were unspecified fracture of lower limb of right femur, cellulitis of left lower limb, cognitive communication deficit (difficulty with thinking and using language), COPD (lung disease), and depression. Record review of Resident #1's MDS 3.0 completed [DATE], revealed a BIMS (interview to determine a resident's mental status) score of 13 (cognitively intact). Record review of the facility'sgrievance log from January- [DATE] revealed there were not any concerns regarding staff customer service or activities. In an interview on [DATE] at 12:57 pm with the SW, she stated that she attended a care plan meeting for Resident #1 on [DATE]. In attendance were the DON, Admin, and members of Resident #1's family. During the meeting the resident stated that she felt that the AD did not like her and had not liked her since her admission in February of 2024. She stated that earlier that week, the activities director told her Snitches get stitches and end up in ditches. That was the first time any of the staff had heard that and they immediately asked her what happened. The Administrator intervened and told her she would speak to her in private after the care plan meeting. The police were called on site and Resident #1 and the AD were asked to give statements. The psychiatrist was also requested at the facility and arrived the following day on [DATE]. The SW said she followed up with the resident later on [DATE] and asked her how she was feeling. Resident #1 stated that she felt threatened when she heard AD make the comment about stitches. Although she currently felt stressed, she felt better now that everything was out in the open and she was happy that staff were aware so that they could keep an eye on the AD and the resident. The SW stated that the AD had been suspended while the investigation was ongoing and that she had not received any grievances or complaints about the AD. In addition to activities, the AD was head of the resident council, and she would document any grievances from residents and give them to the Admin or DON. The SW stated that she had received training on abuse and neglect the week prior and on [DATE]. In an interview on [DATE] at 1:13 pm, Resident #1 stated that she had been at the facility for about a month and although residents at the facility went on a weekly store outing, she had not been on one since she had arrived. She explained that every time she would ask the AD, there would be an excuse such as the bus was full and she had already picked who she wanted to ride with her. The van the facility used was only able to accommodate so many wheelchairs, but the AD would never schedule her for a different outing/day. On [DATE], Resident #1 told the DON about that, and the DON said she would speak with the AD and make sure that she could go on the next one. Following that, Resident #1 and Resident #2 were sitting in the designated smoking area outside of the facility. The AD came outside and stated Where I come from, snitches get stitches and wind up in ditches. Resident #1 was not sure if this was directed to her but it was said within earshot. Resident #1 felt like the AD was always on her case because Resident #1 did not prefer the activities she provided. On [DATE], the resident was in the hallway and CNA A, who is related to the AD, got too close to her wheelchair and she accidentally ran over her foot. She stated I told her (CNA A) a thousand times do not get too close to my wheelchair and she put her foot directly in front of my wheel. I didn't move fast enough and her foot got caught underneath my wheelchair. CNA A let out a loud scream and staff came to assist her. Resident #1 expressed that the AD was taunting her the following day and told her that she was going to sue the facility and Resident #1. Resident #1 responded that she did not have anything to sue for and the only reason that she was at the facility was because they accepted her insurance. She stated that that along with the comment about snitches, was her last straw and prompted her family to bring up these issues in the care plan meeting. She stated that she did not tell anyone in the facility because she did not want and problems and only wanted piece. She revealed that after her family brought up with situation in the care plan meeting, she felt a sense of relief that the behaviors from the AD were out in the open and that now people from the facility could be watch both the AD and herself. In an interview on [DATE] with the LVN at 2:23 pm, she stated that she saw when Resident #1's electric wheelchair was on CNA A's foot mid-day on [DATE]. She explained that Resident #1 did not have good peripheral vision and explained that she did not respond fast because she was not a quick thinker. She believed that it truly was an accident and did not feel that Resident #1 intentionally ran over the CNA's foot. The CNA left the facility and went to the hospital and came back on [DATE] wearing a boot on her foot. In an interview on [DATE] at 03:02 pm with the AD, she explained that every month she would take ,d+[DATE] residents on a trip of their choice around the county, but she also had to account for the amount of staff who must go to help with residents in wheelchairs. When asked if she kept a list, she stated that she did write it down, but she did not keep a list per visit and she apologized for not keeping up with it. She stated that on Monday's, she would get a list of things that residents requested from the store and take one person to accompany her. She stated that she absolutely did not make the statement where I come from snitches get stitches and end up in ditches and she had never taunted Resident #1. The AD said that she did not know why Resident #1 had a vendetta against her and assumed that her problem could be that Resident #1 wanted to smoke in areas outside of the designated smoking area. During a monthly outing, The AD caught Resident #2 eating a cake inside of the grocery store and she told her that she could go to jail for that. When they returned, she reported Resident #2 to the facility. The AD believed that Residents #1 and #2 were targeting her. When asked if she had been outside with Resident #1 in the designated smoking area, she said maybe, because she was always out there. An attempted interview call was made to CNA A on [DATE] at 03:22 pm. She did not answer and a voicemail was left requesting a call back. In an interview on [DATE] at 03:21 pm with the DON, she recounted that her first time hearing of the behavior between the AD and Resident #1 was at the care plan meeting on [DATE]. A family member of Resident #1 was first to bring it up and Resident #1 stated that the AD said something regarding snitches getting stitches and ending up in ditches. After that was revealed, the staff quickly finished the care plan meeting, and the Administrator began to investigate it because she knew it would be a reportable offense. She had no knowledge of their being any type of static between the AD and Resident #1. She stated that the facility's administration always spoke about abuse and neglect with staff and told the residents that they would want to know those things. In an interview on [DATE] at 03:50 pm with the Admin, she revealed that a care plan meeting was scheduled with Resident #1 and her family because there were some challenges with her following the facility rules. The IDT discussed the idea of switching the resident from a motorized to a mechanical wheelchair and the family understood. When a member of the family mentioned the statement of snitches, the Admin told them that the statement sounded like verbal abuse and a threat. The family stated that they did not believe that Resident #1 was threatened by the AD, but they did want the facility to follow up on the process, which would be to contact the state and the police. The Admin revealed that a witness to the incident was Resident #2, and she stated that the AD did not say it directly to her Resident #1, but she did say it in the air and labeled it as trash or street talk. When the police arrived, Resident #1 was questioned and she stated that she did not want to press charges, however the Admin felt that she needed to be more professional and they always covered topics like customer service in the all staff meeting. The police came to the facility on the afternoon of [DATE] and interviewed Resident #1, Resident #2, and the AD. Resident #1 did not state that the statement from the AD was made directly to her, but she felt strongly that the AD was talking indirectly about her when she said it. Resident #1 told the police that she did not want to press charges, but she was glad that this situation was now in the open. The AD was suspended from work pending the outcome of the investigation and Admin had scheduled an all staff meeting on [DATE] to begin in-services. She stated that a solution going forward may be to separate staff and resident smoking areas and she would be terminating the AD after she discussed the findings with the surveyor after their investigation. When the Admin spoke about the incident where Resident #1 ran over CNA A's foot, she stated that she did not do it on purpose, but she thought that the AD probably thought it was something more serious because her CNA A was in her 70's. After the incident, the facility felt they should transition Resident #1 to a manuall wheelchair. In an interview on [DATE] at 09:30 am, Resident #2 said that the outing last week to the store was horrible. She explained that she ate a banana in the grocery store and that she was from a small town and that was what they did. The AD was very loud when she confronted her and said that's theft!. She stated that made her feel bad and she explained that she had another banana in her basket to weigh at the register so she could pay for the one she ate prior to being confronted. Resident #2 felt that the AD did not speak kindly. She received a phone call during this interview and it was continued at a later time. In an interview on [DATE] at 10:11 am with CNA B, she stated that she had heard the AD say y'all asses are ungrateful. I spent my money on these gifts and y'all don't like it after a game of bingo with the Residents. She explained that the AD had prizes like popcorn, chips, and candy that she purchased out of pocket, but it still did not give her the right to speak like that. Resident #1 was called ungrateful because she had won a headband in bingo, but because Resident #1 only had one functioning arm, she could not use it. CNA B stated that she witnessed the incident between the AD and Resident #1. Afterwards, CNA B stated that she told Resident #1 that she needed to report that incident to the abuse coordinator (Admin). CNA B stated the outburst exhibited by the AD was not an isolated incident and that she believed some residents were afraid. In the follow up interview with Resident #2 on [DATE] at 10:26 am, she recapped that when the AD made the comment about snitches lie in ditches, she had come to the smoking area after Resident #1 and Resident #2 were outside. Resident #2 referred to her comment as slang and said that it didn't bother her, she would just take her comments and try to keep her mouth shut. She stated that she thought that the AD came outside and made the comment because she heard from another employee that Resident #1 told on her to the DON. She felt that the DON did not make the statement directly to Resident #1 and herself, but she said it aloud while they were gathered in the facility smoking area and they were the only 3 people outside. Resident #2 also added that the AD would tell the residents what she bought for bingo, and she would say that she would not ever spend a dime on them. Resident #2 stated that it was not the residents' problem, to have to worry about the finances of stuff, but they heard thenAD speak about it anyways. She recalled a time that Resident #1 asked her what time bingo was and the AD replied There won't be none because I'm tired of spending money around here. The AD also was real ugly about letting Resident #1 know that she was responsible for CNA's foot. Resident #2 stated that We have already enough heck going on. It makes me feel like wow, this is the authority, this is the leadership up here. It makes me feel like Bologna. It's not good to live up here. In a follow up interview on [DATE] at 12:08 pm, CNA B was asked why she did not report any behaviors from the AD to the Admin. She stated that she was honestly in shock when she heard the AD say it. She did not know how the AD would come at her because she was rude and she wanted to avoid the confrontation. She admitted that she was supposed to tell the Admin and she felt comfortable with telling her things like that. She stated that when she heard the comment made by the AD, The steps would be to not address her but follow the chain of command and go to the abuse coordinator (Admin). After, the Admin would do an investigation. She did not feel like the AD would necessarily retaliate, but there would be some kind of tension. She said she knew she should have reported it, but she liked to come to work where things were peaceful and everybody got along. In a follow up interview on [DATE] at 12:15 pm with the Admin, she told the surveyor that she would be writing up CNA B for not informing her about the incident she overheard with the AD and Resident #1. Admin stated that staff talked about abuse and neglect often, and they recently had an in-service on abuse and neglect and how to report it to the abuse and neglect coordinator (Admin). She said that AD and CNA B's behavior was unacceptable. Admin also stated that she had been working at that facility for over [AGE] years and she promoted a see something, say something policy. She also stated that she had no knowledge that the AD had spoken to Resident #2 in a way that made her feel bad when she was at the grocery store during the facility's last outing. Record review of an in-service Titled Resident to Resident Altercation, Verbal Abuse and Neglect dated [DATE] revealed that CNA A, CNA B, and the AD were not in attendance. Record review of an in-service titled Abuse, neglect, workplace violence dated [DATE] revealed CNA A and the AD were in attendance. Record review of the AD's employee personnel file of her nurse aid registry documents revealed that her license expired on [DATE]. The Admin provided an extension document from the TX Nurse Aide registry that revealed HHSC is extending a grace period for all nurse aides to all users time to learn and understand the new credentialing systems. All Nurse aides approvals active on [DATE], will be considered active until [DATE]. Record review of the facility's Abuse Prohibition Policy revised [DATE] specified the facility will prohibit neglect, mental or physical abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Record review of the facility's policy titled Resident rights, revised February 2021, specified that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. Be treated with respect, kindness, and dignity. b. Be free from abuse and neglect c. Voice grievances to the facility, or other agencies that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. d. Have the facility respond to his or her grievances.

Based on interview and record review failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, for one (Resident #1) of fifty- one residents reviewed for abuse. CNA B failed to report verbal abuse from the AD to Resident #1 to the Administrator. This failure could place 51 residents who participate in activities at risk of verbal abuse and decreased quality of life. Findings Included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a cerebral infraction (area of tissue death to the brain), cognitive communication deficit (difficulty with thinking and using language), depression, and COPD (lung disease). Record review of Resident #1's MDS completed [DATE], revealed a BIMS (interview to determine a resident's mental status) score of 14 (cognitively intact). Record review of Resident #2's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were unspecified fracture of lower limb of right femur, cellulitis of left lower limb, cognitive communication deficit (difficulty with thinking and using language), COPD (lung disease), and depression. Record review of Resident #1's MDS 3.0 completed [DATE], revealed a BIMS (interview to determine a resident's mental status) score of 13 (cognitively intact). Record review of the facility'sgrievance log from January- [DATE] revealed there were not any concerns regarding staff customer service or activities. In an interview on [DATE] at 12:57 pm with the SW, she stated that she attended a care plan meeting for Resident #1 on [DATE]. In attendance were the DON, Admin, and members of Resident #1's family. During the meeting the resident stated that she felt that the AD did not like her and had not liked her since her admission in February of 2024. She stated that earlier that week, the activities director told her Snitches get stitches and end up in ditches. That was the first time any of the staff had heard that and they immediately asked her what happened. The Administrator intervened and told her she would speak to her in private after the care plan meeting. The police were called on site and Resident #1 and the AD were asked to give statements. The psychiatrist was also requested at the facility and arrived the following day on [DATE]. The SW said she followed up with the resident later on [DATE] and asked her how she was feeling. Resident #1 stated that she felt threatened when she heard AD make the comment about stitches. Although she currently felt stressed, she felt better now that everything was out in the open and she was happy that staff were aware so that they could keep an eye on the AD and the resident. The SW stated that the AD had been suspended while the investigation was ongoing and that she had not received any grievances or complaints about the AD. In addition to activities, the AD was head of the resident council, and she would document any grievances from residents and give them to the Admin or DON. The SW stated that she had received training on abuse and neglect the week prior and on [DATE]. In an interview on [DATE] at 1:13 pm, Resident #1 stated that she had been at the facility for about a month and although residents at the facility went on a weekly store outing, she had not been on one since she had arrived. She explained that every time she would ask the AD, there would be an excuse such as the bus was full and she had already picked who she wanted to ride with her. The van the facility used was only able to accommodate so many wheelchairs, but the AD would never schedule her for a different outing/day. On [DATE], Resident #1 told the DON about that, and the DON said she would speak with the AD and make sure that she could go on the next one. Following that, Resident #1 and Resident #2 were sitting in the designated smoking area outside of the facility. The AD came outside and stated Where I come from, snitches get stitches and wind up in ditches. Resident #1 was not sure if this was directed to her but it was said within earshot. Resident #1 felt like the AD was always on her case because Resident #1 did not prefer the activities she provided. On [DATE], the resident was in the hallway and CNA A, who is related to the AD, got too close to her wheelchair and she accidentally ran over her foot. She stated I told her (CNA A) a thousand times do not get too close to my wheelchair and she put her foot directly in front of my wheel. I didn't move fast enough and her foot got caught underneath my wheelchair. CNA A let out a loud scream and staff came to assist her. Resident #1 expressed that the AD was taunting her the following day and told her that she was going to sue the facility and Resident #1. Resident #1 responded that she did not have anything to sue for and the only reason that she was at the facility was because they accepted her insurance. She stated that that along with the comment about snitches, was her last straw and prompted her family to bring up these issues in the care plan meeting. She stated that she did not tell anyone in the facility because she did not want and problems and only wanted piece. She revealed that after her family brought up with situation in the care plan meeting, she felt a sense of relief that the behaviors from the AD were out in the open and that now people from the facility could be watch both the AD and herself. In an interview on [DATE] with the LVN at 2:23 pm, she stated that she saw when Resident #1's electric wheelchair was on CNA A's foot mid-day on [DATE]. She explained that Resident #1 did not have good peripheral vision and explained that she did not respond fast because she was not a quick thinker. She believed that it truly was an accident and did not feel that Resident #1 intentionally ran over the CNA's foot. The CNA left the facility and went to the hospital and came back on [DATE] wearing a boot on her foot. In an interview on [DATE] at 03:02 pm with the AD, she explained that every month she would take ,d+[DATE] residents on a trip of their choice around the county, but she also had to account for the amount of staff who must go to help with residents in wheelchairs. When asked if she kept a list, she stated that she did write it down, but she did not keep a list per visit and she apologized for not keeping up with it. She stated that on Monday's, she would get a list of things that residents requested from the store and take one person to accompany her. She stated that she absolutely did not make the statement where I come from snitches get stitches and end up in ditches and she had never taunted Resident #1. The AD said that she did not know why Resident #1 had a vendetta against her and assumed that her problem could be that Resident #1 wanted to smoke in areas outside of the designated smoking area. During a monthly outing, The AD caught Resident #2 eating a cake inside of the grocery store and she told her that she could go to jail for that. When they returned, she reported Resident #2 to the facility. The AD believed that Residents #1 and #2 were targeting her. When asked if she had been outside with Resident #1 in the designated smoking area, she said maybe, because she was always out there. An attempted interview call was made to CNA A on [DATE] at 03:22 pm. She did not answer and a voicemail was left requesting a call back. In an interview on [DATE] at 03:21 pm with the DON, she recounted that her first time hearing of the behavior between the AD and Resident #1 was at the care plan meeting on [DATE]. A family member of Resident #1 was first to bring it up and Resident #1 stated that the AD said something regarding snitches getting stitches and ending up in ditches. After that was revealed, the staff quickly finished the care plan meeting, and the Administrator began to investigate it because she knew it would be a reportable offense. She had no knowledge of their being any type of static between the AD and Resident #1. She stated that the facility's administration always spoke about abuse and neglect with staff and told the residents that they would want to know those things. In an interview on [DATE] at 03:50 pm with the Admin, she revealed that a care plan meeting was scheduled with Resident #1 and her family because there were some challenges with her following the facility rules. The IDT discussed the idea of switching the resident from a motorized to a mechanical wheelchair and the family understood. When a member of the family mentioned the statement of snitches, the Admin told them that the statement sounded like verbal abuse and a threat. The family stated that they did not believe that Resident #1 was threatened by the AD, but they did want the facility to follow up on the process, which would be to contact the state and the police. The Admin revealed that a witness to the incident was Resident #2, and she stated that the AD did not say it directly to her Resident #1, but she did say it in the air and labeled it as trash or street talk. When the police arrived, Resident #1 was questioned and she stated that she did not want to press charges, however the Admin felt that she needed to be more professional and they always covered topics like customer service in the all staff meeting. The police came to the facility on the afternoon of [DATE] and interviewed Resident #1, Resident #2, and the AD. Resident #1 did not state that the statement from the AD was made directly to her, but she felt strongly that the AD was talking indirectly about her when she said it. Resident #1 told the police that she did not want to press charges, but she was glad that this situation was now in the open. The AD was suspended from work pending the outcome of the investigation and Admin had scheduled an all staff meeting on [DATE] to begin in-services. She stated that a solution going forward may be to separate staff and resident smoking areas.When the Adminspoke about the incident where Resident #1 ran over CNA A's foot, she stated that she did not do it on purpose, but she thought that the AD probably thought it was something more serious because her CNA A was in her 70's. After the incident, the facility felt they should transition Resident #1 to a manuall wheelchair. In an interview on [DATE] at 09:30 am, Resident #2 said that the outing last week to the store was horrible. She explained that she ate a banana in the grocery store and that she was from a small town and that was what they did. The AD was very loud when she confronted her and said that's theft!. She stated that made her feel bad and she explained that she had another banana in her basket to weigh at the register so she could pay for the one she ate prior to being confronted. Resident #2 felt that the AD did not speak kindly. She received a phone call during this interview and it was continued at a later time. In an interview on [DATE] at 10:11 am with CNA B, she stated that she had heard the AD say y'all asses are ungrateful. I spent my money on these gifts and y'all don't like it after a game of bingo with the Residents. She explained that the AD had prizes like popcorn, chips, and candy that she purchased out of pocket, but it still did not give her the right to speak like that. Resident #1 was called ungrateful because she had won a headband in bingo, but because Resident #1 only had one functioning arm, she could not use it. CNA B stated that she witnessed the incident between the AD and Resident #1. Afterwards, CNA B stated that she told Resident #1 that she needed to report that incident to the abuse coordinator (Admin). CNA B stated the outburst exhibited by the AD was not an isolated incident and that she believed some residents were afraid. In the follow up interview with Resident #2 on [DATE] at 10:26 am, she recapped that when the AD made the comment about snitches lie in ditches, she had come to the smoking area after Resident #1 and Resident #2 were outside. Resident #2 referred to her comment as slang and said that it didn't bother her, she would just take her comments and try to keep her mouth shut. She stated that she thought that the AD came outside and made the comment because she heard from another employee that Resident #1 told on her to the DON. She felt that the DON did not make the statement directly to Resident #1 and herself, but she said it aloud while they were gathered in the facility smoking area and they were the only 3 people outside. Resident #2 also added that the AD would tell the residents what she bought for bingo, and she would say that she would not ever spend a dime on them. Resident #2 stated that it was not the residents' problem, to have to worry about the finances of stuff, but they heard thenAD speak about it anyways. She recalled a time that Resident #1 asked her what time bingo was and the AD replied There won't be none because I'm tired of spending money around here. The AD also was real ugly about letting Resident #1 know that she was responsible for CNA's foot. Resident #2 stated that We have already enough heck going on. It makes me feel like wow, this is the authority, this is the leadership up here. It makes me feel like Bologna. It's not good to live up here. In a follow up interview on [DATE] at 12:08 pm, CNA B was asked why she did not report any behaviors from the AD to the Admin. She stated that she was honestly in shock when she heard the AD say it. She did not know how the AD would come at her because she was rude and she wanted to avoid the confrontation. She admitted that she was supposed to tell the Admin and she felt comfortable with telling her things like that. She stated that when she heard the comment made by the AD, The steps would be to not address her but follow the chain of command and go to the abuse coordinator (Admin). After, the Admin would do an investigation. She did not feel like the AD would necessarily retaliate, but there would be some kind of tension. She said she knew she should have reported it, but she liked to come to work where things were peaceful and everybody got along. In a follow up interview on [DATE] at 12:15 pm with the Admin, she told the surveyor that she would be writing up CNA B for not informing her about the incident she overheard with the AD and Resident #1. Admin stated that staff talked about abuse and neglect often, and they recently had an inservice on abuse and neglect and how to report it to the abuse and neglect coordinator (Admin). She said that AD and CNA B's behavior was unacceptable. Admin also stated that she had been working at that facility for over [AGE] years and she promoted a see something, say something policy. Record review of an in-service Titled Resident to Resident Altercation, Verbal Abuse and Neglect dated [DATE] revealed that CNA A, CNA B, and the AD were not in attendance. Record review of an in-service titled Abuse, neglect, workplace violence dated [DATE] revealed CNA A and the AD were in attendance. Record review of the AD's employee personnel file of her nurse aid registry documents revealed that her license expired on [DATE]. The Admin provided an extension document from the TX Nurse Aide registry that revealed HHSC is extending a grace period for all nurse aides to all users time to learn and understand the new credentialing systems. All Nurse aides approvals active on [DATE], will be considered active until [DATE]. Record review of the facility's Abuse Prohibition Policy revised [DATE] specified the facility will prohibit neglect, mental or physical abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Record review of the facility's policy titled Resident rights, revised February 2021, specified that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. Be treated with respect, kindness, and dignity. b. Be free from abuse and neglect c. Voice grievances to the facility, or other agencies that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. d. Have the facility respond to his or her grievances.

