Every finding on record at Broadway Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for the front lobby and utility hallway for 1 of 1 facility reviewed for accident hazards. 1.The women's restroom in the front lobby, which was open and accessible to residents, did not have grab bars, a means to call for assistance, the locking mechanism was a latch on the inside of the door, and the door was difficult to open from the inside. 2.The men's restroom in the front lobby, which was open and accessible to residents, did not have grab bars or a means to call for assistance. These deficient practices could result in physical harm to residents. Observation on 04/16/2026 at 3:35 p.m. revealed the women's restroom in the front lobby was open, unlocked, and accessible by residents. Further observation revealed the restroom did not have grab bars, did not have a means to call for assistance, the locking mechanism was a latch on the inside of the door, and the door was difficult to open from the inside. Observation on 04/16/2026 at 3:38 p.m. revealed the men's restroom in the front lobby was open, unlocked, and accessible by residents. Further observation revealed the restroom had grab bars installed but did not have a means to call for assistance should the need occur. During an interview with the Maintenance Assistant on 04/16/2026 at 3:40 p.m., the Maintenance Assistance confirmed that the women's restroom in the front lobby was open, unlocked, and accessible by residents, did not have grab bars, did not have a means to call for assistance, the locking mechanism was a latch on the inside of the door, and the door was difficult to open from the inside. The Maintenance Assistant stated that a resident may not be able to utilize the toilet safely without grab bars, would not be able to call for assistance if needed, and staff would not be able to reach a resident in need of assistance because the door latched from the inside and was not able to be opened from the outside while the latch was engaged. The Maintenance Assistant also stated that the difficulty in opening the door could result in a resident not being able to leave the restroom. The Maintenance Assistant also confirmed that the men's restroom was open, unlocked, and accessible by residents and did not have a means to call for assistance should the need occur. The Maintenance Assistant stated the restrooms should not be accessible to residents due to safety concerns. Observation on 04/16/2026 at 4:00 p.m. revealed a room in the utility hallway which did not have a doorknob or means to lock it contained a number of stored items including three containers labeled biohazard which held syringes that had been utilized. Further observation revealed the utility hallway was accessible by walking from a resident hallway and was accessible by any resident who could ambulate. During an interview with the Maintenance Assistant, at the same time as the observation, the Maintenance Assistant stated the biohazard containers with used syringes should not have been in an area accessible by residents. During an interview with the DON on 04/17/2026 at 1:18 p.m., the DON stated the restrooms should not have been accessible by residents and that they had been secured. The DON also stated that the biohazard material should not have been stored in an area accessible by residents and had been moved to a secure storage area. Record review of the facility policy, Resident Rooms and Environment, revised 08/2020, revealed The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #83) reviewed for medication storage, in that: The facility failed to ensure medication Vick's (nasal decongestant) was not left on Resident #83's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.The findings were: Record review of Resident #83's face sheet, dated 3/25/26, revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses that included Dependence on renal dialysis ( means relying on regular, life-sustaining, procedure to remove waste and excess fluid when kidneys fail) , Depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety disorder mental health condition characterized by excessive uncontrollable fear or worry that persists for six months or more, significantly interfering with daily life). Record review of Resident #83's admission MDS, dated [DATE], revealed a BIMS score of 3, which indicates severe cognitive impairment. Record review of Resident #83's physician orders for April 2026, reviewed on 4/14/26, did not reveal an order to self-administer medications or an order for Vicks VapoRub Record review of Resident #83, physician orders for April 2026, did not reveal an order for Vicks VapoRub. Observation on 04/14/2026 at 9:40 a.m. of Resident #83's room revealed there was a jar of Vicks on the nightstand. Interview with Resident #83 on 4/14/26 at 12:15 p.m., the Resident stated her family purchased Vicks for her and brought it sometime this weekend . The Resident further stated that no one had given her a self-medication assessment. Interview with LVN A on 4/14/26 at 1:30 p.m., LVN A confirmed she was assigned to Resident #83 and verified that a jar of Vicks was on the resident's bedside table. She stated Resident #83 had not received a self-medication assessment and should not have access to medication for self-administration, as this poses a risk of improper use by the Resident or accidental ingestion by others due to lack of secure storage and cognition. Interview with the DON on 04/14/26 at 9:55 a.m., the DON reported a jar of Vicks was found on Resident #83's bedside table. The DON explained that no medication should be left on a resident's bedside table without a self-medication assessment, as this may lead to the resident taking more than the prescribed dosage. Record review of the facility's policy titled Medication Storage, revised January 2026, revealed, Medications must be stored securely to prevent unauthorized access, diversion, loss, contamination, or misuse.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #7) reviewed for infection control, in that: 1. The facility failed to ensure CNA D changed her gloves and sanitized her hands after cleaning Resident #7 and before touching the clean brief and pad. 2.The facility failed to ensure CNAs D and E wore a gown while providing catheter care for Resident #7 who was on enhanced barrier precaution. These failures could place residents at-risk for infection due to improper care practices. The findings were: Record review of Resident #7's face sheet, dated 04/16/2026, revealed an admission date of 07/31/2025, and a readmission date of 01/15/2026, with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Dementia (decline in cognitive abilities), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) Record review of Resident #7's Quarterly MDS assessment, dated 02/18/2026, revealed the resident had a BIMS score of 15, which indicated no cognitive impairment, and was indicated to occasionally be incontinent of bowel and had an indwelling catheter. Record review of Resident #7's care plan, dated 11/26/2025, reflected a problem of The resident has foley Catheter to help manage his bladder function. The foley requires regular care to prevent infection, skin problems or other complications. and an intervention of Monitor/record/report to MD for signs and symptoms of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. 1 Observation on 04/16/2026 at 11:09 a.m. revealed while providing incontinent care for Resident #7, CNA D did not change her gloves and sanitize her hands after cleaning the resident and before touching the clean brief and pad. A sign for enhanced barrier precautions was seen by the door of the resident's room and on top of Resident #7's bed. Personal protective equipment was available at the entrance of the room. During an interview on 04/16/2026 at 11:34 a.m. with CNA D, she stated she did not change her gloves and sanitize her hands after cleaning Resident #7 and before touching the clean brief, while providing incontinent care for Resident #7. She said she was nervous and forgot. She stated she received infection control training within the year. 2, Observation on 04/16/2026 at 11:09 a.m., revealed while providing catheter care for Resident #7, CNAs D and E did not gown up to enter the room and provide care. Resident #7 was on enhanced barrier precaution due to his indwelling catheter. interview on 04/16/2026 at 11:34 a.m. with CNAs D and E revealed they stated they forgot Resident #7 was on enhanced barrier precaution. They stated they had received training on enhanced barrier precautions. Interview on 04/16/2026 at 3:55 p.m. with the DON and the Administrator, revealed they stated the staff needed to wear gown and gloves for resident on enhanced barrier precaution and to sanitize hands between change of gloves for the prevention of infection to the residents but also the staff. The DON stated infection control training was provided was provided and skills were checked annually. Review of facility's policy, titled Standard and Enhanced Precautions , dated 04/01/2024, revealed For resident who EBP (enhanced barrier precaution) are indicated, EBP should be used when performing the following high contact resident care activities: [ .] changing briefs or assisting with toileting [ .] Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventialtor. Review of facility's policy, titled Hand Hygiene , dated 06/2020, revealed Facility staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to [ .] after removing personal protective equipment [ .] [NAME], [NAME] (7) [NAME]-[NAME], morgane (34788) - Urinary Catheter or UTI 04/16/2026 11:09 AM [NAME] (Resident #7)Incontinent care/catheter care provided by CNA Zulay [NAME] and CNA [NAME] CNAs did not put a gown on before providing the care. An EBP sign was at the door and on the wall behind the resident's bed. PPE was available at the door. CNAs did not close the privacy curtain to provide privacy during the care. The resident was naked and could have been seen from the door if somebody opened the door during the care. The resident's roommate was laying on his bed watching television during the care. CNA Zulay wipe the resident's penis from base to tip CNA Zulay did not change her gloves and sanitize her hands after cleaning the resident's buttocks and before placing the clean brief and pad under the resident. 11:34AM Interview with CNAs Confirmed findings. Confirmed receiving training from the ADON and DON, confirmed having her skills checked and revealed she was very nervous and forgot. [NAME], [NAME] (7) [NAME]-[NAME], morgane (34788) - RESIDENT NOTE No Notes

Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators (Resident #29) reviewed. The personal refrigerator in Resident #29's room contained food items that were unlabeled and undated. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food.The findings were: Record review of Resident #29's face sheet, dated 4/14/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Major Depressive Disorder, (is a serious mental health condition characterized by a persistent low mood, loss of interest in activities), Hypertension (a chronic condition where the force of blood against artery walls is consistently too high), and Benign Prostatic Hyperplasia (non-cancerous condition in men where the prostate gland becomes enlarged as they get older). Record review of Resident #29's BIMS assessment, completed 1/24/26, revealed a BIMS score of 15, which indicated intact cognition. Observations on 4/14/2026 at 11:45 a.m. revealed that the personal refrigerator for Resident #29 contained an unlabeled, undated storage container with unidentified fuzzy, slimy patches in shades of green, black, and white. Further observations on 4/14/2026 at 11:55 a.m. of the personal refrigerator of Resident #29 revealed that the unlabeled, undated storage container was still present. Interview with Resident #29 on 4/14/2026 at 12:30 p.m. revealed that he was unaware of the unlabeled container in his personal refrigerator. Resident #29 stated he stored snacks in his personal refrigerator but was unaware that items had to be dated. Interview on 04/14/2026 at 12:45 p.m. with CNA D, who stated she was assigned to Resident #29 and confirmed that the personal refrigerator in Resident #29's room contained a container that was undated and unlabeled. She did not know who was responsible for checking the president's personal refrigerator for expired food but would check with the charge nurse. Interview with LVN C on 4/14/2026 at 1:00 p.m. revealed she was the assigned nurse for Resident #29 and confirmed there was an unlabeled and undated storage container in the personal refrigerator for the resident. LVN C added all staff were responsible for removing undated and unlabeled food items from residents' personal refrigerators weekly. Resident #29 risked some form of food-borne illness by possibly consuming food that was unlabeled and undated. During an interview with the DON on 04/14/26, at 1:15 p.m., the DON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food. The DON stated that all staff were responsible for removing undated, unlabeled food items from residents' refrigerators weekly, including assisting families in labeling and dating food items brought in. The DON stated that families sometimes bring food for residents without notifying the nursing staff. She added that her charge nurses were responsible for overseeing this task, and her ADONs would be monitored at random. Record review of the facility policy, Personal Refrigerator , revised 1/1/2026, revealed: Facility staff will monitor the resident refrigerator weekly .

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 5 residents (Resident #74) reviewed for call light. Resident #74's call light was not placed within reach of her . This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.Findings included: Record review of Resident's #74's face sheet, 4/14/2026, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: [Chronic obstructive pulmonary disease] (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), Diabetes is a chronic metabolic disease characterized by high blood glucose (sugar) levels, occurring when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it makes) and Fibromyalgia (is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues). Review of Resident # 74's admission MDS assessment dated [DATE] revealed a BIMS score of 15, suggesting the patient was cognitively intact. Record review of Resident #74's care plan dated 3/11/2026 revealed keep call light within reach of resident Observation and interview on 04/14/2026 at 10:30 AM of Resident #74's room revealed that the call light was not visible. Further observation revealed Resident #74's call light was wound around the call light box . Resident #74 stated she did not have a call light and did not know where her call light was. During an interview on 04/14/2026 at 10:35 AM with CNA B, confirmed Resident #74's call light was on the floor; and she wound the call light on the call light box that morning when she made the bed and probably forgot to leave it with in the residents reach . CNA B noted that the lack of accessibility of a call light could negatively affect any resident if they needed assistance. Interview on 04/14/2026 at 11:00 am with LVN A, she stated Resident #74's call light was out of reach of Resident #74. However, she confirmed that it was not normal nursing practice for one resident to be left without a call light. LVN A remarked that the absence of the call light could constitute potential harm if the resident needed assistance in an emergency. Interview on 04/14/26 at 12:00 PM with the DON, she stated the facility had a call light policy and staff has been in-serviced many times to keep call light within residents' reach. The DON also confirmed that Resident # 74's care plan addressed the need for a call light within reach. She said she did not know why it was not within Resident # 74's reach but would ensure all staff was in-serviced on this process again. Record review of the facility policy's. Communication-Call System, revised 6/2020, revealed Call cords will be placed within the resident's reach in the resident's room.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Resident #7) reviewed for resident rights, in that: CNAs D and E did not completely close Resident #7's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents who received incontinent care at-risk of loss of dignity, embarrassment, and a decline in quality of life.The findings were: Record review of Resident #7's face sheet, dated 04/16/2026, revealed an admission date of 07/31/2025, and a readmission date of 01/15/2026, with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Dementia (decline in cognitive abilities), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) Record review of Resident #7's Quarterly MDS assessment, dated 02/18/2026, revealed the resident had a BIMS score of 14, which indicated intact cognition, and he was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #7's care plan, dated 11/26/2025, with a problem of The resident has foley Catheter to help manage his bladder function. The foley requires regular care to prevent infection, skin problems or other complications. and an intervention of Monitor/record/report to MD for signs and symptoms of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temperature, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 04/16/2026 at 11:05 a.m. revealed CNAs D and E provided catheter/incontinent care care for Resident #7. During care CNAs D and E did not pull the curtain at the end of the bed to offer privacy to the resident. Further observation revealed Resident #7 could have been seen by someone opening the room's door and his genitals were fully exposed. During an interview with CNAs D and E on 04/17/2026 at 11:34 a.m., CNAs D and E stated the privacy curtain was not closed while they provided care for Resident #7 but should have been. CNAs D and E stated they had received resident rights training from the DON and ADON. During an in interview with the DON and the Administrator on 04/16/2026 at 3:55 p.m., they stated privacy must be provided during nursing care and Resident #7's privacy curtain should have been closed completely. They stated Resident rights training had been provided for the staff within the current year. Record review of the facility's policy titled, Resident rights, dated 08/2020, revealed, State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to: [ .] E. Privacy and confidentiality.

Based on interview and record review, the facility failed to ensure that PRN (as needed) orders for psychotropic medications were limited to fourteen days for 1 (Resident #5) of 25 residents reviewed, in that: Resident #5's PRN order for ABH gel (Ativan/Benadryl/Haldol) was not limited to fourteen days. This deficient practice could result in residents who receive PRN psychotropic medications being administered such medications for staff convenience rather than resident need.The findings were: Record review of Resident #5's face sheet, dated 04/17/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: generalized anxiety disorder, major depressive disorder, psychotic disturbance, and altered mental status. Record review of Resident #5's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #5's care plan, revised 04/13/2026, revealed, The resident requires psychotropic medications. Record review of Resident #5's order summary as of 04/17/2026, revealed an order with start date 04/09/2026 and no end date, Ativan-Benadryl-Haldol: ABH Gel 1-25-1 Apply 1 application transdermally every 8 hours as needed for Anxiety/Agitation/Restlessness. During an interview with the DON on 04/17/2026 at 1:18 p.m., the DON stated the ABH gel was a psychotropic medication, and the PRN order should have an end date of no more than fourteen days past the start date. Record review of the facility policy, Physician Orders, revised 06/2020, revealed, The Medical Records Department will verify that physician orders are complete, accurate, and clarified as necessary.

Based on observation, record review, and interview, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 2 residents (Resident #87) reviewed for new admissions. The facility failed to develop a baseline care plan within 48 hours of admission for Resident #87. This failure could lead to residents not receiving necessary care and decreased quality of life.Findings included: Record review of Resident #87's face sheet, dated 4/14/2026, revealed that a [AGE] year-old male was admitted to the facility on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease ( is a progressive, treatable lung disease that causes obstructed airflow, making it difficult to breathe), Diabetes mellitus (is a chronic metabolic disease characterized by high blood sugar levels resulting from the body's inability to produce enough insulin or use it effectively), and Hypertension (is a chronic condition where blood forces against artery walls too strongly) Record review of Resident #87's baseline care plan report, printed 4/14/2026, revealed no care plan to address the hearing deficit or the use of hearing aids. Record review of Resident #87's admission MDS admission assessment dated [DATE] revealed a BIMS score of 13, which indicated his cognition was intact. Record review of hospital admission clinicals for Resident #87 dated 4/3/2026, revealed: Hearing impaired / wears hearing aids in both ears. Record review of Resident #87's admission MDS assessment dated [DATE] revealed that under section D0300, hearing aids were selected. Observation on 4/15/2025 at 10:20 AM revealed that Resident #87 was wearing hearing aids in both ears. Interview with Resident #87 on 4/15/2026 at 10:30 AM stated he arrived at the current facility with hearing aids and used them for years due to his hearing loss. In an interview with MDS Nurse on 4/15/2026 at 10:40 AM, she stated that a baseline care plan should include anything a resident needs to receive proper care, including allergies, fall risks, skin conditions, code status, hospice (if applicable), bowel and bladder needs, pain, and nutrition. She also stated that the current care plan was insufficient to provide care for Resident #87. In an interview with the DON on 4/15/2026 at 11:11 AM, after reviewing Resident #87's baseline care plan together, she stated the document should have contained medications, transfer status, therapy needs, etc. She reported that the potential harm to residents from an insufficient care plan was that they might not receive proper care. Review of the facility's policy document titled Care Planning, Comprehensive Person-Centered (revised June 2020), which revealed, The facility will develop a person-centered Base Care Plan for each resident within 48 hours of admission .

Based on interview and record review, the facility failed to develop a comprehensive care plan with the participation of the resident and the resident's representative within seven days after completion of the comprehensive assessment for 1 (Resident #30) of 25 residents reviewed, in that: Resident #30's care plan conference meeting was held twenty-five days after completion of comprehensive assessment. This deficient practice could result in the needs and/or concerns of residents and their representatives being unheard and unaddressed. The findings were: Record review of Resident #30's face sheet, dated 04/17/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, hyperlipidemia, and secondary hypertension. Record review of Resident #30's admission MDS, dated [DATE], revealed a BIMS score of 5 which indicated severe cognitive impairment. Record review of Resident #30's Care Plan Conference note, dated 04/13/2026, revealed the conference was held on 04/15/2026. Further review revealed the resident and the resident's representative were invited but did not attend. During an interview with the Social Worker on 04/17/2026 at 4:07 p.m. revealed the Social Worker stated the care plan conference should have been held earlier and was not due to an oversight. Record review of the facility policy, Care Planning, revised 06/2020, revealed, The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment, and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. XI. The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following individuals: A. The Attending Physician; B. The Resident Assessment Coordinator; C. The Licensed Nurse who has responsibility for the resident; D. The Dietary Supervisor and/or registered dietician; E. Social Service staff member responsible for the resident; F. The Activity Director; G. Therapists as applicable; H. Consultants (as appropriate); I. The Director of Nursing (as applicable); J. Certified Nursing Assistants and/or RNAs responsible for the resident's care; K. The resident and/or his/her family or legal representative.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Residents #7) reviewed for incontinent care and catheter care, in that: While providing incontinent care for Resident #7, CNA D used a back-and-forth motion to clean Resident #7. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #7's face sheet, dated 04/16/2026, revealed an admission date of 07/31/2025, and a readmission date of 01/15/2026, with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Dementia (decline in cognitive abilities), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) Record review of Resident #7's Quarterly MDS assessment, dated 02/18/2026, revealed the resident had a BIMS score of 15, which indicated no cognitive impairment, and was indicated to occasionally be incontinent of bowel and had an indwelling catheter. Record review of Resident #7's care plan, dated 11/26/2025, reflected a problem of The resident has foley Catheter to help manage his bladder function. The foley requires regular care to prevent infection, skin problems or other complications. and an intervention of Monitor/record/report to MD for signs and symptoms of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 04/16/2026 at 11:09 a.m. revealed CNAs D and E provided catheter/incontinent care for Resident #7. During care CNA D used a back and forth motion to wipe the resident instead of a front to back motion. She wiped Resident #7's penis from base to tip instead of tip to base. During an interview with CNA D on 04/17/2026 at 11:34 a.m., CNA D stated the proper motion to clean a resident's penis was front to back or tip to base. She did not realize she was using the wrong motion and stated she was nervous. She stated she received training in incontinent care within the year from the DON and ADON. During an in interview with the DON and the Administrator on 04/16/2026 at 3:55 p.m., they stated the correct motion to clean a resident was front to back to prevent the contamination of the urinal tract with fecal matter and prevention of infection. They stated the staff was provided incontinent care training and their skills were checked annually and as needed. Record review of facility's policy titled, Clinical competency validation catheter: indwelling urinary care of, dated 09/23/2025, revealed, Male: washes around catheter insertion site and then from the tip of the penis down to the body.

