Every finding on record at Capstone Healthcare of Daingerfield

Based on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accidents and hazards for 1 of 7 residents (Resident #1) reviewed for accident hazards. 1. The facility failed to ensure CNA B performed a safe transfer for Resident #1 on 6/24/2026. 2. The facility failed to ensure CNA B, LVN A and CMA C performed a safe transfer on Resident #1 while assisting her from the floor to the bed and assisting her from the bed to the wheelchair on 6/24/2026. These failures could place residents at risk of injury.Findings included: Record review of Resident #1's face sheet dated 6/30/26 indicated she was a [AGE] year old female, admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified dementia (forgetfulness), metabolic encephalopathy (a general term for brain dysfunction caused by an underlying chemical imbalance in the body), Alzheimer's disease (a progressive brain disorder that accounts for 60% to 80% of dementia cases), Parkinson's disease (a progressive nervous system disorder that affects movement), major depressive disorder (a serious mental health condition), and anxiety disorder. Record review of Resident #1's comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS of 9 which indicated she had moderate cognitive impairment. The MDS indicated Resident #1 required substantial/maximal assistance from staff with chair/bed-to-chair transfers. Record review of Resident #1's care plan dated 6/30/26 indicated she had an ADL self-care performance deficit related to cognitive impairment, fatigue and limited mobility. Intervention indicated transfer: Requires assistance with transfer with 1-2 care team members for assistance with transfers. Provide directions by using short, simple instructions. Provide step-by-step guidance during transfer process, encouraging their participation as much as possible. During a record review of a video on 6/30/26 at 11:36 AM, CNA B was attempting to transfer Resident #1 from the bed to the wheelchair. The transfer started after CNA B applied Resident #1's pants to her lower legs then proceeded to set her up on the side of the bed. CNA B attempted to place Resident #1's hands on the wheelchair arm rest to assist her with standing while transferring, but Resident #1 was not able to grasp on to the arm rest. CNA B tried to get Resident #1 to stand while she tried to guide her to the wheelchair, but while trying to stand Resident #1's knees buckled and CNA B attempted to grab her by the brief, then grabbed her in the torso (human truck) area and under her arms, then assisted her to the floor. During a second attempt to assist Resident #1 to the wheelchair from the floor CNA B wrapped her arms around Resident #1's torso (human trunk) area and under her arms to lift her off the floor to the wheelchair, but Resident #1 was too heavy for CNA B to lift. CNA B assisted Resident #1 back to the floor and secured her torso (human trunk) up against the bed to in an upright sitting position. CNA B went to get help and returned with LVN A and MA B to Resident #1's room to assist with getting her off the floor. The staff removed Resident #1 from the floor by grabbing under her arms and pulling on her brief and placed her on the bed. Then the staff transferred Resident #1 from the bed to the wheelchair; during the transfer CNA B grabbed her under the left arm and MA C grabbed her under the right arm while pulling her pants up, then sat her in the wheelchair. During an interview on 6/30/26 at 1:32 PM, CNA D stated Resident #1 was a one-person assist and a gait belt transfer if staff felt safe, but if staff did not feel comfortable, they could use 2 people. She stated Resident #1 did not assist with transferring as she did in the past, but she should not be transferred with a Hoyer lift (a medical device designed to safely transfer patients with limited mobility) yet. She stated a risk for not using a gait belt was the resident could fall and get injured. During an interview on 6/30/26 at 2:11 PM, CNA B stated Resident #1 was a 1-person assist. She stated she has been a CNA for over 40 plus years and she knew she was supposed to apply a gait belt when transferring a resident, but she did not apply one that day, because Resident #1 usually stood up on her own, but that day she just quit standing. She stated Resident #1 usually grabbed the wheelchair and stood up, and she would just help her get into the chair, but that day she did not stand. CNA B stated LVN A and CMA C assisted her with getting Resident #1 off the floor and putting her in the wheelchair. CNA B stated she knew they were supposed to use a gait belt when getting the resident off the floor to the bed, but she had not been using it because Resident #1 usually could stand. CNA B stated Resident #1 did not sustain any injuries from the incident. She stated a negative effect of not using the gait belt when staff transferred a resident could fall. She stated a gait belt helped the residents keep their balance without staff having to pull on body parts or clothing. During an interview on 6/30/26 at 2:22 PM, LVN A stated Resident #1 was able to do more when she first arrived at the facility. She stated the incident when Resident #1 was lowered to the floor was the first time, she had seen her not able to stand. LVN A stated Resident #1 was not even trying to stand. She stated the facility changed Resident #1 to a 2-person assist with a gait belt since the incident. She stated anytime a staff member was assisting a resident to transfer from the bed to the wheelchair they were supposed to use a gait belt. She stated that when she herself and the other 2 staff members were transferring Resident #1 from the floor to the bed, they should have used gait belt. She stated Resident #1 did not sustain any injuries during the incident. She stated CNA B assisted Resident #1 down to the floor while trying to transfer her and she was on a fall mat when she was assisted to the floor. She stated when staff transfer a resident manually, they should use a gait belt. She stated a risk of not using a gait belt during a manual transfer was the resident could fall. She also stated the gait belt helped the residents to keep their balance while the staff have a handle on them. During an observation and interview on 6/30/26 at 2:36 PM, Resident #1 was lying in bed. Resident #1 stated she remembered the incident when CNA B was trying to put her in the wheelchair; she stated she did not get hurt and she did not