Based on observation, interview, and record review, the facility failed to ensure the resident has the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. -The facility failed to ensure Resident #1 was free from abuse when CNA A allowed her significant other to verbally abuse Resident #1, allowed the significant other entry into the facility, and took him to Resident #1's room. The Significant other then threatened Resident #1 by pointing a gun at him. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of physical harm, mental anguish or emotional distress, pain and/or death. The findings included: Record review of Resident #1's Admission Record, dated 03/05/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), paraplegia (condition that affects the lower half of the body, making it hard or impossible to walk, stand, or control the pelvic muscles), acute transverse myelitis demyelinating disease of central nervous system (neurological condition wherein the spinal cord is inflamed), and acquired absence (medical condition that indicates the loss or amputation) of right leg below knee. Record review of Resident #1's Quarterly MDS assessment, dated 02/05/24, revealed a BIMS score of 15, indicating intact cognitive skills. Further review revealed he required substantial/maximal assistance with toileting, bathing, and dressing. Record review of Resident #1's undated care plan revealed he required staff assistance for meeting emotional, intellectual, physical, and social needs related to physical limitations. The resident required extensive assistance with bed mobility and total assistance with transfers. Observation and interview on 03/04/24 at 12:15 p.m., revealed Resident #1 was lying in bed watching television. He said on 03/03/24 (he could not recall the time) Nurse B was in his room performing wound care on him while CNA A assisted. He said CNA A's phone kept going off and Nurse B told her not to answer. He said when they were done with his wound care, CNA A finally answered her phone, and it was her significant other. He said he could hear CNA A's significant other yelling at her and saying bitch, why didn't you answer this motherfucking phone. It does not take two hours to do wound care. He said he told Nurse B maybe CNA A's significant other needed to get his RN license or CNA so he could see that it took that long to do wound care. He said CNA A's significant other told her to tell him to shut the fuck up and CNA A told him. He said CNA A put her significant other on speaker phone and Resident #1 said he told him [NAME], you shut the fuck up. He said CNA A's significant other and him continued to curse at one another. He said CNA A left his room and came back approximately two minutes later and told him he needed to apologize to her significant other who was on speaker phone. He said her significant other also told him that he needed to apologize to him. He said he told them he was not going to apologize, and CNA A left his room again. He said it felt like CNA A was gone for approximately four to five minutes after she left his room the second time. He said Resident #2 was in his room when CNA A and her significant other entered his room. He said CNA A's significant other told her to get her bitch ass out and she left the room. He said he told Resident #2 to leave the room and he left. He said CNA A's significant other pulled out a gun and pointed it at him. He said soon after, Nurse B entered his room and pushed the significant other out. He said Nurse B told CNA A and her significant other that CNA A should have never let him in the building. He said he told police he did not want to press charges but did press charges against CNA A's significant other. He said he was not traumatized from having a gun pointed at him but was worried about the other residents. He said he was alright and felt safe at the facility. In an interview on 03/04/24 at 12:55 p.m., the Administrator said she had been working at the facility since August 2022. She said she received a call from the DON on Sunday, 03/03/24, between 2:30 p.m. and 2:50 p.m. She said she was told CNA A was doing wound care with Nurse B on Resident #1. She said she was told that while they were doing wound care, CNA A's significant other called her to go to lunch/go outside but she was saying to him she could not because she was in the middle of helping Nurse B. She said she guessed the significant other said some curse words to CNA A to relay to Resident #1 and from her understanding CNA A relayed what her significant other said to Resident #1. She said she was told Resident #1 said some curse words for CNA A to tell her significant other in return and then it sounded like it escalated to where her significant other wanted to come to the building so he could tell Resident #1 in person what he wanted to tell him. She said to her knowledge CNA A's significant other told her to go to the door and open it. She said CNA A opened the facility's door for her significant other and they went to Resident #1's room. She said she believed there was a yelling match and staff (unknown) called 911. She said the police came to the facility and escorted CNA A and her significant other off the property. She said she told the ADON to start in-servicing on violence in the workplace, abuse, neglect, and exploitation, to conduct safe surveys to check on the residents, gather witness statements, and told the DON to refer the resident to psych services to make sure he was okay and did not suffer any trauma. She said CNA A was suspended until further investigation was completed. She said the police were called and was told they would be patrolling the area a little more frequently for the next two weeks. She said all the keycode pads were recoded. She said they were planning on starting HIPPA staff in-service training violation because CNA A should not have been saying what care she was providing to Resident #1 and/or if the Resident #1's name was mentioned. She said staff were told that there were to be no more cell phones when providing care because it could have prevented the incident from occurring. She said the incident may have happened around 12:30ish p.m. In an interview on 03/04/24 at 1:47 p.m., the ADON said she had been working at the facility since 10/28/23. She said Nurse B called her on 03/03/24 and reported that CNA A and she were doing wound care on Resident #1. She said Nurse B told her CNA A was on the phone with her significant other who told CNA A that it was taking too long to do wound care. She said she was not sure if CNA A had her phone on speaker or at some point the significant other told CNA A to put the phone on speaker. She said Nurse B told her when CNA A had her phone on speaker, Resident #1 and the significant other started saying f-Us to each other and CNA A's significant other threatened to come to the facility with a handgun to handle Resident #1. She said she went to the facility and the cops were on the scene. She said she found out that CNA A entered the keycode in to the south hall's door, let her significant other inside the facility, and escorted him to Resident #1's room. She said she was present when Nurse B was talking to the cops and Nurse B told them the significant other had a handgun in his waistband. She said she walked away and went to speak with the resident. She said Resident #1 told her CNA A's significant other had a handgun, that it was visible, was in his hand, and went inside his room. She said she asked Resident #1 if the significant other pointed the handgun at him and he told her no. She said she asked him if he felt safe and he told her yes. She said Resident #1 told her he did not feel traumatized and did not need psych services. She said he told her the significant other said he would be back. In a telephone interview on 03/04/24 at 4:14 p.m., Nurse B said CNA A was helping her with Resident #1's wound care and had no clue that she was on the phone because she had her air pods/headphones in her ear. She said she was in the middle of taking off Resident #1's dressings and putting on new ones, and CNA was making and getting the bedding ready. She said CNA A said a few things (did not know what she said) and Resident #1 asked CNA A if she was talking to the air because they did not know she was on the phone. She said out of nowhere, CNA A blurted out it does take me two hours to do wound care. She said CNA A's significant other was upset because it was taking two hours. She said she asked CNA A what she was talking about, and CNA A told her she was talking to her significant other. She said she asked her what she meant, and she said CNA A told her that she answered her phone on her air pods/headphones. She said she asked CNA A to please not do that, especially at bedside. She said CNA A ignored her and continued talking on the phone. She said Resident #1 told CNA A to tell her significant other to go get his RN license and become a nurse and when he got his RN license and had to do wound care, he would see how extensive his wounds were and that it took two hours. She said after Resident #1 said that she carried on with what she was doing and thought CNA A got off the phone but then out of nowhere CNA A told Resident #1 that her significant other said, shut the fuck up. She said she was shocked that CNA A repeated those words, was still on her phone, and said that to the resident. She said she asked CNA A to exit the room, that it was very inappropriate, and why would she tell that to a resident. She said CNA A got an attitude and exited the room. She said CNA A went back to the hall and was walking around talking to her significant other. She said when she was done helping another resident, she went back down to Resident #1's room. She said Resident #1 told her CNA A had come in his room after she left, was on speaker phone with her significant other and cussed him out at bedside. She said that was when she found out CNA A was not down the hall. She said she was super busy because she was at the nurse's station charting, but from the corner of her eye she saw people walk past her but did not see who it was. She said she then heard really, really, really, loud screaming and was like what in the heck and triggered that oh my god it was probably CNA A's significant other going after Resident #1. She said she had a bad feeling about it because of the way they had talked and threatened each other over the phone. She said she jumped up, ran to the room, and heard the significant other tell Resident #1 I'm not a fucking boy, I'm a fucking man, and I am about to show you. She said when she got to the resident's room, CNA A's significant other looked at CNA A and told her to step out the room and shut the door behind her. She said she told CNA A's significant other, oh no, we are not doing this. She said he was at Resident #1's bedside hoovering over him. She said CNA A's significant other was wearing baggy pants and a real big baggy jacket, so she did not see the pistol at first. She said he had one arm around his waist, and had his other arm bunched up like he was nudging at Resident #1 trying to intimidate him while he was also screaming at him. She said she told CNA A's significant other we are not doing this; you need to get out of the room right now. She said Resident #1 told her that it was okay and to let him stay but she said no we are not doing this. She said she told Resident #1 they were not going to have him in there threatening him and that it was not happening. She said she was literally screaming at the top of her lungs. She said Resident #1 looked at her again and said that it was okay and to let him stay and she said she told the resident no. She said at that point she was confused and did not understand why the resident was telling her to let him stay. She said she had no clue what was going on and all she knew was CNA A let her significant other in the building and he was screaming at Resident #1 and had a pistol. She said at the time when she got in front of CNA A's significant other, she did not see the pistol. She said when he turned around, she was in between him and Resident #1, and told him to exit the room. She said he was trying to push up against her, nudging her, like a chest pump. She said she would not move so he did not get to Resident #1, but he was trying to stay there. She said she told him no, forced him backwards out of the room, and when he turned around to get in the hallway that was when she saw the pistol. She said when she noticed the pistol, she was like oh my god, just play it off, pretend you did not see it and she continued to escort CNA A and her significant other out of the building. She said she told them there was the exit and kept being forceful with them and said, exit the building, both of y'all. She said when she finally got CNA A and her significant other out the door area, she told both of them, do not come back on the premises, do not come back in this door. She said he did not care when he got out to the door. She said he was flaunting the pistol everywhere. She said he had it in his hand and was nonchalantly talking. She said she shut the door quickly and someone called 911. She said the cops went to the facility and after, she went back in the facility and talked to Resident #1. She said Resident #1 told her he told her to let CNA A's significant other to stay in his room because she did not see the pistol, and he did not want her to get hurt. She said Resident #1 told her it was going to be what it was. She said Resident #1 did not want her or Resident #2 to get hurt or shot if something went down. She said at the time it was not that scary, but when she thought back about it, it was pretty scary. She said she was just in full force mode trying to fix the situation and make it stop and did not think about how serious it was. In an interview on 03/04/24 at 5:33 p.m., CNA B said she had been working at the facility for [AGE] years and worked the 6:00 a.m. to 6:00 p.m. shift. She said she would tell the Administrator if there was someone in the building with a weapon but said she did not know what she would do if the administrator was not at the facility. She said she did not know what the facility's Emergency Procedure - Workplace Aggression/Violence procedure was. In an interview on 03/05/24 at 8:02 a.m., CNA C said she had been working at the facility for approximately 4 months. She said she received ANE, HIPPA, and cell phone use training yesterday, 03/04/24. She said the Administrator went over some other information during the in-service trainings, but she could not remember what it was about. She said she was not feeling well, and her brain was kind of foggy. In an interview on 03/05/24 at 10:08 a.m., CNA D said she had been working at the facility for approximately 2 1/2 years. She said she did not receive Emergency Procedure - Aggression/Violence training. She said it was her signature on the in-service sign in sheet, but said she thought she was just signing off on getting the abuse policy. She said the sign-in sheet did not have the topics listed when she signed. In a follow-up interview on 03/05/24 at 10:32 a.m., CNA B said it was her signature on the in-service sign in sheet. She said they (could not recall who gave out the policies) gave out copy of the policies, reviewed the information, but said she just could not recall what was covered during the in-service trainings. In an interview on 03/05/24 at 12:35 p.m., Resident #2 said he was in Resident #1's room when a man came in and started arguing with Resident #1. He said he did not see a gun and did not know who the man was. He said Resident #1 told him to leave the room and he said he left right away. He said he did not remember what time it happened. In a telephone interview on 03/05/24 at 2:03 p.m., CNA A said she was in Resident #1's room doing care on him. She said her significant other called when she was doing wound care and she answered. She said when she answered the call, Resident #1 said something smart (could not recall what was said) to her significant other. She said Resident #1 then called her significant other a bitch, said he was a stay-at-home dad, and called him a MF word. She said Resident #1 was being vulgar and saying the B word and she told Resident #1 to respect her significant other and he said no. She said she told Resident #1 then to respect her by respecting her significant other. She said she was talking to her significant other on her headphones. She said her significant other did not say anything, but Resident #1 was still talking vulgarly. She said her significant other went to the facility to get her. She said she let her significant other in the building through the side door. She said she took her significant other to Resident #1's room, and he told Resident #1 to respect him as a man three times and then they left. She said her significant other did not have a gun. She said they were in Resident #1's room for about a minute. She said she was not on the phone when she was doing patient care but was on the phone while getting the bed linen up off the floor. In an interview on 03/07/24 at 8:22 a.m., the DON said the ADON notified her on 03/03/24 and she notified the Administrator. She said the ADON told her that CNA A may have to be sent home. She said the ADON told her that CNA A let her significant other in the building and in Resident #1's room. She said when the ADON made it to the building the police were already on the scene, and she said she told the ADON to go ahead and figure out what was going on and to call her back. She said she called the Administrator and told her what the ADON said happened. She said they got on the phone with regional support and the Regional Director of Operations, and the Administrator called in the report to the State. She said the ADON called her back, told her something about CNA A was on her phone, there was something about air pods, and that her significant other could hear conversations. She said she was told there was something about Resident #1 getting smart, phone being put on speaker, and an exchange of words between CNA A's significant other and Resident #1. She said she was told that CNA A's significant other went to the facility, and CNA A let him in Resident #1's room. She said the ADON said Nurse B and Resident #1 saw a pistol. Record review of the facility's policy titled Abuse Prohibition Policy, revised date 11/07/23, read in part .each resident has the right to be free from abuse .Policy: 1. The facility will prohibit neglect, mental or physical abuse .Definitions: Abuse means the willful infliction of injury .intimidation . Record review of the facility's policy titled Emergency Procedure - Workplace Aggression/Violence, dated 06/07/2023, read in part . The following procedure is utilized in the event of a Workplace Aggression/Violence incident in or near our facility. 1. If an incident or verbal aggression escalates or appears to be escalating to physical aggression, announce CODE GRAY: AGGRESSIVE (or any other code as adopted by the facility) with the location of the incident. 2. Call 911 if there is threat-based screaming, fighting, weapons involved, or any threat of danger. IF IN DOUBT, CALL 911. Provide the 911 dispatcher with as much relevant information as possible. 3. Instruct staff to move the residents and themselves immediately to safe, secure refuge and remain there until ALL CLEAR . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on 03/05/24 at 5:03 p.m. The IJ template was presented to the facility and the POR was requested at this time. The following Plan of Removal submitted by the facility was accepted on 03/06/24 at 12:08 p.m. and included: Plan of Removal Immediate Jeopardy On 03/03/2024, an abbreviated survey was initiated at [the facility]. On 03/05/2024 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: F689: Quality of Care, Accidents/Hazards the facility failed to provide a safe environment on 3/3/2024 when CNA allowed her significant other, who was armed with a pistol, to enter the facility through south hall's locked and coded door and access to Resident #1 Room. Administrator/Designee conducted life safety satisfaction assessment for all residents to ensure that no other resident affected completed by 3/5/2024. The facility also conducted In-Services on Workplace aggression/violence and ANE. Documents are in POR binder and uploaded to charts. The facility will follow policy and procedure regarding Workplace Aggression/Violence and ANE. Administrator/Designee will conduct in-services and they will be completed by 3/5/2024. Action on CNA A - suspended pending investigation on 3/3/2024. Psychosocial assessment completed on Resident #1 by social worker and resident no trauma/not affected by incident. Psychologists also saw Resident #1 and agreed to meet therapist on the next visit. Stated he was not affected by the incident. Nurse A was referred to our free services for Psych Services Action: Immediately, on March 5, 2024, Clinical Specialist in serviced DON and ADM to include Quality of care and treatment provided to facility residents. Training and competencies for DON, and ADM were completed on March 5, 2024: workplace violence, facility security, and ANE. On March 5, 2024, ADM/DON initiated in-services with all staff. In-services to include Workplace Aggression/violence and ANE, and life satisfaction surveys and any abnormalities will be given to family, physician, and ADM/DON. Completion date for staff in-services to be completed March 5, 2024. All Nursing staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. HIPAA and no use of cell phone while providing care in services was initiated on March 5, 2024, by ADM. Training will be documented and completed on March 5, 2024. Staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. The above training material (Workplace Aggression/violence and ANE) will be incorporated into the new hire orientation by ADM effective March 5, 2024, and ongoing. On March 5, 2024 an audit was conducted by ADM/Designee to identify other residents with potential trauma of from violence in the work place. Via direct observation, staff interviews, and record review, no other residents were identified as having an issue. In order to monitor current residents for potential risk, ADM/Designee will monitor residents with change in condition daily beginning March 5, 2024, for 30 days on all residents via Life Satisfaction/Trauma. The purpose of this log is to monitor residents with change in conditions. DON compliance will be monitored weekly by ADM/Designee for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted (by ADM/Designee) immediately for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Start Date: 3/5/2024 Completion Date: 3/5/2024 Responsible: ADM and DON. Monitoring of the POR included: During interviews on 03/06/24 and 03/07/24, with staff from all shifts, revealed the following staff members were able to verbalize an understanding of the steps to take if an incident of workplace aggression/violence occurred: Administrator, DON, ADON, Rehab Director, Housekeeping/Laundry Manager, Nurses D, E and F, Medication Aide A, and CNAs A, B, E, and F. Record review of in-service sign in sheets for Workplace Aggression/Violence, ANE, HIPPA and cell phones revealed 44 staff signatures. Record review of Resident Life Satisfaction Round surveys, dated 03/05/24, revealed all 42 resident surveys were completed. Record review of CNA A's personnel file revealed the employee was suspended on 03/03/24 pending the facility's investigation. Record review of Resident #1's progress notes revealed the Social Worker completed a psychosocial assessment and resident reported no trauma from the incident. An Immediate Jeopardy was identified on 03/05/24 at 5:03 p.m. While the IJ was removed on 03/07/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems/plan of correction.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards for 1 (Resident #1) of 5 residents reviewed for quality of care. -The facility failed to provide a safe environment when CNA A allowed her significant other, who was armed with a pistol, entry into the facility's locked building, and access to Resident #1. -The facility failed to provide the Emergency Procedure - Workplace Aggression/Violence training. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of physical harm, mental anguish or emotional distress, pain and/or death. The findings included: Record review of Resident #1's Admission Record, dated 03/05/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), paraplegia (condition that affects the lower half of the body, making it hard or impossible to walk, stand, or control the pelvic muscles), acute transverse myelitis demyelinating disease of central nervous system (neurological condition wherein the spinal cord is inflamed), and acquired absence (medical condition that indicates the loss or amputation) of right leg below knee. Record review of Resident #1's Quarterly MDS assessment, dated 02/05/24, revealed a BIMS score of 15, indicating intact cognitive skills. Further review revealed he required substantial/maximal assistance with toileting, bathing, and dressing. Record review of Resident #1's undated care plan revealed he required staff assistance for meeting emotional, intellectual, physical, and social needs related to physical limitations. The resident required extensive assistance with bed mobility and total assistance with transfers. Observation and interview on 03/04/24 at 12:15 p.m., revealed Resident #1 was lying in bed watching television. He said on 03/03/24 (he could not recall the time) Nurse B was in his room performing wound care on him while CNA A assisted. He said CNA A's phone kept going off and Nurse B told her not to answer. He said when they were done with his wound care, CNA A finally answered her phone, and it was her significant other. He said he could hear CNA A's significant other yelling at her and saying bitch, why didn't you answer this motherfucking phone. It does not take two hours to do wound care. He said he told Nurse B maybe CNA A's significant other needed to get his RN license or CNA so he could see that it took that long to do wound care. He said CNA A's significant other told her to tell him to shut the fuck up and CNA A told him. He said CNA A put her significant other on speaker phone and Resident #1 said he told him [NAME], you shut the fuck up. He said CNA A's significant other and him continued to curse at one another. He said CNA A left his room and came back approximately two minutes later and told him he needed to apologize to her significant other who was on speaker phone. He said her significant other also told him that he needed to apologize to him. He said he told them he was not going to apologize, and CNA A left his room again. He said it felt like CNA A was gone for approximately four to five minutes after she left his room the second time. He said Resident #2 was in his room when CNA A and her significant other entered his room. He said CNA A's significant other told her to get her bitch ass out and she left the room. He said he told Resident #2 to leave the room and he left. He said CNA A's significant other pulled out a gun and pointed it at him. He said soon after, Nurse B entered his room and pushed the significant other out. He said Nurse B told CNA A and her significant other that CNA A should have never let him in the building. He said he told police he did not want to press charges but did press charges against CNA A's significant other. He said he was not traumatized from having a gun pointed at him but was worried about the other residents. He said he was alright and felt safe at the facility. In an interview on 03/04/24 at 12:55 p.m., the Administrator said she had been working at the facility since August 2022. She said she received a call from the DON on Sunday, 03/03/24, between 2:30 p.m. and 2:50 p.m. She said she was told CNA A was doing wound care with Nurse B on Resident #1. She said she was told that while they were doing wound care, CNA A's significant other called her to go to lunch/go outside but she was saying to him she could not because she was in the middle of helping Nurse B. She said she guessed the significant other said some curse words to CNA A to relay to Resident #1 and from her understanding CNA A relayed what her significant other said to Resident #1. She said she was told Resident #1 said some curse words for CNA A to tell her significant other in return and then it sounded like it escalated to where her significant other wanted to come to the building so he could tell Resident #1 in person what he wanted to tell him. She said to her knowledge CNA A's significant other told her to go to the door and open it. She said CNA A opened the facility's door for her significant other and they went to Resident #1's room. She said she believed there was a yelling match and staff (unknown) called 911. She said the police came to the facility and escorted CNA A and her significant other off the property. She said she told the ADON to start in-servicing on violence in the workplace, abuse, neglect, and exploitation, to conduct safe surveys to check on the residents, gather witness statements, and told the DON to refer the resident to psych services to make sure he was okay and did not suffer any trauma. She said CNA A was suspended until further investigation was completed. She said the police were called and was told they would be patrolling the area a little more frequently for the next two weeks. She said all the keycode pads were recoded. She said they were planning on starting HIPPA staff in-service training violation because CNA A should not have been saying what care she was providing to Resident #1 and/or if the Resident #1's name was mentioned. She said staff were told that there were to be no more cell phones when providing care because it could have prevented the incident from occurring. She said the incident may have happened around 12:30ish p.m. In an interview on 03/04/24 at 1:47 p.m., the ADON said she had been working at the facility since 10/28/23. She said Nurse B called her on 03/03/24 and reported that CNA A and she were doing wound care on Resident #1. She said Nurse B told her CNA A was on the phone with her significant other who told CNA A that it was taking too long to do wound care. She said she was not sure if CNA A had her phone on speaker or at some point the significant other told CNA A to put the phone on speaker. She said Nurse B told her when CNA A had her phone on speaker, Resident #1 and the significant other started saying f-Us to each other and CNA A's significant other threatened to come to the facility with a handgun to handle Resident #1. She said she went to the facility and the cops were on the scene. She said she found out that CNA A entered the keycode in to the south hall's door, let her significant other inside the facility, and escorted him to Resident #1's room. She said she was present when Nurse B was talking to the cops and Nurse B told them the significant other had a handgun in his waistband. She said she walked away and went to speak with the resident. She said Resident #1 told her CNA A's significant other had a handgun, that it was visible, was in his hand, and went inside his room. She said she asked Resident #1 if the significant other pointed the handgun at him and he told her no. She said she asked him if he felt safe and he told her yes. She said Resident #1 told her he did not feel traumatized and did not need psych services. She said he told her the significant other said he would be back. In a telephone interview on 03/04/24 at 4:14 p.m., Nurse B said CNA A was helping her with Resident #1's wound care and had no clue that she was on the phone because she had her air pods/headphones in her ear. She said she was in the middle of taking off Resident #1's dressings and putting on new ones, and CNA was making and getting the bedding ready. She said CNA A said a few things (did not know what she said) and Resident #1 asked CNA A if she was talking to the air because they did not know she was on the phone. She said out of nowhere, CNA A blurted out it does take me two hours to do wound care. She said CNA A's significant other was upset because it was taking two hours. She said she asked CNA A what she was talking about, and CNA A told her she was talking to her significant other. She said she asked her what she meant, and she said CNA A told her that she answered her phone on her air pods/headphones. She said she asked CNA A to please not do that, especially at bedside. She said CNA A ignored her and continued talking on the phone. She said Resident #1 told CNA A to tell her significant other to go get his RN license and become a nurse and when he got his RN license and had to do wound care, he would see how extensive his wounds were and that it took two hours. She said after Resident #1 said that she carried on with what she was doing and thought CNA A got off the phone but then out of nowhere CNA A told Resident #1 that her significant other said, shut the fuck up. She said she was shocked that CNA A repeated those words, was still on her phone, and said that to the resident. She said she asked CNA A to exit the room, that it was very inappropriate, and why would she tell that to a resident. She said CNA A got an attitude and exited the room. She said CNA A went back to the hall and was walking around talking to her significant other. She said when she was done helping another resident, she went back down to Resident #1's room. She said Resident #1 told her CNA A had come in his room after she left, was on speaker phone with her significant other and cussed him out at bedside. She said that was when she found out CNA A was not down the hall. She said she was super busy because she was at the nurse's station charting, but from the corner of her eye she saw people walk past her but did not see who it was. She said she then heard really, really, really, loud screaming and was like what in the heck and triggered that oh my god it was probably CNA A's significant other going after Resident #1. She said she had a bad feeling about it because of the way they had talked and threatened each other over the phone. She said she jumped up, ran to the room, and heard the significant other tell Resident #1 I'm not a fucking boy, I'm a fucking man, and I am about to show you. She said when she got to the resident's room, CNA A's significant other looked at CNA A and told her to step out the room and shut the door behind her. She said she told CNA A's significant other, oh no, we are not doing this. She said he was at Resident #1's bedside hoovering over him. She said CNA A's significant other was wearing baggy pants and a real big baggy jacket, so she did not see the pistol at first. She said he had one arm around his waist, and had his other arm bunched up like he was nudging at Resident #1 trying to intimidate him while he was also screaming at him. She said she told CNA A's significant other we are not doing this; you need to get out of the room right now. She said Resident #1 told her that it was okay and to let him stay but she said no we are not doing this. She said she told Resident #1 they were not going to have him in there threatening him and that it was not happening. She said she was literally screaming at the top of her lungs. She said Resident #1 looked at her again and said that it was okay and to let him stay and she said she told the resident no. She said at that point she was confused and did not understand why the resident was telling her to let him stay. She said she had no clue what was going on and all she knew was CNA A let her significant other in the building and he was screaming at Resident #1 and had a pistol. She said at the time when she got in front of CNA A's significant other, she did not see the pistol. She said when he turned around, she was in between him and Resident #1, and told him to exit the room. She said he was trying to push up against her, nudging her, like a chest pump. She said she would not move so he did not get to Resident #1, but he was trying to stay there. She said she told him no, forced him backwards out of the room, and when he turned around to get in the hallway that was when she saw the pistol. She said when she noticed the pistol, she was like oh my god, just play it off, pretend you did not see it and she continued to escort CNA A and her significant other out of the building. She said she told them there was the exit and kept being forceful with them and said, exit the building, both of y'all. She said when she finally got CNA A and her significant other out the door area, she told both of them, do not come back on the premises, do not come back in this door. She said he did not care when he got out to the door. She said he was flaunting the pistol everywhere. She said he had it in his hand and was nonchalantly talking. She said she shut the door quickly and someone called 911. She said the cops went to the facility and after, she went back in the facility and talked to Resident #1. She said Resident #1 told her he told her to let CNA A's significant other to stay in his room because she did not see the pistol, and he did not want her to get hurt. She said Resident #1 told her it was going to be what it was. She said Resident #1 did not want her or Resident #2 to get hurt or shot if something went down. She said at the time it was not that scary, but when she thought back about it, it was pretty scary. She said she was just in full force mode trying to fix the situation and make it stop and did not think about how serious it was. In an interview on 03/04/24 at 5:33 p.m., CNA B said she had been working at the facility for [AGE] years and worked the 6:00 a.m. to 6:00 p.m. shift. She said she would tell the Administrator if there was someone in the building with a weapon but said she did not know what she would do if the administrator was not at the facility. She said she did not know what the facility's Emergency Procedure - Workplace Aggression/Violence procedure was. In an interview on 03/05/24 at 8:02 a.m., CNA C said she had been working at the facility for approximately 4 months. She said she received ANE, HIPPA, and cell phone use training yesterday, 03/04/24. She said the Administrator went over some other information during the in-service trainings, but she could not remember what it was about. She said she was not feeling well, and her brain was kind of foggy. In an interview on 03/05/24 at 10:08 a.m., CNA D said she had been working at the facility for approximately 2 1/2 years. She said she did not receive Emergency Procedure - Aggression/Violence training. She said it was her signature on the in-service sign in sheet, but said she thought she was just signing off on getting the abuse policy. She said the sign-in sheet did not have the topics listed when she signed. In a follow-up interview on 03/05/24 at 10:32 a.m., CNA B said it was her signature on the in-service sign in sheet. She said they (could not recall who gave out the policies) gave out copy of the policies, reviewed the information, but said she just could not recall what was covered during the in-service trainings. In an interview on 03/05/24 at 12:35 p.m., Resident #2 said he was in Resident #1's room when a man came in and started arguing with Resident #1. He said he did not see a gun and did not know who the man was. He said Resident #1 told him to leave the room and he said he left right away. He said he did not remember what time it happened. In a telephone interview on 03/05/24 at 2:03 p.m., CNA A said she was in Resident #1's room doing care on him. She said her significant other called when she was doing wound care and she answered. She said when she answered the call, Resident #1 said something smart (could not recall what was said) to her significant other. She said Resident #1 then called her significant other a bitch, said he was a stay-at-home dad, and called him a MF word. She said Resident #1 was being vulgar and saying the B word and she told Resident #1 to respect her significant other and he said no. She said she told Resident #1 then to respect her by respecting her significant other. She said she was talking to her significant other on her headphones. She said her significant other did not say anything, but Resident #1 was still talking vulgarly. She said her significant other went to the facility to get her. She said she let her significant other in the building through the side door. She said she took her significant other to Resident #1's room, and he told Resident #1 to respect him as a man three times and then they left. She said her significant other did not have a gun. She said they were in Resident #1's room for about a minute. She said she was not on the phone when she was doing patient care but was on the phone while getting the bed linen up off the floor. In an interview on 03/07/24 at 8:22 a.m., the DON said the ADON notified her on 03/03/24 and she notified the Administrator. She said the ADON told her that CNA A may have to be sent home. She said the ADON told her that CNA A let her significant other in the building and in Resident #1's room. She said when the ADON made it to the building the police were already on the scene, and she said she told the ADON to go ahead and figure out what was going on and to call her back. She said she called the Administrator and told her what the ADON said happened. She said they got on the phone with regional support and the Regional Director of Operations, and the Administrator called in the report to the State. She said the ADON called her back, told her something about CNA A was on her phone, there was something about air pods, and that her significant other could hear conversations. She said she was told there was something about Resident #1 getting smart, phone being put on speaker, and an exchange of words between CNA A's significant other and Resident #1. She said she was told that CNA A's significant other went to the facility, and CNA A let him in Resident #1's room. She said the ADON said Nurse B and Resident #1 saw a pistol. Record review of the facility's policy titled 'Emergency Procedure - Workplace Aggression/Violence, dated 06/07/2023, read in part . The following procedure is utilized in the event of a Workplace Aggression/Violence incident in or near our facility. 1. If an incident or verbal aggression escalates or appears to be escalating to physical aggression, announce CODE GRAY: AGGRESSIVE (or any other code as adopted by the facility) with the location of the incident. 2. Call 911 if there is threat-based screaming, fighting, weapons involved, or any threat of danger. IF IN DOUBT, CALL 911. Provide the 911 dispatcher with as much relevant information as possible. 3. Instruct staff to move the residents and themselves immediately to safe, secure refuge and remain there until ALL CLEAR . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on 03/05/24 at 5:03 p.m. The IJ template was presented to the facility and the POR was requested at this time . The following Plan of Removal submitted by the facility was accepted on 03/06/24 at 12:08 p.m. and included: Plan of Removal Immediate Jeopardy On 03/03/2024, an abbreviated survey was initiated at [the facility]. On 03/05/2024 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: F689: Quality of Care, Accidents/Hazards the facility failed to provide a safe environment on 3/3/2024 when CNA allowed her significant other, who was armed with a pistol, to enter the facility through south hall's locked and coded door and access to Resident #1 Room. Administrator/Designee conducted life safety satisfaction assessment for all residents to ensure that no other resident affected completed by 3/5/2024. The facility also conducted In-Services on Workplace aggression/violence and ANE. Documents are in POR binder and uploaded to charts. The facility will follow policy and procedure regarding Workplace Aggression/Violence and ANE. Administrator/Designee will conduct in-services and they will be completed by 3/5/2024. Action on CNA A - suspended pending investigation on 3/3/2024. Psychosocial assessment completed on Resident #1 by social worker and resident no trauma/not affected by incident. Psychologists also saw Resident #1 and agreed to meet therapist on the next visit. Stated he was not affected by the incident. Nurse A was referred to our free services for Psych Services Action: Immediately, on March 5, 2024, Clinical Specialist in serviced DON and ADM to include Quality of care and treatment provided to facility residents. Training and competencies for DON, and ADM were completed on March 5, 2024: workplace violence, facility security, and ANE. On March 5, 2024, ADM/DON initiated in-services with all staff. In-services to include Workplace Aggression/violence and ANE, and life satisfaction surveys and any abnormalities will be given to family, physician, and ADM/DON. Completion date for staff in-services to be completed March 5, 2024. All Nursing staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. HIPAA and no use of cell phone while providing care in services was initiated on March 5, 2024, by ADM. Training will be documented and completed on March 5, 2024. Staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. The above training material (Workplace Aggression/violence and ANE) will be incorporated into the new hire orientation by ADM effective March 5, 2024, and ongoing. On March 5, 2024 an audit was conducted by ADM/Designee to identify other residents with potential trauma of from violence in the work place. Via direct observation, staff interviews, and record review, no other residents were identified as having an issue. In order to monitor current residents for potential risk, ADM/Designee will monitor residents with change in condition daily beginning March 5, 2024, for 30 days on all residents via Life Satisfaction/Trauma. The purpose of this log is to monitor residents with change in conditions. DON compliance will be monitored weekly by ADM/Designee for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted (by ADM/Designee) immediately for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Start Date: 3/5/2024 Completion Date: 3/5/2024 Responsible: ADM and DON. Monitoring of the POR included: During interviews on 03/06/24 and 03/07/24, with staff from all shifts, revealed the following staff members were able to verbalize an understanding of the steps to take if an incident of workplace aggression/violence occurred: Administrator, DON, ADON, Rehab Director, Housekeeping/Laundry Manager, Nurses D, E and F, Medication Aide A, and CNAs A, B, E, and F. Record review of in-service sign in sheets for Workplace Aggression/Violence, ANE, HIPPA and cell phones revealed 44 staff signatures. Record review of Resident Life Satisfaction Round surveys, dated 03/05/24, revealed all 42 resident surveys were completed. Record review of CNA A's personnel file revealed the employee was suspended on 03/03/24 pending the facility's investigation. Record review of Resident #1's progress notes, revealed the Social Worker completed a psychosocial assessment and resident reported no trauma from the incident. An Immediate Jeopardy was identified on 03/05/24 at 5:03 p.m. While the IJ was removed on 03/07/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems/plan of correction.