Based on interview and record review the facility failed to ensure were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter for 4 of 7 Residents (Resident #2, Resident #3, Resident #4, Resident #5) reviewed for physician visits. The facility failed to ensure Resident #2's, Resident #3's, Resident #4's and Resident #5's were visited by their physician at least every 60 days after their 90-day admission period. This deficient practice could place residents at risk for not having an MD assessing their health status. The findings were:1.Review of Resident #2's face sheet, dated 3/27/26, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia (decline in cognitive function severe enough to interfere with daily life) in other diseases classified elsewhere mild, with agitation (indicating dementia as a symptom of an underlying condition) and other stimulant abuse with stimulant induced anxiety disorder (misuse of stimulants leads to the development of anxiety disorders). Review of Resident #2's quarterly MDS assessment, dated 3/16/26, revealed his BIMS was 8 of 15 reflecting moderate cognitive impairment and had a diagnosis of anxiety. Review of Care Plan, dated 2/20/26, revealed he had cognitive impairment/Dementia, one of the interventions reflected Discuss concerns about confusion, disease process, NH placement with the resident/family/caregivers, he has a behavior problem r/t throwing items at other people, one of the interventions reflected Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes). 2. Review of Resident #3's face sheet, dated 3/27/26, revealed he was admitted to the facility on [DATE] with diagnosis including unspecified Dementia (decline in cognitive function severe enough to interfere with daily life), unspecified severity, with other behavioral disturbance. Review of Resident #3's Care Plan, dated 12/10/25, read The resident has impaired cognitive function/dementia or impaired thoughtprocesses. One of the interventions included Ask yes/no questions in order to determine the resident's needs). Review of Resident #3's History and Physical, dated 3/20/26, revealed the NP had completed the History and Physical. Further review Resident #3's physician signed it but did not date it. 3. Review of Resident #4's face sheet, dated 3/27/26, revealed he was admitted to the facility on [DATE] with diagnosis including Dementia (decline in cognitive function severe enough to interfere with daily life), in other diseases classified elsewhere, mild, with anxiety. Review of Resident #4's quarterly MDS, dated [DATE], revealed his BIMS score was 15 of 15 reflecting no cognitive impairment. Review of Resident #4's Care Plan, dated 11/26/25, read The resident has impaired cognitive function/dementia or impaired thoughtprocesses. One of the interventions included (Identify yourself at each interaction. Face the resident when speaking and make eye contact). 4. Review of Resident #5's face sheet, dated 3/27/26, revealed she was admitted to the facility on [DATE] with diagnosis including Schizoaffective Disorder, Bipolar type (form of mental illness that has the features of both schizophrenia and a mood disorder. It has two variations: bipolar type and depressive type. A hallmark feature of bipolar type schizoaffective disorder is the presence of manic episodes). Review of Resident #5's quarterly MDS, dated [DATE], revealed her BIMS score was 15 of 15 reflecting no cognitive impairment. Review of Resident #5's Care Plan, dated 12/13/25, read Resident #5 has mood problem related to Bipolar disorder, Insomnia, depression,anxiety. She is at risk for changes in mood related to pain/discomfort. She is prescribed anticonvulsant medications for bipolar disorder. Review of Resident #2's, Resident #3's, Resident #4's and Resident #5's EHR revealed there were no physician progress notes/assessments or History and Physical's completed by their physician from 3/27/25 to 3/27/26. Interview on 3/27/26 at 4:00 PM with the DON and ADM revealed #2's, Resident #3's, Resident #4's and Resident #5's rounded on his residents on Wednesday's. The ADM and DON stated the Resident's physician would sign off on the NP's notes and stated they did not have any of the physician's notes written by the physician himself. The ADM provided a copy of Resident #3's History and Physical completed by the NP on 3/20/26. It was signed by Resident #3's physician but not dated. The ADM stated Resident #2's, Resident #4's and Resident #5's NP's progress notes for all of them would all be signed by the Resident's physician. The ADM and DON stated they were unable to provide any written physician progress notes or an H&P for any of the residents. Review of facility policy Physician Services & Visits, dated 8/20/20, 08/2020, read in relevant part Physician Services & Visits:I. Physician services include, but are not limited toA. The resident's Attending Physician participation in the resident's assessment and careplanning, monitoring changes in resident's medical status, and providing consultation ortreatment when called by the FacilityB. The Attending Physician must:i. Evaluate the resident as needed and at least every 30 days for the first 90 daysafter admissions, and at least once every 60 days thereafter unless there is analternate schedule or state specific requirement. The Attending Physician willdocument the visits in the resident's health record. II. Patient diagnosesA. Provide advice, treatment and determination of appropriate level of care needed for eachpatient.B. Providing written and signed orders for diet, care, diagnostic tests and treatment ofpatients by others with the exception of influenza and pneumococcal vaccines, which maybe administered after an assessment for contraindications.C. Health record progress notes and other appropriate entries in the patient's healthrecords.i. Physician orders and progress notes shall be maintained in accordance withcurrent OBRA regulations and Facility policy.

Based on observation, interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) 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 of 7 residents (Resident #1) whose records were reviewed. LVN A failed to notify Resident 1, Resident 1's physician or NP and Resident 1's emergency contact when LVN A received a critical CO2 lab result (A CO2 blood test measures the amount of carbon dioxide in your blood, primarily in the form of bicarbonate (HCO3). This test is often part of a broader electrolyte panel or comprehensive metabolic panel (CMP), which helps evaluate your body's acid-base balance and overall metabolic function). This deficient practice could place residents at risk of not having the opportunity to make informed decisions about their health status. The findings were: Review of Resident #1's face sheet, dated 3/25/26, revealed she was admitted into the facility on 3/1/26 with diagnoses including heart failure, obstructive sleep apnea (is a common sleep disorder characterized by repeated interruptions in breathing during sleep due to airway blockage), chronic pulmonary edema (long-term condition where fluid gradually accumulates in the lungs, often due to heart or lung problems, leading to persistent breathing difficulties) and acute and chronic respiratory failure with hypoxia (occurs when the lungs cannot supply enough oxygen to the blood, leading to low tissue oxygen levels, and can be life-threatening if untreated). Review of Resident #1's admission MDS assessment, dated 3/3/26, revealed her BIMS score was 15 of 15 reflecting no cognitive impairment and she was receiving oxygen therapy. Review of Resident #1's Care Plan, dated 3/1/26, revealed Resident #1 had a pacemaker and one of the interventions included to monitor vital signs as ordered/per facility protocol and record, she had altered respiratory status and one of the interventions included Monitor for s/sx of respiratory distress and report to MD PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Review of Resident #1's lab results dated 3/2/26 revealed a critical lab value for CO2 of 42 which was labeled at HH in red. Further review revealed LVN A was notified of the critical lab on 3/2/26 at 8:34 PM pacific time (10:34 PM central time). Review of Resident #1 progress note dated 3/3/26 at 1:14 AM written by LVN A read Resident (#1) has critical lab results for CO2 at 42 (reference range 21-31) informed NP and DON. Resident stable at this time. Review of progress note for Resident #1 dated 3/3/26 at 06:52 AM written by LVN B read Night nurse (LVN A) stated he sent results to NP pending response. Review further of Resident #1's progress notes revealed there was no other documentation entered by LVN A in response to the critical lab. Review of Resident #1's assessments for March 2026 revealed there was not a change of condition assessment completed in response to Resident #1 critical lab value of CO2, dated 3/2/26. Review of NP progress note, dated 3/3/26, read Orders:1. Utilize [NAME] Inpatient Care Protocol Orders, please notify NP accordingly.2. SLUMS X 1 BY REHAB SERVICES, please upload document in MISC/Documents tab.3. LABS: CBC, BMP, BNP, MAG, PHOS every MONDAY starting next week. Summary: Call from (LVN B, no date), CO2 reported by (LVN B), however, pt on O2 and needs to be off due to retention of CO2. Pt has CHONIC HYPERCARBIC RESP FAILURE with elevated CO2 levels (R79.81). Discussed and verbal understanding with (LVN B). Pt breathing 16-21, unlabored and sat > 96%. Pt denies dyspnea (shortness of breath). Monitor for acute needs. Interview on 3/25/26 at 4:25 PM with the DON revealed on 3/3/26 nurse (LVN A) received a critical lab, CO2 at 42. LVN A noted he informed the NP and himself. He stated LVN A notified the NP and himself via phone text. He stated he received it when he woke up on 3/3/26 and the NP never responded to LVN A's text. The DON stated (LVN A) should have called the NP and himself for a critical lab which was considered a change of condition. LVN A should have called the on-call nurse if he was unable to make contact with the NP and himself. He stated according to LVN B's skilled nursing note dated 3/3/26 at 6:14 AM Resident #1's O2 level was documented at 95%. The DON stated he did not recall talking with the NP about Resident #1's critical lab on Wednesday 3/4/26 when the NP was on-site. He stated the NP rounded on residents every Monday, Wednesday and Friday. The DON stated the importance of following protocols for a change of condition was to avoid worsening of Resident #1's condition. Nursing staff would continue to monitor more frequently and start interventions in a timely manner once orders were received. Interview on 3/26/25 at 10:55 AM with LVN B revealed she had worked at the facility for about 5 years. She stated facility protocols for change of condition required she notify the NP or MD and nursing management via phone call. Upon receipt of a critical lab she would call immediately and would keep calling until she got an answer. She stated it was important to make contact because a change of condition could be life threatening. LVN B stated on 3/3/26 LVN A reported he had notified the NP and was pending a response. She stated LVN A did not share when he received the critical lab or when he notified the NP. LVN B stated she called the NP on 3/3/26 around breakfast time to inform her of the critical lab value for CO2 and of Resident #1's daily assessment. She stated the NP said she planned to ween Resident #1 off oxygen and would address it with Resident #1 during rounding. LVN A stated she did not enter a progress note after contacting the NP. She stated she must have forgotten to enter the note. LVN B stated she let the DON know that she had called the NP about the critical lab for Resident #1. Telephone interview on 3/26/26 at 4:58 PM with LVN A revealed he had worked at the facility for 6 years on the night shift. He stated he did not remember the details about receiving a critical lab for Resident #1. He stated facility protocols when receiving a critical lab included immediately calling the NP and the DON and to follow orders. He stated a critical lab would be considered a change of condition and would be required to assess the resident and obtain vitals prior to calling the NP and the DON, to complete a change of condition, notify the RP which he would document in the assessment and on a progress note. LVN A stated sending a text was not sufficient when responding to a change of condition/critical lab. He stated he would monitor the resident until he received a call back from the NP and the DON. In the event they did not call within 10 minutes he would send the resident out to the hospital. LVN A stated a resident who had a critical lab value of 42 for CO2 could go into cardiac arrest and for a resident like Resident #1 who had a history of heart problems could lead to death if the change of condition was not addressed right away. LVN A stated sometimes the NP took a long time to respond when he reached out to her during the night shift. He stated the DON would respond but sometimes it takes time to get a response. He stated his option was to call the ADON when having difficulties getting a response from the NP and the DON. He stated he had reached out to ADON before but not every time. LVN A stated he did not remember what he did in response to receiving a critical lab for Resident #1. Observation and interview on 3/26/25 at 4:17 PM with Resident #1, her emergency contact and a close personal friend revealed they were visiting. Surveyor asked Resident #1 if anyone talked with her about an abnormal lab result received earlier in the month (March). Resident #1 stated and her emergency contact stated facility staff did not notify them of any abnormal lab results. The emergency contact stated hospital staff told him Resident #1 had retained a lot of carbon dioxide because of her breathing patterns. The emergency contact stated if they called him, he did not answer numbers he did not recognize but stated he had talked with nursing staff before on the phone. Resident #1 stated it was upsetting that no one talked to her about it because she would want the opportunity to decide whether or not to go to the hospital as needed. Interview on 3/27/26 at 9:30 AM with the DON revealed he talked with LVN A about what he did in response to receiving the critical lab for Resident #1. The DON stated LVN A reported he assessed the resident and she was in stable condition. He agreed to call and not text when communicating with the NP and himself regarding a critical lab. The DON stated he acknowledged he did not complete documentation reflecting what he did to ensure the residents safety. Interview on 3/27/26 at 11:57 AM with the NP revealed LVN A often did not follow protocols. She stated he texted her about Resident #1's critical lab for CO2 via his personal email which was not allowed because it was not secure and it violated HIPAA. The NP stated she would not have done anything differently had LVN A called her because she understood Resident #1's health status and stated Resident #1 had complicated comorbidities. She stated Resident #1 had a tendency to open her mouth when receiving oxygen which would make her CO2 level go up. The NP stated Resident #1 was not in any distress when LVN B assessed her on the morning of 3/3/26 and when she rounded on Resident #1 on 3/4/26. Review of facility policy dated 01/2025 read Change of Condition Notification Nursing Manual - Nursing AdministrationPolicy No. - NP - 104CONFIDENTIAL AND PROPRIETARY INFORMATION Page 1 of 2PurposeTo ensure residents, family, legal representatives, and physicians are informed of changes in theresident's condition in a timely manner.PolicyDefinition: An acute change of condition (ACOC) is a sudden, clinically important deviation from apatient's baseline in physical, cognitive, behavioral, or functional domains. Clinically importantmeans a deviation that, without intervention, may result in complications or death. (AMDA 2003)I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs andsymptoms that might represent an ACOC.II. The Facility will promptly inform the resident, consult with the resident's Attending Physician, andnotify the resident's legal representative when the resident endures a significant change in theircondition caused by, but not limited to:A. An injury/accident;B. A significant change in the resident's physical, cognitive, behavioral or functional status;C. A significant change in treatment; and/orD. A decision to transfer or discharge the resident from the Facility.ProcedureI. The Licensed Nurse will notify the resident's Attending Physician when there is an:A. Incident/accident involving the resident;B. An accident involving the resident which results injury and has the potential for requiringphysician intervention;C. A significant change in the resident's physical, mental or psychosocial status, e.g.,deterioration in health, mental or psychosocial status, life-threatening conditions orclinical complications;D. A need to alter treatment significantly;E. A decision to transfer or discharge the resident from the Facility.II. The Licensed Nurse will assess the resident's change of condition and document the observationsand symptoms.III. Notifying the Attending Physician:A. The Attending Physician will be notified timely with a resident's change in condition.B. Notification to the Attending Physician will include a summary of the condition changeand an assessment of the resident's vital signs and system review focusing on thecondition and/or signs and symptoms for which the notification is required.C. The Licensed Nurse will review the resident's advanced directives and ensure that theAttending Physician is aware of the resident's wishes. Interventions should be inaccordance with the resident's instructions.IV. Reporting Information to the Attending PhysicianA. Emergency Situationsi. In emergency situations, (e.g., a resident is experiencing unexpected shortness ofbreath, intense pain, unexpected bleeding, serious abnormal labs or x-ray) theLicensed Nurse will:a. Immediately call the Attending Physician.Change of Condition NotificationNursing Manual - Nursing AdministrationPolicy No. - NP - 104CONFIDENTIAL AND PROPRIETARY INFORMATION Page 2 of 2(i) NOTE: If the Licensed Nurse is unable to reach the AttendingPhysician or the Physician on call during emergency situations,he/she will notify the Facility's Medical Director.(ii) If the resident deteriorates, the symptoms are serious, and themost rapid intervention available by a physician would place theresident in great jeopardy, call 911 for transport to hospital;b. Notify the Nursing Supervisor of emergency situation; andV. Family NotificationA. The Licensed Nurse will notify the resident, the resident's responsible party, or thefamily/surrogate decision-makers of any changes in the resident's condition as soon aspossible.VI. DocumentationA. A Licensed Nurse will document the following:i. Date, time, and pertinent details of the incident and the subsequent assessmentin the Nursing Notes.ii. The time the Attending Physician was contacted, the method by which he wascontacted, the response time, and whether or not orders were received.iii. The time the family/responsible person was contacted.iv. Update the Care Plan to reflect the resident's current status.v. The incident and brief details in the 24-Hour Report.vi. If the resident is transferred to an acute care hospital, complete an inter-facilitytransfer form.vii. Complete an incident report per Facility policy.B. A Licensed Nurse will communicate any changes in required interventions to the IDTmembers involved in the resident's care.C. A Licensed Nurse will document each shift for at least seventy-two (72) hours.D. Documentation pertaining to a change in the resident's condition will be maintained inthe resident's medical record and on the 24-Hour Report.ReferencesSources:42 C.F.R. S 483.10(g)(14). American Medical Directors Association (AMDA)Forms:NoneEmployees:Nursing StaffVersion No. 1.0 Date Revised: 01/2025.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse for 1 of 7 Residents (Resident #2) whose records were reviewed for abuse. The ADM failed to report an allegation of abuse when Resident #2 threw a plastic cup at Resident #3 causing a skin tear over his left eyebrow within two hours after the allegation was made. This deficient practice could place residents at risk of further abuse. The findings were:Review of Resident #2's face sheet, dated 3/27/26, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia in other diseases classified elsewhere mild, with agitation (indicating dementia as a symptom of an underlying condition) and other stimulant abuse with stimulant induced anxiety disorder (misuse of stimulants leads to the development of anxiety disorders). Review of Resident #2's quarterly MDS assessment, dated 3/16/26, revealed his BIMS was 8 of 15 reflecting moderate cognitive impairment and had a diagnosis of anxiety. Review of Resident #2's Care Plan, dated 2/20/26, revealed he had cognitive impairment/Dementia, one of the interventions reflected Discuss concerns about confusion, disease process, NH placement with the resident/family/caregivers, he has a behavior problem r/t throwing items at other people, one of the interventions reflected Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes). Review of the Provider Investigation Report, dated 1/13/26 revealed on 1/6/26 at 5:45 PM Resident #2 threw an empty cup towards Resident #3 because he tried to open privacy curtain during care. The cup hit Resident #3 and caused a small skin tear. The injury was treated in-house. Resident #3 was moved to another room. Both residents were referred for psychiatric services. Further review revealed the ADM reported the resident-to-resident altercation on 1/7/26 at 11:04 AM. Observation and interview on 3/24/26 at 2:06 PM revealed Resident #2 was lying in bed. He stated he had a roommate who would talk a lot of shit and stated the other resident wasn't all there. Resident #2 said his roommate would talk about his Mom and one day, staff was changing his clothes and the roommate opened the privacy curtain. He stated his roommate opened it a couple times before and talked shit about his Mom. Resident #2 stated he lost his temper and threw a cup at his roommate and hit him over the left eye. He stated the roommate had a small skin tear. Resident #2 stated he felt bad and had tried to help his roommate, but he got tired of his roommate's mouth. Resident #2 stated staff intervened and then his roommate was moved. Resident #2 stated he had not had any other problems with other residents. Further observation revealed Resident #2 did not have a roommate. Observation on 3/24/26 at 2:25 PM with Resident #3 revealed he was lying in bed. Attempted interview with Resident #3 revealed he presented as being alert to self (he responded to his name) with confusion. Resident #3 did engage in conversation. Further observation revealed Resident #3 did not have any skin tears or discoloration on his face. Interview on 3/27/25 at 3:30 PM with the ADM revealed Resident #2 threw a cup at Resident #3 because Resident #3 opened the privacy while care was provided to Resident #2. She stated Resident #2 admitted he threw the cup at Resident #3. The ADM stated she reported the resident-to-resident incident between Resident #2 and Resident #3 within 24 hours. Upon reviewing the regulation, the ADM stated she understood she should report an allegation of abuse within 2 hours when the resident sustained serious bodily injury which was not the case. The ADM stated she did not have a problem with reporting allegations of abuse and stated having to report it within 2 hours was a technicality. The ADM stated Resident #3 was moved to a different room and did not have any lasting emotional affects but stated based on Survey's interpretation she would report allegations of abuse within 2 hours. Review of facility policy Abuse Prevention and Prohibition Program, dated October 24, 2022, read in relevant part To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.IX. Reporting/ResponseD. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. See AN - 01 - Form E - Initial Report - Facility Reported Incidents.i. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation). See AN - 01 - Form G - Crosswalk of Abuse Reporting Requirements.ii. No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation). See AN - 01 - Form G - Crosswalk of Abuse Reporting Requirements.

Based on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 7 Residents (Resident #1) whose records were reviewed. LVN A and LVN B failed to document what they did in response to Resident #1's critical lab, CO2 for value of 42, This deficient practice could place residents at risk of not having their medical records reflecting the care and services the residents received. The findings were:Review of Resident #1 progress note dated 3/3/26 at 1:14 AM read Resident (1) has critical lab results for C02 at 42 (reference range 21-31) informed NP and DON. Resident stable at this time. Review of progress note for Resident #1 dated 3/3/26 at 06:52 AM read Night nurse (LVN A) stated he sent results to NP pending response. Review of Resident #1's progress notes revealed no other documentation related to Resident #1's critical lab was entered by LVN A. Review of Resident #1's assessments for March 2026 revealed there was not a change of condition assessment in response to Resident #1's critical lab value of C02, dated 3/2/26. Interview on 3/26/25 at 10:55 AM with LVN B revealed she called the NP on 3/3/26 around breakfast time and the NP did not provide any new orders. LVN B stated she did not enter a progress note after contacting the NP. She stated she must have forgotten to enter the note. She stated it was important to document so that other nursing staff knew the NP had been contacted and there were no new orders. She stated other nursing staff would not know the exact status in response to the critical lab. Telephone interview on 3/26/26 at 4:58 PM with LVN A revealed he did not remember the details about receiving a critical lab for Resident #1 if he wrote any notes. Interview on 3/27/26 at 9:30 AM with the DON revealed he talked with LVN A about what he did in response to receiving the critical lab for Resident #1. The DON stated LVN A reported he assessed the resident and she was in stable condition and he texted the NP and himself. The DON stated LVN A acknowledged he did not complete documentation reflecting what he did to ensure the residents safety. He stated communication was a form of coordination of care which was important to ensure Resident #1 received the care and services she needed. Review of facility policy Change of Condition Notification, dated 01/2025, read in relevant part VI. DocumentationA. A Licensed Nurse will document the following:i. Date, time, and pertinent details of the incident and the subsequent assessmentin the Nursing Notes.ii. The time the Attending Physician was contacted, the method by which he wascontacted, the response time, and whether or not orders were received.iii. The time the family/responsible person was contacted.iv. Update the Care Plan to reflect the resident's current status.v. The incident and brief details in the 24-Hour Report.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 2 of 4 residents (Residents #1 and #2) reviewed for accidents and hazards. 1. The facility failed to ensure the environment was free of hazards to Resident #1 after the resident was hospitalized for suicidal ideation on 05/14/2025 and then on 08/14/2025 the resident attempted to self-infict an injury to her wrist with a razor. Resident #1 was discovered with a bleeding right wrist and a shaving razor on her bed on 08/14/2025 at 5:00 PM. 2. The facility failed to ensure Resident #1 was provide supervision the resident after being hospitalized for a suicidal ideation on 05/14/2025, resulting in the resident's attempt at self-injury on 08/14/2025.3. The facility failed to put effective measures in place to prevent Resident #2 from eloping from the memory care unit on 07/04/2025. An IJ was identified on 8/21/2025. The IJ template was provided to the facility on 8/21/2025 at 12:44 PM. While the IJ was removed on 8/23/2025 at 2:27 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because the facility needed to evaluate the effectiveness of the POR and complete required staff training. These failures could place residents at risk of inadequate supervision and monitoring leading to an environment that is not free of accidents/hazards. Findings included: 1. Record review of Resident #1’s admission record (Face sheet) dated 08/19/2025 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (a condition where brain tissue dies due to a blockage in a blood vessel), anxiety disorder (excessive and persistent worry that interferes with daily life), hemiplegia affecting right dominant side (a condition where paralysis or weakness affects the right side of the body), and depression (a serious mood disorder that affects how one thinks, feels, and acts, often making daily activities difficult). Record review of Resident #1’s quarterly MDS dated [DATE] revealed a BIMS score of 15/15 indicating the resident’s cognitive skills for daily decision making were not impaired, she felt down/depressed/hopeless several days, and she sometimes felt socially isolated. The resident was able to ambulate with the use of a walker and eat, dress, toilet, and perform personal hygiene independently. Record review of Resident #1’s comprehensive care plan, updated 08/06/2025 and reviewed on 08/19/2025, revealed a focus area indicating the resident was at risk for changes in mood related to migraines, depression, insomnia, seizures, anxiety and pain; an initial mood evaluation where she reported little interest or pleasure in doing things; feeling down, depressed or hopeless; impaired sleep pattern; little energy; feeling bad about self; and having a hard time concentrating on things (initiated 05/02/2025). The goal was for the resident to have improved mood state through the review date (initiated 05/02/2025, revised on 07/24/2025). Interventions/tasks included: Administering medications as ordered and monitoring for side effects and effectiveness; assisting the resident to identify strengths and positive coping skills; behavioral health consults as needed; monitoring/recording mood to determine if problems seem to be related to external causes; and monitoring/recording/reporting to MD prn risk for harming others; increased anger, labile mood or agitation; feeling threatened by others or thoughts of harming someone; possession of weapons or objects that could be used as weapons (all initiated 05/02/2025). The care plan also revealed focus areas for the resident's use of antidepressant medication, with the intervention/task of monitor/document/report PRN social isolation, suicidal thoughts and withdrawal (initiated 04/22/2025); and the resident's anxiety diagnosis and use of antianxiety medication, with the interventions/task of monitoring/documenting/reporting PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harming or trying to harm self, refusing to eat, drink, take medications or therapies or sense of hopelessness, impaired judgment or safety awareness (initiated 04/22/2025). There was no focus area in Resident #1's comprehensive care plan indicating the resident had a history of and hospitalization for a suicidal ideation on 05/14/2025 and had also attempted to injure herself on 08/14/2025. Record review of Resident #1's electronic Physician's Orders revealed orders for: -Duloxetine HCL oral capsule delayed release sprinkle 30 mg, give one capsule by mouth one time a day for depression with an order date of 08/06/2025 and a start date of 08/07/2025 -Duloxetine HCL oral capsule delayed release sprinkle 60 mg, give one capsule by mouth one time a day for depression with an order date of 04/22/2025 and a start date of 04/23/2025 -Hydroxyzine HCL oral tablet 25 mg, give one tablet by mouth every 8 hours as needed for anxiety with an order and start date of 08/05/2025 Record review of Resident #1's Medication Administration Record from 08/01/2025 - 08/20/2025 revealed she was monitored daily for side effects to antianxiety medication but only monitored on 08/20/2025 for side effects to antidepressant medications. Record review of a progress note dated 05/14/2025 at 7:27 AM in Resident #1’s EHR revealed the resident was found crying in her bedroom by a CNA. Resident #1 stated she did not want to live and “did not want to be here anymore.” The resident’s RP and MD were contacted and the resident was transferred to the hospital. The resident returned to the facility on [DATE] to the general population. Record review of Resident #1’s psychiatric evaluation dated 05/14/2025 during her hospital admission noted the resident was physically able to harm herself, was not supervised at her current facility, and would potentially be able to do so. The psychiatrist recommended a memory care facility with closer observation. Record review of Resident #1's EHR revealed the resident received routine psychiatric care, with the most recent psychiatric assessment on 08/13/2025. The note revealed staff reported the resident seemed paranoid and delusional at times, thinking people were talking about her and she did not want to take medications from the staff. The provider spoke with the resident's sister, who confirmed the resident had a history of non-compliance with medications. The note revealed the resident was anxious but not suicidal and there was no risk of aggression. Record review of a progress note by LVN B dated 08/14/2025 at 5:00 PM in Resident #1's EHR dated 08/14/2025 at 5:00 PM revealed the resident was bleeding from her right wrist with a women's shaving razor on the bed beside her. The resident informed the nurse she wanted to die and to go to the hospital. Pressure was applied to the site, the wound was cleaned, treated with antibiotic cream, and dressed with a dry dressing. The wound was superficial and approximately 2 cm long. The resident's vital signs were taken and within normal ranges. The DON was informed, the resident's physician and RP were notified, the resident was on 1:1 watch until transport arrived, and the resident was transported to the ER. The resident returned to the facility on [DATE] to her previous room, which was not on the memory care unit. Record review of a self-reported incident filed by the administrator of the facility on 08/16/2025 revealed: “Brief narrative summary of the reportable incident: Resident sent out to hospital on [DATE] due to suicidal ideation. Returned to facility today 08/16/2025 with hospital records that resident with acute fracture to right ulnar and a healing fracture of distal radius.” During an interview on 08/19/2025 at 2:30 PM, LVN A stated Resident #1 was agitated the morning she cut her right wrist, but later relaxed and asked to speak with the ADON. She had contacted the resident’s psychiatric NP but she didn’t get back to her that day. She spoke to the resident’s family member. LVN A stated she was aware of Resident #1's suicidal ideation and hospitalization in May 2025 and informed management she believed it would be better for Resident #1 to be placed in memory care because it was safer, residents could not have glass or scissors, and staff would go through items brought by family members. During an interview on 08/19/2025 at 2:40 PM, CNA G stated she had never seen Resident #1 sad but the other CNA who cares for her reported she was occasionally depressed after coming back from an outing with her family. Her family brought her things, such as food and personal care items. She never saw the resident try to hurt herself. Residents were not allowed to have razors; if she saw one, she would report it to a nurse. Resident #1 got along well with her roommate. An observation on 08/19/2025 at 3:56 PM revealed the clean utility room was unlocked and contained ladies’ and men’s shaving razors, nail clippers and aerosol cans of deodorant. During an interview on 08/20/2025 at 8:04 AM, LVN C stated he was told in May 2025 that Resident #1 had thoughts of killing herself and did not want to live but had no plan. He contacted her physician and they sent her to the hospital for evaluation. He spoke with her family, and they reported she tended to have hallucinations. He did not know how she obtained a razor. He recalled the resident had groceries delivered that day, so it was possible it was in one of the bags. The clean utility room did not have a lock, but the staff supervised it. During an interview on 08/20/2025 at 10:05 AM, the ADON stated she had gone into Resident #1’s room sometime between 10:00 – 10:30 AM on 08/14/2025 and Resident #1 told her she was crying because she believed everyone was talking about her. At 5:00 PM, the ADON and DON received a call from LVN B that Resident #1 was having an emergency situation. They both went to Resident #1’s room and observed the resident laying on her bed and holding her right wrist with a towel. LVN B stated it looked like the resident attempted to use a razor to cut herself. The ADON remained with the resident while LVN B called psychiatric services, the resident’s doctor and the resident’s family. The resident was calm at this time. The resident was transferred to the hospital. During an interview on 08/22/2025 at 4:20 PM, the Administrator stated she had assumed the position of administrator earlier that month. She was out of town the day Resident #1 attempted to injure herself. She received a call from the DON, who described the situation as the resident having a suicidal ideation and she did not believe the resident's attempt to injure herself with the razor was a suicide attempt, and she did not believe the resident's attempt to injure herself with the razor was a suicide attempt and required reporting to the state agency. During an interview on 08/22/2025 at 4:30 PM, the DON stated he called the Administrator on 08/14/2025 and told her Resident #1 was sent to the hospital. He recalled describing the resident cutting herself but did not recall if he used the term suicide attempt, as it was an ongoing situation. He remembered Resident #1 being hospitalized in May 2025 for a suicidal ideation but was unaware of the recommendation by the hospital psychiatrist to have the resident admitted to a secure unit. The DON did not believe the resident needed a secure unit and could be managed with increased supervision. Record review of the facility policy Incidents and Accidents, revised 04/11/2025, revealed, Policy explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. 5. The following incidents/accidents require an incident/accident report but are not limited to: self inflicted injuries; suicide or attempted suicide. Record review of the facility policy Resident Rights, updated 20252, revealed, Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Record review of the facility’s policy, “Abuse, Neglect and Exploitation,” updated 2025, revealed, “It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.” An Immediate Jeopardy was identified on 08/21/2025. The Administrator and DON were notified of the Immediate Jeopardy on 08/21/2025 at 12:44 PM and were given a copy of the Immediate Jeopardy template and a Plan of Removal (POR) was requested. The facility's POR for the Immediate Jeopardy was accepted on 08/22/2025 at 10:16 AM and reflected the following: The Medical Director was notified of the Immediate Jeopardy on 08/22/2025 at 12:34 PM. 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #1 assessed, first aid administered, Primary Physician notified orders given to send to ER for evaluation and treatment. Person(s) Responsible: Charge Nurse Date: 8/14/2025 Action: Resident #1 has been receiving psychiatric services since 6/23/2025. Prior to the 8/14/2025 incident, the resident seen on 8/13/2025. Most recent visit 8/20/2025. Person(s) Responsible: The facility's contract psychology and psychiatry services. Date: 8/13/2025, 8/20/2025, on-going Action: Resident #1 placed in secure unit per resident’s request. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/20/2025 Action: Resident #1s room cleared of all items that the resident could use to harm self. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/14/2025 Completed on the same day Action: Resident #1 care plan updated to reflect risk for suicidal behavior and need for increased supervision. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/21/2025 2. How the Facility Identified Other Possibly Affected Residents: Action: Conduct safe surveys with residents/family for signs of suicidal ideation. No other residents identified. If a resident expresses or exhibits signs/symptoms of suicidal ideation during a safe survey assessment: The staff member immediately notifies the Charge Nurse, DON/ADON, and Administrator. The physician and psychiatric provider are contacted immediately for further evaluation and treatment orders. The resident is placed on one-to-one monitoring until cleared by a licensed practitioner. The resident’s responsible party is notified. The care plan is updated with individualized interventions within 24 hours. Documentation is completed in PCC, including a behavior note and entry on the 24-hour report. If the DON/Administrator is unavailable, the ADON or RN Supervisor assumes responsibility to ensure no delay in intervention. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, Charge Nurse, Administrator Date: 8/22/2025 by 5 pm and ongoing Action: For Suicidal Ideation: Reviewed current resident population for diagnosis associated with suicidal Ideation and updated care plans with individualized interventions (e.g. Assess for underlying causes, consult mental health and/or psychiatric provider, individualized behavior intervention, Implement a behavior monitoring). Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/21/2025 Action: Suicidal Ideation: Conduct staff interviews to ask staff if any residents who: Have exhibited or voiced suicidal ideation: Has a plan, withdrawing from activities and family/friends, extreme mood swings, eating or sleeping pattern change, making statements like “I want to hurt myself” Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Social Services Date: 8/21/2025 Action: Reviewed Incident Reports and Nursing Notes for the past 6 months to identify residents with suicidal ideation. No other residents identified. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, Social Services Date: 8/21/2025 Action: Upon admission and/or identification of suicidal ideation, the resident will be provided education regarding the importance of reporting suicidal thoughts to staff and the interventions available for support. The responsible party and family members will also receive education on recognizing signs of suicidal ideation and the importance of communicating concerns to facility staff. Education will be documented in the resident’s medical record and reflected in the individualized care plan. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, Social Services, Date: Ongoing Action: All suicidal or self-harm behaviors will be documented in PointClickCare (PCC) through: Behavior Monitoring Flowsheets, 24-Hour Report, and/or Progress notes. Staff are trained to immediately escalate any report of suicidal ideation or self-harm. If the DON/Administrator is unavailable or on leave, the ADON or designated RN Supervisor assumes responsibility for receiving notifications and ensuring interventions are implemented without delay. All incidents will be reviewed by the interdisciplinary team and integrated into the residents’ individualized care plan within 24 hours. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing, RN Supervisor, Charge Nurses Action: Elopement: Conduct staff interviews: ask staff if any residents who: Have exhibited signs of attempting to exit the facility (testing door alarms, approaching doors when other staff or visitors are entering/exiting). No other residents identified. Person(s) Responsible: DON/ADON Date: 8/22/2025 by noon Action: Suicidal Ideation: Education provided to all staff on suicidal ideation and measures to take if identified (notify DON/Administrator immediately). All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm Action: Review all hospital documentation on residents that admitted or re-admitted over the past 3 months for documentation related to suicidal ideation. Continue to monitor all admissions/re-admissions documentation for suicidal ideation. Updated Care plans as needed. No new residents identified. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Administrator Date: 8/22/2025 by 5 pm and ongoing Action: Ensure current staff and new hires receive Incident, accident, and management of resident behavior training during orientation before working independently and annually thereafter. All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Suicidal Ideation: Education provided to all staff on suicidal ideation and measures to take if identified (notify DON/Administrator immediately). All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm Action: Review all hospital documentation on residents that admitted or re-admitted over the past 3 months for documentation related to suicidal ideation. Continue to monitor all admissions/re-admissions documentation for suicidal ideation. Updated Care plans as needed. No new residents identified. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Administrator Date: 8/22/2025 by 5 pm and ongoing Action: Ensure current staff and new hires receive Incident, accident, and management of resident behavior training during orientation before working independently and annually thereafter. All staff will be educated prior to working their next shift and new staff will be educated prior to working their first shift. Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 8/22/2025 by 5 pm 4. How the Corrective Actions Will be Monitored/Ensure Comprehension, by whom and for how long: Action: The Interdisciplinary team will conduct daily room rounds Monday through Friday on all residents observing any items that could be used for self-harm (e.g. razors, sharp objects, cords, glass). The Manager on Duty will conduct rounds on Saturday and Sunday observing any items that could be used for self-harm (e.g. razors, sharp objects, cords, glass) and immediately remove those items. All rounds will be discussed in the morning meeting. Person(s) Responsible: Interdisciplinary Team and Manager on Duty Date: 8/22/2025 by 5 pm and ongoing Action: Families will be educated on prohibited items during admission and re-educated as needed to ensure unsafe items are not brought into the facility. CNAs and nurses are trained to observe and report unsafe items daily while providing routine care. DON/ADON will review audit results weekly and document compliance in QAPI. Responsible: Director of Nursing and Assistant Director of Nursing, Charge Nurse Date: Ongoing Action: Interview 5 staff weekly x 4 weeks then monthly x 3 months to ensure no residents have voiced suicidal thoughts or attempted self-harm. With verbal comprehension of what to do in the event of resident self-harm or report of suicidal ideation. Responsible: Director of Nursing and Assistant Director of Nursing, Charge Nurse Action: Interview 5 staff weekly x 4 weeks then monthly x 3 months to ensure no residents have exhibited signs or attempts of elopement. With verbal comprehension of what to do in the event of elopement. Responsible: Director of Nursing and Assistant Director of Nursing, , Charge Nurse Date: Ongoing QAPI— Action: Medical Director informed of the deficient practice/IJ and the facility’s plan to remove the immediacy. Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Date: 8/21/2025 The facility's verification of the POR was as follows: 1. Record review of progress note dated 08/14/2025 at 5:00 PM by LVN B revealed, “Pressure applied to site, cleansed with normal saline sol. patted dry, TAO, dry dressing applied, wound superficial 2cm long. T-98.8, P-105, R-20, BP-133/85. DON, NP notified. Record review of progress note dated 08/14/2025 at 8:46 PM by NP revealed, “Chief Complaint: Suicidal ideations, took shaving disposable razor and cut wrist sent to ER.” 2. Record review of Resident #1’s electronic health record revealed psychiatric notes dated 06/23/25, 06/25/25, 07/09/25, 07/30/25, 08/06/25, 08/13/25 and 08/20/25. 3. a. Record review of Resident #1’s electronic health record revealed psychiatric notes dated 08/20/2025 with the following entry: “Spoke with administrator and ADON to move patient to locked memory unit, private room, remove all sharp objects, use of plasticware for meals. Also discussed patient's desire to move to another facility which family has declined at this time. Will continue to monitor closely. Hospitalization is not necessary at this time. b. Observation on 08/21/2025 at 8:30 AM revealed Resident #1 was residing on the secure unit. 4. Observation on 08/21/2025 at 11:00 AM of Resident #1’s room and bathroom revealed there were no sharp objects or anything the resident could use to harm herself. 5. Record review of Resident #1’s care plan, updated 08/21/2025, revealed: “The resident is at risk for changes in mood r/t migraines, depression, insomnia, seizures, anxiety, pain, initial phq9 of 12 where she reported, little interest or pleasure in doing things, feeling down, depressed or hopeless, impaired sleep pattern, little energy, feeling bad about self, hard time concentrating on things. Res has hx of suicidal ideation on 5/14/2025. 8/14/2025 had a suicide attempt using a women's shaving razor. Interventions: o Move to the secured unit for decreased stimulation o Psychiatric evaluation o Staff to speak with family and educate regarding what items can be ordered for resident. Record review of Resident #1’s care plan, initiated 08/21/2025, & revised on 8/22/25 revealed: “Resident exhibits self-injurious behavior (e.g., hitting self, biting, scratching, head banging), which poses a risk to safety and physical well-being. She has a history of scraping her skin with at sharp item. Interventions: o Assess for underlying causes such as psychiatric illness, cognitive impairment, sensory processing disorder, pain, frustration, or past trauma. o Conduct regular skin assessments and medical reviews to monitor for injury and address complications promptly. o Educate staff on warning signs of escalation, de-escalation techniques, and emergency procedures for managing self-injury. o Engage family or responsible party in care plaining and to gather relevant history that may inform effective intervention strategies. o Monitor resident room to ensure no sharp objects are present. o Provide a safe environment, removing or padding items that could be used for self-harm and ensuring close supervision during high-risk periods. 6. Record review of documentation from facility revealed interviewed 48 residents on signs of suicidal ideation. After the POR was accepted, record review of Resident #10's EHR revealed the resident stated to social worker on 08/22/20225 at 11:59 AM he wanted to hurt himself with a plan (he wanted to walk out into freeway; however, resident is bed-bound and not ambulatory). Resident #10 was evaluated by the psych NP the same day and sent to the hospital. Care plan was updated in a timely manner. 7. Staff interviews were conducted on 08/21 - 08/22/2025. RN/LVN = 11; CNA = 18; Dietary = 8; Housekeeping/Laundry/Maintenance = 5; PT/OT = 7; Admin = 8. Staff not interviewed will be interviewed prior to beginning work from 08/22 - 08/25/2025. Staff was asked: o Has any resident ever expressed to you that they may want to self-harm: o Do you know of any residents that you feel would potentially be at risk of self-harm? o If you suspect any resident of self-harm, what would you do? o Who would you report this to? All staff indicated no resident expressed to them a desire for self harm, they were unaware of any residents at potential risk for self-harm, and if they suspected such a risk they would report this immediately to the charge nurse/DON. 8. Record review revealed one resident was identified with a suicidal ideation on 08/08/2025. The resident was sent to the hospital immediately and returned to the facility on [DATE]. This resident verbalized another SI on 08/21/2025 and was again sent to the hospital. 9. Record review of Resident #1’s electronic health record revealed in psych note dated 08/20/2025 the resident received education regarding the importance of reporting suicidal thoughts to staff and the interventions available for support. The resident’s RP also received education on recognizing signs of suicidal ideation and the importance of communicating concerns to facility staff. 10. Record review of resident electronic health records revealed documentation in PointClickCare of resident suicidal and self-harm behaviors for Residents #1 and Resident #10. 11. Record review 8/22/2025 at 3:50 PM of staff roster provided by Admin on 8/22 indicating staff that received in-service training/were asked about elopement behaviors. RN/LVN = 11; CNA = 18; Dietary = 8; Housekeeping/Laundry/Maintenance = 5; PT/OT = 7; Admin = 8. Staff not interviewed will be interviewed prior to beginning work from 08/22 - 08/25/2025. 12. Record review revealed facility included in Resident Welcome Packet section on Restricted Items which included unsafe items. 13. Called the facility's medical director on 08/22/2025 at 12:35 PM; left voice message requesting return call. Record review of QAPI sign-in roster revealed Psych NP was present and the medical director participated by phone. 2. Record review of Resident #2's face sheet, dated 8/19/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 7/8/2025. Relevant diagnoses included senile degeneration of the brain (progressive memory and cognitive decline), schizophrenia (a mental health illness that causes difficulty distinguishing reality from their own thoughts and delusions), and dementia (a progressive disorder affecting cognition and behavior). Record review of Resident #2's physician orders revealed an order dated 7/3/2025 indicating the resident was admitted to the facility for a planned, five-day hospice-respite stay. Record review of Resident #2's discharge MDS, dated [DATE] revealed a BIMS score of 00, indicating severe cognitive decline. Record review of Resident #2's baseline care plan, date printed 8/19/2025, revealed the following: Resident demonstrates wandering and/or exit-seeking behavior placing self at risk for elopement or injury, had elopement on 7/4/2025. Record review of Resident #2's progress notes revealed the following documentation, dated 7/4/2025 at 1:12 PM by LVN D: Resident was seen 5 Minutes before this nurse went into nurses station restroom, after this nurse

Based on observations, interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 2 of 14 residents (Resident #8 and # 1) reviewed for care plan revisions. 1. The facility failed to ensure Resident #1's care plan was comprehensive and reflected Resident #1's history of hospitalization for suicidal ideation on 05/14/2025 and had attempted to injure herself on 08/14/2025.2. The facility failed to ensure Resident #8's care plan was comprehensive and updated to reflect Resident #8 used a geriatric chair (a large, padded chair with wheeled bases, designed to assist seniors with limited mobility) as a fall prevention. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings include: 1. Record review of Resident #1’s admission record (Face sheet) dated 08/19/2025 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (a condition where brain tissue dies due to a blockage in a blood vessel), anxiety disorder (excessive and persistent worry that interferes with daily life), hemiplegia affecting right dominant side (a condition where paralysis or weakness affects the right side of the body), and depression (a serious mood disorder that affects how one thinks, feels, and acts, often making daily activities difficult). Record review of Resident #1’s quarterly MDS dated [DATE] revealed a BIMS score of 15/15 indicating the resident’s cognitive skills for daily decision making were not impaired, she felt down/depressed/hopeless several days, and she sometimes felt socially isolated. Record review of Resident #1’s comprehensive care plan, reviewed 08/06/2025, revealed a focus area indicating the resident was at risk for changes in mood related to migraines, depression, insomnia, seizures, anxiety and pain; an initial mood evaluation where she reported little interest or pleasure in doing things; feeling down, depressed or hopeless; impaired sleep pattern; little energy; feeling bad about self; and having a hard time concentrating on things (initiated 05/02/2025). The goal was for the resident to have improved mood state through the review date (initiated 05/02/2025, revised on 07/24/2025). Interventions/tasks included: Administering medications as ordered and monitoring for side effects and effectiveness; assisting the resident to identify strengths and positive coping skills; behavioral health consults as needed; monitoring/recording mood to determine if problems seem to be related to external causes; and monitoring/recording/reporting to MD prn risk for harming others; increased anger, labile mood or agitation; feeling threatened by others or thoughts of harming someone; possession of weapons or objects that could be used as weapons (all initiated 05/02/2025). There was no focus area noting the resident had a history of and hospitalization for a suicidal ideation on 05/14/2025 and had also attempted to injure herself on 08/14/2025. Record review of a progress note dated 05/14/2025 at 7:27 AM in Resident #1’s EHR revealed the resident was found crying in her bedroom by a CNA. Resident #1 stated she did not want to live and “did not want to be here anymore.” The resident’s RP and MD were contacted and the resident was transferred to the hospital. The resident returned to the facility on [DATE]. Record review of Resident #1’s psychiatric evaluation dated 05/14/2025 during her hospital admission revealed the resident was physically able to harm herself, was not supervised at her current facility, and would potentially be able to do so. The psychiatrist recommended a memory care facility with closer observation. During an interview on 08/19/2025 at 2:30 PM, Resident #1 was agitated and stated she was upset and believed the staff was talking about her behind her back and posting about her on social media. During an interview on 08/22/2025 at 4:20 PM, the Administrator stated she had assumed the position of administrator earlier that month. She was out of town the day Resident #1 attempted to injure herself. She received a call from the DON, who described the situation as the resident having a suicidal ideation. During an interview on 08/22/2025 at 4:30 PM, the DON stated he called the Administrator on 08/14/2025 and told her Resident #1 was sent to the hospital. He recalled describing the resident cutting herself but did not recall if he used the term suicide attempt, as it was an ongoing situation. He remembered Resident #1 being hospitalized in May 2025 for a suicidal ideation but was unaware of the recommendation by the psychiatrist to have the resident admitted to a secure unit. The DON did not believe the resident needed a secure unit at that time and could be managed with increased supervision. The resident’s care plan should have been updated in May 2025 to note the resident’s history of suicidal ideation and in August 2025 to note the resident’s attempt to injure herself. 2. Record review of Resident #8’s admission Record (Face sheet) dated 8/23/25, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer’s diseases (progressive loss of memory and cognitive decline that impairs an individual to perform daily tasks), dementia (cognitive decline that impairs an individual to preform activities of daily living), high blood pressure, anxiety disorder (excessive and persistent worry that interferes with daily life). Record review of Resident #8’s MDS, a Significant Change assessment dated [DATE] revealed the resident’s cognitive skills for daily decision making were moderately impaired, used a wheelchair for mobility, was under hospice care, and since the previous assessment had 1 fall with no injury. Record review of Resident #8’s care plan for hospice services revealed it was initiated 07/29/2025 with a goal “…to focus on comfort, dignity, and quality of life during my remaining time.” Record review of Resident #8’s care plan for “Resident #8 is at risk for falls r/t [related to] impaired mobility, impaired cognition…history of falls, use of walker and wheelchair” revealed it was initiated 8/24/24 and revised on 08/06/2025 with the addition of interventions of “care plan scheduled with family and hospice” and “up at nurses’ station while anxious”. The care plan did not have a geriatric chair listed as an intervention to prevent falls. Record review of Resident #8’s Physician Orders revealed an order dated 07/25/2025 to admit to Hospice A services. Record review of Resident #8’s Texas Medicaid Hospice Election form, dated 07/25/2025 revealed she was admitted to hospice care with terminal diagnoses of Senile Degeneration of the Brain (severe cognitive impairment that inhibits an individual’s ability to perform activities of daily living). Record review of Resident #8’s SBAR, dated 7/30/25 at 03:32 (3:32 AM), completed by the ADON revealed the resident had a fall because she tried to get up and walk without assistance, the resident’s vital signs were obtained, the responsible party was notified, and the physician was notified. Record review of Resident #8’s nurse’s note, dated 07/30/2025 at 05:23 (5:23 AM), LVN E noted “[Resident #8] at the nurses’ station still trying to get up medicated for anxiety and pain.” Record review of Resident #8’s nurse’s note, dated 07/30/2025 at 07:19 (7:19 AM), LVN E noted “Fall with swelling to right eyes [sic] family member and hospice decided to send her out to hospital ER for eval [evaluation]”. Record review of Resident #8’s nurse’s note, dated 07/31/2025 at 11:34 (11:34 AM), ADON noted the resident was in bed resting, family was at bedside, it was status post fall day 1, and the resident had bruising to forehead, nose, and lips; and the hospice nurse was in the facility. In a telephone interview on 08/22/2025 from 3:13 PM to 3:55 PM, LVN E stated he worked the night shift (11 PM – 7 AM) on the memory care unit. LVN E stated Resident #8 had recently declined, she would try to get up and walk without assistance which caused her to fall. LVN E stated fall prevention measures included being near Resident #8 when she was in a wheelchair to remind the resident to “sit back” in the chair because otherwise she would try to walk and would fall. LVN E stated Resident #8’s hospice company provided a geriatric chair for the resident to use after she was sent to the hospital for a fall in July. LVN E said Resident #8 would try to get up from the geriatric chair when in the reclined position so staff would have to be near the resident when she was in it. LVN E stated Resident #8 had 2 falls in one night in July, he wasn’t certain on the date as he didn’t have her clinical record in front of him. LVN E stated one of the falls happened in the resident’s room, fall mats were on the floor when he entered the room, he didn’t see any injuries to the resident after that fall and took the resident to the nurse’s station while he notified Hospice A of the fall. Then later when Resident #8 was sitting at the nurses’ station, she fell again because she had tried to get up and had placed her body weight to the right side of the wheelchair and fell which caused a bump above her eye. LVN E stated he obtained her vital signs, did neurological checks, notified hospice and the resident’s responsible party. Observations on 08/22/2025 from 5:33 PM to 5:43 PM revealed Resident #8 was sitting at a dining table in a wheelchair with the DON sitting next to the resident. Resident #8 tried to stand up multiple times during the meal service, and the DON reminded her in Spanish to sit back down each time as he assisted her with the evening meal. Observation on 08/23/2025 at 5:34 AM revealed Resident #8 was sitting in the geriatric chair, which was reclined back, was awake, occasionally would say something in Spanish and was not trying to get out of the geriatric chair. Observation on 08/23/2025 from 6:24 AM to 7:05 AM revealed Resident #8 was next to the nurses’ station sitting in the geriatric chair, which was reclined back, was awake, fiddling with the blanket that was on her lap, speaking Spanish at times, was not agitated and did not try to get out of the geriatric chair. Observation on 08/23/2025 from 9:24 AM to 9:45 AM revealed Resident #8 was sitting in the geriatric chair that was pushed up to the dining room table next to the nurses’ station and the chair was not reclined. The resident was dipping a spoon into a bowl of oatmeal that was on the table. She was not trying to get out of the chair and would speak in Spanish to other residents who walked by her, she was not agitated. In a telephone interview on 08/23/2025 at 11:53 AM, Hospice RN A stated Resident #8 was provided a geriatric chair from Hospice A on 07/29/2025, but she did not know the reason the chair was provided as she was the weekend on-call nurse and did not provide care to Resident #8. In an interview on 08/23/2025 at 3:41 PM, ADON stated Hospice A provided Resident #8 with the geriatric chair after she came back from the hospital after she had a fall. ADON stated she thought Resident #8’s family member wanted the resident to be up so hospice felt the geriatric chair was better for the resident so she wouldn’t fall. In an interview on 08/23/2025 at 4:09 PM, CNA F stated the geriatric chair was used as a measure to prevent Resident #8 from falling but the resident could get herself out of the geriatric chair when it was reclined and had done so the previous weekend when CNA F worked on the secured unit, so staff would be near Resident #8 when she was in the geriatric chair to ensure this did not happen. In an interview on 08/23/2025 from 3:27 PM to 3:38 PM, MDS Nurse stated Resident #8’s Risk for Falls care plan was updated on 08/06/2025 when the interventions of having the resident up at the nurses’ station when anxious and scheduled care plan with family and hospice were added. The MDS Nurse stated she did not know when Resident #8 was provided with the geriatric chair, the chair was used as in intervention for positioning to calm her down and because of her fall risk. The MDS Nurse verified the geriatric chair was not listed as an intervention and she didn’t not have a reason why it was not added to the care plan. Record review of the facility’s undated Care Plan Revisions Upon Status Change policy revealed “The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. …1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of change in status, the nurse will notify the MDS Coordinator, the physician, and he resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options…d. The care plan will be updated with the new or modified interventions…f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member…”.