Based on observation, interview and record review, the facility failed to fully investigate, prevent, and correct an alleged violations of abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 on the North Hall and 2 (Resident #30 and #35) of 17 on the South Hall. The facility did not thoroughly investigate and correct an allegations of abuse that resulted in Resident #7, #8, #9, #23, 30, #35, and #38 causing psycho social harm and fearby TA K, while allowing him to continue working with residents in the facility. The Administrator and DON failed to provide residents necessary protection from staff member (TA K) who was threatening physical and verbal abuse in retaliation against residents who alleged incidents of his abusive behavior On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/22 at 12:30 pm, the facility remained out of compliance at a severity level of more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 09/25/22 at 12:30 PM. This failure could place residents at risk of verbal, mental and physical abuse, neglect and mental anguish. Findings include: Resident #38 Record review of Resident #38's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #38's MDS re-admitted d 05/26/2022 revealed she had a BIMS (brief interview for memory status) of 15 indicating she was cognitively intact and able to make her needs known. Section G (functional status) revealed she required supervision for personal hygiene. Record review of Resident #38's Care Plan dated 05/22/2022 revealed she was at risk for falls, weight loss due to chronic diarrhea, and use of anti-depressant medication. Record review of Resident #38's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During initial tour of the facility on 09/20/22 at 9:35 AM, interview with Resident #38 asked the surveyor what she should do if a staff member threatened her for being a tattle tale. She said she would explain in further detail, but she was on her way to an outing with the activity director and fell ow residents and would explain later. During an interview on 09/21/2022 at 8:00 AM, Resident #38 said TA K worked last night and told her that the state was in the building and that if she told on him (regarding the verbal abuse) it was going to be bad for her (threaten retribution) . She said it was an ongoing issue because of the problems he initially had with the smokers and the complaints against him regarding not giving showers and the allegation of being sexually inappropriate with Resident #35. She said she was afraid of him because of his behaviors, he yells at residents and slams doors and enter rooms without knocking. She said he worked last night (09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM) and told her these things. She said she was told to sign the questionnaire when the thing with Resident #35 came up (sexual abuse allegation) but did not feel comfortable with it. During an interview 09/21/2022 at 8:10 AM with Resident #38's roommate ( Resident #9) who participates in the smoking area was alert and oriented times three (aware of person place and time). said she witnessed TA K making threatening remarks when he came into their room during his shift ( 09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM)(but in the morning-unsure of the exact time) and accused Resident #9 of telling on him (regarding to the showers, and verbal abuse) and when Resident #9 said she did not tell on him, he then accused Resident #38 and said he would get her. Resident #38 understood TA K threatened to physically assault her. During an interview on 09/22/2022 at 2:00 PM with Resident #38, while she was on the telephone with her mother, her mother told the surveyor she was aware of the threats Resident #38 was receiving from TA K and hoped the surveyor will help resolve the threats she was receiving him (from TA K). Resident #35 Record review of Resident #35's undated face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's annual MDS dated [DATE] revealed Resident #35 had a BIMS of 15 indicating she was cognitively intact and able to make her needs known. Section G (Functional Status) revealed she required extensive assistance with dressing, bathing, toilet use and hygiene with one person assistance. Review of Resident #35's Care Plan dated 08/21/2022 revealed resident had communication difficulty, at risk for pressure ulcers, utilize wheelchair for mobility, risk for falls and morbidly obese. Review of the facility's Incident Report dated 08/31/2022 revealed the following: Sexual assault allegation reported by resident (Resident #35) Resident stated male CNA (TA K) hugged her and made a humping movement rubbed his penis against her arms. Resident said she told male CNA (TA K) to stop. Male CNA (TA K) suspended until further notice pending investigation of allegation of sexual assault allegations . Authorities notified . Review of Police Report (undated report case #22- ) revealed Insufficient evidence to substantiate the assault and the State Agency investigator did not find sufficient evidence to substantiate the allegation. Resident #35 disputed their findings and feared TA K. During Resident Council meeting on 09/21/2022 at 10:15 AM, 14 residents attended, Resident #35 was the president of the council (preceding over the meeting). Residents 6 of (14) expressed grievances regarding TA K because he said he would only give out two cigarettes due to the residents complaining about him about showers. The said he told the residents on the smoke break he can do whatever he wanted to and when he gives out the cigarettes for the breaks even though three cigarettes were giving on other breaks. Several (4 on the north hall) residents said TA K would go up and down the hall and slam doors, yell at residents and just walk into rooms without knocking and especially when the ladies were dressing. Surveyor asked residents attending the Resident Council Meeting how many people were afraid of TA, 9 residents held up their hands including Resident #7, #,8, #23, #35 and #38 (4 others did not wish to be identified). Resident #8 Review of Resident #8's undated face sheet revealed she was a [AGE] year-old-female readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's last assessed MDS dated [DATE] revealed she had a BIMS score of 12 indicating she was moderately cognitively impaired but able to make her needs known. Section G (Function Status) revealed she needed set up and supervision with personal hygiene. Review of Resident #8's Care Plan dated 10/11/2018 revealed to participate in activities, risk for falls due to safety awareness, and chronic illness due to lupus ([CONDITION(S)] syndrome). During interview on 09/22/2022 at 10:50 AM Resident #8 said, TA K would yell at the residents and would bump into them inappropriately hugging them. She said she was afraid of TA K; he had a habit of coming into women's room not knocking when he knew they were dressing. She said she was afraid of him because he was always threatening the residents in one way or another (unspecific regarding threats). She said she was told to sign the questionnaire (about Resident #35's sexual assault allegation and if they felt safe) and was uncomfortable about being identified. During an interview on 09/22/2022 at 2:20 PM with Resident #8's family member, (son) said she mentioned the inappropriate behavior TA K displayed (inappropriate hugging, yelling at residents, slamming doors making threatening comments) and he was in the process of getting her moved out. Resident #23 Review of Resident #23's undated face sheet revealed she was a [AGE] year-old-female readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Initial MDS dated [DATE] revealed she had a BIMS score of 14 indicating she was cognitively intact and able to make her needs known. Section G (Function Status) revealed she required extensive assistance with personal hygiene. Review of Resident #23's Care Plan dated 08/10/2022 revealed she was at risk for pressure ulcers and at risk for [CONDITION(S)]. During an interview with Resident #23 on 09/22/2022 at 11:05 AM, she said TA K came one night to change her and told her we need to make love. She said she told him that was a very inappropriate statement. She said, he said she misunderstood him and changed her brief. She said he made her very uncomfortable, and she was lucky she only needed to be changed one time. She said her family member, Resident #32 (lives in same room) said he did not hear the conversation, but TA K goes down the hall and yells and was very loud. Resident #30 Review of Resident #30's undated face sheet revealed he was a [AGE] year-old-male admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's MDS dated [DATE] revealed a BIMS of 3 indicating he was severely cognitively impaired. Section G (Function Status) revealed he required extensive assistance for personal hygiene. During one-on-one interview with Resident #30 on 09/23/2022 3:00 PM, he stated he was familiar with TA K, and he worked the night shift. He stated he was uncomfortable around him and felt intimidated. He stated he would rather stay wet than ask him for help because he could tell it (changing his briefs from an incontinent episode) made TA K mad. He stated no one else made him feel that way. He stated TA K acted mad and smarted off to us when he took the smokers out to smoke. He stated he could not remember what he said but he knew TA K made him feel bad He could not remember a specific date or time. Resident #7 Review of Resident #7's undated face sheet revealed he was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 indicating he was cognitively intact and able to make his needs known. Section G (Functional Section) revealed he required extensive assistance for personal hygiene. During an interview with Resident #7 on 09/22/2022 at 2:45 PM, he said he was always arguing with TA K because he always made a fuss about changing him. He said he called him a [OBSCENITY] and not being a man because Resident #7 needed someone to change him. (Resident #7 said no use to complaining because no one does anything about it. He said they (residents) complain about TA K, but nothing is done (Resident Council grievances) During an interview with the Administrator and DON on 09/22/2022 at 11:40 AM, they said they must find out what was going on. The Administrator said she found out TA K left one night and went home around 11:00 PM (disciplinary documentation stated date of incident 08/31/2022) and was missing for 5 hours. The Administrator said human resources (corporate) told Administrator and DON they had the options of terminating him or counsel him and allow him to return to work. She said we were given that options. The DON said the Aide who worked with him said he left for 5 hours and fell asleep at home. The Administrator said HR (human resources) told them it was clear cut reason to terminate him, but we were given the option of counseling him. The Administrator and DON stated they chose to allow him to return to work. Interview with the Activity Director on 09/22/2022 at 12:15 PM, said she was aware of the problems the residents who participates in the smoke breaks during the smoke breaks (#7, #8, #9 #35, and #38 and four more not willing to be identified) was having with TA (transition assistant) and has given the Resident Council minutes to the ADON (resident council minutes and grievances were reviewed by surveyor prior to the Resident Council meeting on 09/21/2022 at 10:15 AM) and they discuss the problem in the stand-up meetings (morning meeting of facility department heads). She said they counseled him and let him come back. She said she has no influence on who to hire or fire. She said, all I can do is make the Administrator know. During an interview with Resident #38 on 09/22/2022 at 12:35 PM, said the call lights will turn on and a light will come on outside the room, but the alarm will not come on. Resident #38 resides on the hall where TA K works. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. Resident #38 said because of the sexual abuse allegation TA K had to work on the North Hall the call lights would not sound he TA K could be threatening, yell at the resident slam doors and threaten them. Observation of Resident #38's Call light being turned on 09/22/2022 at 12:35 PM revealed the light outside of her room coming on but not audible sound coming on. Observation on 09/23/2022 at 9:30 AM alarm system was checked on the North Hall, in the center of the hall a switch could be turn off and on. When the switch was in the Off position, the audio alarm did not activate when the resident activated the call light system in their room. When the switch was in the on position, the audio alarm sounded when the call light was activated by the resident. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. During an interview with ADON on 09/22/2022 at 4:35 PM, she said she has never been given any of the grievances or Resident Council minutes by the Activities Director and has not been aware of residents being threatened. During an interview with the Administrator on 09/23/2022 at 10:40 AM, surveyor asked if she was aware of the complaints from the residents, that they were being threatened by TA K. She said this was the first time she heard about the complaints and never received any of the Resident Council Minutes or grievances. Administrator was told by the survey team. During interview with CNA I on 09/23/2022 at 3:00 PM, she said she was working the South Hall and noticed the call light panel going off for residents on the North Hall. She said TA K was only allowed to work the North Hall because of the allegations of sexual abuse alleged by Resident #35. She said she went to the North Hall and noticed several call lights on and took care of the residents. She said she then texted TA K and asked where he was, she said he wrote back and said he went home and fell asleep. She said he said he will be back. She said he did not come back untill 5 AM in the morning. She said he threatened her if she told anyone. CNA I was unspecific about the threat but noticed someone was trying to vandalize her car the next night She called the Administrator who said not to take any more calls from him. Record review revealed inappropriate behavior dated 09/21/2022 at 6:00 AM ADON confronted TA K regarding his charting .he did not give a [OBSCENITY] about charting the point of care in the computer, and they would not be done. She said she asked him to discuss the matter with her and he said, he did not have to talk to her . The Administrator told ADON to write down this encounter for disciplinary action. Attempts to interview TA K was made on 09/23/2022 at 2:00 PM, Regional Operations Manager also attempted to call TA K at an undisclosed time on 09/23/2022 for an interview he said TA K hung up the telephone and would not speak to the Regional Operations Manager as told to surveyors. Attempts to interview Charge nurse on 09/23/2022 regarding TA K leaving the facility for 5 hours was made without success in returning telephone calls. During an interview with the Administrator 09/25/2022 at 2:30 PM, she said Resident #35 came to her and said TA K was telling us on smoke break we were all a bunch of liars, and he would preach about he was tight with God, and we were going to hell and Resident #35 was making up the sexual assault allegation. She said regarding the interview of CNA L, Administrator said because of the sexual abuse allegation there were not to be any discussions about what happened that was why she told her not to take any more calls from TA K. When asked by the surveyors what the Administrator thought about TA K calling the residents liars and preaching, she said she told TA K not to preach to the residents anymore. Administrator added TA K has been terminated. Review of Email provided by Administrator to Human Resources dated 09/23/2022 at 8:10 AM confirmed termination of TA K. Review of the Grievances dated 08/28/2022 On 6:30 PM recorded by the Resident Council secretary revealed: during smoke break TA K informed everyone that we were only getting two cigarettes instead of three that we usually get for the last smoke break of the day. When asked why he said we complained about the showers not being given then we were to have our break cut short. Then asked if it was the nurses or the management, he said it was his decision and if we did not like it that we could go in and not go bother to come out for the next smoke break that he would be taking us out on. He told a group since he got in trouble that we were only getting two cigarettes instead of the three. He continues to push the issue about showers so that Resident #7 was the blame for only getting two cigarettes since he complained about the showers . TA K said he was taking us out of the kindness of his heart. TA K continued to argue with Resident #35 and said he was in charge and that what he says is final and if we don't like it, there is the door. It was brought to my attention as Resident Council Secretary by Resident Council President that Resident #35 said when TA K was giving her hugs, he was making a motion as if humping her. Review of the Grievances dated 09/06/2022 revealed the following: (Activities Director and Social Worker in attendance and emergency Resident Council meeting was called) Social Worker - 1. Recognizing and reviewing malicious grievances. Just because you don't like someone is not a reason for a grievance. But if they are threatening you or bullying you or touching you in appropriately or when told not to. This is malicious grievance and should be told to an employee and written up. Harassing is not tolerated in this facility. 2. Only the employees are to call and talk to resident family. No one is to have the phone number It has been brought to the attention that a resident has been calling other resident family unless it's the resident themselves or have the business to call other than the facility or the resident in question. It has been brought to the attention that a resident has been calling other resident family or guardian . Review of the Grievances dated 09/15/2022 recorded by the Resident Council secretary revealed the following: During the 6:30 PM smoke break. One of the aides said something about the one in purple (Resident #35) thinking it was her (related to sexual assault allegation) Things got heated Then TA K said that at this facility the residents have many real Big Liars Then he started in on a soap box sermon about him and God are like that! And that those liars were going to Hell. The residents here will be struck down. I (resident #38 Resident Council Secretary). Told the charge nurse and she said that the incident was reported to her. I did not know that all the situation was not reported. Review of the Grievances dated 09/21/2022 recorded by the R revealed the following: TA K split up the smokers into 2 groups sending out one group. TA K kept stating that the Administrator told him he had to take us out into groups instead of all at once. No one was told of this until we were on our way to the patio. TA K told Resident #8 he could not come outside because he did not have cigarettes. Resident #38 was awakened at 11:30 PM by a loud noise in her room TA K told me If you have any complaints about me (beating his chest) then keep your mouth shut. He then turned to my roommate and asked her if she called the Administrator and report me. She said No. Then he said your neighbor is doing that. On the same day Resident #35 asked to keep her door open, and TA K yelled and slammed the door shut time was 10:15 PM During an interview with Administrator on 09/23/2022 at 4:40 PM she said TA K's only had abuse and neglect training completed with no other modules completed at the time of hire. Review of TA K's hire date provided by the facility was 08/16/2022. Record review of TA K's disciplinary action dated 08/31/2022 revealed the following: Final Warning- Time clock abuse - Not clocking out (5 hours left the building) contacting employees while investigation is ongoing - contacting and engaging with residents during investigation. Immediate termination if this problem occurs (Need) to follow command when leaving the building - clocking out when leaving the building - not reaching out to employees or residents when investigation is ongoing. Review of facility policy and procedure dated June 2021 titled, Abuse Prevention Program revealed the following [in part]: .2 Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The includes but is not limited to freedom from corporate punishment involuntary seclusion verbal mental sexual or physical abuses . 5. Our Center will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 6. Our Center will protect residents from harm, reprisal, discriminating or coercion during investigations of abuse allegations. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the Center management. Findings of abuse investigation will also be reported. 8. Our Center will provide protection for the health, welfare and the rights of each resident residing in the Center to ensure the reporting of crimes. Immediate Jeopardy (IJ) situation was identified on 09/23/2022 at 5:10 PM and the administrator was informed. The IJ template was provided at this time. The POR (Plan of Removal) was accepted on 9/24/2022 at 12:40 PM The POR revealed in part: Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of removal. The facility failed to ensure residents were free from verbal, mental, or sexual abuse. Action Item: 1. Administrator and the DON were suspended on 9/24/22 pending investigation of incident 2. Review of all resident grievances to identify allegations of abuse; all allegations will be reported timely. All residents will be interviewed for active grievances and allegations of abuse 3. Review of all resident grievances occurs daily Monday through Friday in the morning meeting. Any allegations of abuse/neglect will be reported timely. 4. Resident grievance forms are posted on the walls in wall hangers throughout the center. The resident/representative can leave the form in the file folder outside the administrator's office, with or without signing the form. Resident counsel occurred on 9/24/22, the minutes include the grievance process, how to file an anonymous grievance, who the abuse coordinator is, how to report abuse, zero retaliation policy. 5. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. 6. Staff education on the grievance process to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. 7. QA committee will review the POR is effective 8. Safe surveys will be completed with all residents that are interview able; responsible parties will be phone interviewed for all residents that are un-interview able and those residents will be assessed for signs of physical or psychosocial distress. 9. TA K has been terminated as of 9/22/22 and Activity Director will be suspended pending investigation on 9/23/22. 10. Physical and emotional assessments to be completed on all residents. Change of condition events to be completed as identified. The event includes physician and family/responsible parties. Notifications. The Medical Director and resident physicians were notified of the immediate jeopardy on 9/24/22. 11. Employee TA K has notified that he not allowed on property by the Regional Director of Operations on 9/24/22. Staff education completed on terminated employee TA not being allowed on property and to notify Regional Director of Operations and police if former staff member attempts to enter center to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. Regional Director of Operations on 9/24/22 at 2:30 pm initiated education of employees. All will be completed by end of today except for one staff member who is out of state, another is on a second job. Will not be allowed to return to work until training is completed. Observation and interview with Regional Operations Manager 0n 09/25/2022 at 2:40 pm revealed signs related to Resident Council Minuets were posted in the lobby, 2 hallways and behind the glass board. Grievance forms were in the lobby area in a hanging file with signage. Grievance forms were placed in the box outside the Administrators door or can hand it to any department heads. Observation on 09/24/22 at 4:00 pm revealed Regional Operations Director conducting a Resident Council Meeting. He went over the grievance process, how to file a grievance and who the Grievance officer was. Interviewed the following residents on 9/24/2022 at 5:00 pm Resident #20, #31, #11, and #5, (all went to the Resident Council meeting), discussion included how to file a grievance, name of the grievance officer, and retaliation. One resident who did not attend the Resident Council meeting due to being on Transmission Based Precautions said staff came in and educated him on abuse and how to file a grievance. Interview with LVN C on 09/24/22 at 3:00 pm (day shift)stated she had an In-service this morning before she started work. She said she had another one at approx. 10:00 am and another one at 12:30 pm. In services were with ROM and MDS Nurse and BOM. She said in-services were about abuse and reporting abuse and she completed a written test. Interview with Housekeeping Supervisor on 09/24/22 at 3:10 pm (day shift)stated she had was in-service at 8:00 am and at 9:30 am by ROM and MDS Nurse. Housekeeping Supervisor Stated she in-services her employees this morning. Interview Housekeeper and Laundry Aide on 09/24/22 at 3:20 pm (day shift) said they were educated this morning by Housekeeping Supervisor on how to report abuse. Observation on 09/24/22 at 3:30 pm revealed, Business office Manager (BOM) in-servicing, LVN B and Home care 1 on (day shift) concerning Regional [NAME] President was acting Abuse Coordinator and how to report abuse, etc. Interview, with CNA F on 09/24/22 at 3:35 pm (day shift)stated she received education concerning how to recognize abuse and how to report it earlier this morning after the residents had breakfast. All staff educated by ROM took a written test scoring 80% or greater. Observation at 3:37pm revealed ROM educate CNA F concerning the Regional Operations Manager (ROM) is the abuse coordinator and how to report abuse. Interview with LVN B on 09/24/22 at 3:40 pm (day shift)stated she received training this morning shortly after she came to work his morning. The training was conducted by ROM. The training consisted of abuse, how to identify abuse and report it and took a written test. Interview with LVN D on 09/24/22 at 8:44 pm (night shift) said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with CNA I on 09/24/22 at 8:56 pm said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with LVN A on 09/24/22 at 9:00 pm said she was trained before shift by the BOM. The Training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Staff Social Worker, CMA and PT (who are out of town and/or out of the country) will be interview regarding abuse and neglect prior to their shift. The Regional Operations Director, Administrator, DON, ADON, and Corporate Nurse were informed the Immediate Jeopardy was removed on 09/25/22 at 12:40 p.m. The facility remained out of compliance at a severity level of 2 with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews, observations, and record reviews the facility failed to ensure residents were free from abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 residents on the North Hall and 2 (Resident #30 and #35) of 17 residents on the South Hall. The Administrator and DON failed to provide necessary protection from staff member (TA K) who verbally and mentally Intimidated residents by yelling at them in angry tones, slammed resident doors to create fear, threatened residents with physical abuse, used retaliatory behavior in not providing timely care and invaded resident privacy by entering residents rooms without knocking or asking permission when female residents were undressing affecting residents' psycho social well-being causing fear and psycho social harm. On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/22 at 12:30 pm, the facility remained out of compliance at a severity level of more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 09/25/22 at 12:30 PM. These failures could place the residents at an unsafe environment exposing them to verbal, mental and physical abuse, neglect and mental anguish. Findings Included: Resident #38 Record review of Resident #38's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #38's MDS re-admitted d 05/26/2022 revealed she had a BIMS (brief interview for memory status) of 15 indicating she was cognitively intact and able to make her needs known. Section G (functional status) revealed she required supervision for personal hygiene. Record review of Resident #38's Care Plan dated 05/22/2022 revealed she was at risk for falls, weight loss due to chronic diarrhea, and use of anti-depressant medication. Record review of Resident #38's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During initial tour of the facility on 09/20/22 at 9:35 AM, interview with Resident #38 asked the surveyor what she should do if a staff member threatened her for being a tattle tale. She said she would explain in further detail, but she was on her way to an outing with the activity director and fell ow residents and would explain later. During an interview on 09/21/2022 at 8:00 AM, Resident #38 said TA K worked last night and told her that the state was in the building and that if she told on him (regarding the verbal abuse) it was going to be bad for her (threaten retribution) . She said it was an ongoing issue because of the problems he initially had with the smokers and the complaints against him regarding not giving showers and the allegation of being sexually inappropriate with Resident #35. She said she was afraid of him because of his behaviors, he yells at residents and slams doors and enter rooms without knocking. She said he worked last night (09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM) and told her these things. She said she was told to sign the questionnaire when the thing with Resident #35 came up (sexual abuse allegation) but did not feel comfortable with it. During an interview 09/21/2022 at 8:10 AM with Resident #38's roommate ( Resident #9) who participates in the smoking area was alert and oriented times three (aware of person place and time). said she witnessed TA K making threatening remarks when he came into their room during his shift ( 09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM)(but in the morning-unsure of the exact time) and accused Resident #9 of telling on him (regarding to the showers, and verbal abuse) and when Resident #9 said she did not tell on him, he then accused Resident #38 and said he would get her. Resident #38 understood TA K threatened to physically assault her. During an interview on 09/22/2022 at 2:00 PM with Resident #38, while she was on the telephone with her mother, her mother told the surveyor she was aware of the threats Resident #38 was receiving from TA K and hoped the surveyor will help resolve the threats she was receiving him (from TA K). Resident #35 Record review of Resident #35's undated face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's annual MDS dated [DATE] revealed Resident #35 had a BIMS of 15 indicating she was cognitively intact and able to make her needs known. Section G (Functional Status) revealed she required extensive assistance with dressing, bathing, toilet use and hygiene with one person assistance. Review of Resident #35's Care Plan dated 08/21/2022 revealed resident had communication difficulty, at risk for pressure ulcers, utilize wheelchair for mobility, risk for falls and morbidly obese. Review of the facility's Incident Report dated 08/31/2022 revealed the following: Sexual assault allegation reported by resident (Resident #35) Resident stated male CNA (TA K) hugged her and made a humping movement rubbed his penis against her arms. Resident said she told male CNA (TA K) to stop. Male CNA (TA K) suspended until further notice pending investigation of allegation of sexual assault allegations . Authorities notified . Review of Police Report (undated report case #22- ) revealed Insufficient evidence to substantiate the assault and the State Agency investigator did not find sufficient evidence to substantiate the allegation. Resident #35 disputed their findings and feared TA K. During Resident Council meeting on 09/21/2022 at 10:15 AM, 14 residents attended, Resident #35 was the president of the council (preceding over the meeting). Residents 6 of (14) expressed grievances regarding TA K because he said he would only give out two cigarettes due to the residents complaining about him about showers. The said he told the residents on the smoke break he can do whatever he wanted to and when he gives out the cigarettes for the breaks even though three cigarettes were giving on other breaks. Several (4 on the north hall) residents said TA K would go up and down the hall and slam doors, yell at residents and just walk into rooms without knocking and especially when the ladies were dressing. Surveyor asked residents attending the Resident Council Meeting how many people were afraid of TA, 9 residents held up their hands including Resident #7, #,8, #23, #35 and #38 (4 others did not wish to be identified). Resident #8 Review of Resident #8's undated face sheet revealed she was a [AGE] year-old-female readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's last assessed MDS dated [DATE] revealed she had a BIMS score of 12 indicating she was moderately cognitively impaired but able to make her needs known. Section G (Function Status) revealed she needed set up and supervision with personal hygiene. Review of Resident #8's Care Plan dated 10/11/2018 revealed to participate in activities, risk for falls due to safety awareness, and chronic illness due to lupus ([CONDITION(S)] syndrome). During interview on 09/22/2022 at 10:50 AM Resident #8 said, TA K would yell at the residents and would bump into them inappropriately hugging them. She said she was afraid of TA K; he had a habit of coming into women's room not knocking when he knew they were dressing. She said she was afraid of him because he was always threatening the residents in one way or another (unspecific regarding threats). She said she was told to sign the questionnaire (about Resident #35's sexual assault allegation and if they felt safe) and was uncomfortable about being identified. During an interview on 09/22/2022 at 2:20 PM with Resident #8's family member, (son) said she mentioned the inappropriate behavior TA K displayed (inappropriate hugging, yelling at residents, slamming doors making threatening comments) and he was in the process of getting her moved out. Resident #23 Review of Resident #23's undated face sheet revealed she was a [AGE] year-old-female readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Initial MDS dated [DATE] revealed she had a BIMS score of 14 indicating she was cognitively intact and able to make her needs known. Section G (Function Status) revealed she required extensive assistance with personal hygiene. Review of Resident #23's Care Plan dated 08/10/2022 revealed she was at risk for pressure ulcers and at risk for [CONDITION(S)]. During an interview with Resident #23 on 09/22/2022 at 11:05 AM, she said TA K came one night to change her and told her we need to make love. She said she told him that was a very inappropriate statement. She said, he said she misunderstood him and changed her brief. She said he made her very uncomfortable, and she was lucky she only needed to be changed one time. She said her family member, Resident #32 (lives in same room) said he did not hear the conversation, but TA K goes down the hall and yells and was very loud. Resident #30 Review of Resident #30's undated face sheet revealed he was a [AGE] year-old-male admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's MDS dated [DATE] revealed a BIMS of 3 indicating he was severely cognitively impaired. Section G (Function Status) revealed he required extensive assistance for personal hygiene. During one-on-one interview with Resident #30 on 09/23/2022 3:00 PM, he stated he was familiar with TA K, and he worked the night shift. He stated he was uncomfortable around him and felt intimidated. He stated he would rather stay wet than ask him for help because he could tell it (changing his briefs from an incontinent episode) made TA K mad. He stated no one else made him feel that way. He stated TA K acted mad and smarted off to us when he took the smokers out to smoke. He stated he could not remember what he said but he knew TA K made him feel bad He could not remember a specific date or time. Resident #7 Review of Resident #7's undated face sheet revealed he was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 indicating he was cognitively intact and able to make his needs known. Section G (Functional Section) revealed he required extensive assistance for personal hygiene. During an interview with Resident #7 on 09/22/2022 at 2:45 PM, he said he was always arguing with TA K because he always made a fuss about changing him. He said he called him a [OBSCENITY] and not being a man because Resident #7 needed someone to change him. (Resident #7 said no use to complaining because no one does anything about it. He said they (residents) complain about TA K, but nothing is done (Resident Council grievances) During an interview with the Administrator and DON on 09/22/2022 at 11:40 AM, they said they must find out what was going on. The Administrator said she found out TA K left one night and went home around 11:00 PM (disciplinary documentation stated date of incident 08/31/2022) and was missing for 5 hours. The Administrator said human resources (corporate) told Administrator and DON they had the options of terminating him or counsel him and allow him to return to work. She said we were given that options. The DON said the Aide who worked with him said he left for 5 hours and fell asleep at home. The Administrator said HR (human resources) told them it was clear cut reason to terminate him, but we were given the option of counseling him. The Administrator and DON stated they chose to allow him to return to work. Interview with the Activity Director on 09/22/2022 at 12:15 PM, said she was aware of the problems the residents who participates in the smoke breaks during the smoke breaks (#7, #8, #9 #35, and #38 and four more not willing to be identified) was having with TA (transition assistant) and has given the Resident Council minutes to the ADON (resident council minutes and grievances were reviewed by surveyor prior to the Resident Council meeting on 09/21/2022 at 10:15 AM) and they discuss the problem in the stand-up meetings (morning meeting of facility department heads). She said they counseled him and let him come back. She said she has no influence on who to hire or fire. She said, all I can do is make the Administrator know. During an interview with Resident #38 on 09/22/2022 at 12:35 PM, said the call lights will turn on and a light will come on outside the room, but the alarm will not come on. Resident #38 resides on the hall where TA K works. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. Resident #38 said because of the sexual abuse allegation TA K had to work on the North Hall the call lights would not sound he TA K could be threatening, yell at the resident slam doors and threaten them. Observation of Resident #38's Call light being turned on 09/22/2022 at 12:35 PM revealed the light outside of her room coming on but not audible sound coming on. Observation on 09/23/2022 at 9:30 AM alarm system was checked on the North Hall, in the center of the hall a switch could be turn off and on. When the switch was in the Off position, the audio alarm did not activate when the resident activated the call light system in their room. When the switch was in the on position, the audio alarm sounded when the call light was activated by the resident. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. During an interview with ADON on 09/22/2022 at 4:35 PM, she said she has never been given any of the grievances or Resident Council minutes by the Activities Director and has not been aware of residents being threatened. During an interview with the Administrator on 09/23/2022 at 10:40 AM, surveyor asked if she was aware of the complaints from the residents, that they were being threatened by TA K. She said this was the first time she heard about the complaints and never received any of the Resident Council Minutes or grievances. Administrator was told by the survey team. During interview with CNA I on 09/23/2022 at 3:00 PM, she said she was working the South Hall and noticed the call light panel going off for residents on the North Hall. She said TA K was only allowed to work the North Hall because of the allegations of sexual abuse alleged by Resident #35. She said she went to the North Hall and noticed several call lights on and took care of the residents. She said she then texted TA K and asked where he was, she said he wrote back and said he went home and fell asleep. She said he said he will be back. She said he did not come back untill 5 AM in the morning. She said he threatened her if she told anyone. CNA I was unspecific about the threat but noticed someone was trying to vandalize her car the next night She called the Administrator who said not to take any more calls from him. Record review revealed inappropriate behavior dated 09/21/2022 at 6:00 AM ADON confronted TA K regarding his charting .he did not give a [OBSCENITY] about charting the point of care in the computer, and they would not be done. She said she asked him to discuss the matter with her and he said, he did not have to talk to her . The Administrator told ADON to write down this encounter for disciplinary action. Attempts to interview TA K was made on 09/23/2022 at 2:00 PM, Regional Operations Manager also attempted to call TA K at an undisclosed time on 09/23/2022 for an interview he said TA K hung up the telephone and would not speak to the Regional Operations Manager as told to surveyors. Attempts to interview Charge nurse on 09/23/2022 regarding TA K leaving the facility for 5 hours was made without success in returning telephone calls. During an interview with the Administrator 09/25/2022 at 2:30 PM, she said Resident #35 came to her and said TA K was telling us on smoke break we were all a bunch of liars, and he would preach about he was tight with God, and we were going to hell and Resident #35 was making up the sexual assault allegation. She said regarding the interview of CNA L, Administrator said because of the sexual abuse allegation there were not to be any discussions about what happened that was why she told her not to take any more calls from TA K. When asked by the surveyors what the Administrator thought about TA K calling the residents liars and preaching, she said she told TA K not to preach to the residents anymore. Administrator added TA K has been terminated. Review of Email provided by Administrator to Human Resources dated 09/23/2022 at 8:10 AM confirmed termination of TA K. Review of the Grievances dated 08/28/2022 On 6:30 PM recorded by the Resident Council secretary revealed: during smoke break TA K informed everyone that we were only getting two cigarettes instead of three that we usually get for the last smoke break of the day. When asked why he said we complained about the showers not being given then we were to have our break cut short. Then asked if it was the nurses or the management, he said it was his decision and if we did not like it that we could go in and not go bother to come out for the next smoke break that he would be taking us out on. He told a group since he got in trouble that we were only getting two cigarettes instead of the three. He continues to push the issue about showers so that Resident #7 was the blame for only getting two cigarettes since he complained about the showers . TA K said he was taking us out of the kindness of his heart. TA K continued to argue with Resident #35 and said he was in charge and that what he says is final and if we don't like it, there is the door. It was brought to my attention as Resident Council Secretary by Resident Council President that Resident #35 said when TA K was giving her hugs, he was making a motion as if humping her. Review of the Grievances dated 09/06/2022 revealed the following: (Activities Director and Social Worker in attendance and emergency Resident Council meeting was called) Social Worker - 1. Recognizing and reviewing malicious grievances. Just because you don't like someone is not a reason for a grievance. But if they are threatening you or bullying you or touching you in appropriately or when told not to. This is malicious grievance and should be told to an employee and written up. Harassing is not tolerated in this facility. 2. Only the employees are to call and talk to resident family. No one is to have the phone number It has been brought to the attention that a resident has been calling other resident family unless it's the resident themselves or have the business to call other than the facility or the resident in question. It has been brought to the attention that a resident has been calling other resident family or guardian . Review of the Grievances dated 09/15/2022 recorded by the Resident Council secretary revealed the following: During the 6:30 PM smoke break. One of the aides said something about the one in purple (Resident #35) thinking it was her (related to sexual assault allegation) Things got heated Then TA K said that at this facility the residents have many real Big Liars Then he started in on a soap box sermon about him and God are like that! And that those liars were going to Hell. The residents here will be struck down. I (resident #38 Resident Council Secretary). Told the charge nurse and she said that the incident was reported to her. I did not know that all the situation was not reported. Review of the Grievances dated 09/21/2022 recorded by the R revealed the following: TA K split up the smokers into 2 groups sending out one group. TA K kept stating that the Administrator told him he had to take us out into groups instead of all at once. No one was told of this until we were on our way to the patio. TA K told Resident #8 he could not come outside because he did not have cigarettes. Resident #38 was awakened at 11:30 PM by a loud noise in her room TA K told me If you have any complaints about me (beating his chest) then keep your mouth shut. He then turned to my roommate and asked her if she called the Administrator and report me. She said No. Then he said your neighbor is doing that. On the same day Resident #35 asked to keep her door open, and TA K yelled and slammed the door shut time was 10:15 PM During an interview with Administrator on 09/23/2022 at 4:40 PM she said TA K's only had abuse and neglect training completed with no other modules completed at the time of hire. Review of TA K's hire date provided by the facility was 08/16/2022. Record review of TA K's disciplinary action dated 08/31/2022 revealed the following: Final Warning- Time clock abuse - Not clocking out (5 hours left the building) contacting employees while investigation is ongoing - contacting and engaging with residents during investigation. Immediate termination if this problem occurs (Need) to follow command when leaving the building - clocking out when leaving the building - not reaching out to employees or residents when investigation is ongoing. Review of facility policy and procedure dated June 2021 titled, Abuse Prevention Program revealed the following [in part]: .2 Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The includes but is not limited to freedom from corporate punishment involuntary seclusion verbal mental sexual or physical abuses . 5. Our Center will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 6. Our Center will protect residents from harm, reprisal, discriminating or coercion during investigations of abuse allegations. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the Center management. Findings of abuse investigation will also be reported. 8. Our Center will provide protection for the health, welfare and the rights of each resident residing in the Center to ensure the reporting of crimes. Immediate Jeopardy (IJ) situation was identified on 09/23/2022 at 5:10 PM and the Administrator was informed. The IJ Template was provided at this time. The POR (Plan of Removal) was accepted on 9/24/2022 at 12:40 PM The POR revealed in part: Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of removal. The facility failed to ensure residents were free from verbal, mental, or sexual abuse. Action Item: 1. Administrator and the DON were suspended on 9/24/22 pending investigation of incident 2. Review of all resident grievances to identify allegations of abuse; all allegations will be reported timely. All residents will be interviewed for active grievances and allegations of abuse 3. Review of all resident grievances occurs daily Monday through Friday in the morning meeting. Any allegations of abuse/neglect will be reported timely. 4. Resident grievance forms are posted on the walls in wall hangers throughout the center. The resident/representative can leave the form in the file folder outside the administrator's office, with or without signing the form. Resident counsel occurred on 9/24/22, the minutes include the grievance process, how to file an anonymous grievance, who the abuse coordinator is, how to report abuse, zero retaliation policy. 5. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. 6. Staff education on the grievance process to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. 7. QA committee will review the POR is effective 8. Safe surveys will be completed with all residents that are interview able; responsible parties will be phone interviewed for all residents that are un-interview able and those residents will be assessed for signs of physical or psychosocial distress. 9. TA K has been terminated as of 9/22/22 and Activity Director will be suspended pending investigation on 9/23/22. 10. Physical and emotional assessments to be completed on all residents. Change of condition events to be completed as identified. The event includes physician and family/responsible parties. Notifications. The Medical Director and resident physicians were notified of the immediate jeopardy on 9/24/22. 11. Employee TA K has notified that he not allowed on property by the Regional Director of Operations on 9/24/22. Staff education completed on terminated employee TA not being allowed on property and to notify Regional Director of Operations and police if former staff member attempts to enter center to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. Regional Director of Operations on 9/24/22 at 2:30 pm initiated education of employees. All will be completed by end of today except for one staff member who is out of state, another is on a second job. Will not be allowed to return to work until training is completed. Observation and interview with Regional Operations Manager 0n 09/25/2022 at 2:40 pm revealed signs related to Resident Council Minuets were posted in the lobby, 2 hallways and behind the glass board. Grievance forms were in the lobby area in a hanging file with signage. Grievance forms were placed in the box outside the Administrators door or can hand it to any department heads. Observation on 09/24/22 at 4:00 pm revealed Regional Operations Director conducting a Resident Council Meeting. He went over the grievance process, how to file a grievance and who the Grievance officer was. Interviewed the following residents on 9/24/2022 at 5:00 pm Resident #20, #31, #11, and #5, (all went to the Resident Council meeting), discussion included how to file a grievance, name of the grievance officer, and retaliation. One resident who did not attend the Resident Council meeting due to being on Transmission Based Precautions said staff came in and educated him on abuse and how to file a grievance. Interview with LVN C on 09/24/22 at 3:00 pm (day shift)stated she had an In-service this morning before she started work. She said she had another one at approx. 10:00 am and another one at 12:30 pm. In services were with ROM and MDS Nurse and BOM. She said in-services were about abuse and reporting abuse and she completed a written test. Interview with Housekeeping Supervisor on 09/24/22 at 3:10 pm (day shift)stated she had was in-service at 8:00 am and at 9:30 am by ROM and MDS Nurse. Housekeeping Supervisor Stated she in-services her employees this morning. Interview Housekeeper and Laundry Aide on 09/24/22 at 3:20 pm (day shift) said they were educated this morning by Housekeeping Supervisor on how to report abuse. Observation on 09/24/22 at 3:30 pm revealed, Business office Manager (BOM) in-servicing, LVN B and Home care 1 on (day shift) concerning Regional [NAME] President was acting Abuse Coordinator and how to report abuse, etc. Interview, with CNA F on 09/24/22 at 3:35 pm (day shift)stated she received education concerning how to recognize abuse and how to report it earlier this morning after the residents had breakfast. All staff educated by ROM took a written test scoring 80% or greater. Observation at 3:37pm revealed ROM educate CNA F concerning the Regional Operations Manager (ROM) is the abuse coordinator and how to report abuse. Interview with LVN B on 09/24/22 at 3:40 pm (day shift)stated she received training this morning shortly after she came to work his morning. The training was conducted by ROM. The training consisted of abuse, how to identify abuse and report it and took a written test. Interview with LVN D on 09/24/22 at 8:44 pm (night shift) said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with CNA I on 09/24/22 at 8:56 pm said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with LVN A on 09/24/22 at 9:00 pm said she was trained before shift by the BOM. The Training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Staff Social Worker, CMA and PT (who are out of town and/or out of the country) will be interview regarding abuse and neglect prior to their shift. The Regional Operations Director, Administrator, DON, ADON, and Corporate Nurse were informed the Immediate Jeopardy was removed on 09/25/22 at 12:40 p.m. The facility remained out of compliance at a severity level of 2 with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 2 of 12 residents (CR #1 and Resident #2) reviewed for quality of care. The facility failed to follow CR #1's physicians orders and did not administer the ordered insulin for 4 days, resulting in the resident having an increase in blood sugar and an increase in confusion. The facility failed to ensure Resident #2 received insulin as ordered ([MEDICATION(S)] 70/30, 5 units, once a day) resulting in going four days without insulin. An Immediate Jeopardy (IJ) situation was identified on 9/17/21 at 5:23 PM. While the IJ was removed on 9/21/21, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate care, infections or decline in health. Findings include: CR #1 Record review of CR #1's face sheet dated 9/21/2020 indicated she was an [AGE] year-old female, admitted to the facility on [DATE] and discharged on [DATE] to the hospital. CR #1 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's MDS dated [DATE] indicated a BIMS score of 12, indicating resident was moderately impaired cognitively. The MDS indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's medical record revealed there was no 48-hour baseline care plan and no comprehensive care plan. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date was 9/4/21 with a discontinue date of 9/7/21. Record review of CR #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on 9/5/21, 9/6/21 or 9/7/21, with the not administered reason of drug/item unavailable. Record review of CR#1's physicians orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physicians orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physicians orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physicians orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1's progress note dated 9/6/21 written by the nurse practitioner read in part, This is an [AGE] year-old [NAME] female newly admitted to the post-acute facility status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Her past medical history includes: Type 2 diabetes, [CONDITION(S)], hypertension, coronary artery disease, dementia, [CONDITION(S)] and chronic UTIs . She is currently on 5 units of 70/30 insulin which was never administered since admission, nor Accu-Checks performed . Record review of CR #1's nursing note written by LVN A dated 9/4/21 at 5:40 AM read in part, Received resident, who was alert and oriented x2 . Resident admitted with a with a DX of Altered Mental Status, and Metabolic [CONDITION(S)], and a history of Diabetes Mellitus . A swab/sample from residents' nose is tested with a result being negative for the Corona Virus. A complete head to toe is conducted with vital signs within normal parameters . Record review of CR #1's nursing progress notes revealed no additional notes between 9/4/21 and 9/8/21. Record review of CR #1's nursing note written by LVN B dated 9/8/21 at 2:50 PM read, Resident husband visiting with resident and states some concerns regarding resident apparent decline in condition. Resident requiring help with transfers, increased confusion and difficulty swallowing. New orders received for labs and speech therapy to eval and treat. Resident husband at bedside and aware of new orders. Will continue to monitor resident frequently Record review of CR #1's nursing note written by LVN B dated 9/8/21 at 5:30 PM read in part, Resident continues with lethargy. V/s 123/76,77,18,98.1,98% room air and blood sugar 498. MD notified and new order received to give resident 8u insulin and monitor again in 1 hour. If blood sugar isn't below 300 MD to be notified again. Record review of CR #1's nursing note written by LVN C dated 9/8/21 at 6:40 PM read in part, FSBS (finger stick blood sugar) 477 at 1840 (6:40 p.m.). Doctor notified. N.O.s (new orders) received for and additions 8 units of [MEDICATION(S)] r insulin now, and recheck FSBS in 2 hours . Record review of CR #1's nursing note written by LVN C dated 9/8/21 at 9:00 PM read in part, FSBS 344. Doctor notified. NNOs (no new orders) at this time . Record review of CR #1's vitals log for Blood sugar revealed the blood sugar was first checked on 9/8/21 at 5:30 PM. The blood sugar was 498 was in read, which indicated out of range. Record review of CR #1's nursing note written by the ADON dated 9/15/21 at 4:46 PM read in part, Received Order from Medical Provider to Transfer Resident to: Hospital ER . Primary Reason for Transfer: family wants resident to be evaluated and treated elsewhere . In an interview on 9/16/21 at 8:07 AM, with CR #1's family member revealed CR #1 admitted on [DATE] and did not receive any insulin or blood sugar checks since admission. CR #1's family member stated CR #1 had also not received physical therapy since being at the facility. CR #1's family member stated that as CR #1 was in the facility, she continued to have a decline in her health. CR #1's family stated that on 9/8/21 during the visitation, the nurse was asked if her blood sugar was checked and the last time she received her insulin and the nurse said no and that she was unaware that CR #1 needed insulin or to have her blood sugars checked. CR #1's family member stated once her blood sugar was checked it was 498. In an interview on 9/16/21 at 11:43 AM, CNA C stated she was in-serviced on identifying changes in conditions with residents. She stated she was informed if a resident had any changes, she should notify the nurse immediately. In an interview on 9/16/21 at 11:45 AM, LVN D stated she had residents with accuchecks this morning and have given insulin to the required residents. She stated she was in-serviced on how to identify changes in condition and residents who have insulin or are diabetic. In an interview on 9/16/21 at 11:48 AM, LVN D stated each admission nurse should contact the doctor to inform that a new patient was is in the facility. The nurse should check the discharge medication from the hospital and input in the system. She stated if a resident is a diabetic or has kidney disease, each nurse should ensure they have the proper medication or insulin. Resident #2 Review of Resident #2's facesheet indicated Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's annual MDS dated [DATE] indicated a BIMS score of 5, which indicated he had severe cognitive impairment. Record review of Resident #2's care plan dated 6/28/21 indicated Resident #2 was at risk for hyper/[CONDITION(S)] episodes, secondary to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] insuline, per sliding scale, before meals, with a start date of 4/22/21 -[MEDICATION(S)], 40 units, subcutaneous, at bedtime (8PM), with a start date of 7/30/21 -[MEDICATION(S)], 45 units, subcutaneous, once a day, with a start date of 7/26/21 Record review of Resident #2's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] insulin (per sliding scale, before meals at 6:30 AM, 11:30 AM, 4:30 PM) on 9/1/21, 9/2/21, 9/3/21, 9/5/21, 9/7/21, 9/10/21 and 9/12/21; -[MEDICATION(S)] insulin (45 units) at 630 AM on 9/1/21, 9/2/21 or 9/7/21; and -[MEDICATION(S)] insulin (40 units) at 8 PM on 9/4/21, 9/5/21, 9/6/21, or 9/12/21 there was no documentation indicating why the medication was not given . In an interview on 9/16/21 at 12:47 PM, the DON stated for new admissions, the resident comes with their admission packet from the hospital and the facility also provides the clinicals to the nurses prior to the admission. The nurses review the packet and will go over the medication and reconcile the medication with the doctor. The nurse will get the medications from the hospital discharge records and compare with the current med list and will input the medication in the list. The DON stated the nurse should notate that the medication should be reconciled with the doctor or whoever they talked to from the doctor's office. The DON stated she was aware of CR #1's insulin orders, but thought they were discontinued by the doctor. The Administrator and the DON were notified on 9/17/21 at 5:23 PM, that an Immediate Jeopardy (IJ) existed due to the above failures. The Administrator was provided with the IJ template on 9/17/21 at 5:49 PM. In an interview on 9/18/21 at 11:07 AM, LVN E stated she had 15 residents with insulin, and she knows to check their blood sugars as ordered. She stated with a new admission she would look at the hospital records, verify medication from the residence and the hospital chart, and reconcile the medication with the physician. In an interview on 9/18/21 at 11:12 AM, CMA A stated she was recently in-serviced on identifying residents with any change in condition. She stated she will notify the nurse and they will complete an assessment on the resident. In an interview on 9/18/21 at 11:33 AM, the Administrator stated when residents are admitted , the nurse will have a clinical packet that is reviewed by the DON/ADON. The packet will give the nurse clinical information regarding the resident. The nurse enters all information into system and will notify DON that the resident had been admitted . When the resident admits, the nurse will review all orders, contact doctor and notify ADON. The Administrator stated if a resident needs medication, they will notify DON, call the pharmacist and/or get the medication out of the emergency kit (e-kit). She stated it is important to monitor the signs and symptoms of a resident to avoid a change in condition or to monitor if a change has occurred. The Plan of Removal was submitted by the and was accepted on 9/20/21 at 9:55 AM. The Plan of Removal was provided by the Administrator. STAFF WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND REEDUCATION. Issue: The facility failed to address the diabetic needs of CR#1, an insulin dependent diabetic upon admission to the facility on [DATE]. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: On 9/15/21, CR #1 discharged from the facility with no plans to return. On/or before 9/18/21, the Director of Nurses and Assistant Director of Nurses will audit residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On/or before 9/18/21, the Director of Nurses/Designee will clarify any orders needing clarification with the Physician. On/or before 9/18/21, the Director of Nurses/Designee will educate the Licensed Nurses on reviewing all new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On/or before 9/18/21, the Director of Nurses will educate the Licensed Nurses on assessing residents, identifying changes of conditions and timely notification to NP/MD/RP On/or before 9/18/21, the Director of Nurses/Designee will educate the nurse aides on notifying the Licensed Nurse on any residents they've identified to have had a change in condition. On/or before 9/18/21, the Director of Nurses/Designee will re-educate the Licensed Nurses, including agency Nurses on the facility diabetic management clinical protocol, which includes conducting blood sugar checks prior to administration of insulin and following the residents' orders according to blood sugar results. On/or before 9/18/21, the Regional Nurse Manager/Designee will educate the Director of Nurses on reviewing new admissions/re-admissions orders in the clinical morning meeting and validating medication availability and following up with the Physician as needed. On/or before 9/18/21, the Regional Vice President of Operations will educate the Administrator and Director of Nurses on the admissions process including the clinical capabilities grid and do not admit list. On/or before 9/18/21, the Administrator will educate staff on the admissions process and communication of new/returning admissions to the center staff and ensuring necessary documentation is available prior to admission. All staff will receive education on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor Verification of Plan of Removal was as follows: In an interview on 9/20/21 at 11:33 AM, the Administrator stated the IJ came about due to missing documentation with staffing and utilizing staffing agency. She stated it has been a challenge getting ahold of the agency staff who do not come back to the facility. She also stated at times, clinicals not being sent with the residents when they come from the hospital. The Administrator stated systems were put in place but were not being followed. She stated to ensure issues don't occur again, she has reached out to the agency to ensure nurses are trained prior to being in the facility. There will be a flow chart that is uploaded to the agency system so nurses will have to do a course study to ensure they are competent, and the proof must be done before they can accept a shift. She stated the DON or ADON will also train new agency staff before they start their shift. In an interview on 9/20/21 at 11:37 AM, the DON stated an audit was completed on all diabetics in the facility. She stated she did identify some issues with receiving medications but will continue to in-service and educate nursing staff. She stated she had been in contact with the medical director of the facility, who has made medication changes to some of the diabetic residents. She stated residents who have diabetes will have their insulin checked and documented every Monday, Wednesday and Friday, to ensure no changes have occurred. In an interview on 9/21/21 at 5:56 AM, CNA E stated she had a recent in-service this week on identifying changes in condition with residents and stated she would notify her charge nurse with any changes. In an interview on 9/21/21 at 6:00 AM, LVN C stated she had an in-service last night on the admission process. She stated for all new admissions the nurses are to complete a full head to toe assessment, look at the medical record from the hospital to review the medication and put them in the system. She stated before any agency staff can pick up a shift for the facility, they must complete an orientation regarding the facility policies and be trained by the DON at the facility or the ADON. She stated if a resident is a diabetic, they will go based off the orders of the doctor if the resident is needing insulin. In an interview on 9/21/21 at 6:48 AM, LVN I and CNA H both stated today was their first day working at the facility. LVN I and CNA H both stated that prior to the shift they were in-serviced on the admission process and identifying changes in condition. Interview on 9/21/21 at 7:00 AM, the DON stated if a resident is refusing insulin, the nurse is to make three attempts, and document refusals in the nursing progress notes. The nurse is also to notify the doctor, the family, and the DON. In an interview on 9/21/21 at 8:46 AM, the Nurse Practitioner for CR #1 stated he discussed insulin for CR #1 and at the time of admission, he changed it to only 5 units, due to her being stable. He stated CR #1's blood sugar spiked to 498 and she was given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the nursing staff should have been completing accuchecks on the resident since she admitted to the facility. The Nurse Practitioner stated accuchecks should be done before breakfast and dinner. He stated if a resident has a blood sugar of 498 (4-500 range), the resident can become dehydrated as the body is trying to get rid of toxins. In an interview on 9/21/21 at 9:21 AM, LVN B stated she worked with CR #1 once while at the facility. LVN B stated CR #1 was a new patient to her. She stated she was informed by CR #1's family member that CR #1 didn't look well and was more confused. She stated she informed the DON that this was her baseline since she admitted . LVN B stated she went to talk to the family to get more information on CR #1. She stated the family asked her if she checked CR #1's vitals and checked her blood sugar. LVN B stated she didn't check her blood sugar, due to not being aware she needed her blood sugar checked. LVN B stated she went to tell the DON and call the doctor for a one-time dose of insulin. She was not aware CR #1 was on insulin or needed her blood sugars checked. LVN B stated each diabetic resident is different regarding checking blood sugars and it depends on what the doctor orders. She stated she wasn't familiar with the CR #1 and was not aware she was a diabetic. In an interview on 9/21/21 at 9:28 AM, LVN C stated CR #1 was alert to herself. She stated she did not complete the admission for CR #1 but worked with her after she was admitted . LVN C stated a couple days into CR #1 being at the facility, she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN C stated she was aware that CR #1 was to have accuchecks completed twice a day, but it was not during her shift, as she worked overnight. LVN C stated while she was working with CR #1, she was not aware of a change in condition for her. Record review of facility in-service sheets dated 9/18/21 revealed an in-service regarding the facility clinical meeting, which the interdisciplinary team will review changes in residents' condition, review assessments to ensure accuracy during the morning clinical meeting. Record review of facility in-service sheets dated 9/18/21 revealed an in-service regarding the facility admission process was signed by nurses from both shifts, including weekends and weekdays. Record review of facility in-service sheets dated 9/18/21 revealed an in-service regarding the facility readmission process was signed by nurses from both shifts, including weekends and weekdays. Record review of facility in-service sheets dated 9/18/21 revealed an in-service regarding the facility medication ordering process for new admission was signed by nurses from both shifts, including weekends and weekdays. Record review of facility in-service sheets dated 9/18/21 revealed an in-service regarding the facility process to assess and identify a change in condition was signed by nursing staff from all shifts, including weekends and weekdays. Record review of facility in-service sheets dated 9/18/21 revealed an in-service regarding the facility diabetic clinical protocol was signed by nurses from both shifts, including weekends and weekdays. The Administrator and the DON was informed the Immediate Jeopardy was removed on 9/21/21 at 7:15 AM. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to effectively maintain an infection prevention and control program designed to help prevent the spread of infections for 3 of 11 residents reviewed for infection control and COVID-19. -The facility failed to ensure CR #1 was isolated from other residents and wearing a face mask to prevent the spread of COVID-19 after he developed a cough on [DATE]. CR #1's COVID-19 assessments were not completed accurately for three days before he was hospitalized on [DATE] for treatment of [REDACTED]. -The facility failed to ensure they had dedicated staff working on the COVID positive unit. -The facility failed to complete the daily COVID-19 assessments for CR #5 and Resident #6 per CDC guidelines. -The facility failed to ensure residents temperatures were taken every shift per CDC guidelines for 16 residents on [DATE]. -The facility failed to effectively screen and/or document COVID-19 visitor screening results in its entirety on all staff and/or visitors entering the building per CDC guidelines. -The facility failed to ensure staff were wearing face masks while in the building per CDC guidelines and quarantine orders. These failures resulted in an immediate jeopardy on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of widespread and severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed residents and staff at risk of infection and COVID-19. Findings include: CR #1 Record review of CR #1's face sheet revealed, a [AGE] year-old-male admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's nursing progress notes dated [DATE] read in part, Resident was seen by MD, noted resident coughing, was assessed and ordered chest X-ray stat. resident was out of bed in w/c denies any pain or discomfort, will continue to monitor and treat. Further record review of CR #1's nursing progress notes dated [DATE] read in part, CXR results faxed to physician, moderate opacity in the right lower lung concerning for PNA. New orders for [MEDICATION NAME] 500mg po BID x 7 days and Duo nebs QID x 7days. Management and guardian notified O2sats 96% on O2 at 3LPM per nasal cannula. No fever noted this shift. Further record review of CR #1's nursing progress notes dated [DATE] read in part, 6:20AM Resident Sitting on side of bed yelling I can't breathe!. Nurse entered room and noted resident has removed nasal cannula. Nurse replaced nasal cannula and assessed vitals. O2 74% on 2 LPM. Resident became more SOB even with O2. Nurse place a non-rebreather mask on at 10LPM. O2 sats increased to 88% but resident remains in respiratory distress. Physician notified and new order to send to ED. EMT transported resident and will let facility know where resident will be because of Covid-19. Resident had mask on at the time of transport. Family will be notified of location at that time. Further record review of CR #'1 nursing progress notes revealed, no documentation showing the resident was isolated from other residents or proper PPE was used when a new onset cough was identified on [DATE] to prevent spread of suspected COVID-19. Record review of CR #1's COVID-19 monitoring assessment dated [DATE] revealed, under Observation Details Symptoms: Cough (New Onset) No was checked. Further record review of CR #1's COVID-19 monitoring assessment dated [DATE] revealed, under Observation Details Symptoms: Cough (New Onset) No was checked. Further record review of CR #1's COVID-19 monitoring assessment dated [DATE] revealed, the resident was transferred to the hospital for SOB and decreased O2 sat on [DATE]. The COVID-19 assessment was not completed until [DATE]. Further record review of the assessment revealed, No was documented for Symptoms of Short of Breath (New Onset). Telephone interview on [DATE] at 10:45am with the Administrator, he stated one more resident, CR #2 tested positive for Covid-19 on Thursday, [DATE], and was sent out to the hospital at 4am. He stated CR #1 and CR #2 were still in the hospital. He said the roommate of CR #1, CR #3 was on Hospice and expired on Friday [DATE] and was not tested for Covid-19 further stating he was not sure if a postmortem test would be completed. He said the roommate of CR #2, CR #4 also passed away on Friday at 4am stating the roommate had a sudden change of condition then went into respiratory distress two minutes after the change of condition. He said EMS was called, and they worked on the resident, but he expired stating he never made it out of the EMS vehicle. He stated said he did not know if the two deceased residents would be tested for COVID-19. Further telephone interview on [DATE] at 10:45am with the Administrator, when asked if a resident had s/s of potential COVID exposure, did the staff or resident wear the appropriate PPE to prevent potential spread of [MEDICAL CONDITION], he said they follow the CDCs guidelines stating facemask guidelines did not come out until Friday, [DATE]. He further stated he thought the staff put themselves in harm's way stating they completed sign in sheets, vital signs every shift and when residents developed any s/s, PPE was utilized. He said they started wearing the facemasks on Monday, [DATE], after they had their first confirmed case. Further telephone interview on [DATE] at 10:45am with the Administrator, when asked what the facility's screening process included, he said they screened everyone initially stating he has a COVID Binder with the information. He said temperatures were checked, questionnaires from the CDC guidelines were completed and all persons entering the facility must use ABHR prior to entering and must wear a face mask. He further stated anyone entering the facility must wear a facemask as of [DATE]. When asked if staff were working at other health care facilities or if they were only working at this facility, he stated he had been asked this before and he really did not know if staff worked a 2nd job, they may not say if they were. Interview on [DATE] at 11:18am with the Administrator, he stated the CDC instructions were not clear and two days prior to CR #1 testing positive for COVID, he was in contact with staff and other residents stating he was not wearing a face masks. He said once the resident started to cough on [DATE] a CXR was done and he was started on antibiotics. He stated prior to this he was not wearing a mask and was in contact with other residents. He said the resident could have been infected at the previous facility he transferred from. He stated no one was wearing a mask and residents were not being isolated, again stating the instructions were bad. Staffing/PPE Observation and interview on [DATE] at 9:55am with CNA A, the CNA was observed wearing a yellow gown with a surgical face mask and gloves performing patient care on the COVID negative unit. When asked if she was assigned to the COVID negative unit, she stated she was the only CNA for the entire building stating the positive unit did not have a CNA. When asked if she did any patient care on the COVID positive side, she stated she helped pass trays on both sides. When asked if she used the N95 mask when she goes to the positive unit, she said she had not asked for a N95, further stating she puts two surgical masks on when she goes to the positive unit. Observation of the Regional Chief Clinical Coordinator on [DATE] at 10:35am, she was observed on the COVID positive unit entering resident rooms and checking on residents. She was observed wearing a yellow gown and surgical face mask. Observation and interview on [DATE] at 11:09am of the laundry room, the surveyor was unable to enter the dirty side of the laundry room due to large grey barrels full of laundry blocking the door. To enter the room, the surveyor had to enter the side with the dryers. There were four large grey barrels full and overflowing with laundry, and three clear plastic bags with dirty mop heads and cloths inside of the bags sitting on the floor by the door. Interview on [DATE] at 11:11am with the Housekeeping Supervisor, when asked who was responsible for laundry if they only have two housekeepers including himself, he stated that was something they had to work on further stating Housekeeper A will be working on the laundry today. Observation on [DATE] at 11:12am of the Administrator revealed he assisted Resident #8 back into the facility after she returned from [MEDICAL TREATMENT]. The resident was sitting in a w/c wearing a facemask. The Administrator was observed checking her temperature and pushing the resident in her w/c to the COVID negative unit. Interview on [DATE] at 11:46am with the Administrator, when asked if they had dedicated staff working on the COVID positive unit, he stated they did not have enough staff to do so, further stating staff were going back and forth and were changing their PPE. He said it may take some time to get the documents requested because some of the department heads whowere also CNAs were working on the floor. He stated he was also a CNA and was assisting on the floor as well. Observation on [DATE] at 11:51am of the Administrator revealed he entered the COVID positive unit with a face mask, yellow gown and gloves after interview was completed. He was previously observed pushing Resident #8 to the COVID negative unit at 11:12am. Observation of the Regional Chief Clinical Coordinator on [DATE] at 12:03pm, she was observed passing lunch trays to residents in their rooms on the COVID negative side. Record review of the facility's Notice To Person Who Owns or Controls Property: Quarantine of Property order from the local health department addressed to the facility dated [DATE] read in part, .Resident Monitoring and Restrictions .Implement protocols for cohorting ill residents with dedicated HCP .Cohorting: .All staff members need to wear PPE and be cohorted. Observation on [DATE] at 12:10pm revealed, Chef A answered the front door and was not wearing a face mask. She checked the surveyor's temperature after asking if she was supposed to check it and requested surveyor to use the ABHR and complete the COVID screening questions. She walked back into the kitchen without wearing a face mask and did not review the screening assessment completed by the surveyor. Observation of CNA A on [DATE] at 1:24pm. She was observed walking from the COVID negative unit to the dining room without a face mask on. She stood at a computer located in the dining room and began typing on the computer. The Social Worker walked up to CNA A in the dining room, the social worker was wearing a face mask and gown and began to have a conversation with the CNA. The CNA continued with the conversation and did not put a face mask on. Observation of Chef A on [DATE] at 1:21pm, she was observed leaving the kitchen to answer the front door. The chef was not wearing a face mask when she walked out of the kitchen to answer the door. She opened the door and let Chef B into the building. Chef A walked back into the kitchen without putting a face mask on. Observation of Chef B on [DATE] at 1:22pm, she was observed standing at the front entrance waiting for staff to assist her with completing the COVID screening assessment. She was not wearing a face mask upon entrance and while waiting for staff to assess her. The Chef was observed taking her own temperature until the Administrator came to assist. Observation on [DATE] at 1:28pm of the Administrator and Chef B, the Administrator was observed walking to the front entrance wearing a face mask and gown to screen Chef B. After he completed the screening, Chef B entered the kitchen without wearing a face mask. Observation on [DATE] at 1:30pm, Chef A and Chef B were observed talking in the kitchen without face masks on. Observation and interview on [DATE] at 1:31pm of CNA A, the CNA walked from the dining room to the double door of the COVID negative unit without a face mask on. The surveyor asked the CNA if she was aware she should have a face mask on while in the facility. She stated she was eating lunch and that was why she removed it. The surveyor informed the CNA that she was observed without a face mask from 1:24pm until 1:31pm when the surveyor intervened. She then stated she ate Frito chips and that the mask gets hot. The surveyor again informed the CNA that she was supposed to have the mask on while in the facility. The CNA put the mask on after surveyor intervention. Observation and interview on [DATE] at 1:33pm with the Culinary Service Manager, she was observed leaving the kitchen with a face mask on. When asked if kitchen staff should wear face masks while in the facility and kitchen area, she stated yes. She was informed of the observations earlier of Chef A and Chef B in the kitchen. After surveyor intervention, the Culinary Service Manager waked into the kitchen and asked Chef A and Chef B to put their masks on. Record review of COVID-19 Long-Term Care Facility Guidance dated [DATE] read in part, .For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility . Record review of the Second Notice to Person Who Owns or Controls Property: Quarantine of Property dated [DATE] read in part, .Incorporate COVID-19 into emergency management operations planning for the facility .Healthcare Personnel Monitoring and Restrictions: Implement use of facemask for HCP while in the facility . CR #5 Record review of CR #5's face sheet revealed a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #5's COVID-19 Assessments revealed, COVID-19 assessments were not completed for six days, [DATE] through [DATE]. Record review of CR #5's vital signs report revealed the following Heart Rate results: on [DATE], HR was 115 bpm; on [DATE] there was no documentation of a HR; on [DATE], HR was 107 bpm; on [DATE], HR was 119 bmp; on [DATE], HR was 113 bpm; and on [DATE], HR waas 111 bpm. Record review of CR #5's temperature log revealed the following: on [DATE] at 12:00am, temperature was 99.5; on [DATE] at 10:35am, temperature was 99.0; on [DATE], temperature was 99.0; and on [DATE] at 9:45am and 4:42pm, temperature was 99.7. Record review of CR #5's nursing progress notes revealed, no documentation showing the MD and/or NP were notified the resident had a COC with consistently elevated HR for five days and an elevated temperature from baseline for three days. Further record review of nursing progress notes revealed on [DATE] the NP was notified of the residents COC and gave orders to transfer the resident to the hospital. Further record review of CR #5's nursing progress notes dated [DATE] read in part, Contacted RP in regard to resident behavior; he is guarding, expressing pain, especially in right arm. BP at this time Temp 99.7, ,[DATE], P 111, SPO@ 95%. Awaiting further instruction from physician at this time. Resident took all am medication as ordered. Resting quietly in bed at this time. CNA reported that his behavior has not been his usual and that he slumps over excessively while up in w/c. Further record review of CR #5's nursing notes dated [DATE] read in part, 4:17PM Resident bp ,[DATE], P 64, R 16, Spo2 77%. Temp orally 99.7. Resident put on 02 with non-rebreather; 85% with 02 open. Called EMS. Contacted RP; Resident to be transferred to (local hospital). (Family member) verbalized understanding. Resident #6 Record review of Resident #6's face sheet revealed, a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's COVID-19 Assessments revealed, COVID-19 assessments were not completed for 12 days, [DATE] through [DATE]. Interview on [DATE] at 8:36am with LVN A, when asked if a resident had changes in any vital signs from baseline which were not listed on the COVID assessment, should the nurse monitor and notify the MD and/or NP of these changes, she stated she would assume the changes would be monitored because of all of the different symptoms that could occur, further stating the MD would be notified of any changes. When asked if changes in vital signs should be documented, she stated yes, they would be documented in the vital signs tab in the EHR and would always be documented in the progress notes and in the focused assessment. Interview on [DATE] at 9:14am with the Interim DON, when asked how often the COVID-19 assessments were completed on residents, she stated every shift. When asked if there would be a reason the assessment would not be completed, she said no further stating if they were in the facility, the assessment would be completed. When asked if a resident had any changes in vital signs from baseline should the MD and/or NP be notified of the changes, she stated if it was a change of condition then the MD should be notified so it can be addressed, and orders followed. She said the changes in vital signs should be documented under the vital signs tab further stating, you should also see something in the progress notes. Further interview on [DATE] at 9:14am with the Interim DON, when she was informed CR #5 and Resident #6 were missing several days of the COVID-19 assessments, she stated she would have to follow up with this stating it may be documented elsewhere in the EHR. When the DON was informed CR #5's roommate tested positive for COVID-19 and was moved to the COVID positive hall on [DATE] and CR #5 began to have changes in his HR and temperature from baseline starting on [DATE]. She was further informed there was no documentation showing what monitoring was completed and if the MD or NP were notified, she stated she would have to ask about the MD notification, she was not sure if it was completed. Interview on [DATE] at 10:15am with the Administrator, when informed CR #5 and Resident #6 had multiple days of missing COVID-19 assessments, he stated they started moving residents on [DATE] through [DATE] stating, possibly those COVID assessments weren't not done due to moving residents to the positive side and the staffing issue. He further stated there were a lot of moving parts for that time frame. Further interview on [DATE] at 10:15am with the Administrator, when asked why the MD and/or NP were not notified CR #5 had six consistent days of an elevated HR and three consistent days of elevated temperatures from baseline when his roommate who tested positive for COVID and had to be moved to the positive side on [DATE], he stated at no time was the residents' temperature not taken or reach the CDCs recommendations regarding COVID which he stated was 100.4. Further interview on [DATE] at 10:15am with the Administrator, when asked if the resident had changes in his vital signs from baseline and shared a room with a positive COVID residents should the NP and/or MD have been notified of the changes, he stated the temperature and HR were reflecting changes from baseline, and the NP was notified on [DATE] and a FaceTime visit was completed and IV and other measures were ordered further stating the resident began to experience other symptoms and was sent out on ,[DATE]. Record review of CR #5's physician orders [REDACTED]. There was no further documentation showing orders prior to [DATE], or IV orders. Record review of a CMS letter ,[DATE] for Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Nursing Homes dated [DATE] read in part, .Per CDC, prompt detection, triage and isolation of potentially infectious residents are essential to prevent unnecessary exposures among residents, healthcare personnel, and visitors at the facility. Therefore, facilities should continue to be vigilant in identifying any possible infected individuals. Facilities should consider frequent monitoring for potential symptoms of respiratory infection as needed throughout the day .Implement active screening of residents and staff for fever and respiratory symptoms Facilities should identify staff that work at multiple facilities (e.g., agency staff, regional or corporate staff, etc.) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19 Record review of COVID-19 Long-Term Care Facility Guidance dated [DATE] read in part, .In accordance with previous CDC guidance, every resident should be assessed for symptoms and have their temperature checked every day . Record review of the facility's March COVID-19 Visitor Screening log revealed, the screening questionnaire was not completed in its entirety on [DATE] for 14 visits. Record review of the facility's April COVID-19 Visitor Screening log revealed, the screening questionnaire was not completed in its entirety on [DATE] for 33 visits, on [DATE] for 29 visits, on [DATE] for 33 visits, on [DATE] for 29 visits, and on [DATE] for 14 visits. Record review of COVID-19 Long-Term Care Facility Guidance dated [DATE] read in part, .In accordance with previous CMS guidance, every individual regardless of reason entering a long-term facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked . Record review of the facility's temperature log dated [DATE] revealed, 16 residents on the COVID negative side had their temperatures taken once daily and not twice daily per the Quarantine order. Record review of the facility's Notice to Person Who Owns or Controls Property: Quarantine of Property order from the local health department dated [DATE] read in part, .COVID-19 residents who tested negative are now considered Persons Under Monitoring (PUMs), PUMs need to be monitored twice a day . The facility Administrator, CEO, Regional VPO, Regional nurse, and Regional clinical coordinator were notified on [DATE] at 12:51 PM that an IJ situation had been identified due to the above failures. The IJ template was provided. A Plan of Removal was submitted by the Administrator on [DATE]. After several revisions, the final Plan of Removal was accepted on [DATE] at 11:34 AM. The plan of removal included the following: On [DATE], the facility implemented a schedule for a dedicated staff member to be at the sole entrance of the facility from 9am-6pm, after that the staff on the negative hall will be responsible to be attentive to the doorbell to continue the screening of staff/visitor upon entry of the facility that began [DATE]. On [DATE], the designated screening staff were educated by the Nurse Manager on the screening schedule and the staff/visitor screening log, screening questions and the log being completed in entirety prior to allowing staff/visitors entrance to the facility. On [DATE] 100% of staff educated or will be educated before the next scheduled shift by the Nurse Manager/Designee on the screening questions such as temperature, cough, sore throat and shortness of breath to include that a negative response or a temperature of 100.0 may not be allowed entry into the facility. On [DATE], the Regional Nurse Manager educated the Administrator on randomly auditing the screening log five days a week for completion and retaining all screening logs for record keeping. On [DATE], the facility implemented blue gowns to be utilized on the positive COVID unit and yellow gowns to be utilized on the negative unit. 100% of staff educated or will be educated before the next scheduled shift by the Nurse Managers/Designee on the distinction of gowns and not to cross units. On [DATE], 100% of staff educated, or will be re-educated before the next scheduled shift by the Nurse Managers/Designee on infection control protocol, hand washing and utilization of PPE. On [DATE], Nursing Managers/Designee will conduct hand washing and PPE competencies on 100% of staff, or staff will be educated before the next scheduled shift. On [DATE], the Administrator requested additional Housekeeping staffing from contracted provider in addition to the two staff members they currently have. On [DATE], the Administrator submitted a request through SETRAC for medical volunteers. On [DATE], the facility implemented a new schedule to identify which staff are designated to the Positive and Negative Units. On [DATE], the Nurses and CNAs were re-educated by Nursing Management/Designee to continue COVID-19 monitoring on all residents including monitoring for shortness of breath, cough, temperature and sore throat. On [DATE], the facility purchased two additional oral thermometers which are currently in house. The facility also ordered 2 temporal thermometers that will arrive to the center by [DATE]. On [DATE], the facility initiated the HHSC Infection Control Self-Assessment. On [DATE], the Administrator and Interim DON were re-educated to continue to follow the CDC, HHSC and Harris County Public Health Department guidelines related to COVID-19. On [DATE], the facility identified that the COVID-19 Unit requires 1 Nurse, 1 Medication Aide, 2 Certified Nursing Assistants on day and evening shifts and 1 Nurse and Certified Nursing Assistant on night shift. The Negative unit requires the same staffing, less the Certified Medication Aide. On [DATE], the facility contacted eight agency providers across the state of Texas to request assistance in filling the identified open shifts. On [DATE], the facility implemented COVID-19 pay stipend to employees working in the center. On [DATE], the facility extended the COVID-19 pay bonus and a weekly bonus to direct care staff across the company that were interested in communing to LaPorte to pick up shifts. In addition to the COVID-19 pay stipend and weekly bonus the facility is covering lodging, mileage, and meals for any company staff/agency staff commuting to LaPorte to assist in filling open shifts. Any open shifts not covered with LaPorte staff, SLP support staff from sister facilities, or agency provided staff will be filled by Regional and/or Corporate appropriately certified/licensed staff. The surveyor monitored the POR and included the following: Interview on [DATE] at 5:59am with LVN F. She said she worked the night shift with 1 CNA last night. She said she had been here since Wednesday from a sister facility in Abilene. She said she did care for residents on both the positive and negative side of the facility and the CNA also cared for residents on the positive and negative side but she said they worked one side and then switched to the other side and they have a system of using blue gowns for the positive side and yellow gowns for the negative side and both she and the CNA sanitized and changed gowns and masks when they moved from side to side. She said she and another LVN are from Abilene and are helping out by working 12 hour shifts for the next week. Interview on [DATE] at 6:05am with CNA E. She said she worked last night as the CNA and she was now waiting for the day shift to come in before she leaves. Observation on [DATE] at 6:15am revealed the only staff in the facility were LVN F and CNA E from night shift and 1 additional LVN who was scheduled to work the day shift. No additional day shift staff were present. Interview and observation on [DATE] at 6:33am with CNA E. She said last night she had to work both the COVID negative and COVID postive side. She said they usually had two aides at night, but last night it was just her. She said she and the LVN worked one side first and then changed gowns and went to the other side. She was observed to be wearing a surgical mask. When asked if she had an N95 mask she said the only mask she had was the one she was wearing. Record review of the visitor/staff COVID screening log dated ,[DATE]-[DATE] revealed all questions completed, temperatures documented and signatures of the staff reviewing the questions. Record review of staff in-services dated ,[DATE], [DATE], and ,[DATE] revealed, in-service completed by the Regional nurse on topics; PPE positive and negative side, reusable (blue) gowns and disposable (yellow) gowns, proper screening of visitors/staff, IC policy, COVID-19 outbreak (south hall) isolation stations, hand hygiene, handling of linen/storage, after hours (6p) negative hall screen, s/s COVID-19 night shift nurse screen staff. Record review of In-service training report dated [DATE] revealed, in-service topic on Audit of screening logs for completion, retaining logs for record keeping, continued to follow CDC + HHSC Guidelines pertaining to COVID-19, COVID-19 Designated staff at entrance completed by the Regional nurse for Administrative staff. Record review of the Facility COVID-19 Self-assessment was completed and signed by the interim DON on [DATE]. Observation on [DATE] of the facility's PPE revealed, the facility had adequate surgical and N95 face mask, face shields, gowns, gloves, and ABHR on both the COVID negative and positive units. Observation on [DATE] at 11:34am revealed the Social Worker sitting at the entrance screening staff/visitors upon entrance. She was observed checking temperatures, asking the COVID screening questions, and ensured visitors/staff used ABHW upon entrance. Further observation revealed, the Social worker ensuring the COVID screening log was completed in its entirety. Interview on [DATE] at 11:34 am with the Social Worker, she stated she was responsible to ensure all persons entering the facility are properly screened upon entrance and the COVID screening assessment was completed. She stated she will sit at the entrance from 9am-6pm and after 6pm, the nurse on the negative COVID unit will be responsible for completing the COVID screening process. Interview on [DATE] at 2:25pm with the Interim DON and Administrator, the Interim DON stated they have the Social Worker sitting at the entrance from 9am-6pm to complete the COVID screening assessment further stating after 9pm, the nurse on the COVID negative unit will be responsible for the screening process. The DON stated they have scheduled one nurse, two CNAs and 1 MA scheduled to work on the COVID positive side for the day and evening shift. She further stated the COVID negative side will have one nurse, 2 CNAs scheduled for the day and evening shift and the night shift both sides will have one nurse and one CNA scheduled. Interview and observation on [DATE] at 2:38pm with LVN A revealed, the LVN wearing a yellow gown, with face mask, and gloves. She stated she was screened upon entrance into the facility stating her temperature was taken, she was asked the COVID questions, and used ABHR. She stated she was in-serviced on proper PPE use and disposal. When asked if she is assigned to the COVID negative unit or working on both positive and negative unit, she stated, she can only work on the negative side. When asked how often residents were screened and what type of screening was completed, she stated they were screened every shift for a cough, SOB, fever, and if they have any change of condition. Further interview on [DATE] at 2:38pm with LVN A, when asked about staffing on the COVID negative side, she stated there was one nurse and two CNAs. Interview and observation on [DATE] at 2:44pm of CNA A, she was observed wearing a yellow gown,(TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure residents weere free from neglect for 1 of 4 residents (Resident #1) reviewed for abuse and neglect in that: Resident #1 was care planned for incontinent care to be provided by 2 persons. She received incontinent care with one aide, slid from the bed and sustained a fractured humerus. This failure affected 1 resident and placed all 34 additional residents at risk of pain, harm or decreased quality of life due to neglect. Findings include: Incident Intake # 3 Resident #1 Record review of the clinical chart for Resident #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED].-displaced fracture of greater tuberosity of right humerus, initial encounter for closed fracture, dysphagia and other symbolic dysfunctions. Record review of the care plan dated 3/12/18 revealed she was care-planned for falls. The care plan read in part Problem . due to her history of [MEDICAL CONDITION] and the potential to fall and at risk of injury. The section entitled Approach read, requires 2 aides to perform incontinent care and staff will make sure with positioning her that she's not on the edge of bed and at risk for falls. Record review of the admission MDS with an ARD of 4/17/18 revealed Resident #1 scored a 12 on the BIMS test indicating she is moderately cognitively impaired. The review further revealed the resident's functional status for activities of daily living was total dependence. Toilet use was listed as, activity did not occur.' The MDS assessment revealed she had a limitation to her upper extremity on one side which interfered with daily functions or placed resident at risk of injury. The resident had a fall since admission which caused an injury (excluding major injury). Record review of the Provider Investigation Report dated 6/22/18 revealed that an agency aide (a nurse aide hired on a temporary basis), CNA A, was performing incontinent care and changing the resident's linens on 6/17/18 at 5:00pm. The aide rolled the resident over on her left side and asked her to hold the bed rail with her right hand. The report further revealed that Resident #1 let go of the hand rail and rolled off the bed to the floor. The review also revealed the resident began crying in pain and stating her shoulder was hurting. The charge nurse instructed the medication aide to give Resident #1 scheduled [MEDICATION NAME] for pain. Review of the section- Investigation Summary read in part, investigation of this incident indicated that Aide did not follow the Plan of care while providing care to the resident . Record review of an Incident Report dated 6/17/18 revealed on this date at 5:00pm, Resident #1 had a witnessed fall. A statement written by CNA A read in part . While I was changing her, I was applying clean sheets to her bed. I rolled her over to her left side and made her hold on the the rail with her right hand, she let go of the rail while receiving care and fell to the floor by rolling off the bed. Treatment included an x-ray, first aid and assessment. Record review of a witness statement completed by LVN A dated 6/20/18 revealed on 6/17/18, she was called to Resident #1's room by a CNA. Resident #1 was on the floor with a pillow under her head crying and saying, Oh, my shoulder hurts, my shoulder hurts. LVN A completed a head to toe assessment. I am going to check your shoulder and ask your med aide to give you something for pain .carefully assisted resident back to bed with assistance of the two CNAs present .Recieved MD order for x-ray to left shoulder . Record review of the on-site x-ray conducted 6/18/18 read in part, 6/18/18 .SIGNIFICANT FINDINGS Left Shoulder 3 views .Findings: [MEDICATION NAME] neck of the humerus with impaction and possible comminuted component. Probable chronic fracture deformity of distal clavicle and recommend correlation with date of injury. Record review of Resident #1's nurse notes dated 6/18/2018 revealed after the results of the x-ray were confirmed, the resident was transferred to the hospital and returned the following day with an immobilizer to the left arm. Record review of a Physician's order dated 6/18/18 at 9:00am revealed an order to send Resident #1 to the hospital for fracture. Observation and interview with Resident #1 were conducted on 6/22/18 at 2:00 PM. The resident who appeared to be alert and oriented was observed in bed with her left arm covered and in a sling. She was asked about events that caused her injury and stated that an aide let her fall out of bed. She stated she was experiencing pain and the nurse was notified. Interview with the Vice-President of Operations and with the Regional Nurse on 6/22/2018 at 2:30pm revealed the aide worked for an agency and felt very bad about her mistake and they would no longer be using her at the facility. Record review of the facility policy for Abuse Prevention dated 8/8/2017 read in part . Our facility implements an effective system for the prevention of abuse and neglect .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. According to the Facility's Form 802, the census was 35.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 1 of 4 residents (Resident #1) reviewed for care plans in that: Resident #1 was care planned for incontinent care to be provided by 2 persons. She received incontinent care with one aide, slid from the bed and sustained a fractured humerus. This failure affected 1 resident and placed all 34 additional residents at risk of pain, harm or decreased quality of life due to not having their stated needs met. Findings include: Incident Intake # 3 Resident #1 Record review of the clinical chart for Resident #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED].-displaced fracture of greater tuberosity of right humerus, initial encounter for closed fracture, dysphagia and other symbolic dysfunctions. Record review of the care plan dated 3/12/18 revealed she was care-planned for falls. The care plan read in part Problem . due to her history of [MEDICAL CONDITION] and the potential to fall and at risk of injury. The section entitled Approach read, requires 2 aides to perform incontinent care and staff will make sure with positioning her that she's not on the edge of bed and at risk for falls. Record review of the admission MDS with an ARD of 4/17/18 revealed Resident #1 scored a 12 on the BIMS test indicating she is moderately cognitively impaired. The review further revealed the resident's functional status for activities of daily living was total dependence. Toilet use was listed as, activity did not occur.' The MDS assessment revealed she had a limitation to her upper extremity on one side which interfered with daily functions or placed resident at risk of injury. The resident had a fall since admission which caused an injury (excluding major injury). Record review of the Provider Investigation Report dated 6/22/18 revealed that an agency aide (a nurse aide hired on a temporary basis), CNA A, was performing incontinent care and changing the resident's linens on 6/17/18 at 5:00pm. The aide rolled the resident over on her left side and asked her to hold the bed rail with her right hand. The report further revealed that Resident #1 let go of the hand rail and rolled off the bed to the floor. The review also revealed the resident began crying in pain and stating her shoulder was hurting. The charge nurse instructed the medication aide to give Resident #1 scheduled [MEDICATION NAME] for pain. Review of the section- Investigation Summary read in part, investigation of this incident indicated that Aide did not follow the Plan of care while providing care to the resident . Record review of an Incident Report dated 6/17/18 revealed on this date at 5:00pm, Resident #1 had a witnessed fall. A statement written by CNA A read in part . While I was changing her, I was applying clean sheets to her bed. I rolled her over to her left side and made her hold on the the rail with her right hand, she let go of the rail while receiving care and fell to the floor by rolling off the bed. Treatment included an x-ray, first aid and assessment. Record review of a witness statement completed by LVN A dated 6/20/18 revealed on 6/17/18, she was called to Resident #1's room by a CNA. Resident #1 was on the floor with a pillow under her head crying and saying, Oh, my shoulder hurts, my shoulder hurts. LVN A completed a head to toe assessment. I am going to check your shoulder and ask your med aide to give you something for pain .carefully assisted resident back to bed with assistance of the two CNAs present .Received MD order for x-ray to left shoulder . Record review of the on-site x-ray conducted 6/18/18 read in part, 6/18/18 .SIGNIFICANT FINDINGS Left Shoulder 3 views .Findings: [MEDICATION NAME] neck of the humerus with impaction and possible comminuted component. Probable chronic fracture deformity of distal clavicle and recommend correlation with date of injury. Record review of Resident #1's nurse notes dated 6/18/2018 revealed after the results of the x-ray were confirmed, the resident was transferred to the hospital and returned the following day with an immobilizer to the left arm. Record review of a Physician's order dated 6/18/18 at 9:00am revealed an order to send Resident #1 to the hospital for fracture. Observation and interview with Resident #1 were conducted on 6/22/18 at 2:00 PM. The resident who appeared to be alert and oriented was observed in bed with her left arm covered and in a sling. She was asked about events that caused her injury and stated that an aide let her fall out of bed. She stated she was experiencing pain and the nurse was notified. Interview with the Vice-President of Operations and with the Regional Nurse on 6/22/2018 at 2:30pm revealed the aide felt very bad about her mistake and they would no longer be using her at the facility. Record review of the facility policy for care plans dated 10/10/2017 read in part . each resident will have a person-centered care plan developed in accordance with state and federal guidelines that will address both the resident's strengths and weaknesses. This care plan will guide staff in providing services that assist the resident in reaching their goals . According to the Facility's Form 802, the census was 35.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards and failed to ensure each resident had adequate supervision for 6 of 11 Residents (Resident #3, #4, #5, #6, #7, #8) reviewed for accidents and hazards in that: -The facility failed to have a functioning call light system since (MONTH) (YEAR) for residents to report ADL needs or emergencies in restroom/bathrooms and bedrooms. The facility failed to have manual call bells for Residents #3, #6, #7 who required extensive assistance with transfers. The facility failed to implement effective interventions to address the non-functioning call light system in case of emergency. -The facility failed to have a functioning fire panel and fire system since (MONTH) (YEAR), and increase staffing to ensure fire watch was being conducted 24 Hours a day. The facility failed to complete routine fire drills. The facility failed to ensure the corridor door on 2 of 2 hallways were able to close and latch without impediment. The facility failed to implement effective interventions to address the non-functioning fire panel and fire system in case of emergency. -The facility failed to have adequate staff on the night shift in case of an emergency evacuation. The facility failed to have enough certified nursing aides and nurse staff to conduct fire watch and evacuate residents in an emergency. There were 6 residents in the facility that required 2 staff assistance with a mechanical lift for transfers. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures affected 6 residents and placed 25 residents at risk of not having needs met in the case of emergency resulting in injury or harm. The findings were: Observation on [DATE] at 5:42 AM revealed there were no call lights on and the system was not making noise. Some rooms had manual bells in them. Observation of the facility fire panel revealed the system was red tagged on [DATE] by INCA Fire Trio which means the fire panel was out of service. In an interview on [DATE] at 6:05 AM CNA Z stated tonight there is only one Nurse Aide scheduled on 10p-6a shift. CNA X would be the only CNA tonight. Observation on [DATE] at 5:20 AM revealed Surveyor rang door bell and knocked on front door but nobody answered. A resident who was sitting in chair in front of door started yelling somebody is at the door. Observation on [DATE] at 5:25 AM outside of facility front door revealed LVN T pulled up in a car and got out of the car with CNA V. Once in the facility, CNA S was observed as the only staff member at the facility. In an interview on [DATE] at 5:36 AM LVN T stated she was on fire watch today and yesterday. She said the facility only had 2 staff on 10p-6a shift. Record review of the fire watch book on [DATE] revealed the 15 minute checklist was filled out until 6:00 AM by LVN T. LVN T was on fire watch from 12:00 AM to 6:00 AM, with checks reported every 15 minutes. In an interview on [DATE] at 6:08 AM CNA V stated LVN T picked her up down the street for work. CNA V walked to work. In an interview on [DATE] at 5:52 AM LVN T stated CNA V did not have a car and she went to go pick her up on [DATE]. She said staff try to go pick her up when they can. She knew she needed to be at the facility in case of an emergency and to do fire watch. Observation on [DATE] at 6:09 AM, the facility had a layout shaped like an 'H.' The North and South hallways were separated by the front lobby, kitchen and dining room. Observation on [DATE] at 6:09 AM revealed no staff on North side of building to monitor residents. There were 14 residents on the hallway. Observation on [DATE] at 7:31 AM revealed no staff monitoring the South side of building. There were 20 residents on the hallway. Observation on [DATE] at 9:27 am revealed the fire-rated door near the beauty salon leading to the resident corridor was propped open with a white wedge and would not close and latch without impediment. Observation on [DATE] at 9:28 am revealed the fire-rated door near the soiled utility room leading to the resident corridor was propped open with a white wedge and would not close and latch without impediment. In an interview on [DATE] at 9:29 AM with the Administrator, at the times of observation, she confirmed the doors were propped open and could not latch and close without impediment. In an interview on [DATE] at 9:44 AM the Administrator stated the repair company was here to work on the call light system today. In an interview on [DATE] at 5:30 AM CNA Z stated she worked at the facility PRN, when they need help. She said 10p-6a staff have to work with 1 Nurse Aide for 30 residents. She said the nurse aides complained about being short-staffed to the facility administration. The residents used manual call bells so it was hard to hear residents on the other side of the building if you are by yourself. She said the residents had manual hand bells because the call light system was out. She said the fire alarm system did not work either, and the staff had to do fire watch. In an interview on [DATE] at 9:57 AM LVN T stated she worked some nights and the facility had 1 aide and 1 LVN. The staff tried to manage the best way they could. The facility had 30 residents for 2 staff. She said the ratio was not right at the facility. In a telephone interview on [DATE] at 10:14 AM CNA X stated the facility had 30 residents for 1 aide. The last 2 weeks she had been working like this. Staffing was bad even during the day. She said 2 aides were not enough during the day. She said sometimes she had to work double shifts when staff didn't come. She said some days she took off because she knew she was going to be by herself. She said some days, she had to do fire watch and she was the only aide at the building which was against the law. The person doing fire watch was supposed to do this all the time. She said all of the residents didn't have call bells either. In an interview on [DATE] at 11:00 AM CNA V stated at night there was 1 CNA and 1 LVN. Sometimes they didn't have a designated staff member for fire watch so nursing staff had to do that also. Today she was working both sides of the building and some of her residents were on the other side of the building. She said the facility had 30 residents at the facility which was a lot for 2 staff. She said she couldn't give everyone showers sometimes, and had to give bed baths. She said the administration complained and wanted us to take breaks but said she had not stopped working since she had been at the building. She said during lunch sometimes meal service was late because staff were in rooms assisting residents. She said staff can't take breaks because resident care would get behind. She had two other residents waiting for her on the other side of the building. One needed to be changed and the other needed to be showered. In an interview on [DATE] at 5:30 AM CNA S stated the facility had 2 staff here at night. She said staff had to do fire watch from 10:30 PM forward on the night shift. The Maintenance Director was on fire watch but left the building at 10:30 PM. She said staff had to do fire watch and also take care of the residents. She said the same thing happened the night before. In a telephone interview on [DATE] at 7:31 AM CNA X stated she had to do fire watch during the month of (MONTH) while only being on shift with just 2 staff. She said all of the residents did not have call bells. She said staff had to work on the floor and try to do fire watch. In an interview on [DATE] at 8:08 AM the Administrator stated she was trying to get 2 aides at night and 1 LVN with another person to do fire watch. In an interview on [DATE] at 9:15 AM the Administrator stated she did not know how many staff were needed to meet the needs of residents or evacuate residents. In an interview on [DATE] at 9:34 AM the Maintenance Supervisor stated the last fire drill was conducted on [DATE] after the fire panel was red tagged. In the Fire Drill Binder the facility only had fire drills up until [DATE] because the other fire drills were in a storage unit in a box, due to repairs at the facility. He did not do an assessment to determine how many staff the facility would need to evacuate residents. In an interview on [DATE] at 2:36 PM the MDS Nurse stated the facility had 6 resident that require mechanical lift for transfer. Resident #3 Record review of Resident #3's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's MDS dated [DATE] revealed she had a BIMS of 15 indicative of intact cognition. Resident #3 required extensive assist with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #3's Care Plan dated [DATE] revealed she was total assist x ,[DATE] staff members for transfer, toileting, & bathing due to [MEDICAL CONDITION]. Staff are to have call light near Resident #3 and answer promptly. Observation on [DATE] at 6:00 AM revealed Resident #3 was in bed and did not have a manual call bell near her bed. In an interview on [DATE] at 6:00 AM Resident #3 stated the facility needed more staff so bad and the facility would not do anything about it. She said they complained but it did no good. She said she had a call bell but gave it to another resident who didn't have one. She used her phone when she needed something. She said the call light system did not work, and sometimes they are short staffed at night. They are losing good help at the facility. In an interview on [DATE] at 6:36 AM LVN Y stated Resident #3 does not have a call bell but uses her cell phone to call staff for help. Resident #6 Record review of Resident #6's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's MDS dated [DATE] revealed he had a BIMS of 10 indicative of moderately intact cognition. Resident #6 was totally dependent on staff for bed mobility and transfers. Record review of Resident #6's Care Plan dated [DATE] revealed Resident #6 had a self-care deficit related to paraplegic and required total assistance with ADL's. Resident #6 required ,[DATE] total assist with bed mobility, transfers, showers, dressing and hygiene. Observation on [DATE] at 10:51 AM revealed Resident #6 was lying in bed. He had a catheter attached to his bed that was covered. Resident #6 did not have a manual call bell in his room. In an interview on [DATE] at 10:51 AM Resident #6 stated it took a while for staff to help you. He said the facility did not have enough staff. Resident #6 said he did not even have a call bell. He said the staff could not hear it if he did have one in his room because no staff were on this side of the building. In an interview on [DATE] at 12:55 PM Resident #6 stated, Can you help me get a call light system, that's all I want. He said the facility gave him a bell now but the staff could not hear it. Record review of Mechanical Lift List provided by facility revealed Resident #6 required mechanical lifts for transfer. Resident #4 Record review of Resident #4's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's MDS dated [DATE] revealed he had a BIMS of 10 which indicated he had moderate cognitive impairment. Resident #4 required total assistance with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #4's Care Plan dated [DATE] revealed he needed extensive to total assist of ,[DATE] staff members for bed mobility, transfers, toileting, and bathing due to limited mobility. Provide assistance with bathing/showering 3 times a week and a sponge bath on non-shower days if needed. Observation on [DATE] at 9:55 AM revealed Resident #4 was lying in bed with his manual call bell in his hand. LVN T entered the room and told Resident #4 he had to wait to get out of bed because the nurse aide is busy. In an interview on [DATE] at 9:55 AM Resident #4 asked if the Surveyor could get someone to get him out of bed. He had been waiting to get out of bed since morning. In an interview on [DATE] at 10:29 AM CNA W stated she was doing showers today so it took a while to get to Resident #4. She usually got him up at about 10:00 AM. She said today was shower day for Resident #4 but staff were very busy and Resident #4 would just have to get a bed bath. She said she was busting her ass at this place. The other nurse aide usually helped her with showers but not today. She said Resident #4 was a 2 person assist with mechanical lift. Resident #7 Record review of Resident #7's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS dated [DATE] revealed he had a BIMS of 15 which revealed he was cognitively intact. Resident #7 was extensive assist for bed mobility and limited assist for transfer, dressing, and personal hygiene. Record review of Resident #7's Care Plan dated [DATE] revealed he had a self-care deficit related to [MEDICAL CONDITION] and required assistance with ADL's. Resident #7 required ,[DATE] assist with transfers. Observation on [DATE] at 10:52 AM revealed Resident #7 was sitting up in bed near his wheel chair. Resident #7 did not have a manual call bell. In an interview on [DATE] at 10:52 AM Resident #7 stated the staff took a while to come and help assist people. He did not have a manual call bell in his room. He stated, Depending on what is going on in the facility will determine when staff can get to you. Resident #7 said he was waiting for someone to help him transfer to his wheelchair. Resident #5 Record review of Resident #5's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed she had a BIMS of 15 indicative of intact cognition. Observation on [DATE] at 8:15 AM revealed Resident #5 sitting in the dining room. She ambulated with a cane. In an interview on [DATE] at 8:15 AM Resident #5 stated they didn't have enough staff at the facility. She said residents had to wait over an hour for care and medications. She said staff had bad attitudes because they were overworked. Resident #8 Record review of Resident #8's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS dated [DATE] revealed he had a BIMS of 15 indicative of intact cognition. Resident #8's required total assistance with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #8's Care Plan dated [DATE] revealed Resident #8 had a self-care deficit related to dementia and required assistance with ADL's. Resident #8 required 2 person assist with transfers with mechanical lift. Observation on [DATE] at 10:43 AM revealed Resident #8 was in the hallway in his wheelchair. He had amputations to both legs. In an interview on [DATE] at 10:43 AM Resident #8 stated sometimes they had to wait hours before they could get care at night because there were not enough staff to help. Record review of mechanical Lift List provided by facility revealed Resident #8 required mechanical lifts for transfer. In an interview on [DATE] at 8:27 AM the Administrator stated the call light system went out during repairs for Hurricane Harvey in (MONTH) (YEAR). She said the facility had not repaired the call light system and they were using manual call bells. In a continued interview on [DATE] at 8:27 AM, The Administrator said the facility had a fire in the attic on (MONTH) 24, (YEAR). The wire in the attic sparked and the insulation caught on fire, then the fire department put it out. She said the fire panel system couldn't be repaired, so the system was red-tagged on (MONTH) 3, (YEAR). She said the facility was waiting on the Fire Marshall to approve plans to fix fire alarm system. The facility was going back and forth with the Fire Marshall on the plan. She said the person that could approve the plan would not be back in the office until next week. In an interview on [DATE] at 11:20 AM the Administrator stated some resident's manual call bells may be in their old rooms and they would check. She said the facility had some residents switch rooms, and some of the residents were new. She had some extra call bells in a bag in the DON's office. If the facility did not have enough call bells they would go and buy some more. She said sometimes they break so the facility had to replace them. The Administrator stated the facility had a problem with staffing for fire watch so she decided to rotate department heads for fire watch. Sometimes the DON and Administrator stay for the fire watch at night but it was hard because staff call out at the last minute, and they had to find someone to cover their shift. She said if someone came in for fire watch, they would try to let them go home after they do fire watch. She said the facility always had 1 LVN at night. She said the facility had 1 nurse aide at night because the census was low. She said the facility was increasing their census. She said she was trying to hire people but things had been hard since they had been on fire watch for over 4 weeks. She said they could not pull the fire watch staff to do floor work in the building. She said it was hard to get nurse aides, sometimes they come, get mad and leave. In an interview on [DATE] at 10:16 AM the Administrator stated Staff are only to do fire watch when assigned to fire watch. Ideally, the facility would have staff for fire watch and the floor. She said at night the 2 staff are to rotate so they may do fire watch duties then their floor duties. She said on Tuesday, an aide quit. She hired an aide who was supposed to do orientation today but she never showed up. She said nursing staff were supposed to be in the building, and should not leave the facility. She said LVN T left to pick up another staff member. She had not thought that far on evacuation situation and staffing needs for safe evacuation. Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated [DATE] revealed Date the facility first learned of incident: [DATE] .Report Details While completing building repairs, the call light system was damaged. So, we have disconnected the call system and have provided all residents with hand held bells. There is an employee on the hall at all times .Description of in-service training: The staff was in-serviced that the hand held bell must be in the residents reach at all times. They were also in-serviced that a staff member, must be on the hall at all times Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated [DATE] revealed Date the facility first learned of incident: [DATE] Report Details .The fire alarm system continued to alarm uncontrollably without evidence of a fire. So we had our contacted Fire and Alarm Company, Inca Fire Trio, to come out to repair our Fire Alarm system. However, after troubleshooting the system, they deemed it irreparable. They shut down the system and red tagged it. We have implemented a 24 hour fire watch and the local fire marshall's office has been contacted. An estimate and designs plan have been submitted for the replacement of the fire Alarm System, and the work will be completed timely .Description of in-service training . Fire Watch Protocol and Fire Protocol (RACE and PASS). Record review of the In-Service Training Report dated [DATE] revealed . call light system is inactive, manual call bells should be at all residents beside (in-reach) at all times. All new admits should receive a call bell upon admission . Record review of the Daily Staff Assignment Sheets revealed the following: - [DATE] revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. - There was no sheet for [DATE]. - [DATE] revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. Record review of the Employee Time Cards revealed the following: - [DATE] revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - ,[DATE] /18 revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - [DATE] revealed there was 1 CNA on 10p-6a shift - [DATE] revealed there was 1 CNA on 10p-6a shift. - [DATE] revealed there was 1 LVN, 1 CNA on 10p-6a shift. In an interview on [DATE] at 10:40 AM the Administrator stated she was the LVN on the floor on [DATE] and [DATE]. She did not have a time card because she does not punch in. Record review of the Facility Staffing Postings revealed the following: - [DATE] revealed 30 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. - [DATE] revealed 34 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. Record review of the fire watch log dated (MONTH) and (MONTH) (YEAR) revealed staff were signing for fire watch every 15 minutes. Record review of the fire drill binder revealed the last documented fire drill was on [DATE] at 4:00 PM. The Administrator was notified of the Immediate Jeopardy on [DATE] at 1:20 PM due to the above failures. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. After several revisions, the Plan of Removal was accepted on [DATE] at 6:56pm. The Plan of Removal reflected: The following information is in relation to the Immediate Jeopardy and Immediate Threat cited on [DATE]. This serves as notification of our plan to lower the severity. Fire Panel o La Porte Healthcare Center signed a contract with Firetrol Protection Systems on [DATE] to replace the Fire Alarm System. The projected time for completion is as documented on the timeline below, provided by Firetrol Protection Systems: I. Our design team will draft and submit a fire alarm plan to the La Porte Fire Marshal based on the plan provided at the time of bid. Design should take 10 days, with another 10 days to receive back from the Fire Marshal II. Pending his approval, we will then order the material which has a ,[DATE] day lead time. III. While the material is being shipped, our installation department will begin pulling the fire alarm cable based on the layout provided and approved by the local AHJ. This should take roughly a week to install. IV. Once the material has come in we will then begin installing the devices. This should take a week. V. After installation and troubleshooting any issues we will do a pretest of the system. This will take ,[DATE] days. VI. After successful pretesting is finished, we will then call for a fire marshal test. This test will be completed in 1 day. VII. The final stage would be to demo the existing system and cable after the Fire Marshal has signed off on the installation. o Start date of Fire Alarm System installation pending Fire Marshalls approval of plans. Call Light System o INCA Fire Trio is currently installing the new Call Light System. The Entire system will be up and running on Friday, [DATE]. o While the Call Light System is being replaced, the facility has provided hand held call bells to all residents. Staff in-servicing on this process began [DATE]. o During fire watch rounds, staff will ensure that all residents have a call bell in reach every 15 minutes. Staff in-servicing on this process was originally completed on [DATE], Re-training on this process began [DATE]. o The Administrator or Designee will ensure that there is a staff member on each hall at all times, to respond to the ringing of the call bells. Staff in-servicing on this process began [DATE] Fire Watch o There is an employee on duty to Fire Watch 24 hours a day, 7 days a week. Fire watch was started on [DATE], when the Fire Panel was Red Tagged. Staff was notified immediately that the Fire Alarm System was no longer functional, and the facility was on Fire Watch. o The Fire Watch is conducted by an able bodied , competent adult over the age of 21. o The employee on Fire Watch has no other duties or jobs during their designated time. They only serve as the Fire Watch and have no other responsibilities for the entire duration of the shift of said Fire Watch, no exceptions. o The employee on Fire Watch is on constant patrol, ensuring that 100% of the premises are covered every 15 minutes. a) The employee on Fire Watch has all keys required to access all spaces with them the entire shift and be capable of accessing said spaces. b) During breaks/lunches of the employee on Fire Watch, a replacement Fire Watch will assume all roles and responsibilities until relieved by the Fire Watch on shift. o The Facility ensures that the employee on Fire Watch has a cell phone in their possession at all times, for notification to the fire department. Their only duty is to perform constant patrols of the protected premises and keep watch for fires during all hours. o All employees have been notified, in writing, and signed a log indicating that they are aware that the Fire Alarm system is inactive, and in the event they discover a fire that the system will not alert the Fire Department, so they must call 911. A copy of the employee notice with the log shall remain on premises and available to the La Porte Fire Marshal's Office at all times. o All employees are notified, at the beginning of each shifts that the Fire Alarm system is inactive, and in the event they discover a fire that the system will not alert the Fire Department. They should immediately call 911, if they see fire, smoke, or heat of any kind. o Staff in-serviced, that fire doors must be shut immediately if there are any signs of smoke or fire. o Fire doors will remain we closed once the Call Light system is operational. o Staff in-servicing on this process was originally completed on [DATE], Re-training on this process began [DATE]. Evacuation o Staff was in-serviced on Facility's evacuation procedure on [DATE]. o Facility has ensured that there is adequate staff in the building: to monitor wanderers, elopement risk, and assist 2 person transfers at all times. Staff in-servicing on this process began [DATE]. o Staff was in-serviced, that during an evacuation someone must stay outside to monitor the wanderers and elopement risk, and that remaining staff (2 or more at all times) will evacuate the other residents. Staff in-servicing on this process began [DATE] o Administrator or Designee has ensured that there is adequate staff in the building at all times to facilitate a safe evacuation of residents. Staff in-servicing on this process began [DATE]. Staffing o Administrator or Designee has ensured that the facility has adequate staff to perform quality care for all residents, and additional staff to complete fire watch on every shift. o On the 10pm-6am shift, we will be staffing 4 employees, with a designated Fire Watch person included. This staffing pattern began on [DATE]. o Employee recruitment ads were requested to be posted on Indeed and the local newspaper on [DATE]. We are actively responding to resumes and trying to hire staff daily. This weekend we set up a profile with Shiftkey, to help us staff through their agency until we have adequate staff to meet our staffing needs. Life Safety o The Administrator or Designee will fax or email the daily Fire Watch logs to the LSC Program Manager, weekly, as requested by the LSC Program Specialist. This process was initiated on [DATE]. Administrator or Designee will ensure that all staff and new hires have completed all of the above in-services before returning or starting to work. In-servicing of 100% of staff, will be completed by 11:00 p.m. on [DATE]. Monitoring observations were conducted: In an observation on [DATE] at 5:00am, the facility had 1 LVN, 1 CNA, the Administrator providing care to the residents. The Dietary Manager was on fire watch. While on fire watch, she was not doing other tasks. In an observation on [DATE] at 6:00am, the facility had 1 LVN and 2 CNAs providing care to the residents. The Business Office Manager was on fire watch. While on fire watch, she was not doing other tasks. Monitoring interviews were conducted on [DATE] with the Dietary Manager at 5:00am and the Administrator at 6:00am. Monitoring interview was conducted on [DATE] with the Business office Manager at 7:13am. Monitoring interviews were conducted at various times on [DATE] with staff the following staff: CNA S at 5:47 AM LVN T at 5:52 AM CNA F at 5:57 AM MDS Nurse at 6:03 AM Dietary Manager at 6:05 AM CNA H at 6:07 AM LVN R at 6:10 AM CNA J at 6:40 AM CNA I at 6:46 AM Business Office Manager at 9: (TRUNCATED)

Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being in that: The Administrator, who was the Abuse Prohibition Coordinator, failed to implement the facility policies and procedures regarding neglect. The Administrator failed to ensure there were enough staff at the facility to meet resident needs. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures could affect all 30 residents who could need help with ADL's or have an emergency at risk for neglect by placing them at risk of harm or injury. Findings Included: Observation on [DATE] at 5:42 AM revealed there were no call lights on and the system was not making noise. Some rooms had manual bells in them. Observation of the facility fire panel revealed the system was red tagged on [DATE] by INCA Fire Trio which means the fire panel was out of service. In an interview on [DATE] at 6:05 AM CNA Z stated tonight there is only one Nurse Aide scheduled on 10p-6a shift. CNA X would be the only CNA tonight. Observation on [DATE] at 5:20 AM revealed Surveyor rang door bell and knocked on front door but nobody answered. A resident who was sitting in chair in front of door started yelling somebody is at the door. Observation on [DATE] at 5:25 AM outside of facility front door revealed LVN T pulled up in a car and got out of the car with CNA V. Once in the facility, CNA S was observed as the only staff member at the facility. In an interview on [DATE] at 5:36 AM LVN T stated she was on fire watch today and yesterday. She said the facility only had 2 staff on 10p-6a shift. Record review of the fire watch book on [DATE] revealed the 15 minute checklist was filled out until 6:00 AM by LVN T. LVN T was on fire watch from 12:00 AM to 6:00 AM, with checks reported every 15 minutes. In an interview on [DATE] at 6:08 AM CNA V stated LVN T picked her up down the street for work. CNA V walked to work. In an interview on [DATE] at 5:52 AM LVN T stated CNA V did not have a car and she went to go pick her up on [DATE]. She said staff try to go pick her up when they can. She knew she needed to be at the facility in case of an emergency and to do fire watch. Observation on [DATE] at 6:09 AM, the facility had a layout shaped like an 'H.' The North and South hallways were separated by the front lobby, kitchen and dining room. Observation on [DATE] at 6:09 AM revealed no staff on North side of building to monitor residents. There were 14 residents on the hallway. Observation on [DATE] at 7:31 AM revealed no staff monitoring the South side of building. There were 20 residents on the hallway. Observation on [DATE] at 9:27 am revealed the fire-rated door near the beauty salon leading to the resident corridor was propped open with a white wedge and would not close and latch without impediment. Observation on [DATE] at 9:28 am revealed the fire-rated door near the soiled utility room leading to the resident corridor was propped open with a white wedge and would not close and latch without impediment. In an interview on [DATE] at 9:29 AM with the Administrator, at the times of observation, she confirmed the doors were propped open and could not latch and close without impediment. In an interview on [DATE] at 9:44 AM the Administrator stated the repair company was here to work on the call light system today. In an interview on [DATE] at 8:27 AM the Administrator stated the call light system went out during repairs for Hurricane Harvey in (MONTH) (YEAR). She said the facility had not repaired the call light system and they were using manual call bells. In a continued interview on [DATE] at 8:27 AM, The Administrator said the facility had a fire in the attic on (MONTH) 24, (YEAR). The wire in the attic sparked and the insulation caught on fire, then the fire department put it out. She said the fire panel system couldn't be repaired, so the system was red-tagged on (MONTH) 3, (YEAR). She said the facility was waiting on the Fire Marshall to approve plans to fix fire alarm system. The facility was going back and forth with the Fire Marshall on the plan. She said the person that could approve the plan would not be back in the office until next week. In an interview on [DATE] at 11:20 AM the Administrator stated some resident's manual call bells may be in their old rooms and they would check. She said the facility had some residents switch rooms, and some of the residents were new. She had some extra call bells in a bag in the DON's office. If the facility did not have enough call bells they would go and buy some more. She said sometimes they break so the facility had to replace them. The Administrator stated the facility had a problem with staffing for fire watch so she decided to rotate department heads for fire watch. Sometimes the DON and Administrator stay for the fire watch at night but it was hard because staff call out at the last minute, and they had to find someone to cover their shift. She said if someone came in for fire watch, they would try to let them go home after they do fire watch. She said the facility always had 1 LVN at night. She said the facility had 1 nurse aide at night because the census was low. She said the facility was increasing their census. She said she was trying to hire people but things had been hard since they had been on fire watch for over 4 weeks. She said they could not pull the fire watch staff to do floor work in the building. She said it was hard to get nurse aides, sometimes they come, get mad and leave. In an interview on [DATE] at 8:08 AM the Administrator stated she was trying to get 2 aides at night and 1 LVN with another person to do fire watch. In an interview on [DATE] at 9:15 AM the Administrator stated she did not know how many staff were needed to meet the needs of residents or evacuate residents. In an interview on [DATE] at 10:16 AM the Administrator stated Staff are only to do fire watch when assigned to fire watch. Ideally, the facility would have staff for fire watch and the floor. She said at night the 2 staff are to rotate so they may do fire watch duties then their floor duties. She said on Tuesday, an aide quit. She hired an aide who was supposed to do orientation today but she never showed up. She said nursing staff were supposed to be in the building, and should not leave the facility. She said LVN T left to pick up another staff member. She had not thought that far on evacuation situation and staffing needs for safe evacuation. During an interview on [DATE] at 1:18 p.m. the Administrator said she thought the immediate jeopardy was a result of the renovations at the facility, a decrease in residents and then a sudden increase in residents, lack of ability to attain staff quickly, failure to follow up with fire service company, and failure of fire service company to do the work. In an interview on [DATE] at 2:36 PM the MDS Nurse stated the facility has 6 resident that require Hoyer lift for transfer. Record review of 2 Person Transfer List provided by the facility revealed the facility had 3 residents that required a 2 person assist for transfers. Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated [DATE] revealed Date the facility first learned of incident: [DATE] .Report Details While completing building repairs, the call light system was damaged. So, we have disconnected the call system and have provided all residents with hand held bells. There is an employee on the hall at all times .Description of in-service training: The staff was in-serviced that the hand held bell must be in the residents reach at all times. They were also in-serviced that a staff member, must be on the hall at tall times Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated [DATE] revealed Date the facility first learned of incident: [DATE] Report Details .The fire alarm system continued to alarm uncontrollably without evidence of a fire. So we had our contacted Fire and Alarm Company, Inca Fire Trio, to come out to repair our Fire Alarm system. However, after troubleshooting the system, they deemed it irreparable. They shut down the system and red tagged it. We have implemented a 24 hour fire watch and the local fire marshall's office has been contacted. An estimate and designs plan have been submitted for the replacement of the fire Alarm System, and the work will be completed timely .Description of in-service training . Fire Watch Protocol and Fire Protocol (RACE and PASS). Record review of the In-Service Training Report dated [DATE] revealed . call light system is inactive, manual call bells should be at all residents beside (in-reach) at all times. All new admits should receive a call bell upon admission . Record review of the Daily Staff Assignment Sheets revealed the following: - [DATE] revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. - There was no sheet for [DATE]. - [DATE] revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. Record review of the Employee Time Cards revealed the following: - [DATE] revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - ,[DATE] /18 revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - [DATE] revealed there was 1 CNA on 10p-6a shift - [DATE] revealed there was 1 CNA on 10p-6a shift. - [DATE] revealed there was 1 LVN, 1 CNA on 10p-6a shift. In an interview on [DATE] at 10:40 AM the Administrator stated she was the LVN on the floor on [DATE] and [DATE]. She did not have a time card because she does not punch in. Record review of the Facility Staffing Postings revealed the following: - [DATE] revealed 30 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. - [DATE] revealed 34 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. Record review of the Senior Living Properties Abuse Prevention Policy dated [DATE] revealed .Policy Statement: Our facility implements an effective system for the prevention of abuse and neglect .The facility initiates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect . The facility will ensure that any allegations of abuse and neglect are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal laws . Prevention 1. Identify, assess, care-plan and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care or are totally dependent on staff 2. Identify characteristics of physical environment that may make abuse and or neglect more likely to occur: equipment or devices will be properly maintained and used in accordance with manufacture's specifications .Functioning call systems .3 . Supervision will be provided for those individuals with known special needs such as: impaired individuals with known elopement risk; dementia dependent residents with adequate call system in place . An Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 1:20 PM. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 6:56pm. The Plan of Removal reflected: The following information is in relation to the Immediate Jeopardy and Immediate Threat cited on [DATE]. This serves as notification of our plan to lower the severity. Fire Panel La Porte Healthcare Center signed a contract with Firetrol Protection Systems on [DATE] to replace the Fire Alarm System. The projected time for completion is as documented on the timeline below, provided by Firetrol Protection Systems: I. Our design team will draft and submit a fire alarm plan to the La Porte Fire Marshal based on the plan provided at the time of bid. Design should take 10 days, with another 10 days to receive back from the Fire Marshal II. Pending his approval, we will then order the material which has a 7?10 day lead time. III. While the material is being shipped, our installation department will begin pulling the fire alarm cable based on the layout provided and approved by the local AHJ. This should take roughly a week to install. IV. Once the material has come in we will then begin installing the devices. This should take a week. V. After installation and troubleshooting any issues we will do a pretest of the system. This will take 2?3 days. VI. After successful pretesting is finished, we will then call for a fire marshal test. This test will be completed in 1 day. VII. The final stage would be to demo the existing system and cable after the Fire Marshal has signed off on the installation. Start date of Fire Alarm System installation pending Fire Marshalls approval of plans. Call Light System INCA Fire Trio is currently installing the new Call Light System. The Entire system will be up and running on Friday, [DATE]. While the Call Light System is being replaced, the facility has provided hand held call bells to all residents. Staff in-servicing on this process began [DATE]. During fire watch rounds, staff will ensure that all residents have a call bell in reach every 15 minutes. Staff in-servicing on this process was originally completed on [DATE], Re-training on this process began [DATE]. The Administrator or Designee will ensure that there is a staff member on each hall at all times, to respond to the ringing of the call bells. Staff in-servicing on this process began [DATE] Fire Watch There is an employee on duty to Fire Watch 24 hours a day, 7 days a week. Fire watch was started on [DATE], when the Fire Panel was Red Tagged. Staff was notified immediately that the Fire Alarm System was no longer functional, and the facility was on Fire Watch. The Fire Watch is conducted by an able bodied , competent adult over the age of 21. The employee on Fire Watch has no other duties or jobs during their designated time. They only serve as the Fire Watch and have no other responsibilities for the entire duration of the shift of said Fire Watch, no exceptions. The employee on Fire Watch is on constant patrol, ensuring that 100% of the premises are covered every 15 minutes. a) The employee on Fire Watch has all keys required to access all spaces with them the entire shift and be capable of accessing said spaces. b) During breaks/lunches of the employee on Fire Watch, a replacement Fire Watch will assume all roles and responsibilities until relieved by the Fire Watch on shift. The Facility ensures that the employee on Fire Watch has a cell phone in their possession at all times, for notification to the fire department. Their only duty is to perform constant patrols of the protected premises and keep watch for fires during all hours. All employees have been notified, in writing, and signed a log indicating that they are aware that the Fire Alarm system is inactive, and in the event they discover a fire that the system will not alert the Fire Department, so they must call 911. A copy of the employee notice with the log shall remain on premises and available to the La Porte Fire Marshal's Office at all times. All employees are notified, at the beginning of each shifts that the Fire Alarm system is inactive, and in the event they discover a fire that the system will not alert the Fire Department. They should immediately call 911, if they see fire, smoke, or heat of any kind. Staff in-serviced, that fire doors must be shut immediately if there are any signs of smoke or fire. Fire doors will remain we closed once the Call Light system is operational. Staff in-servicing on this process was originally completed on [DATE], Re-training on this process began [DATE]. Evacuation Staff was in-serviced on Facility's evacuation procedure on [DATE]. Facility has ensured that there is adequate staff in the building: to monitor wanderers, elopement risk, and assist 2 person transfers at all times. Staff in-servicing on this process began [DATE]. Staff was in-serviced, that during an evacuation someone must stay outside to monitor the wanderers and elopement risk, and that remaining staff (2 or more at all times) will evacuate the other residents. Staff in-servicing on this process began [DATE] Administrator or Designee has ensured that there is adequate staff in the building at all times to facilitate a safe evacuation of residents. Staff in-servicing on this process began [DATE]. Staffing Administrator or Designee has ensured that the facility has adequate staff to perform quality care for all residents, and additional staff to complete fire watch on every shift. On the 10pm-6am shift, we will be staffing 4 employees, with a designated Fire Watch person included. This staffing pattern began on [DATE]. Employee recruitment ads were requested to be posted on Indeed and the local newspaper on [DATE]. We are actively responding to resumes and trying to hire staff daily. This weekend we set up a profile with Shiftkey, to help us staff through their agency until we have adequate staff to meet our staffing needs. Life Safety The Administrator or Designee will fax or email the daily Fire Watch logs to Mark Smith, the LSC Program Manager, weekly, as requested by the LSC Program Specialist. This process was initiated on [DATE]. Administrator or Designee will ensure that all staff and new hires have completed all of the above in-services before returning or starting to work. In-servicing of 100% of staff, will be completed by 11:00 p.m. on [DATE]. Monitoring interviews were conducted at various times on [DATE] with staff the following staff: CNA S at 5:47 AM LVN T at 5:52 AM CNA F at 5:57 AM MDS Nurse at 6:03 AM Dietary Manager at 6:05 AM CNA H at 6:07 AM LVN R at 6:10 AM CNA J at 6:40 AM CNA I at 6:46 AM Business Office Manager at 9:51 AM Administrator at 9:52 AM Staff interviewed were representative of various facility shifts. Staff were able to provide return demonstration and competency regarding Fire Watch, Evacuations Procedures, and Call light monitoring. CMS Form 672 signed and dated on [DATE] revealed resident census of 30.

Based on observation, interview and record review, the facility failed to provide services by sufficient numbers of staff to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for six (6) of (11) eleven residents (Residents #3, #4, #5, #6, #7, #8) reviewed for evacuation and nursing services. -The facility failed to have adequate staff on the night shift to evacuate residents in case of emergency. -The facility failed to ensure a licensed nurse was at the building to respond to resident's medical needs or in case of emergency. -The facility faild to have sufficient nursing staff to provider personal care and transfer assistance. -The facility failed to have sufficient staff to monitor residents and the facility when their call light system and fire panel were non-fuctioning. An Immediate Jeopardy (IJ) was identified on 04/06/18. While the IJ was lowered on 04/10/18, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread due to needing to train staff and monitor their implementation of the Plan of Removal (POR). This deficient practice affected six residents and placed 24 residents at risk of having too few licensed staff to respond to their needs. Findings included: Observation on 03/28/18 at 5:42 AM revealed there were no call lights on and the system was not making noise. Some rooms had manual bells in them. Observation of the facility fire panel revealed the system was red tagged on 02/03/18 by INCA Fire Trio which means the fire panel was out of service. In an interview on 03/28/18 at 6:05 AM CNA Z stated tonight there is only one Nurse Aide scheduled on 10p-6a shift. CNA X would be the only CNA tonight. Observation on 04/05/18 at 5:20 AM revealed Surveyor rang door bell and knocked on front door but nobody answered. A resident who was sitting in chair in front of door started yelling somebody is at the door. Observation on 04/05/18 at 5:25 AM outside of facility front door revealed LVN T pulled up in a car and got out of the car with CNA V. Once in the facility, CNA S was observed as the only staff member at the facility. In an interview on 04/05/18 at 5:36 AM LVN T stated she was on fire watch today and yesterday. She said the facility only had 2 staff on 10p-6a shift. Record review of the fire watch book on 4/5/18 revealed the 15 minute checklist was filled out until 6:00 AM by LVN T. LVN T was on fire watch from 12:00 AM to 6:00 AM, with checks reported every 15 minutes. In an interview on 04/05/18 at 6:08 AM CNA V stated LVN T picked her up down the street for work. CNA V walked to work. In an interview on 04/10/18 at 5:52 AM LVN T stated CNA V did not have a car and she went to go pick her up on 4/5/18. She said staff try to go pick her up when they can. She knew she needed to be at the facility in case of an emergency and to do fire watch. Observation on 04/05/18 at 6:09 AM, the facility had a layout shaped like an 'H.' The North and South hallways were separated by the front lobby, kitchen and dining room. Observation on 04/05/18 at 6:09 AM revealed no staff on North side of building to monitor residents. There were 14 residents on the hallway. Observation on 04/05/18 at 7:31 AM revealed no staff monitoring the South side of building. There were 20 residents on the hallway. In an interview on 04/05/18 at 9:44 AM the Administrator stated the repair company was here to work on the call light system today. In an interview on 03/28/18 at 5:30 AM CNA Z stated she worked at the facility PRN, when they need help. She said 10p-6a staff have to work with 1 Nurse Aide for 30 residents. She said the nurse aides complained about being short-staffed to the facility administration. The residents used manual call bells so it was hard to hear residents on the other side of the building if you are by yourself. She said the residents had manual hand bells because the call light system was out. She said the fire alarm system did not work either, and the staff had to do fire watch. In an interview on 03/28/18 at 9:57 AM LVN T stated she worked some nights and the facility had 1 aide and 1 LVN. The staff tried to manage the best way they could. The facility had 30 residents for 2 staff. She said the ratio was not right at the facility. In a telephone interview on 03/28/18 at 10:14 AM CNA X stated the facility had 30 residents for 1 aide. The last 2 weeks she had been working like this. Staffing was bad even during the day. She said 2 aides were not enough during the day. She said sometimes she had to work double shifts when staff didn't come. She said some days she took off because she knew she was going to be by herself. She said some days, she had to do fire watch and she was the only aide at the building which was against the law. The person doing fire watch was supposed to do this all the time. She said all of the residents didn't have call bells either. In an interview on 03/28/18 at 11:00 AM CNA V stated at night there was 1 CNA and 1 LVN. Sometimes they didn't have a designated staff member for fire watch so nursing staff had to do that also. Today she was working both sides of the building and some of her residents were on the other side of the building. She said the facility had 30 residents at the facility which was a lot for 2 staff. She said she couldn't give everyone showers sometimes, and had to give bed baths. She said the administration complained and wanted us to take breaks but said she had not stopped working since she had been at the building. She said during lunch sometimes meal service was late because staff were in rooms assisting residents. She said staff can't take breaks because resident care would get behind. She had two other residents waiting for her on the other side of the building. One needed to be changed and the other needed to be showered. In an interview on 04/05/18 at 5:30 AM CNA S stated the facility had 2 staff here at night. She said staff had to do fire watch from 10:30 PM forward on the night shift. The Maintenance Director was on fire watch but left the building at 10:30 PM. She said staff had to do fire watch and also take care of the residents. She said the same thing happened the night before. In a telephone interview on 04/05/18 at 7:31 AM CNA X stated she had to do fire watch during the month of (MONTH) while only being on shift with just 2 staff. She said all of the residents did not have call bells. She said staff had to work on the floor and try to do fire watch. In an interview on 04/05/18 at 8:08 AM the Administrator stated she was trying to get 2 aides at night and 1 LVN with another person to do fire watch. In an interview on 04/05/18 at 9:15 AM the Administrator stated she did not know how many staff were needed to meet the needs of residents or evacuate residents. In an interview on 04/05/18 at 9:34 AM the Maintenance Supervisor stated he did not do an assessment to determine how many staff the facility would need to evacuate residents. In an interview on 04/05/18 at 2:36 PM the MDS Nurse stated the facility had 6 resident that require mechanical lift for transfer. Resident #3 Record review of Resident #3's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's MDS dated [DATE] revealed she had a BIMS of 15 indicative of intact cognition. Resident #3 required extensive assist with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #3's Care Plan dated 12/11/17 revealed she was total assist x 1-2 staff members for transfer, toileting, & bathing due to [MEDICAL CONDITION]. Staff are to have call light near Resident #3 and answer promptly. Observation on 03/28/18 at 6:00 AM revealed Resident #3 was in bed and did not have a manual call bell near her bed. In an interview on 03/29/18 at 6:00 AM Resident #3 stated the facility needed more staff so bad and the facility would not do anything about it. She said they complained but it did no good. She said she had a call bell but gave it to another resident who didn't have one. She used her phone when she needed something. She said the call light system did not work, and sometimes they are short staffed at night. They are losing good help at the facility. In an interview on 03/28/18 at 6:36 AM LVN Y stated Resident #3 does not have a call bell but uses her cell phone to call staff for help. Resident #6 Record review of Resident #6's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's MDS dated [DATE] revealed he had a BIMS of 10 indicative of moderately intact cognition. Resident #6 was totally dependent on staff for bed mobility and transfers. Record review of Resident #6's Care Plan dated 03/20/18 revealed Resident #6 had a self-care deficit related to paraplegic and required total assistance with ADL's. Resident #6 required 1-2 total assist with bed mobility, transfers, showers, dressing and hygiene. Observation on 03/28/18 at 10:51 AM revealed Resident #6 was lying in bed. He had a catheter attached to his bed that was covered. Resident #6 did not have a manual call bell in his room. In an interview on 03/28/18 at 10:51 AM Resident #6 stated it took a while for staff to help you. He said the facility did not have enough staff. Resident #6 said he did not even have a call bell. He said the staff could not hear it if he did have one in his room because no staff were on this side of the building. In an interview on 04/05/18 at 12:55 PM Resident #6 stated, Can you help me get a call light system, that's all I want. He said the facility gave him a bell now but the staff could not hear it. Record review of Mechanical Lift List provided by facility revealed Resident #6 required mechanical lifts for transfer. Resident #4 Record review of Resident #4's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's MDS dated [DATE] revealed he had a BIMS of 10 which indicated he had moderate cognitive impairment. Resident #4 required total assistance with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #4's Care Plan dated 12/11/17 revealed he needed extensive to total assist of 1-2 staff members for bed mobility, transfers, toileting, and bathing due to limited mobility. Provide assistance with bathing/showering 3 times a week and a sponge bath on non-shower days if needed. Observation on 03/28/18 at 9:55 AM revealed Resident #4 was lying in bed with his manual call bell in his hand. LVN T entered the room and told Resident #4 he had to wait to get out of bed because the nurse aide is busy. In an interview on 03/28/18 at 9:55 AM Resident #4 asked if the Surveyor could get someone to get him out of bed. He had been waiting to get out of bed since morning. In an interview on 03/29/18 at 10:29 AM CNA W stated she was doing showers today so it took a while to get to Resident #4. She usually got him up at about 10:00 AM. She said today was shower day for Resident #4 but staff were very busy and Resident #4 would just have to get a bed bath. She said she was busting her ass at this place. The other nurse aide usually helped her with showers but not today. She said Resident #4 was a 2 person assist with mechanical lift. Resident #7 Record review of Resident #7's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS dated [DATE] revealed he had a BIMS of 15 which revealed he was cognitively intact. Resident #7 was extensive assist for bed mobility and limited assist for transfer, dressing, and personal hygiene. Record review of Resident #7's Care Plan dated 03/26/18 revealed he had a self-care deficit related to [MEDICAL CONDITION] and required assistance with ADL's. Resident #7 required 1-2 assist with transfers. Observation on 03/28/18 at 10:52 AM revealed Resident #7 was sitting up in bed near his wheel chair. Resident #7 did not have a manual call bell. In an interview on 03/28/18 at 10:52 AM Resident #7 stated the staff took a while to come and help assist people. He did not have a manual call bell in his room. He stated, Depending on what is going on in the facility will determine when staff can get to you. Resident #7 said he was waiting for someone to help him transfer to his wheelchair. Resident #5 Record review of Resident #5's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed she had a BIMS of 15 indicative of intact cognition. Observation on 03/28/18 at 8:15 AM revealed Resident #5 sitting in the dining room. She ambulated with a cane. In an interview on 03/28/18 at 8:15 AM Resident #5 stated they didn't have enough staff at the facility. She said residents had to wait over an hour for care and medications. She said staff had bad attitudes because they were overworked. Resident #8 Record review of Resident #8's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS dated [DATE] revealed he had a BIMS of 15 indicative of intact cognition. Resident #8's required total assistance with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #8's Care Plan dated 03/28/18 revealed Resident #8 had a self-care deficit related to dementia and required assistance with ADL's. Resident #8 required 2 person assist with transfers with mechanical lift. Observation on 03/28/18 at 10:43 AM revealed Resident #8 was in the hallway in his wheelchair. He had amputations to both legs. In an interview on 03/28/18 at 10:43 AM Resident #8 stated sometimes they had to wait hours before they could get care at night because there were not enough staff to help. Record review of mechanical Lift List provided by facility revealed Resident #8 required mechanical lifts for transfer. In an interview on 03/28/18 at 8:27 AM the Administrator stated the call light system went out during repairs for Hurricane Harvey in (MONTH) (YEAR). She said the facility had not repaired the call light system and they were using manual call bells. In a continued interview on 3/28/18 at 8:27 AM, The Administrator said the facility had a fire in the attic on (MONTH) 24, (YEAR). The wire in the attic sparked and the insulation caught on fire, then the fire department put it out. She said the fire panel system couldn't be repaired, so the system was red-tagged on (MONTH) 3, (YEAR). She said the facility was waiting on the Fire Marshall to approve plans to fix fire alarm system. The facility was going back and forth with the Fire Marshall on the plan. She said the person that could approve the plan would not be back in the office until next week. In an interview on 03/28/18 at 11:20 AM the Administrator stated some resident's manual call bells may be in their old rooms and they would check. She said the facility had some residents switch rooms, and some of the residents were new. She had some extra call bells in a bag in the DON's office. If the facility did not have enough call bells they would go and buy some more. She said sometimes they break so the facility had to replace them. The Administrator stated the facility had a problem with staffing for fire watch so she decided to rotate department heads for fire watch. Sometimes the DON and Administrator stay for the fire watch at night but it was hard because staff call out at the last minute, and they had to find someone to cover their shift. She said if someone came in for fire watch, they would try to let them go home after they do fire watch. She said the facility always had 1 LVN at night. She said the facility had 1 nurse aide at night because the census was low. She said the facility was increasing their census. She said she was trying to hire people but things had been hard since they had been on fire watch for over 4 weeks. She said they could not pull the fire watch staff to do floor work in the building. She said it was hard to get nurse aides, sometimes they come, get mad and leave. In an interview on 04/05/18 at 10:16 AM the Administrator stated Staff are only to do fire watch when assigned to fire watch. Ideally, the facility would have staff for fire watch and the floor. She said at night the 2 staff are to rotate so they may do fire watch duties then their floor duties. She said on Tuesday, an aide quit. She hired an aide who was supposed to do orientation today but she never showed up. She said nursing staff were supposed to be in the building, and should not leave the facility. She said LVN T left to pick up another staff member. She had not thought that far on evacuation situation and staffing needs for safe evacuation. Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated 02/03/18 revealed Date the facility first learned of incident: 09/18/17 .Report Details While completing building repairs, the call light system was damaged. So, we have disconnected the call system and have provided all residents with hand held bells. There is an employee on the hall at all times .Description of in-service training: The staff was in-serviced that the hand held bell must be in the residents reach at all times. They were also in-serviced that a staff member, must be on the hall at all times Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated 02/03/18 revealed Date the facility first learned of incident: 02/03/18 Report Details .The fire alarm system continued to alarm uncontrollably without evidence of a fire. So we had our contacted Fire and Alarm Company, Inca Fire Trio, to come out to repair our Fire Alarm system. However, after troubleshooting the system, they deemed it irreparable. They shut down the system and red tagged it. We have implemented a 24 hour fire watch and the local fire marshall's office has been contacted. An estimate and designs plan have been submitted for the replacement of the fire Alarm System, and the work will be completed timely .Description of in-service training . Fire Watch Protocol and Fire Protocol (RACE and PASS). Record review of the In-Service Training Report dated 09/20/17 revealed . call light system is inactive, manual call bells should be at all residents beside (in-reach) at all times. All new admits should receive a call bell upon admission . Record review of the Daily Staff Assignment Sheets revealed the following: - 03/25/18 revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. - There was no sheet for 4/3/18. - 04/04/18 revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. Record review of the Employee Time Cards revealed the following: - 03/28/18 revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - 03/29 /18 revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - 03/31/18 revealed there was 1 CNA on 10p-6a shift - 04/01/18 revealed there was 1 CNA on 10p-6a shift. - 04/03/18 revealed there was 1 LVN, 1 CNA on 10p-6a shift. In an interview on 04/10/18 at 10:40 AM the Administrator stated she was the LVN on the floor on 03/31/18 and 04/01/18. She did not have a time card because she does not punch in. Record review of the Facility Staffing Postings revealed the following: - 03/28/18 revealed 30 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. - 04/05/18 revealed 34 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. The Administrator was notified of the Immediate Jeopardy on 04/06/18 at 1:20 PM due to the above failures. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. After several revisions, the Plan of Removal was accepted on 04/09/18 at 6:56pm. The Plan of Removal reflected: The following information is in relation to the Immediate Jeopardy and Immediate Threat cited on 4/6/2018. This serves as notification of our plan to lower the severity. Staffing o Administrator or Designee has ensured that the facility has adequate staff to perform quality care for all residents, and additional staff to complete fire watch on every shift. o On the 10pm-6am shift, we will be staffing 4 employees, with a designated Fire Watch person included. This staffing pattern began on 4/5/2018. o Employee recruitment ads were requested to be posted on Indeed and the local newspaper on 3/23/2018. We are actively responding to resumes and trying to hire staff daily. This weekend we set up a profile with Shiftkey, to help us staff through their agency until we have adequate staff to meet our staffing needs. Administrator or Designee will ensure that all staff and new hires have completed all of the above in-services before returning or starting to work. In-servicing of 100% of staff, will be completed by 11:00 p.m. on 4/7/2018. Monitoring observations were conducted: In an observation on 4/7/18 at 5:00am, the facility had 1 LVN, 1 CNA, the Administrator providing care to the residents. The Dietary Manager was on fire watch. While on fire watch, she was not doing other tasks. In an observation on 4/8/18 at 6:00am, the facility had 1 LVN and 2 CNAs providing care to the residents. The Business Office Manager was on fire watch. While on fire watch, she was not doing other tasks. Monitoring interviews were conducted on 4/7/18 with the Dietary Manager at 5:00am and the Administrator at 6:00am. Monitoring interview was conducted on 4/8/18 with the Business office Manager at 7:13am. Monitoring interviews were conducted at various times on 04/10/18 with staff the following staff: CNA S at 5:47 AM LVN T at 5:52 AM CNA F at 5:57 AM MDS Nurse at 6:03 AM Dietary Manager at 6:05 AM CNA H at 6:07 AM LVN R at 6:10 AM CNA J at 6:40 AM CNA I at 6:46 AM Business Office Manager at 9:51 AM Administrator at 9:52 AM Staff interviewed were representative of various facility shifts. Staff were able to provide return demonstration and competency regarding Fire Watch, Evacuations Procedures, and manual call light monitoring. According to the CMS 672 dated 03/28/18 the facility census was 30.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for six (Resident #3, #4, #5, #6, #7, #8) of eleven residents reviewed for neglect. -The facility failed to have a functioning call light system since (MONTH) (YEAR) for residents to report ADL needs or emergencies in restroom/bathrooms and bedrooms. The facility failed to have manual call bells for Residents #3, #6, #7 who required extensive assistance with transfers. The facility failed to report the non-functioning call light system to state agency within required time frame. -The facility failed to have a functioning fire panel and fire system since (MONTH) (YEAR), and increase staffing to ensure fire watch was being conducted 24 Hours a day. The facility failed to complete routine fire drills. The facility failed to ensure the corridor door on 2 of 2 hallways were able to close and latch without impediment. -The facility failed to have adequate staff on the night shift in case of an emergency evacuation. The facility failed to have enough certified nursing aides and nurse staff to monitor hallways due to non-functioning call light system and conduct fire watch and evacuate residents in an emergency. There were 6 residents in the facility that required 2 staff assistance with a mechanical lift for transfers. -The facility failed to ensure a licensed nurse was at the building to respond to resident's medical needs or in case of emergency. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures affected 6 residents and had the potential to affect 24 other residents at the facility, placing them at risk of not having needs met which could result in injury or harm. Findings Included: Observation on [DATE] at 5:42 AM revealed there were no call lights on and the system was not making noise. Some rooms had manual bells in them. Observation of the facility fire panel revealed the system was red tagged on [DATE] by INCA Fire Trio which means the fire panel was out of service. In an interview on [DATE] at 6:05 AM CNA Z stated tonight there is only one Nurse Aide scheduled on 10p-6a shift. CNA X would be the only CNA tonight. Observation on [DATE] at 5:20 AM revealed Surveyor rang door bell and knocked on front door but nobody answered. A resident who was sitting in chair in front of door started yelling somebody is at the door. Observation on [DATE] at 5:25 AM outside of facility front door revealed LVN T pulled up in a car and got out of the car with CNA V. Once in the facility, CNA S was observed as the only staff member at the facility. In an interview on [DATE] at 5:36 AM LVN T stated she was on fire watch today and yesterday. She said the facility only had 2 staff on 10p-6a shift. Record review of the fire watch book on [DATE] revealed the 15 minute checklist was filled out until 6:00 AM by LVN T. LVN T was on fire watch from 12:00 AM to 6:00 AM, with checks reported every 15 minutes. In an interview on [DATE] at 6:08 AM CNA V stated LVN T picked her up down the street for work. In an interview on [DATE] at 5:52 AM LVN T stated CNA V did not have a car and she went to go pick her up on [DATE]. She said staff try to go pick her up when they can. She knew she needed to be at the facility in case of an emergency and to do fire watch. Observation on [DATE] at 6:09 AM, the facility had a layout shaped like an 'H.' The North and South hallways were separated by the front lobby, kitchen and dining room. Observation on [DATE] at 6:09 AM revealed no staff on North side of building to monitor residents. There were 14 residents on the hallway. Observation on [DATE] at 7:31 AM revealed no staff monitoring the South side of building. There were 20 residents on the hallway. Observation on [DATE] at 9:27 am revealed the fire-rated door near the beauty salon leading to the resident corridor was propped open with a white wedge and would not close and latch without impediment. Observation on [DATE] at 9:28 am revealed the fire-rated door near the soiled utility room leading to the resident corridor was propped open with a white wedge and would not close and latch without impediment. In an interview on [DATE] at 9:29 AM with the Administrator, at the times of observation, she confirmed the doors were propped open and could not latch and close without impediment. In an interview on [DATE] at 9:44 AM the Administrator stated the repair company was here to work on the call light system today. In an interview on [DATE] at 5:30 AM CNA Z stated she worked at the facility PRN, when they need help. She said 10p-6a staff have to work with 1 Nurse Aide for 30 residents. She said the nurse aides complained about being short-staffed to the facility administration. The residents used manual call bells so it was hard to hear residents on the other side of the building if you are by yourself. She said the residents had manual hand bells because the call light system was out. She said the fire alarm system did not work either, and the staff had to do fire watch. In an interview on [DATE] at 9:57 AM LVN T stated she worked some nights and the facility had 1 aide and 1 LVN. The staff tried to manage the best way they could. The facility had 30 residents for 2 staff. She said the ratio was not right at the facility. In a telephone interview on [DATE] at 10:14 AM CNA X stated the facility had 30 residents for 1 aide. The last 2 weeks she had been working like this. Staffing was bad even during the day. She said 2 aides were not enough during the day. She said sometimes she had to work double shifts when staff didn't come. She said some days she took off because she knew she was going to be by herself. She said some days, she had to do fire watch and she was the only aide at the building which was against the law. The person doing fire watch was supposed to do this all the time. She said all of the residents didn't have call bells either. In an interview on [DATE] at 11:00 AM CNA V stated at night there was 1 CNA and 1 LVN. Sometimes they didn't have a designated staff member for fire watch so nursing staff had to do that also. Today she was working both sides of the building and some of her residents were on the other side of the building. She said the facility had 30 residents at the facility which was a lot for 2 staff. She said she couldn't give everyone showers sometimes, and had to give bed baths. She said the administration complained and wanted us to take breaks but said she had not stopped working since she had been at the building. She said during lunch sometimes meal service was late because staff were in rooms assisting residents. She said staff can't take breaks because resident care would get behind. She had two other residents waiting for her on the other side of the building. One needed to be changed and the other needed to be showered. In an interview on [DATE] at 5:30 AM CNA S stated the facility had 2 staff here at night. She said staff had to do fire watch from 10:30 PM forward on the night shift. The Maintenance Director was on fire watch but left the building at 10:30 PM. She said staff had to do fire watch and also take care of the residents. She said the same thing happened the night before. In a telephone interview on [DATE] at 7:31 AM CNA X stated she had to do fire watch during the month of (MONTH) while only being on shift with just 2 staff. She said all of the residents did not have call bells. She said staff had to work on the floor and try to do fire watch. In an interview on [DATE] at 8:08 AM the Administrator stated she was trying to get 2 aides at night and 1 LVN with another person to do fire watch. In an interview on [DATE] at 9:15 AM the Administrator stated she did not know how many staff were needed to meet the needs of residents or evacuate residents. In an interview on [DATE] at 9:34 AM the Maintenance Supervisor stated the last fire drill was conducted on [DATE] after the fire panel was red tagged. In the Fire Drill Binder the facility only had fire drills up until [DATE] because the other fire drills were in a storage unit in a box, due to repairs at the facility. He did not do an assessment to determine how many staff the facility would need to evacuate residents. In an interview on [DATE] at 2:36 PM the MDS Nurse stated the facility had 6 resident that require mechanical lift for transfer. Resident #3 Record review of Resident #3's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's MDS dated [DATE] revealed she had a BIMS of 15 indicative of intact cognition. Resident #3 required extensive assist with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #3's Care Plan dated [DATE] revealed she was total assist x ,[DATE] staff members for transfer, toileting, & bathing due to [MEDICAL CONDITION]. Staff are to have call light near Resident #3 and answer promptly. Observation on [DATE] at 6:00 AM revealed Resident #3 was in bed and did not have a manual call bell near her bed. In an interview on [DATE] at 6:00 AM Resident #3 stated the facility needed more staff so bad and the facility would not do anything about it. She said they complained but it did no good. She said she had a call bell but gave it to another resident who didn't have one. She used her phone when she needed something. She said the call light system did not work, and sometimes they are short staffed at night. They are losing good help at the facility. In an interview on [DATE] at 6:36 AM LVN Y stated Resident #3 does not have a call bell but uses her cell phone to call staff for help. Resident #6 Record review of Resident #6's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's MDS dated [DATE] revealed he had a BIMS of 10 indicative of moderately intact cognition. Resident #6 was totally dependent on staff for bed mobility and transfers. Record review of Resident #6's Care Plan dated [DATE] revealed Resident #6 had a self-care deficit related to paraplegic and required total assistance with ADL's. Resident #6 required ,[DATE] total assist with bed mobility, transfers, showers, dressing and hygiene. Observation on [DATE] at 10:51 AM revealed Resident #6 was lying in bed. He had a catheter attached to his bed that was covered. Resident #6 did not have a manual call bell in his room. In an interview on [DATE] at 10:51 AM Resident #6 stated it took a while for staff to help you. He said the facility did not have enough staff. Resident #6 said he did not even have a call bell. He said the staff could not hear it if he did have one in his room because no staff were on this side of the building. In an interview on [DATE] at 12:55 PM Resident #6 stated, Can you help me get a call light system, that's all I want. He said the facility gave him a bell now but the staff could not hear it. Record review of Mechanical Lift List provided by facility revealed Resident #6 required mechanical lifts for transfer. Resident #4 Record review of Resident #4's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's MDS dated [DATE] revealed he had a BIMS of 10 which indicated he had moderate cognitive impairment. Resident #4 required total assistance with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #4's Care Plan dated [DATE] revealed he needed extensive to total assist of ,[DATE] staff members for bed mobility, transfers, toileting, and bathing due to limited mobility. Provide assistance with bathing/showering 3 times a week and a sponge bath on non-shower days if needed. Observation on [DATE] at 9:55 AM revealed Resident #4 was lying in bed with his manual call bell in his hand. LVN T entered the room and told Resident #4 he had to wait to get out of bed because the nurse aide is busy. In an interview on [DATE] at 9:55 AM Resident #4 asked if the Surveyor could get someone to get him out of bed. He had been waiting to get out of bed since morning. In an interview on [DATE] at 10:29 AM CNA W stated she was doing showers today so it took a while to get to Resident #4. She usually got him up at about 10:00 AM. She said today was shower day for Resident #4 but staff were very busy and Resident #4 would just have to get a bed bath. She said she was busting her ass at this place. The other nurse aide usually helped her with showers but not today. She said Resident #4 was a 2 person assist with mechanical lift. Resident #7 Record review of Resident #7's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS dated [DATE] revealed he had a BIMS of 15 which revealed he was cognitively intact. Resident #7 was extensive assist for bed mobility and limited assist for transfer, dressing, and personal hygiene. Record review of Resident #7's Care Plan dated [DATE] revealed he had a self-care deficit related to [MEDICAL CONDITION] and required assistance with ADL's. Resident #7 required ,[DATE] assist with transfers. Observation on [DATE] at 10:52 AM revealed Resident #7 was sitting up in bed near his wheel chair. Resident #7 did not have a manual call bell. In an interview on [DATE] at 10:52 AM Resident #7 stated the staff took a while to come and help assist people. He did not have a manual call bell in his room. He stated, Depending on what is going on in the facility will determine when staff can get to you. Resident #7 said he was waiting for someone to help him transfer to his wheelchair. Resident #5 Record review of Resident #5's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed she had a BIMS of 15 indicative of intact cognition. Observation on [DATE] at 8:15 AM revealed Resident #5 sitting in the dining room. She ambulated with a cane. In an interview on [DATE] at 8:15 AM Resident #5 stated they didn't have enough staff at the facility. She said residents had to wait over an hour for care and medications. She said staff had bad attitudes because they were overworked. Resident #8 Record review of Resident #8's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS dated [DATE] revealed he had a BIMS of 15 indicative of intact cognition. Resident #8's required total assistance with bed mobility, transfer, dressing, and personal hygiene. Record review of Resident #8's Care Plan dated [DATE] revealed Resident #8 had a self-care deficit related to dementia and required assistance with ADL's. Resident #8 required 2 person assist with transfers with mechanical lift. Observation on [DATE] at 10:43 AM revealed Resident #8 was in the hallway in his wheelchair. He had amputations to both legs. In an interview on [DATE] at 10:43 AM Resident #8 stated sometimes they had to wait hours before they could get care at night because there were not enough staff to help. Record review of mechanical Lift List provided by facility revealed Resident #8 required mechanical lifts for transfer. In an interview on [DATE] at 8:27 AM the Administrator stated the call light system went out during repairs for Hurricane Harvey in (MONTH) (YEAR). She said the facility had not repaired the call light system and they were using manual call bells. In a continued interview on [DATE] at 8:27 AM, The Administrator said the facility had a fire in the attic on (MONTH) 24, (YEAR). The wire in the attic sparked and the insulation caught on fire, then the fire department put it out. She said the fire panel system couldn't be repaired, so the system was red-tagged on (MONTH) 3, (YEAR). She said the facility was waiting on the Fire Marshall to approve plans to fix fire alarm system. The facility was going back and forth with the Fire Marshall on the plan. She said the person that could approve the plan would not be back in the office until next week. In an interview on [DATE] at 11:20 AM the Administrator stated some resident's manual call bells may be in their old rooms and they would check. She said the facility had some residents switch rooms, and some of the residents were new. She had some extra call bells in a bag in the DON's office. If the facility did not have enough call bells they would go and buy some more. She said sometimes they break so the facility had to replace them. The Administrator stated the facility had a problem with staffing for fire watch so she decided to rotate department heads for fire watch. Sometimes the DON and Administrator stay for the fire watch at night but it was hard because staff call out at the last minute, and they had to find someone to cover their shift. She said if someone came in for fire watch, they would try to let them go home after they do fire watch. She said the facility always had 1 LVN at night. She said the facility had 1 nurse aide at night because the census was low. She said the facility was increasing their census. She said she was trying to hire people but things had been hard since they had been on fire watch for over 4 weeks. She said they could not pull the fire watch staff to do floor work in the building. She said it was hard to get nurse aides, sometimes they come, get mad and leave. In an interview on [DATE] at 10:16 AM the Administrator stated Staff are only to do fire watch when assigned to fire watch. Ideally, the facility would have staff for fire watch and the floor. She said at night the 2 staff are to rotate so they may do fire watch duties then their floor duties. She said on Tuesday, an aide quit. She hired an aide who was supposed to do orientation today but she never showed up. She said nursing staff were supposed to be in the building, and should not leave the facility. She said LVN T left to pick up another staff member. She had not thought that far on evacuation situation and staffing needs for safe evacuation. Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated [DATE] revealed Date the facility first learned of incident: [DATE] .Report Details While completing building repairs, the call light system was damaged. So, we have disconnected the call system and have provided all residents with hand held bells. There is an employee on the hall at all times .Description of in-service training: The staff was in-serviced that the hand held bell must be in the residents reach at all times. They were also in-serviced that a staff member, must be on the hall at all times The incident was reported to Health and Human Services Commission on [DATE]. Record review of the Consumer Rights and Services Provider Self-Reporting of Incidents form dated [DATE] revealed Date the facility first learned of incident: [DATE] Report Details .The fire alarm system continued to alarm uncontrollably without evidence of a fire. So we had our contacted Fire and Alarm Company, Inca Fire Trio, to come out to repair our Fire Alarm system. However, after troubleshooting the system, they deemed it irreparable. They shut down the system and red tagged it. We have implemented a 24 hour fire watch and the local fire marshall's office has been contacted. An estimate and designs plan have been submitted for the replacement of the fire Alarm System, and the work will be completed timely .Description of in-service training . Fire Watch Protocol and Fire Protocol (RACE and PASS). Record review of the In-Service Training Report dated [DATE] revealed . call light system is inactive, manual call bells should be at all residents beside (in-reach) at all times. All new admits should receive a call bell upon admission . Record review of the Daily Staff Assignment Sheets revealed the following: - [DATE] revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. - There was no sheet for [DATE]. - [DATE] revealed there was 2 staff on 10p-6a shift, 1 LVN, 1 CNA. Record review of the Employee Time Cards revealed the following: - [DATE] revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - ,[DATE] /18 revealed there was 1 LVN, 1 CNA, 1 Fire Watch Staff on 10p-6a-shift. - [DATE] revealed there was 1 CNA on 10p-6a shift - [DATE] revealed there was 1 CNA on 10p-6a shift. - [DATE] revealed there was 1 LVN, 1 CNA on 10p-6a shift. In an interview on [DATE] at 10:40 AM the Administrator stated she was the LVN on the floor on [DATE] and [DATE]. She did not have a time card because she does not punch in. Record review of the Facility Staffing Postings revealed the following: - [DATE] revealed 30 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. - [DATE] revealed 34 Residents at the facility. The staffing pattern was 1 LVN and 1 CNA for 10p-6a shift. Record review of the fire watch log dated (MONTH) and (MONTH) (YEAR) revealed staff were signing for fire watch every 15 minutes. Record review of the Texas Health and Human Services Provider Letter ,[DATE] dated [DATE] read in part . A (nursing facility) must report to (the state agency) any emergency situation that poses a threat to residents, staff or the public health and safety .The following are some examples of emergency situations that pose a treat to resident health and safety that must be reported .a non-functioning call system .The reporting expectation in the example is focused on a more widespread system call system failure . Record review of the facility Abuse Prevention Policy dated [DATE] revealed .Policy Statement: Our facility implements an effective system for the prevention of abuse and neglect .The facility initiates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect . The facility will ensure that any allegations of abuse and neglect are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal laws . Prevention 1. Identify, assess, care-plan and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care or are totally dependent on staff 2. Identify characteristics of physical environment that may make abuse and or neglect more likely to occur: equipment or devices will be properly maintained and used in accordance with manufacture's specifications .Functioning call systems .3 . Supervision will be provided for those individuals with known special needs such as: impaired individuals with known elopement risk; dementia dependent residents with adequate call system in place . The Administrator was notified of the Immediate Jeopardy on [DATE] at 1:20 PM due to the above failures. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. After several revisions, the Plan of Removal was accepted on [DATE] at 6:56pm. The Plan of Removal reflected: The following information is in relation to the Immediate Jeopardy and Immediate Threat cited on [DATE]. This serves as notification of our plan to lower the severity. Fire Panel o La Porte Healthcare Center signed a contract with Firetrol Protection Systems on [DATE] to replace the Fire Alarm System. The projected time for completion is as documented on the timeline below, provided by Firetrol Protection Systems: I. Our design team will draft and submit a fire alarm plan to the La Porte Fire Marshal based on the plan provided at the time of bid. Design should take 10 days, with another 10 days to receive back from the Fire Marshal II. Pending his approval, we will then order the material which has a ,[DATE] day lead time. III. While the material is being shipped, our installation department will begin pulling the fire alarm cable based on the layout provided and approved by the local AHJ. This should take roughly a week to install. IV. Once the material has come in we will then begin installing the devices. This should take a week. V. After installation and troubleshooting any issues we will do a pretest of the system. This will take ,[DATE] days. VI. After successful pretesting is finished, we will then call for a fire marshal test. This test will be completed in 1 day. VII. The final stage would be to demo the existing system and cable after the Fire Marshal has signed off on the installation. o Start date of Fire Alarm System installation pending Fire Marshalls approval of plans. Call Light System o INCA Fire Trio is currently installing the new Call Light System. The Entire system will be up and running on Friday, [DATE]. o While the Call Light System is being replaced, the facility has provided hand held call bells to all residents. Staff in-servicing on this process began [DATE]. o During fire watch rounds, staff will ensure that all residents have a call bell in reach every 15 minutes. Staff in-servicing on this process was originally completed on [DATE], Re-training on this process began [DATE]. o The Administrator or Designee will ensure that there is a staff member on each hall at all times, to respond to the ringing of the call bells. Staff in-servicing on this process began [DATE] Fire Watch o There is an employee on duty to Fire Watch 24 hours a day, 7 days a week. Fire watch was started on [DATE], when the Fire Panel was Red Tagged. Staff was notified immediately that the Fire Alarm System was no longer functional, and the facility was on Fire Watch. o The Fire Watch is conducted by an able bodied , competent adult over the age of 21. o The employee on Fire Watch has no other duties or jobs during their designated time. They only serve as the Fire Watch and have no other responsibilities for the entire duration of the shift of said Fire Watch, no exceptions. o The employee on Fire Watch is on constant patrol, ensuring that 100% of the premises are covered every 15 minutes. a) The employee on Fire Watch has all keys required to access all spaces with them the entire shift and be capable of accessing said spaces. b) During breaks/lunches of the employee on Fire Watch, a replacement Fire Watch will assume all roles and responsibilities until relieved by the Fire Watch on shift. o The Facility ensures that the employee on Fire Watch has a cell phone in their possession at all times, for notification to the fire department. Their only duty is to perform constant patrols of the protected premises and keep watch for fires during all hours. o All employees have been notified, in writing, and signed a log indicating that they are aware that the Fire Alarm system is inactive, and in the event they discover a fire that the system will not alert the Fire Department, so they must call 911. A copy of the employee notice with the log shall remain on premises and available to the La Porte Fire Marshal's Office at all times. o All employees are notified, at the beginning of each shifts that the Fire Alarm system is inactive, and in the event they discover a fire that the system will not alert the Fire Department. They should immediately call 911, if they see fire, smoke, or heat of any kind. o Staff in-serviced, that fire doors must be shut immediately if there are any signs of smoke or fire. o Fire doors will remain we closed once the Call Light system is operational. o Staff in-servicing on this process was originally completed on [DATE], Re-training on this process began [DATE]. Evacuation o Staff was in-serviced on Facility's evacuation procedure on [DATE]. o Facility has ensured that there is adequate staff in the building: to monitor wanderers, elopement risk, and assist 2 person transfers at all times. Staff in-servicing on this process began [DATE]. o Staff was in-serviced, that during an evacuation someone must stay outside to monitor the wanderers and elopement risk, and that remaining staff (2 or more at all times) will evacuate the other residents. Staff in-servicing on this process began [DATE] o Administrator or Designee has ensured that there is adequate staff in the building at all times to facilitate a safe evacuation of residents. Staff in-servicing on this process began [DATE]. Staffing o Administrator or Designee has ensured that the facility has adequate staff to perform quality care for all residents, and additional staff to complete fire watch on every shift. o On the 10pm-6am shift, we will be staffing 4 employees, with a designated Fire Watch person included. This staffing pat (TRUNCATED)