Based on interview and record review, the facility failed to convey within 30 days the resident's funds upon discharge for 1 of 3 residents (Resident #9) reviewed for personal funds. The facility failed to ensure Resident #9's personal funds were conveyed within 30 days of the resident's self-initiated discharge from the facility. This failure could result in loss of personal funds or decreased quality life to residents. Findings included: Record review of Resident #9's face sheet, dated [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged home on [DATE]. Record review of Resident #9's discharge MDS, dated [DATE] revealed a BIMS score of 15, indicating no cognitive decline. Record review of Resident #9's HHSC Form 3618, dated [DATE] and printed on [DATE], revealed Resident #9's notification to the state of discharge home (return not anticipated) was processed and accepted by HHSC and the Texas Medicaid and Healthcare Partnership on [DATE]. Record review of Resident #9's transaction record of personal funds, dated [DATE], revealed Resident #9's account had a positive balance of $1,030.01 from a deposit on [DATE] with a description that read SSA Treas [number]. The Business Office Manager position at the facility was vacant at the time of survey, so no interview was performed. In an interview with the Admin. on [DATE] at 1:50 PM, she stated she was not the Admin. of the facility when the resident discharged . She stated that when a resident is discharged and the notification of discharge (form 3618) is processed, Medicaid and the SSA are notified that the account is closed so no further funds would deposit into a resident's account. She said the deposit in Resident #9's account was likely his monthly direct deposit from the SSA, and she explained that since Resident #9's form 3618 was processed after the deposit, he should have received a refund from the facility within 30 days. She was unsure why the refund had not been processed by the facility. She stated the facility's Business Office Manager had unexpectedly and suddenly died 3 days prior, and the facility was working with their corporate office to continue to operations of the Business Office. She stated she would ensure Resident #9 received a refund for the amount in the account. In an interview with Resident #9 on [DATE] at 2:10 PM, he stated he was not aware of the funds in the account at the facility. He stated he had not been notified by the facility that there was a deposit after he discharged home. He stated he spoke with the former Business Office Manager sometime in early August regarding home health care services, but she did not mention his personal funds account. She told him she would return his call regarding his issue, but he had not heard from her since then. Record review of the facility policy titled Resident Rights (dated 2025) revealed the following: The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands including: . required notices as specified in this section. The facility must furnish to each resident a written description of the legal which includes . a description of the manner in protecting personal funds.

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one resident (Resident #1) of 8 residents reviewed for abuse and neglect. The DON failed to notify the Administrator that Resident #1 intentionally cut herself on her right wrist with a shaving razor on 08/14/2025 in an attempt to inflict self-harm, and the Administrator failed to report the self-inflicted injury to the state agency. These failures had the potential to affect residents in the facility by placing them at risk for self-harm.The findings included: Record review of Resident #1's admission record (Face sheet) dated 08/19/2025 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (a condition where brain tissue dies due to a blockage in a blood vessel), anxiety disorder (excessive and persistent worry that interferes with daily life), hemiplegia affecting right dominant side (a condition where paralysis or weakness affects the right side of the body), and depression (a serious mood disorder that affects how one thinks, feels, and acts, often making daily activities difficult). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15/15 indicating the resident's cognitive skills for daily decision making were not impaired, she felt down/depressed/hopeless several days, and she sometimes felt socially isolated. The resident was able to ambulate with the use of a walker and eat, dress, toilet, and perform personal hygiene independently. Record review of Resident #1's comprehensive care plan, updated 08/06/2025 and reviewed on 08/19/2025, revealed a focus area indicating the resident was at risk for changes in mood related to migraines, depression, insomnia, seizures, anxiety and pain; an initial mood evaluation where she reported little interest or pleasure in doing things; feeling down, depressed or hopeless; impaired sleep pattern; little energy; feeling bad about self; and having a hard time concentrating on things (initiated 05/02/2025). The goal was for the resident to have improved mood state through the review date (initiated 05/02/2025, revised on 07/24/2025). Interventions/tasks included: Administering medications as ordered and monitoring for side effects and effectiveness; assisting the resident to identify strengths and positive coping skills; behavioral health consults as needed; monitoring/recording mood to determine if problems seem to be related to external causes; and monitoring/recording/reporting to MD prn risk for harming others; increased anger, labile mood or agitation; feeling threatened by others or thoughts of harming someone; possession of weapons or objects that could be used as weapons (all initiated 05/02/2025). The care plan also revealed focus areas for the resident's use of antidepressant medication, with the intervention/task of monitor/document/report PRN social isolation, suicidal thoughts and withdrawal (initiated 04/22/2025); and the resident's anxiety diagnosis and use of antianxiety medication, with the interventions/task of monitoring/documenting/reporting PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harming or trying to harm self, refusing to eat, drink, take medications or therapies or sense of hopelessness, impaired judgment or safety awareness (initiated 04/22/2025). There was no focus area in Resident #1's comprehensive care plan indicating the resident had a history of and hospitalization for a suicidal ideation on 05/14/2025 and had also attempted to injure herself on 08/14/2025. Record review of a progress note dated 05/14/2025 at 7:27 AM in Resident #1's EHR revealed the resident was found crying in her bedroom by a CNA. Resident #1 stated she did not want to live and did not want to be here anymore. The resident's RP and MD were contacted and the resident was transferred to the hospital. The resident returned to the facility on [DATE] to the general population. Record review of Resident #1's psychiatric evaluation dated 05/14/2025 during her hospital admission noted the resident was physically able to harm herself, was not supervised at her current facility, and would potentially be able to do so. The psychiatrist recommended a memory care facility with closer observation. Record review of a progress note by LVN B dated 08/14/2025 at 5:00 PM in Resident #1's EHR dated 08/14/2025 at 5:00 PM revealed the resident was bleeding from her right wrist with a women's shaving razor on the bed beside her. The resident informed the nurse she wanted to die and to go to the hospital. Pressure was applied to the site, the wound was cleaned, treated with antibiotic cream, and dressed with a dry dressing. The wound was superficial and approximately 2 cm long. The resident's vital signs were taken and within normal ranges. The DON was informed, the resident's physician and RP were notified, the resident was on 1:1 watch until transport arrived, and the resident was transported to the ER. The resident returned to the facility on [DATE] to her previous room, which was not on the memory care unit. Record review of a self-reported incident filed by the administrator of the facility on 08/16/2025 revealed: Brief narrative summary of the reportable incident: Resident sent out to hospital on [DATE] due to suicidal ideation. Returned to facility today 08/16/2025 with hospital records that resident with acute fracture to right ulnar and a healing fracture of distal radius. During an interview on 08/22/2025 at 4:20 PM, the Administrator stated she had assumed the position of administrator on 08/04/2025. She was out of town the day Resident #1 attempted to injure herself. She received a call from the DON, who described the situation as the resident having a suicidal ideation but he did not say the resident had injured herself, and she did not believe the resident's attempt to injure herself with the razor was a suicide attempt and required reporting to the state agency. During an interview on 08/22/2025 at 4:30 PM, the DON stated he called the Administrator on 08/14/2025 and told her Resident #1 was sent to the hospital. He recalled describing the resident cutting herself but did not recall if he used the term suicide attempt, as it was an ongoing situation. He remembered Resident #1 being hospitalized in May 2025 for a suicidal ideation but was unaware of the recommendation by the hospital psychiatrist to have the resident admitted to a secure unit. The DON did not believe the resident needed a secure unit and could be managed with increased supervision. Record review of the facility's policy, Abuse, Neglect and Exploitation, updated 2025, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for 2 (Residents #29 and #68) of 4 D-Hall residents reviewed for dignity. The facility failed to ensure MA B and LVN C treated Residents #29 and #68 with dignity and respect when they referred to the residents' as feeders. This failure could place residents at risk for psychosocial harm due to diminished self-esteem and quality of life. Findings included: Record review of Resident #29's face sheet dated 01/22/2025 revealed she was a [AGE] year-old-woman with an admitted [DATE] and with diagnosis which included: Cerebral Palsy (movement disorder caused by damage or lack of development to brain areas that control muscle movement) and Dementia (general term for loss of memory, language and other thinking abilities). Record review of Resident #29's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #29's Care Plan initiated 06/10/2022 revealed a focus area for limited physical immobility and requires assistance with self care. Interventions include eating with assist of 1, revised 12/18/2024. Record review of Resident #68's face sheet dated 01/22/2025 revealed she was a [AGE] year-old woman admitted on [DATE] with diagnoses which included: Cerebral Vascular Accident (stroke) and Diabetes Mellitus (long-term condition that results in too much sugar in the blood). Record review of Resident #68's Admission MDS assessment dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment and assessed as needing a mechanically altered diet texture. Observation on 01/22/2025 starting at 12:20 p.m. revealed 3 residents sitting together at one dining table, and another resident sitting alone at a separate table. There was one CNA seated at the table with the 3 residents, in between residents Residents #29 and #68, and that CNA was feeding Resident #68 and assisting with the feeding of Resident #29. During an interview with MA B on 01/22/2025 at 12:53 p.m. regarding process and timeframes for distributing meal trays, MA B stated the feeders get served last because they need more assistance from staff, and she gestured towards the table where the 3 residents were seated. When asked what she meant by feeders, she stated they were the residents who needed to be fed or needed increased supervision and assistance from staff during meals During an interview with LVN C on 01/22/2025 at 12:57 p.m. regarding process for checking and distributing meal trays to the residents on D-hall, LVN C stated he was new to the facility, this was his 3rd day on the job, and described the process as the Nurse checking each tray to ensure correct order and texture and adaptive equipment was provided. When asked about information contained on the tray cards, LVN C stated the tray cards do not show which residents needed more feeding assistance, but he knew Resident #68 was a feeder. When asked if he had received training in resident rights he stated he had, both at this facility and at previous facilities he has worked. When asked about the term feeders, he stated he has always referred to residents who needed to be fed as feeders. He then asked is that wrong? Record review of MA B and LVN C's training records revealed both staff had received training in Resident Rights. During an interview with the DON on 01/23/2025 at 2:17 p.m., the DON stated that it was not acceptable or respectful of staff to refer to residents as 'feeders, as it described the residents only by their needs, not as individuals. The DON further stated the use of respectful language when speaking to and about the residents was addressed in orientation for all staff and included training in resident rights and dignity. The DON stated all staff receive periodic in-servicing on resident rights and dignity and she has already started in-servicing all the staff about need for use of respectful language when addressing or talking about the residents, including to avoid use of terms such as feeders or referring to older female residents as mama. Record review of the facility policy titled Resident Rights, revised February 2021, revealed the policy statement Employees shall treat all residents with kindness, respect, and dignity and under Policy Interpretation and Implementation Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . be treated with respect, kindness, and dignity. Further review of the Resident Rights policy revealed .staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents.

Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 2 (Residents #38 and #20) of 14 residents reviewed for informed consent, in that: 1. The facility failed to ensure Resident #38's right to informed consent for treatment with the psychotropic medication Sertraline was provided. 2. The facility failed to ensure Resident #20's right to informed consent for treatment with the psychotropic medication Sertraline was provided. These failures could place residents at-risk of receiving treatment without having been informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he or she prefers. The findings included: 1. Record review of Resident #38's face sheet dated 01/22/2025 revealed he was an [AGE] year-old man with an admitted [DATE] and diagnoses which included: Metabolic Encephalopathy (brain condition that occurs where there is an imbalance of chemicals in the brain resulting in difficulty thinking clearly), Dementia (general term for loss of memory, language, problem-solving and other thinking abilities), and Unspecified Depression (mental disorder that involves prolonged low mood and loss of interest in activities). Record review of Resident #38's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition, and that he had been assessed as having a diagnosis of depression. Record review of Resident #38's Order Summary dated 01/22/2025 revealed an order for Sertraline HCL Oral Tablet 50 MG (Sertraline HCL) Give 1.5 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED with an order date of 11/15/2024. Further review of Resident #38's EHR Orders revealed Sertraline was initially ordered on 03/20/2024. Record review of Resident #38's EHR did not reveal an informed consent for Sertraline. During an interview with the DON on 01/23/2025 at 11:35 a.m., the DON noted that sometimes consents are filed in the wrong area, so she conducted a search of the EHR, and provided copy of an informed consent for Sertraline for Resident's #38, which noted verbal consent was obtained from the RP on 03/20/2024 but was not signed by LVN E until 12/20/2024. The DON stated she believed informed consent was obtained on 03/20/2024, but the LVN did not lock it in until later when the mistake was noted. The DON confirmed that verbal consents needed to have the Nurse's signature who obtained the verbal consent at the time the verbal consent was obtained, not many months later, as was the case with Resident #38's consent for Sertraline, making this consent invalid. 2. Record review of Resident #20's face sheet, dated 01/22/2025, revealed she was admitted to the facility on [DATE] with diagnoses including: Generalized Anxiety Disorder, Major Depressive Disorder, and Insomnia Due to Other Mental Disorder. Record review of Resident #20's Quarterly MDS, dated [DATE], revealed the resident had both short-term and long-term memory problems. Record review of Resident #20's care plan, revised 12/12/2024, revealed, The resident uses psychotropic medications. Currently prescribed: .Sertraline. Record review of Resident #20's Order Summary Report as of 01/24/2025, revealed an order dated 09/05/2024, Sertraline HCl Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED (F33.9). Record review of Resident #20's facility clinical record as of 01/24/2025, revealed an Anti-depressant Medication Informed Consent form had been created in the EMR on 01/24/2025. Further review revealed the consent form had not been signed by the resident or her responsible party. Record review of Resident #20's Medication Administration Record from 09/06/2024 through 01/24/2025, revealed she had received the psychotropic medication, Sertraline, on a daily basis for more than four months without informed consent having been obtained. During an interview with the DON on 01/24/2025 at 10:12 a.m., the DON confirmed that informed consent for the psychotropic medication, Sertraline, had not been obtained and should have been. She stated this was due to an oversight . The DON stated the consent form had been created on 01/24/2025 following an audit of each resident's EHR due to surveyor intervention and stated the facility had attempted to contact Resident #20's responsible party to obtain informed consent for the medication and was awaiting a response at the time of the interview. The DON stated that no additional informed consent forms were missing or incomplete. Record review of the facility policy titled Psychotropic Medication Use dated July 2022 revealed Residents (and/or representatives) have the right to decline treatment with psychotropic medications The staff and physician will review with the resident/representative the risks related to not taking the medications as well as appropriate alternatives.

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment, to include maintenance services necessary to maintain comfortable and safe temperature levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike environment, in that: The facility presented with 2 Heating Ventilation and Air Conditioning systems [HVAC], of which 1 HVAC was not functioning causing cold interiors during the winter season. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 07:04 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This deficient practice placed residents at risk for harm by a diminished quality of life. The Finding were: The HVAC systems did not use 2 of 4 corridors (A Hall and B Hall) for a portion of the return air supply, inspected for return air supply. Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment. Record review revealed the facility had received a Waiver Approval letter dated [DATE] for Corridor Return Air, which had expired on [DATE] and that renewal documents had been submitted during the [DATE] survey period. Observations between on [DATE] between 10:00 a.m. to 11:00 a.m. revealed rooms on A Hall and B Hall were provided with ducted supply air but not with return air intakes. The return air intakes for the HVAC system were located in the corridors outside the rooms, causing the corridors to serve as a part of the return air system for the adjoining areas. During an exit interview on [DATE] at 5:00 p.m., when questioned as to the use of the A and B Halls being used as return air for the HVAC System, the Administrator said that she knew of the return air use in the aforementioned areas and that the facility had a waiver, as issued on [DATE] by the CMS for a three-year period (expired [DATE]). When asked if he knew the waiver had expired, the Administrator said he did and asked that it be renewed. Record review of the past air temperatures for San [NAME], Texas. In [DATE] the average high air temperature was ,d+[DATE] degrees Fahrenheit [F]. In [DATE], [DATE]-21, 2023, was 105 degrees F. The air temperature for [DATE] was ,d+[DATE] degrees F. In [DATE] the average high air temperature was 97 degrees F and with humidity was over 100 degrees F. This summer the county had 74 days of 100 degrees F, and over, ambient air temperatures. Observations on [DATE] at 9:50 AM with Maintenance Director X conducted environmental rounds of the facility and stated the temperatures should be between ,d+[DATE] degrees F. Observations were made of Residents gathered in the main dining room for the activity of Bingo. The Maintenance Director X stated the #1 HVAC unit was not working for a while, the HVAC unit serviced the A and B halls, which included the main dining room. The Maintenance Director X stated he had set the #1 HVAC unit to heat when he learned residents were going to have bingo in the main dining room. The Maintenance Director X stated he was not sure why the #1 HVAC was not at a good temperature and will notify the Administrator. Further observations and temperature records revealed the main dining room was 62.6 degrees F. At 10:20 AM the main dining the air temperature room was 54.9 degrees F. At 10:22 AM in the C end section of hall, the air temperature was 58.0 degrees F. At 10:23 AM in the C start of hall, the air temperature was 67.3 degrees F. At 10:26 AM in the D Hall, at start of hall (memory care unit), the air temperature was 69.3 degrees F. At 10:37 AM in the D Hall, at end of hall, the air temperature was 67.8 degrees F. Interview on [DATE] at 11:25 AM with the Administrator stated he was notified of the air temperature in the A and B Halls by the Life Safety Code surveyor (LSC) and was not aware that the C and D Halls were not heating for residents. No other reply. Interview on [DATE] at 10:06 AM with the ADON stated the HVAC system was having issues since earlier this year, 2023, either May or [DATE]. The ADON stated the resident families first noticed and reported the staff, that was when the facility was testing air temperatures. The facility brought in mobile Air Conditioning units. The ADON stated they discovered the A Hall (previous secure unit) was not cooling and was hot, so they moved those residents to the B Hall . Then the ADON stated the facility noticed the B Hall was not cooling, so the residents were moved to another part of the facility in May or June of 2023. They had a low census at the time. The facility moved the residents who resided on the A Hall secured unit to the first half of the D Hall and the rest of the residents moved to the second half of D Hall and other residents to the C Hall . A record review of the facility's Homelike Environment policy dated February 2021, revealed, policy statement; residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible. policy interpretation and implementation; the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. these characteristics include; . comfortable and safe temperatures (,d+[DATE] degrees F) . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 07:04 PM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 03:10 PM. Immediate Jeopardy PLAN OF REMOVAL [DATE] Immediate Action: - Bids to repair the HVAC system currently out of order are being obtained from [HVAC Contractors]. The ceiling will be secured and repaired as part of the HVAC project. - Is a goal as far as a date to accept a bid by? All bids to be submitted by [DATE]. - Anticipated date of repair? Contractor will be approved to begin work on or before [DATE]. - What is being done in the meantime to ensure residents have a comfortable living environment? No residents currently reside in the area affected by the A/C outage. For the occupied areas of the building, random temperature checks will be taken twice daily (in the morning and in the afternoon/evening) to ensure temperatures are within acceptable range. If temperature is outside limits, thermostats will be adjusted (switched from cooling to heated and vice-versa) as needed. Temperature checks will be completed on regular weekdays by the maintenance director or designee, and on weekends/holidays by the receptionist. The administrator or designee will review the daily temperature logs for completeness and compliance. Plan of Removal Verification [DATE] Record review of several contract bids for HVAC repair. Record review of daily temperature logs, dated [DATE], revealed the morning temperatures were within range for all areas of the facility that were utilized and occupied, apart from the main dining room, which was 64.4 degrees F. The action documented by the facility to remedy the low temperature in the main dining room was switching the HVAC system from A/C to Heat. Further record review of the afternoon/evening temperature logs revealed all temperatures in appropriate ranges for all utilized and occupied areas of the facility. Record review of daily temperature logs, dated [DATE], revealed temperatures to be within appropriate range as required by Appendix PP. Observation on [DATE] at 11:30 AM with Administrator rounded halls for air temperatures revealed Hall D, Hall C and main dining room as required. Observation on [DATE] at 3:45 PM revealed temperatures in all utilized and occupied areas of the building to be as required by the Appendix PP. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:49 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions.

Based on observations, interviews, and record reviews the facility failed to ensure that the residents' environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 facility and 18 of 18 residents (Resident #1, #4 , #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) reviewed for accident hazards and supervision, in that: 1. Residents (Resident # 1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) were residents who resided on the facility's memory care unit and needed supervision and safety monitoring due to their diagnoses of dementia and wander / elopement risks and were without staff care and or supervision, without secured entry exit doors, and without secured windows on 11/17/2023. 2. The facility developed an entrapment hazard when the facility did not effectually disable the electronic locking doors at the previous memory care unit. 3. The facility did not have a functioning call light system for the whole facility - Halls A, B, C, and D. 4. The facility did not have a secured door at the loading dock entry and exit door near Hall D. An IJ was identified on 11/17/2023. The IJ template was provided on 11/17/2023 at 07:04 PM. While the IJ was removed on 11/19/2023, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions These failures could place residents at risk for harm by elopement, entrapment, and neglect. The findings included: 1. Resident #1 A record review of Resident #1's admission record dated 11/18/2023 revealed an admitted [DATE] with diagnoses which included dementia with behavioral disturbance [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #1's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/24/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #1's elopement risk assessment dated [DATE] revealed Resident #01 was assessed as a High Risk for elopement. A record review of Resident #1's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #1's Clinical Census report dated 11/18/2023 revealed Resident #1 resided in the facility's D Hall, in the memory care unit. Resident #4 A record review of Resident #4's admission record dated 11/18/2023 revealed an admitted [DATE] with diagnoses which included dementia and schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality]. A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #0 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #4's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/17/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #4's elopement risk assessment dated [DATE] revealed Resident #4 was assessed as a High Risk for elopement. A record review of Resident #4's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #04's Clinical Census report dated 11/18/2023 revealed Resident #04 resided in the facility's D Hall, in the memory care unit. Resident #12 A record review of Resident #12's admission record dated 11/18/2023 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease [a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment]. A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #04 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #12's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/17/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #12's elopement risk assessment dated [DATE] revealed Resident #12 was assessed as a High Risk for elopement. A record review of Resident #12's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #12's Clinical Census report dated 11/18/2023 revealed Resident #12 resided in the facility's D Hall, in the memory care unit. Resident #14 A record review of Resident #14's admission record dated 11/18/2023 revealed an admitted [DATE] with diagnoses which included dementia. A record review of Resident #14's quarterly MDS assessment dated [DATE] revealed Resident #14 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 04 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #14's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/24/2022, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #14's elopement risk assessment dated [DATE] revealed Resident #14 was assessed as a Moderate Risk for elopement. A record review of Resident #14's Clinical Census report dated 11/18/2023 revealed Resident #14 resided in the facility's D Hall, in the memory care unit. Resident #17 A record review of Resident #17's admission record dated 11/18/2023 revealed an admitted [DATE] with diagnoses which included dementia and Alzheimer's disease. A record review of Resident #17's quarterly MDS assessment dated [DATE] revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #17's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 02/07/2023, Revision on: 05/16/2023 .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #17's elopement risk assessment dated [DATE] revealed Resident #17 was assessed as a Moderate Risk for elopement. A record review of Resident #17's Clinical Census report dated 11/18/2023 revealed Resident #17 resided in the facility's D Hall, in the memory care unit. Resident #23 A record review of Resident #23's admission record dated 11/16/2023 revealed an admitted [DATE] with diagnoses which included dementia and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]. A record review of Resident #23's quarterly MDS assessment dated [DATE] revealed Resident #23 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #23's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 10/03/2023, .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #23's elopement risk assessment dated [DATE] revealed Resident #23 was assessed as a Moderate Risk for elopement. A record review of Resident #23's Clinical Census report dated 11/18/2023 revealed Resident #23 resided in the facility's D Hall, in the memory care unit. Resident #25 A record review of Resident #25's admission record dated 11/16/2023 revealed an admitted [DATE] with diagnoses which included dementia [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities] and [serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality]. A record review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 07 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #25's care plan dated 11/18/2023 revealed, Resident resides on the memory care unit date Initiated: 07/24/2022, .Resident's safety will be maintained through next review date .Monitor Resident per protocol to ensure safety . A record review of Resident #25's elopement risk assessment dated [DATE] revealed Resident #25 was assessed as a High Risk for elopement. A record review of Resident #25's Clinical Census report dated 11/18/2023 revealed Resident #25 resided in the facility's D Hall, in the memory care unit. Resident #38 A record review of Resident #38's admission record dated 11/15/2023 revealed an admitted [DATE] with diagnoses which included dementia. A record review of Resident #38's quarterly MDS assessment dated [DATE] revealed Resident #38 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #38's care plan dated 11/18/2023 revealed, The Resident [#38] has impaired cognitive function/dementia or impaired thought processes Dementia Date Initiated: 08/23/2022 .Cue, reorient and supervise as needed. A record review of Resident #38's elopement risk assessment dated [DATE] revealed Resident #38 was assessed as a Moderate Risk for elopement. A record review of Resident #38's Clinical Census report dated 11/18/2023 revealed Resident #38 resided in the facility's D Hall, in the memory care unit. Resident #40 A record review of Resident #40's admission record dated 11/16/2023 revealed an admitted [DATE] with diagnoses which included dementia. A record review of Resident #40's quarterly MDS assessment dated [DATE] revealed Resident #40 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #40's care plan dated 11/18/2023 revealed, Resident [#40] resides on the memory care unit Date Initiated: 06/27/2022 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #40's elopement risk assessment dated [DATE] revealed Resident #40 was assessed as a High Risk for elopement. A record review of Resident #40's Clinical Census report dated 11/18/2023 revealed Resident #40 resided in the facility's D Hall, in the memory care unit. Resident #41 A record review of Resident #41's admission record dated 11/16/2023 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease. A record review of Resident #41's quarterly MDS assessment dated [DATE] revealed Resident #41 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #41's care plan dated 11/18/2023 revealed, Resident [#41] resides on the memory care unit Date Initiated: 07/24/2022 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #41's physicians' order, dated 10/04/2023, revealed, May reside on a secured unit. A record review of Resident #41's elopement risk assessment dated [DATE] revealed Resident #41 was assessed as a High Risk for elopement. A record review of Resident #41's Clinical Census report dated 11/18/2023 revealed Resident #41 resided in the facility's D Hall, in the memory care unit. Resident #47 A record review of Resident #47's admission record dated 11/17/2023 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease and dementia with behavioral disturbance. A record review of Resident #47's quarterly MDS assessment dated [DATE] revealed Resident #47 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 02 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #47's care plan dated 11/18/2023 revealed, Resident [#47] resides on the memory care unit Date Initiated: 07/24/2022 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #47's physicians' order, dated 01/18/2023, revealed, Admit to secured unit. A record review of Resident #47's elopement risk assessment dated [DATE] revealed Resident #47 was assessed as a Moderate Risk for elopement. A record review of Resident #47's Clinical Census report dated 11/18/2023 revealed Resident #47 resided in the facility's D Hall, in the memory care unit. Resident #48 A record review of Resident #48's admission record dated 11/17/2023 revealed an admitted [DATE] with diagnoses which included dementia with behavioral disturbance. A record review of Resident #48's quarterly MDS assessment dated [DATE] revealed Resident #48 was a [AGE] year-old male admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - ( .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #48's care plan dated 11/18/2023 revealed, Resident [#48] resides on the memory care unit Date Initiated: 05/16/2023 .Resident's safety will be maintained through next review date . Monitor Resident per protocol to ensure safety. A record review of Resident #48's elopement risk assessment dated [DATE] revealed Resident #48 was assessed as a High Risk for elopement. A record review of Resident #48's Clinical Census report dated 11/18/2023 revealed Resident #48 resided in the facility's D Hall, in the memory care unit. Resident #52 A record review of Resident #52's admission record dated 11/17/2023 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease. A record review of Resident #52's quarterly MDS assessment dated [DATE] revealed Resident #52 was a [AGE] year-old female admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #52's care plan dated 11/18/2023 revealed, Resident [#52] resides on the memory care unit for wandering and being at risk for placing self in unsafe place Date Initiated: 07/21/2022 .Resident's safety will be maintained through next review date .Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety . A record review of Resident #52's elopement risk assessment dated [DATE] revealed Resident #52 was assessed as a Moderate Risk for elopement. A record review of Resident #52's Clinical Census report dated 11/18/2023 revealed Resident #52 resided in the facility's D Hall, in the memory care unit. Resident #56 A record review of Resident #56's admission record dated 11/15/2023 revealed an admitted [DATE] with diagnoses which included dementia with behavioral disturbance [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #56's quarterly MDS assessment dated [DATE] revealed Resident #56 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 01 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #56's care plan dated 11/18/2023 revealed, Resident [#56] resides on the memory care unit for elopement risk. He has a history of wandering into other residents' rooms and going outside unattended. Date Initiated: 07/26/2022 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #56's elopement risk assessment dated [DATE] revealed Resident #56 was assessed as a High Risk for elopement. A record review of Resident #56's Clinical Census report dated 11/18/2023 revealed Resident #56 resided in the facility's D Hall, in the memory care unit. Resident #60 A record review of Resident #60's admission record dated 11/17/2023 revealed an admitted [DATE] with diagnoses which included dementia [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #60's quarterly MDS assessment dated [DATE] revealed Resident #60 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #60's care plan dated 11/18/2023 revealed, Resident [#60] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 12/08/2022 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #60's elopement risk assessment dated [DATE] revealed Resident #60 was assessed as a Moderate Risk for elopement. A record review of Resident #60's Clinical Census report dated 11/18/2023 revealed Resident #60 resided in the facility's D Hall, in the memory care unit. Resident #64 A record review of Resident #64's admission record dated 11/17/2023 revealed an admitted [DATE] with diagnoses which included violent behavior, cognitive social or emotional deficit following cerebral infarction [stroke]. A record review of Resident #64's quarterly MDS assessment dated [DATE] revealed Resident #64 was a [AGE] year-old male admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #64's care plan dated 11/18/2023 revealed, Resident [#64] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 12/12/2022 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #64's elopement risk assessment dated [DATE] revealed Resident #64 was assessed as a Moderate Risk for elopement. A record review of Resident #64's Clinical Census report dated 11/18/2023 revealed Resident #64 resided in the facility's D Hall, in the memory care unit. Resident #66 A record review of Resident #66's admission record dated 11/17/2023 revealed an admitted [DATE] with diagnoses which included dementia with behavioral disturbance [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities] and delusional disorders. A record review of Resident #66's quarterly MDS assessment dated [DATE] revealed Resident #66 was a [AGE] year-old female admitted for long term care and could not complete a BIMS assessment and was assessed with disorganized thinking - .the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). A record review of Resident #66's care plan dated 11/18/2023 revealed, Resident [#66] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 02/03/2023 .Resident's safety will be maintained through next review date. Date Initiated: 05/16/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #66's elopement risk assessment dated [DATE] revealed Resident #66 was assessed as a Moderate Risk for elopement. A record review of Resident #66's Clinical Census report dated 11/18/2023 revealed Resident #66 resided in the facility's D Hall, in the memory care unit. Resident #67 A record review of Resident #67's admission record dated 11/17/2023 revealed an admitted [DATE] with diagnoses which included dementia [not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities]. A record review of Resident #67's quarterly MDS assessment dated [DATE] revealed Resident #67 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 07 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #67's care plan dated 11/18/2023 revealed, Resident [#67] resides on the memory care unit for elopement risk. He has a history of wandering. Date Initiated: 05/16/2023 .Resident's safety will be maintained through next review date. Date Initiated: 10/03/2023 .Monitor Resident per protocol to ensure safety A record review of Resident #67's elopement risk assessment dated [DATE] revealed Resident #67 was assessed as a Moderate Risk for elopement. A record review of Resident #67's Clinical Census report dated 11/18/2023 revealed Resident #67 resided in the facility's D Hall, in the memory care unit. During an observation on 11/14/2023 at 10:10 AM revealed the memory care unit housed in the first half of the D Hall presented with 18 residents (Residents #1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67). The memory care unit had 2 sets of double doors which were closed without the ability to lock and no alarm. All the windows in the memory care unit were 4 1/2 inches off the floor and were able to fully open. Further observations revealed the memory care unit had a malfunctioning call light system which would sometimes illuminate a call light without sounds and sometimes would sound and not illuminate. During an interview on 11/14/2023 at 10:20 AM, LVN H and CNA U stated they were the LVN and CNA for the memory care unit which occupied the beginning of the D Hall. LVN H and CNA U stated the call light system had been malfunctioning for weeks. LVN H stated the staff paid attention to the lights and would round on residents frequently. CNA U and LVN H stated the entry exit doors were kept shut but had no locks on the doors which allowed residents and staff to freely pass through. LVN H stated when residents go out of the memory care unit staff redirect the residents back into the unit. LVN H and CNA U stated the memory care unit was set up sometime in the summer of 2023, due to the previous memory care unit, housed in A-Hall, was uninhabitable due to a faulty air-conditioner unit. LVN H and CNA U stated the previous unit had secured doors and windows and a functioning call light system. LVN H and CNA U stated the facility DON had knowledge of the unsecured doors and malfunctioning call light system. During and observation and interview on 11/14/2023 at 10:38 AM, LVN H and surveyor rounded on residents' rooms and revealed no windows were secured and could fully open. LVN H stated she was unaware the windows could fully open and could pose an elopement risk for residents. During an interview on 11/16/2023 at 1:30 PM, Resident #60's representative with power of attorney stated, Resident #60 is confused, young enough, and strong enough to open a window and get out .I expected the memory care unit to be safe and secure for my [Resident #60]. During an observation on 11/17/2023 at 6:28 AM revealed the memory care unit presented without any secured doors for entry and or exit of the memory care unit. Observation revealed a malfunctioning call light system where the call light panel at the nurse station continuously alarmed. Observation revealed 18 residents, [Resident #19 had been discharged ]; Residents #1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67, without staff care and or supervision. Further observation revealed no staff in the memory care unit after a room-to-room search which included a census of each Resident. Continued observation revealed residents ambulating throughout the unit with some residents asleep in their bedrooms. During an observation and interview on 11/17/2023 at 6:40 AM revealed Restorative Aide S entered the memory care unit and stated she was not assigned to care for residents in the memory care unit but was just dropping by to check on residents. RA S stated there were no staff in the memory care unit and she would stay until someone would arrive. During an interview on 11/17/2023 at 6:41 AM LVN B and CNA AA stated they were scheduled to work the D Hall from 11:00 PM to 7:00 AM. LVN B stated CNA F was scheduled to work the memory care unit from 11:00 PM to 6:00 AM and CNA AA was scheduled to care for the rest of the residents on the D Hall who were not residents of the memory care unit. LVN B stated the residents on the memory care unit should have supervision by CNA U who was assigned to relieve CNA F. LVN B stated he was unaware CNA U was not working in the memory care unit. LVN B stated sometimes LVN U was late. LVN B stated no one had reported to him there was no staff in the memory care unit. LVN B stated residents could have eloped and or been injured without staff supervision. LVN B stated he could not be in 2 places and had nursing duties at the end of the non-memory care unit, D Hall. CNA AA stated she was unaware the memory care unit had no staff and was responsible for providing resident care in the non-memory care d-hall. During an observation and interview on 11/17/2023 at 7:00 AM revealed LVN H and CNA U at the facility's time clock. CNA U did not identify herself as CNA U and LVN H stated CNA U should have relieved CNA F at 6:00 AM and stated CNA U had a history of being absent for care in the memory care unit. During an interview on 11/17/2023 at 10:06 AM with the ADON stated the HVAC system was having issues since earlier this year, 2023, either May or June 2023. The ADON stated the resident families first noticed and reported the staff, that was when the facility was testing air temperatures. The facility brought in mobile Air Conditioning units. The ADON stated they discovered the A Hall (previous secure unit) was not cooling and was hot, so they moved those residents to the B Hall . Then the ADON stated the facility noticed the B Hall was not cooling, so the residents were moved to another part of the facility in May or June of 2023. They had a low census at the time. The facility moved the residents who resided on the A Hall secured unit to the first half of the D Hall and the rest of the residents moved to the second half of D Hall and other residents to the C Hall. During an interview on 11/17/2023 at 11:10 AM Staffing Coordinator G stated CNA U had not called in late and his expectation was for CNA U to relieve CNA F. During an interview on 11/17/2023 at 5:02 PM the ADON stated he was unaware the memory care unit was without staff on the morning of 11/17/2023 at 6:00 AM. The ADON stated the expectation was for a staff member to be supervising, caring, and monitoring the residents in the memory care unit and should not leave the unit until the staff member has been relieved by the next staff member. During an interview on 11/18/2023 at 2:22 PM CNA F stated she was scheduled to work 11:00 PM to 6:00 AM in the memory care unit and was usually relieved by CNA U. CNA F stated sometimes she just leaves because CNA U was not there to relieve her at 6:00 AM. CNA F stated LVN B Knows. During an interview on 11/18/2023 at 3:02 PM CNA U stated she did not call anyone to alert them of her tardiness. CNA U stated she had not seen CNA F or LVN B when she arrived on 11/17/2023 at 6:00 AM and stated she had left the memory care unit to use the bathroom. 2. During an observation on 11/16/2023 at 5:35 PM revealed the A Hall previous location of the memory care unit. The path to the unit was clear and unencumbered to any pedestrian or person who used a wheelchair and or walker. The doors to the A Hall presented closed with an electronic keypad adjacent. The doors freely opened without the use of the keypad and locked behind after entry into the unit. Further observation did not reveal any way of exit. The surveyor became entrapped and used the emergency fire exit to exit the A Hall. During an observation and interview on 11/16/2023 at 5:50 PM the Administrator and the Maintenance Director received a report from the surveyor of the entrapment incident. The Administrator and the Maintenance Director demonstrated the secured locked double doors to the A Hall and utilized the keypad to release the locked doors. The Administrator requested the Maintenance Director to enter the secured A Hall and re-set the alarming fire exit door. The Maintenance Director entered the A Hall, the secured doors locked after his entry, he reset the fire alarm door and returned to the locked doors to the A Hall, entered in the code at the keypad to release the doors and exited the A Hall. Upon the Maintenance Directors exit and after the doors shut, the Administrator, to demonstrate the function of the locked door, pushed upon the door and revealed the door opened. The Administrator stated the door should have been locked and asked the Maintenance Director to investigate the malfunction. 3. During an observation on 11/14/2023 from 10:30 to 11:00 AM revealed the call light system on D Hall was not functioning as designed. During an observation and interview on 11/14/2023 at 10:59 AM revealed the call light for Residents #12 and #40 would illuminate outside of their rooms but not illuminate and or sound at the nurses' station. CNA U stated she would round on residents frequently due to the call light system did not sound and furthermore residents usually were not in their rooms. [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #3) reviewed for care, in that: 1. The facility failed to implement gait belt transfer training for unlicensed staff prior to allowing them to provide care for Resident #3. Resident #3 suffered a fall on 02/13/2020 during a transfer by an unlicensed and untrained staff member without using a gait belt resulting in a fracture to her right humerus neck that was identified on 02/14/2020. 2. HA A continued to work at the facility after Resident #3's fall that resulted in a fracture to the right humerus neck on 02/13/2020 for 5 days without training, an in-service or a gait belt skills check from 02/13/2020 until 02/20/2020. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 02/19/2020 due to a failure to provide qualified, competent, and trained staff to meet resident needs and a failure to oversee the implementation of resident care. While the IJ was removed on 02/20/2020 the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. These deficient practices placed residents who required assistance from staff for transfers at risk for injury, physical harm, pain, mental anguish, and emotional distress. The findings were: Record review of the facility's position description for a Hospitality Aide/Nursing Assistant (non-certified) with an effective date of 04/01/2019 revealed: The hospitality aide performs non-nursing, non-direct/hands-on duties pertaining to the comfort and well-being of the residents of the facility. Other Duties: As this job description is not intended to be all-inclusive, the employee will be expected to perform other essential functions and duties as assigned. Standard Responsibilities: 3. Supports, cooperates with, and implements specifics procedures and programs for: A. Safety, including precautions and safe work practices. 4. Supports and participates in common teamwork: A. Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgement. E. Completes requirements for in-service training. Employment Standards: Qualifications: Must be capable of following oral and written instructions. Further review of the Hospitality Aide job description did not specify who the hospitality aide would report to during the course of their shift. Record review of the Provider Self-Reporting of Incidents that was sent to the State Survey Agency (HHSC), dated 02/14/2020 at 8:32 p.m. by the Administrator, revealed Client/Resident/Individual Information: Requires extensive assistance with ADLs. Under the section titled Report Details: 02/13/2020 1030 PM CNA (HA A) was assisting resident into bed from wheelchair using gait belt. Resident foot slipped and both CNA (HA A) and resident fell . No injuries noted or complaints of pain at the time of the incident. 2/14/2020 resident complained of pain to right shoulder. New order from hospice for pain management and X-ray of right shoulder. X-ray of right shoulder completed, results reveal acute humerus neck fracture. Immediate Actions Taken: 2. Skills evaluation completed for CNA (HA A) that performed transfer. Was in-service training provided as a result of this incident? - Yes. Description of in-service training: Initiated staff retraining regarding abuse, neglect, and exploitation per protocols. Skills validation for CNA (HA A) performing transfer. Record review of HA A's application for employment revealed HA A changed job positions from a Dietary Aide to a Hospitality Aide with an effective date of 10/28/2019. During a record review on 02/18/2020 at 6:20 p.m. of HA A's training record, dated 10/16/2019, revealed the facility had not provided a skills check off or training for gait belt transfers for HA A. Further review of HA A's training record revealed the only form of a transfer training that had occurred was for transfers with a mechanical lift. During an interview with the Administrator on 02/18/2020 at 6:52 p.m., the surveyor requested records from the CNA school that HA A attended to verify that a gait belt transfer skills check was part of the curriculum. The Administrator stated she would call in the morning on 02/19/2020. At the time of the exit from the facility on 02/20/2020 there were no records produced from the facility staff to show HA A had completed a skills check for gait belt transfers. Record review of Resident #3's face sheet, dated 02/19/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #3 required extensive assistance from two or more staff members for transfers, to include moving to and from the bed, chair, wheelchair, and standing position. Record review of Resident #3's Care Plan revealed a problem area, initiated on 06/04/2019, that read: ADL Functional/Rehabilitation Potential requires assistance with ADLs. Refuses ADL care from males, 'white women and black women. Only wants care per Hispanic women. The approach for this care area read: Approach start date: 06/05/2019 prefers Hispanic female caregivers only- attempt to provide, however resident requires two care givers at all times due to history of combativeness and false accusations toward staff. Further review of the care plan revealed this problem area and approach were intended for all nursing staff. Further review revealed another problem area that read: Requires 2:1 care due to behaviors-She does have a [DIAGNOSES REDACTED]. Resident is 2 on 1 care. As of 02/14/2020 Resident #3's care plan was updated with a problem area that read: Resident has history of falling related to poor balance. The approach for this problem area read: 2 person assists with transfers. Record review of a radiology report for Resident #3, dated 02/14/2020, revealed the resident had an acute humerus neck fracture. Record review of Resident #3's physician order [REDACTED]. Special Instructions: 2 x assist and/or hoyer. Further review revealed Resident #3 was given new orders for pain control medications on 02/14/2020 to include: [MEDICATION NAME] 20 mg/5 ml; amount: 0.5 mls; sublingual; Special Instructions: Give 0.5 mls every 2 hours. Tylenol-[MEDICATION NAME] #3 tablet; 300-30 mg; amt: 1 tablet; oral. Special Instructions: Give 1 tab three times per day. (DX: Pain, unspecified). Record review of the facility's Time Detail Reporting list revealed HA A worked on the same hall as Resident #3 providing direct care to residents on 02/13/2020 from 7:05 a.m. to 11:07 p.m. (the date of Resident #1's fall with HA A), on 02/14/2020 from 2:54 p.m. to 11:10 p.m., on 02/17/2020 from 2:48 p.m. to 6:04 a.m. on 02/18/2020 (overnight), on 02/18/2020 from 2:52 p.m. to 6:11 a.m. on 02/19/2020 (overnight). During an interview with Resident #3 on 02/18/2020 at 11:03 a.m., Resident #3 stated she was being transferred from her bed to the wheelchair by HA A on 02/13/2020, and when HA A picked her up they both fell over onto the ground. Resident #3 further stated she was still in pain due to the fall. During an interview with HA A on 02/18/2020 at 3:06 p.m., HA A stated she went to answer a call light in Resident #3's room on the evening of 02/13/2020 and Resident #3 asked to be transferred from her bed to the wheelchair. HA A confirmed she had attempted to transfer Resident #3 from her bed to her wheelchair but, the wheelchair was too far from the bed, I missed the chair and we both fell over. HA A further confirmed she had attempted to transfer Resident #3 by herself and without using a gait belt. HA A further confirmed she was not a CNA, and stated she had to work with a certified nurse aide on the floor at all times. At the time of this interview HA A stated she had received an in-service on transfers after the fall occurred with Resident #3. During an interview with the Administrator and DON on 02/18/2020 at 3:58 p.m., the Administrator and DON stated HA A had received an in-service training for gait belt transfers on 02/13/2020 and a skills check off for gait belt transfers on 02/14/2020. The surveyor asked how staff know if a resident was one or two person transfer and the Administrator and DON stated Resident #3 was maybe a one or two person assist. The surveyor showed the Administrator and DON Resident #3's Quarterly MDS, dated [DATE], which indicated Resident #3 was a two-person assist. The surveyor asked if the MDS populated the Care Plan because the care plan did not show, prior to 02/14/2020, that Resident #3 was a two-person assist for transfers. Both the DON and the Administrator stated residents' transfer requirements were determined by the MDS and the care plan. The DON confirmed she updated Resident #3's care plan on 02/14/2020 to show Resident #3 was a two-person assist for transfers. During an interview with RN B on 02/18/2020 at 4:14 p.m., RN B stated she was the nurse on duty in Resident #3's hall on 02/13/2020 and had responded to the fall that occurred with Resident #3 and HA A. RN B confirmed that Resident #3 is a two person transfer. RN B confirmed a gait belt should be used for Resident #3 for transfers. RN B stated on the evening of the incident, 02/13/2020, she was told by CNA C that HA A and Resident #3 had fallen in the room during a transfer. RN B stated she provided a gait belt in-service for HA A on the evening of 02/13/2020 with HA A and Resident #3 after the fall occurred. During an interview with CNA C on 02/18/2020 at 4:51 p.m., CNA C confirmed she was present at the facility on 02/13/2020, the night of the fall involving HA A and Resident #3. CNA C stated she was in another room helping another resident when HA A entered the room and stated she and Resident #3 had fallen during a transfer. CNA C stated she entered the room and observed Resident #3 was lying on the floor face down. CNA C confirmed Resident #3 did not have a gait belt on when CNA C entered the room. CNA C further confirmed Resident #3 was a two-person assist for transfers. CNA C further stated the cookie sign on Resident #3's indicated, It (the cookie sign) means that the resident is a two person assist. CNA C further stated the sign had been in place prior to Resident #3's fall with HA A on 02/13/2020. During an interview with RN B on 02/18/2020 at 5:00 p.m., RN B confirmed the cookie signs on resident rooms indicated the resident was a two-person assist. During an interview with the HR Manager on 02/18/2020 at 5:31 p.m., the HR Manager stated LVN E was the staffing coordinator who would conduct new hire floor orientations. The HR Manager stated she was not sure what the staffing coordinator was responsible for in regard to verifying training or in-services prior to staff caring for residents. The HR Manager stated, I spoke with LVN E and it sounded like the skills check offs were not done for HA A. During an interview with HA A on 02/18/2020 at 6:02 p.m., HA A when asked by the surveyor if another transfer occurred after the fall for Resident #3 on 02/13/2020, HA A responded, Yes, well no. When asked by the surveyor how Resident #3 was moved from the floor to the bed, HA A stated RN B and CNA C moved the resident. HA A stated she had not received training on gait belt transfers by the facility prior to providing direct care to residents. HA A further stated LVN E did not provide training or a skills check off prior to providing direct care to residents when she changed positions from Dietary Aide to Hospitality Aide. HA A confirmed the cookies sign in front of resident rooms indicated for staff to enter the room in pairs. HA A further confirmed the cookies sign had been in place prior to the fall that occurred on 02/13/2020 for Resident #3. During an interview with the Administrator on 02/18/2020 at 6:25 p.m., the Administrator stated she had not asked HA A specifically if she had received a skills check off or in-service on the night of 02/13/2020. The Administrator stated she had asked RN B if she had provided an in-service to HA A and had RN B told her that she had provided an in-service to HA A on the evening of 02/13/2020. During an interview with the Administrator, the DON, HA A, and RN B on 02/18/2020 at 6:28 p.m., RN B stated that after Resident #3's fall on 02/13/2020 she, HA A, and CNA C had all transferred the resident from the floor and back to her bed. RN B stated that after transferring Resident #3 from the floor to the bed, the DON told her to provide an in-service to HA A regarding gait belt transfers. RN B further stated she went back into Resident #3's room with HA A and she had transferred Resident #3 from her bed to her wheelchair. RN B further stated she had HA A do a return demonstration with Resident #3 for a one-person gait belt transfer from the wheelchair to the bed. The surveyor asked HA A if this had occurred, HA A looked at RN B and nodded her head up and down, indicating 'Yes' this had occurred. During an interview with the DON and Administrator on 02/19/2020 at 6:28 p.m., the DON and Administrator stated they had both completed a skills check off with return demonstration on a staff member for HA A prior to entering the room at 6:28 p.m. on 02/18/2020. During an interview with the Administrator on 02/18/2020 at 6:52 p.m., the Administrator stated there was not a policy for the cookie sign on Resident #3's door. During an interview with CNA D on 02/19/2020 at 10:54 a.m., CNA D stated she had worked with Resident #3 since the resident's admitted . CNA D stated Resident #3 was a one-person assist but since the resident's fall the facility told her Resident #3 was now a two-person assist. CNA D stated the cookies sign in front of Resident #3's room meant the resident was friendly and liked to talk to people. CNA D further stated the facility had not provided anyone with any type of in-service or skills check off for gait belt transfers after the Resident #3's fall on 02/13/2020. During an interview with the Administrator and DON on 02/19/2020 at 11:52 a.m., the Administrator and DON stated they both spoke with HA A on the prior evening, 02/18/2020, and HA A had confirmed that RN B had not performed a skills check off or an in-service for gait belt transfers after the Resident #3's fall occurred on 02/13/2020. The Administrator and DON stated HA A and RN B were suspended due to inconsistencies in their version of the events that occurred with Resident #3 on 02/13/2020. During an interview with HA A on 02/19/2020 at 1:30 p.m., HA A stated the facility had suspended her on the morning of 02/19/2020 after her shift ended, pending an investigation. HA A stated she had worked a double shift, from 3:00 p.m. on 02/18/2020 until 6:00 a.m. on 02/19/2020. HA A stated she was aware of the sign in front of Resident #3's room and stated the sign was for two people to go into the room so that there were witnesses present if the residents exhibited any type of behaviors. HA A confirmed she had received a gait belt in-service and skills check off the previous evening on 02/18/2020 by the DON and Administrator. During an interview with LVN E on 02/19/2020 at 1:59 p.m., LVN E confirmed her previous position was as a staffing coordinator and further confirmed she was the staffing coordinator at the time of HA A moving to the HA position. LVN E stated she would not verify skills for direct care staff. LVN E stated that as long as CNAs passed a CNA program the facility assumed the skills checks were completed at the schools the CNAs completed. LVN E stated the sign in front of resident rooms meant staff needed to enter the room in pairs to provide care to the residents. When asked by the surveyor how staff knew if a resident was a one or two-person transfer, LVN E stated there was a Resident Profile Sheet on the inside of each resident's closet which indicated the residents' ADL needs. During an interview with CNA F on 02/19/2020 at 2:28 p.m., CNA F stated the sign with the image of a cookie outside of resident rooms indicated two staff members' needed to care for the residents at all times. When asked how a staff member knew what the transfer needs were for residents, CNA F stated staff communicated with each other and would ask how many people were needed for transfers from other staff members. CNA F further stated that when new CNAs started working in a hall or in the facility a nurse or a therapy assistant would tell them what the transfer requirements were for each resident. During an interview with CNA H on 02/19/2020 at 2:36 p.m., CNA H stated she was aware of the cookie sign on the front of resident rooms that indicated that two staff members should enter the room. CNA H stated, Regardless if the person was a one or two-person transfer, staff need to go in pairs. When asked by the surveyor how staff knew if a resident was a one or two-person transfer, CNA H stated there was a piece of paper (Resident Profile Sheet) inside the resident's closet that would tell them the transfer requirements. During an interview with the Administrator and DON on 02/19/2020 at 4:19 p.m., the Administrator and DON confirmed HA A was not trained on gait belt transfers prior to providing care for residents. The DON and Administrator further confirmed an in-service and/or skill check for gait belts had not been completed immediately after the fall for Resident #3 on 02/13/2020 and the required training for HA A was not completed until the evening of 02/18/2020. Record review of the facility's policy titled, Fall Management, revised 03/29/2019, revealed under the section titled policy: The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. Record review of the facility's policy titled Abuse Prohibition Handout, revised 10/23/2019, revealed under the section of Policy: 3. The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident. Under the section titled Definitions: 6. Neglect is the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Component VI: Investigation: 4. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions: 5. G. Measures taken to prevent future incidents. 6. In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. 7. Guidelines for the investigation: I. The Director of Nursing or his/her designee will review the resident's medical record. On 02/19/2020 at 4:19 p.m. the Administrator and DON were notified of the Immediate Jeopardy (IJ) situation, a completed IJ template was provided to the facility for the above failures, and a Plan of Removal was requested. On 02/20/2020 at 1:16 p.m. the facility's Plan of Removal was accepted and the facility began to conduct in-services and skills checks for staff members. The facility's Plan of Removal was provided by the Administrator, accepted on 02/20/2020, and included the following steps to be taken by the facility: 1. Identified resident is being transferred using 2-person gait belt transfers and using proper technique observed by the Director of Nursing on 2/19/20. Resident #3's care plan and care profile was immediately updated to reflect 2 person gait belt transfer. 2. New hires since October 1, 2019 will be audited for required transfer competencies and any missing will be completed by members of nursing management by 2/20/20. 3. 2-person gait belt transfer competencies will be conducted on Certified Nursing Assistants and HA/NA and Licensed Nurses on February 19, 2020. Any certified nursing assistant, HA/NA or licensed nurse not successfully completing a 2-person gait belt transfer on this date will complete prior to next scheduled shift. Competencies will be done in new hire orientation, annually and as needed based on facility needs. Staff in-service initiated on accessing and reviewing care profile on Point of Care Kiosk. 4. Licensed nurses and Certified Nursing Assistants and Hospitality Aides / Nursing Assistant will be re-educated on the Abuse/Neglect Misappropriation policy. This will be completed on 2/20/20. Anyone not receiving this by this date will receive prior to next scheduled shift. 5. Nursing manager/designee will be re-educated by the Clinical Consultant regarding providing nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety. This will be completed on February 20, 2020. 6. The Director of Nursing / designee will randomly observe certified nursing assistants/hospitality aides a minimum of 3 nursing assistants/hospitality aides and three times weekly for 4 weeks then weekly for 2 additional months. Any concern identified during the observation will be addressed at the time of discovery. Resident's will be reviewed quarterly on the MDS schedule and as needed with changes of condition during our clinical meeting review. Management will follow up as necessary. 7. Certified Nursing Assistants or Nursing Assistants in 120 days prior to certification hired will be reviewed for credentials and competency. The Administrator will validate appropriate competencies on New hire Certified Nursing Assistants, Licensed Nurses and HA/NA prior to providing care for residents without supervision for a period of 3 months. 8. The administrator will oversee compliance with this plan. 9. The medical director was notified of the immediate jeopardy on February 19, 2020 by the administrator. 10. An Ad Hoc Quality Assurance Performance Improvement meeting was held on February 19, 2020 regarding the contents of this plan. The surveyor verification of the Plan of Removal on 02/20/2020 was as follows: Residents who required two-person/gait belt transfer were observed for care from staff who were to have received an in-service and a skills check off. Staff interviews were to be conducted on three separate halls and on two different shifts. In-service sign-in sheets and material covered by the in-services was reviewed onsite on 02/20/2020. The surveyor verified completion of these in-services through staff interviews and observed demonstrations of gait belt transfers. Observation on 02/20/2020 at 2:52 p.m. was made of a gait belt transfer for Resident #6 by CNAs K and N. There was no deficient practice or concerns noted with the gait belt transfer by these staff members. Observation on 02/20/2020 at 3:07 p.m. was made of a gait belt transfer for Resident #7 by CNAs C and V. There was no deficient practice or concerns made during the observation. Interviews occurred on 02/20/2020 from 2:44 PM - 5:49 PM with LVN J, LVN L, LVN M, LVN S, and LVN T. All stated that they had received an in-service regarding abuse and neglect, a skills check with return demonstration for gait belt transfers. All staff interviewed stated they are able to verify transfer requirements from their computers or the kiosks mounted on the walls. All nurses interviewed stated that as nurses for each hallway they will observe CNA/HA staff during gait belt transfers to ensure they were performing the task correctly. Interviews occurred on 02/20/2020 from 2:44 PM - 5:49 PM with CNA C, CNA D, CNA I, CNA K, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA V revealed they had received an in-service regarding abuse and neglect, a skills check with return demonstration for gait belt transfers. All staff interviewed stated they are able to verify transfer requirements from their computers or the kiosks mounted on the walls On 02/20/2020 at 7:19 p.m., the Administrator, DON, the Director of Clinical Operations, and the Regional Vice-President of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all staff were in-serviced.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 of 8 residents (Resident #3) whose care was reviewed for neglect, in that: 1. The facility did not implement structures and processes by not implementing necessary training and staff supervision for HA A, an unlicensed staff, prior to allowing them to provide care for Resident #3. Resident #3 suffered a fall on 02/13/2020 during a transfer by an unlicensed and untrained staff member (HA A, Hospitality Aide) resulting in a fracture to the resident's right humerus neck that was identified on 02/14/2020. 2. The facility did not provide qualified competently trained staff to meet Resident #3's needs. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 02/19/2020 due to a failure to provide qualified, competent, and trained staff to meet resident needs and a failure to oversee the implementation of resident care policies and monitoring of care. While the IJ was removed on 02/20/2020 the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. These deficient practices placed residents who required assistance from staff for transfers at risk for injury, physical harm, pain, mental anguish, and emotional distress. The findings were: Record review of Resident #3's face sheet, dated 02/19/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #3 required extensive assistance from two or more staff members for transfers, to include moving to and from the bed, chair, wheelchair, and standing position. Record review of Resident #3's Care Plan revealed a problem area, initiated on 06/04/2019, that read: ADL Functional/Rehabilitation Potential requires assistance with ADLs. Refuses ADL care from males, 'white women and black women. Only wants care per Hispanic women. The approach for this care area read: Approach start date: 06/05/2019 prefers Hispanic female caregivers only- attempt to provide, however resident requires two care givers at all times due to history of combativeness and false accusations toward staff. Further review of the care plan revealed this problem area and approach were intended for all nursing staff. Further review revealed another problem area that read: Requires 2:1 care due to behaviors-She does have a [DIAGNOSES REDACTED]. Resident is 2 on 1 care. As of 02/14/2020 Resident #3's care plan was updated with a problem area that read: Resident has history of falling related to poor balance. The approach for this problem area read: 2 person assists with transfers. Record review of a radiology report for Resident #3, dated 02/14/2020, revealed the resident had an acute humerus neck fracture. Record review of Resident #3's physician order [REDACTED]. Special Instructions: 2 x assist and/or hoyer. Further review revealed Resident #3 was given new orders for pain control medications on 02/14/2020 to include: [MEDICATION NAME] 20 mg/5 ml; amount: 0.5 mls; sublingual; Special Instructions: Give 0.5 mls every 2 hours. Tylenol-[MEDICATION NAME] #3 tablet; 300-30 mg; amt: 1 tablet; oral. Special Instructions: Give 1 tab three times per day. (DX: Pain, unspecified. Record review of the Provider Self-Reporting of Incidents that was sent to the State Survey Agency (HHSC), dated 02/14/2020 at 8:32 p.m. by the Administrator, revealed Client/Resident/Individual Information: Requires extensive assistance with ADLs. Under the section titled Report Details: 02/13/2020 1030 PM CNA (HA A) was assisting resident into bed from wheelchair using gait belt. Resident foot slipped and both CNA (HA A) and resident fell . No injuries noted or complaints of pain at the time of the incident. 2/14/2020 resident complained of pain to right shoulder. New order from hospice for pain management and X-ray of right shoulder. X-ray of right shoulder completed, results reveal acute humerus neck fracture. Immediate Actions Taken: 2. Skills evaluation completed for CNA (HA A) that performed transfer. Was in-service training provided as a result of this incident? - Yes. Description of in-service training: Initiated staff retraining regarding abuse, neglect, and exploitation per protocols. Skills validation for CNA (HA A) performing transfer. Record review of HA A's application for employment revealed HA A changed job positions from a Dietary Aide to a Hospitality Aide with an effective date of 10/28/2019. Record review of the facility's position description for a Hospitality Aide/Nursing Assistant (non-certified) with an effective date of 04/01/2019 revealed: The hospitality aide performs non-nursing, non-direct/hands-on duties pertaining to the comfort and well-being of the residents of the facility. Other Duties: As this job description is not intended to be all-inclusive, the employee will be expected to perform other essential functions and duties as assigned. Standard Responsibilities: 3. Supports, cooperates with, and implements specifics procedures and programs for: A. Safety, including precautions and safe work practices. 4. Supports and participates in common teamwork: A. Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgement. E. Completes requirements for in-service training. Employment Standards: Qualifications: Must be capable of following oral and written instructions. Further review of the Hospitality Aide job description did not specify who the hospitality aide would report to during the course of their shift. During a record review on 02/18/2020 at 6:20 p.m. of HA A's training record, dated 10/16/2019, revealed the facility had not provided a skills check off or training for gait belt transfers for HA A. Further review of HA A's training record revealed the only form of a transfer training that had occurred was for transfers with a mechanical lift. Record review of the facility's Time Detail Reporting list revealed HA A worked on the same hall as Resident #3 providing direct care to residents on 02/13/2020 from 7:05 a.m. to 11:07 p.m. (the date of Resident #1's fall with HA A), on 02/14/2020 from 2:54 p.m. to 11:10 p.m., on 02/17/2020 from 2:48 p.m. to 6:04 a.m. on 02/18/2020 (overnight), on 02/18/2020 from 2:52 p.m. to 6:11 a.m. on 02/19/2020 (overnight). Record review of the facility's job description for a Certified Nursing Assistant revealed: To provide routine daily nursing care and services that support the care delivered to patients/residents residing in the accordance with the established nursing care policy and procedures as directed by the supervisor. Further review revealed under the section titled Essential Functions and Responsibilities: 16. General Patient/Resident Care: I. Reviews care plans as directed to determine if changes in daily care routine were made. During an interview with Resident #3 on 02/18/2020 at 11:03 a.m., Resident #3 stated she was being transferred from her bed to the wheelchair by HA A on 02/13/2020, and when HA A picked her up they both fell over onto the ground. Resident #3 further stated she was still in pain due to the fall. During an interview with HA A on 02/18/2020 at 3:06 p.m., HA A stated she went to answer a call light in Resident #3's room on the evening of 02/13/2020 and Resident #3 asked to be transferred from her bed to the wheelchair. HA A confirmed she had attempted to transfer Resident #3 from her bed to her wheelchair but, the wheelchair was too far from the bed, I missed the chair and we both fell over. HA A further confirmed she had attempted to transfer Resident #3 by herself and without using a gait belt. HA A further confirmed she was not a CNA, and stated she had to work with a certified nurse aide on the floor at all times. At the time of this interview HA A stated she had received an in-service on transfers after the fall occurred on the evening of 02/13/2020. During an interview with the Administrator on 02/18/2020 at 6:52 p.m., the surveyor requested records from the CNA school that HA A attended to verify that a gait belt transfer skills check was part of the curriculum. The Administrator stated she would call in the morning on 02/19/2020. At the time of the exit from the facility on 02/20/2020 there were no records produced from the facility staff to show HA A had completed a skills check for gait belt transfers. During an interview with the Administrator and DON on 02/18/2020 at 3:58 p.m., the Administrator and DON stated HA A had received an in-service training for gait belt transfers on 02/13/2020 and a skills check off for gait belt transfers on 02/14/2020. The surveyor asked how staff know if a resident was one or two person transfer and the Administrator and DON stated Resident #3 was maybe a one or two person assist. The surveyor showed the Administrator and DON Resident #3's Quarterly MDS, dated [DATE], which indicated Resident #3 was a two-person assist. The surveyor asked if the MDS populated the Care Plan because the care plan did not show, prior to 02/14/2020, that Resident #3 was a two-person assist for transfers. Both the DON and the Administrator stated residents' transfer requirements were determined by the MDS and the care plan. The DON confirmed she updated Resident #3's care plan on 02/14/2020 to show Resident #3 was a two-person assist for transfers. During an interview with RN B on 02/18/2020 at 4:14 p.m., RN B stated she was the nurse on duty in Resident #3's hall on 02/13/2020 and had responded to the fall that occurred with Resident #3 and HA A. RN B confirmed that Resident #3 was a two-person transfer. RN B confirmed a gait belt should be used for Resident #3 for transfers. RN B stated on the evening of the incident, 02/13/2020, she was told by CNA C that HA A and Resident #3 had fallen in the room during a transfer. RN B stated she provided a gait belt in-service for HA A on the evening of 02/13/2020 with HA A and Resident #3 after the fall occurred. During an interview with CNA C on 02/18/2020 at 4:51 p.m., CNA C confirmed she was present at the facility on 02/13/2020, the night of the fall involving HA A and Resident #3. CNA C stated she was in another room helping another resident when HA A entered the room and stated she and Resident #3 had fallen during a transfer. CNA C stated she entered the room and observed Resident #3 was lying on the floor face down. CNA C confirmed Resident #3 did not have a gait belt on when CNA C entered the room. CNA C further confirmed Resident #3 was a two-person assist for transfers. CNA C further stated the cookie sign on Resident #3's indicated, It (the cookie sign) means that the resident is a two person assist. CNA C further stated the sign had been in place prior to Resident #3's fall with HA A on 02/13/2020. Record review of CNA C's training record, dated 07/31/2019, revealed CNA C had performed and passed skills checks for transfers, to include gait belt transfers. During an observation on 02/18/2020 at 4:59 p.m. of the sign outside of Resident #3's bedroom door read: In the cookies of life, Friends are the chocolate chips. During an interview with RN B on 02/18/2020 at 5:00 p.m., RN B confirmed the cookie signs on resident rooms indicated the specific resident was a two-person assist. During an interview with the HR Manager on 02/18/2020 at 5:31 p.m., the HR Manager stated LVN E was the staffing coordinator who would conduct new hire floor orientations. The HR Manager stated she was not sure what the staffing coordinator was responsible for in regard to verifying training or in-services prior to staff caring for residents. The HR Manager stated, I spoke with LVN E and it sounded like the skills check offs were not done for HA A. During an interview with HA A on 02/18/2020 at 6:02 p.m., HA A when asked by the surveyor if another transfer occurred after the fall for Resident #3 on 02/13/2020, HA A responded, Yes, well no. When asked by the surveyor how Resident #3 was moved from the floor to the bed, HA A stated RN B and CNA C moved the resident. HA A stated she had not received training on gait belt transfers by the facility prior to providing direct care to residents. HA A further stated LVN E did not provide training or a skills check off prior to providing direct care to residents when she changed positions from Dietary Aide to Hospitality Aide. HA A confirmed the cookies sign in front of resident rooms indicated for staff to enter the room in pairs. HA A further confirmed the cookies sign had been in place prior to the fall that occurred on 02/13/2020 for Resident #3. During an interview with the Administrator on 02/18/2020 at 6:25 p.m., the Administrator stated she had not asked HA A specifically if she had received a skills check off or in-service on the night of 02/13/2020. The Administrator stated she had asked RN B if she had provided an in-service to HA A and had RN B told her that she had provided an in-service to HA A on the evening of 02/13/2020. During an interview with the Administrator, the DON, HA A, and RN B on 02/18/2020 at 6:28 p.m., RN B stated that after Resident #3's fall on 02/13/2020 she, HA A, and CNA C had all transferred the resident from the floor and back to her bed. RN B stated that after transferring Resident #3 from the floor to the bed, the DON told her to provide an in-service to HA A regarding gait belt transfers. RN B stated she went back into Resident #3's room with HA A and she had transferred Resident #3 from her bed to her wheelchair. RN B further stated she had HA A do a return demonstration with Resident #3 for a one-person gait belt transfer from the wheelchair to the bed. The surveyor asked HA A if this had occurred, HA A looked at RN B and nodded her head up and down, indicating 'Yes' this had occurred. During an interview with the DON and Administrator on 02/18/2020 at 6:28 p.m., the DON and Administrator stated they had both completed a skills check off with return demonstration on a staff member for HA A prior to entering the room at 6:28 p.m. on 02/18/2020. During an interview with the Administrator on 02/18/2020 at 6:52 p.m., the Administrator stated there was not a policy for the cookie sign on Resident #3's door. During an interview with CNA D on 02/19/2020 at 10:54 a.m., CNA D stated she had worked with Resident #3 since the resident's admitted . CNA D stated Resident #3 was a one-person assist but since the resident's fall the facility told her Resident #3 was now a two-person assist. CNA D stated the cookies sign in front of Resident #3's room meant the resident was friendly and liked to talk to people. CNA D further stated the facility had not provided anyone with any type of in-service or skills check off for gait belt transfers after the Resident #3's fall on 02/13/2020. During an interview with the Administrator and DON on 02/19/2020 at 11:52 a.m., the Administrator and DON stated they both spoke with HA A on the prior evening, 02/18/2020, and HA A had confirmed that RN B had not performed a skills check off or an in-service for gait belt transfers after the Resident #3's fall occurred on 02/13/2020. The Administrator and DON stated HA A and RN B were suspended due to inconsistencies in their version of the events that occurred with Resident #3 on 02/13/2020. During an interview with HA A on 02/19/2020 at 1:30 p.m., HA A stated the facility had suspended her on the morning of 02/19/2020 after her shift ended, pending an investigation. HA A stated she had worked a double shift, from 3:00 p.m. on 02/18/2020 until 6:00 a.m. on 02/19/2020. HA A stated she was aware of the sign in front of Resident #3's room and stated the sign was for two people to go into the room so that there were witnesses present if the residents exhibited any type of behaviors. HA A confirmed she had received a gait belt in-service and skills check off the previous evening on 02/18/2020 by the DON and Administrator. During an interview with LVN E on 02/19/2020 at 1:59 p.m., LVN E confirmed her previous position was as a staffing coordinator and further confirmed she was the staffing coordinator at the time of HA A moving to the HA position. LVN E stated she would not verify skills for direct care staff. LVN E stated that as long as CNAs passed a CNA program the facility assumed the skills checks were completed at the schools the CNAs completed. LVN E stated the sign in front of resident rooms meant staff needed to enter the room in pairs to provide care to the residents. When asked by the surveyor how staff knew if a resident was a one or two-person transfer, LVN E stated there was a Resident Profile Sheet on the inside of each resident's closet which indicated the residents' ADL needs. During an interview with CNA F on 02/19/2020 at 2:28 p.m., CNA F stated the sign with the image of a cookie outside of resident rooms indicated two staff members' needed to care for the residents at all times. When asked how a staff member knew what the transfer needs were for residents, CNA F stated staff communicated with each other and would ask how many people were needed for transfers from other staff members. CNA F further stated that when new CNAs started working in a hall or in the facility a nurse or a therapy assistant would tell them what the transfer requirements were for each resident. During an interview with CNA G on 02/19/2020 at 2:32 p.m., CNA G stated the cookie sign in front of resident rooms meant two staff members were to be in the room to provide care. When asked how staff knew the transfer requirements for residents, CNA G stated staff would communicate with each other. During an interview with CNA H on 02/19/2020 at 2:36 p.m., CNA H stated the cookie sign on the front of resident rooms indicated that two staff members should enter the room. CNA H stated, Regardless if the person was a one or two-person transfer, staff need to go in pairs. When asked by the surveyor how staff knew if a resident was a one or two-person transfer, CNA H stated there was a piece of paper (Resident Profile Sheet) inside the resident's closet that would tell them the transfer requirements. During an interview with the Administrator and DON on 02/19/2020 at 4:19 p.m., the Administrator and DON confirmed HA A was not trained on gait belt transfers prior to providing care for residents. The DON and Administrator further confirmed an in-service and/or skill check for gait belts had not been completed immediately after the fall for Resident #3 on 02/13/2020 and the required training for HA A was not completed until the evening of 02/18/2020. Record review of the facility's policy titled, Fall Management, revised 03/29/2019, revealed under the section titled policy: The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. Record review of the facility's policy titled Abuse Prohibition Handout, revised 10/23/2019, revealed under the section of Policy: 3. The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident. Under the section titled Definitions: 6. Neglect is the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Component VI: Investigation: 4. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions: 5. G. Measures taken to prevent future incidents. 6. In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. 7. Guidelines for the investigation: I. The Director of Nursing or his/her designee will review the resident's medical record. On 02/19/2020 at 4:19 p.m. the Administrator and DON were notified of the Immediate Jeopardy (IJ) situation for the above failures, a completed IJ template was provided, and a Plan of Removal was requested. On 02/20/2020 at 1:16 p.m. the facility's Plan of Removal was approved and the facility began to conduct in-services and skills checks for staff members. The facility's Plan of Removal included the following steps to be taken by the facility: 1. Identified resident is being transferred using 2-person gait belt transfers and using proper technique observed by the Director of Nursing on 2/19/20. Resident #3's care plan and care profile was immediately updated to reflect 2 person gait belt transfer. 2. New hires since October 1, 2019 will be audited for required transfer competencies and any missing will be completed by members of nursing management by 2/20/20. 3. 2-person gait belt transfer competencies will be conducted on Certified Nursing Assistants and HA/NA and Licensed Nurses on February 19, 2020. Any certified nursing assistant, HA/NA or licensed nurse not successfully completing a 2-person gait belt transfer on this date will complete prior to next scheduled shift. Competencies will be done in new hire orientation, annually and as needed based on facility needs. Staff in-service initiated on accessing and reviewing care profile on Point of Care Kiosk. 4. Licensed nurses and Certified Nursing Assistants and Hospitality Aides / Nursing Assistant will be re-educated on the Abuse/Neglect Misappropriation policy. This will be completed on 2/20/20. Anyone not receiving this by this date will receive prior to next scheduled shift. 5. Nursing manager/designee will be re-educated by the Clinical Consultant regarding providing nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety. This will be completed on February 20, 2020. 6. The Director of Nursing / designee will randomly observe certified nursing assistants/hospitality aides a minimum of 3 nursing assistants/hospitality aides and three times weekly for 4 weeks then weekly for 2 additional months. Any concern identified during the observation will be addressed at the time of discovery. Resident's will be reviewed quarterly on the MDS schedule and as needed with changes of condition during our clinical meeting review. Management will follow up as necessary. 7. Certified Nursing Assistants or Nursing Assistants in 120 days prior to certification hired will be reviewed for credentials and competency. The Administrator will validate appropriate competencies on New hire Certified Nursing Assistants, Licensed Nurses and HA/NA prior to providing care for residents without supervision for a period of 3 months. 8. The Administrator will oversee compliance with this plan. 9. The medical director was notified of the immediate jeopardy on February 19, 2020 by the Administrator. 10. An Ad Hoc Quality Assurance Performance Improvement meeting was held on February 19, 2020 regarding the contents of this plan. The surveyor verification of the Plan of Removal on 02/20/2020 was as follows: Residents who required two-person/gait belt transfer were observed for care from staff who were to have received an in-service and a skills check off. Staff interviews were conducted on three separate halls and on two different shifts. In-service sign-in sheets and material covered by the in-services was reviewed onsite on 02/20/2020. The surveyor verified completion of these in-services through staff interviews and observed demonstrations of gait belt transfers. Observation on 02/20/2020 at 2:52 p.m. was made of a gait belt transfer for Resident #6 by CNAs K and N. There was no deficient practice or concerns noted with the gait belt transfer by these staff members. Observation was made on 02/20/2020 at 3:07 p.m. of a gait belt transfer for Resident #7 by CNAs C and V. There was no deficient practice or concerns made during the observation. Interviews occurred on 02/20/2020 from 2:44 PM - 5:49 PM with LVN J, LVN L, LVN M, LVN S, and LVN T. All stated that they had received an in-service regarding abuse and neglect, a skills check with return demonstration for gait belt transfers. All staff interviewed stated they are able to verify transfer requirements from their computers or the kiosks mounted on the walls. All nurses interviewed stated that as nurses for each hallway they will observe CNA/HA staff during gait belt transfers to ensure they were performing the task correctly. Interviews occurred on 02/20/2020 from 2:44 PM - 5:49 PM with CNA C, CNA D, CNA I, CNA K, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA V revealed they had received an in-service regarding abuse and neglect, a skills check with return demonstration for gait belt transfers. All staff interviewed stated they are able to verify transfer requirements from their computers or the kiosks mounted on the walls On 02/20/2020 at 7:19 p.m., the Administrator, DON, the Director of Clinical Operations, and the Regional Vice-President of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all staff were in-serviced.