want to talk about it. During an interview on 6/30/26 at 3:26 PM, CMA C stated she had been a CNA since 2018. She stated she helped assist CNA B and LVN A with getting Resident #1 off of the floor and into the wheelchair. She stated every time she helped Resident #1, she was a 1-person assist. She stated that was the first time she had seen her buckle to the floor. She stated when transferring a resident staff should use a gait belt, but with Resident #1 she had good leg strength, so they used the back of her pants to help assist her to transferring. She stated the staff had been in-serviced on using a gait belt while transferring a resident. She stated the risk of not using a gait belt with a resident during a transfer; was pulling under their arms could hurt them. During an interview on 6/30/26 at 3:35 PM, the DON stated Resident #1 was a standby assist. She stated during the incident when CNA B was getting Resident #1 to hold on to the wheelchair, because that was how she usually transferred, bearing her own weight. She stated Resident #1 required little to no weight bearing assistance, then her knees buckled during that transfer. She stated she had therapy to evaluate Resident #1, and she was a 1-person transfer assist. She stated after the incident she had Resident #1 re-evaluated by therapy and they said she was a 1-person assist with a gait belt. She stated if a resident could bear their own weight, then a gait belt would not be required. She stated the facility did not encourage staff to use the gait belt until it was necessary, because that was a dignity issue; by using something the resident does not need. She stated before that incident Resident #1 did not have any weight bearing issues. She stated that she did not see a risk for not using the gait belt. During an interview on 7/1/26 at 9:34 AM, OTA F stated he does not recall working with Resident #1. He stated that anytime a resident needs substantial to maximal assistance a gait belt should be used. He stated if a resident needed substantial to maximal assistance, they should be wearing a gait belt during a transfer. He stated that anytime a resident needed more than moderate assistance; a gait belt should be worn. He stated he was not sure what the risk was of not wearing a gait belt, but the staff want to keep the floor out of the equation as much as possible. During an interview on 7/1/26 at 9:47 AM, the ADON stated Resident #1 assistance changed and it depends on the day with her. She stated that sometimes if Resident #1 does not want to get up she does not try to stand. She stated normally we used a gait belt while assisting a resident with standing or doing anything that required weight bearing. She stated in the video Resident #1 was standing up and holding on to the wheelchair while CNA B tried to pull her pants up and her knees buckled. She stated CNA B should not have used a gait belt while attempting to transfer Resident #1, but staff should have used a gait belt when they were getting Resident #1 up off the floor. She stated herself and the DON were responsible for ensuring that the staff use the appropriate transferring techniques. She stated the risk with an improper transfer was that the resident could fall and possibly get hurt; that was with any resident in the facility. She stated she felt like the residents would not have gotten hurt if they were assisted to the floor. During an interview on 7/1/2026 at 9:59 AM, LVN E stated Resident #1 had always been a 1-person transfer. She stated she would expect the staff to use a gait belt on a 1-person transfer with a resident. She stated Resident #1 could bear weight when she first admitted to the facility, but she could not bear weight on her own now. She stated the risk was the resident falling or an injury. During an interview on 7/1/26 at 10:40 AM, PTA G stated she had seen Resident #1 transferred once and when therapy transferred her, they used a gait belt. She stated if a resident needs assistance with a transfer, she would expect staff to use a gait belt, because it was the safest way. She stated the risk for the resident would be a fall, skin tears, or injury. She stated the risk for staff would be they could hurt their back or have nothing to grab the residents by if resident was to fall. During an interview on 7/1/26 at 11:02 AM, the Administrator stated his expectations were that the staff do everything they could to make sure they did a safe transfer with the information they knew, with the knowledge they had. He stated the facility was responsible for ensuring the staff were transferring the residents appropriately. He stated from his perspective that the video captured a change of condition. He stated the knowledge that the facility had prior to the incident he felt like the gait belt would not been required. He stated what he saw in the video was a staff member attempting to transfer Resident #1 and her knees buckled. He stated that the information he had Resident #1 was a 1-person assist with transferring, but no gait belt was required. He stated from the information he had; he does not think the staff were doing anything outside of what they had documented. He stated he thought CNA B did a very good job in protecting the residents. He stated there was no harm, pain or bruising noted to Resident #1 after the incident. He stated he had no idea the video existed until surveyor walked into the building. He stated he thought the CNA did the best she could with what she had and the facility did everything they could after the incident. Record review of the facility's policy Use of Gait Belt dated 3/1/26, indicated .It is the policy of this facility to use gait belts with residents whenever appropriate to assist with resident transfers, mobility assistance or ambulation. 1. All employees will receive education on the proper use of gait belts. 2. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. 5. Clinical staff may determine that a gait belt is not appropriate based on: a. Therapy recommendations. b. Physician orders. c. Resident refusal. d. Clinical assessment or contraindications . Record review of the facility policy Safe Resident Handling/ Transfers dated 3/1/26 indicated It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use. The interdisciplinary team or designee will evaluate and assess each resident's mobility needs, taking into account other factors as well, such as weight and cognitive status. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations .

Based on interview and record review, the facility failed to ensure that 5 of 6 residents AR2, AR3, AR4, AR5, and AR6 had a right to organize and participate in resident groups. The facility failed to provide regular resident council meetings without staff interference. This failure could place residents at risk of not having the freedom to voice their concerns in a resident meeting setting. Findings included: During an interview on 6/1/2026 at 2:02 PM, the ADM brought in 3 meeting notes from past meetings and stated the Activity Director quit and the facility was working on getting a good Resident council group going. During a confidential interview at an undisclosed date and time, AR 2, AR3, AR4, AR5, and AR6 said resident council meetings were with staff in Town hall meetings. AR4 said the facility held their first meeting in the hallway and staff were in the hallway and they shut the door. During a confidential interview at an undisclosed date and time, AR3 said the facility was without an Activity Director for a couple of months and the residents just had their first resident council meeting. During an interview on 6/2/2026 at 11:00 AM, the Ombudsman said the facility had not had a Resident Council meeting in 2 years. The Ombudsman said all the department heads were in the town hall meetings. During an interview on 6/3/2026 at 11:29 AM, the AD said she had held one Resident Council meeting on 5/28/2026 at 2:00 PM. She said the meetings were held in the dining room area. The AD said the ADM and the ADON started the meeting and then she took notes for the residents. The AD said the residents allowed her to take part in the meeting to take notes. The AD said she was not sure why there were no resident council meetings in the past. The AD said the facility had town hall meetings, but she had only been at the facility for 1 month. The AD said she was not sure how the residents voted for the Resident Council President. The AD said she had gone over the Resident Rights in the meeting and had provided them with the Ombudsman phone number and the State number. The AD said the ADM was previously responsible for setting up the resident council meetings, but she was responsible now. The AD said she does place signs on the doors during the meetings. The AD said staff should not be walking in and out of the area while the residents were conducting their meeting. The AD said staff should have respected the resident council time. The AD said it could hurt the residents' feelings because it was their home and they need their privacy. During an interview on 6/3/2026 at 11:48 AM, CNA B said the facility had town hall meetings one time a month. CNA B said the staff were in the meetings with the residents and said someone should be in there with them to direct them. CNA B said she used to attend the meetings. CNA B said the ADM was responsible for ensuring the meetings were private. During an interview on 6/3/2026 at 12:01 PM, CNA G said she came through the hallway while the meeting was going on. CNA G said she had not attended any meetings in the past. CNA G said she had never observed a sign on the door. CNA G said staff should not be going in and out while the resident council was having their meeting. CNA G said it was a privacy issue. She said it could make the residents wonder why staff were passing through while their meeting was going on. CNA G said the ADM was responsible for making sure the residents have private meetings. During an interview on 06/03/2026 at 1:11 PM, the ADON said resident council meetings were monthly. The ADON said the facility started doing the Town halls prior to the last survey. The ADON said the residents would meet with staff during the town hall. The ADON said the residents would tell us what meal they would like and the Ombudsman would come up. The ADON said the residents voted on the Resident Council President. The ADON said the President wanted something to do but she cannot remember that. The ADON said the staff should not be passing by during a meeting unless invited. The ADON said the residents need to have the freedom to complain and be able to express themselves without staff being there to monitor it. The ADON said she thought the AD was responsible for ensuring the residents have privacy. During an interview on 06/03/2026 at 1:57 PM, the DON said the AD was responsible for putting together the Resident Council. The DON said the residents should be able to voice concerns and complaints, and staff members should not be in the meeting other than the AD. The DON said nobody should be walking down hallway while the residents were having a meeting. The DON said the residents could be distracted or may not express their concerns or feel like they will not be able to speak. During an interview on 06/03/2026 at 2:15 PM, the ADM said they were using Townhall but was in the form of Resident Council format. The ADM said he attended at the beginning of the meeting. The ADM said he would go over the fact that he was the abuse coordinator. The ADM said he helped kick things off to get the meeting going. The ADM said prior to having a President, the AD stayed in there with them. The ADM said a CNA was doing the Activities. The ADM said they were without an AD since April 16, 2026. The ADM said the department heads filled in. The ADM said Resident Council meetings happened, and the residents voted during a meeting through an election. The ADM said he expected the Resident Council to be able to meet without interruptions from outside staff. The ADM said the AD becomes the trusted staff. The ADM said the Resident Council meetings the facility hosted had signs posted on each door. The ADM said besides putting guards out, he said he did not know how to keep staff out of the meeting. Record review of the facility's policy titled, Resident Council Meetings, dated 3/1/2026, indicated .the facility supports the rights of residents to organize and participate in resident groups.resident or family group.is defined as a group of residents or residents' family members that meet regularly to discuss and offer suggestions about facility policies and procedures.is a formal resident group with a President who is appointed by other residents. All residents are eligible to participate.The President serves as a liaison between the group and facility staff.meets at least quarterly, but no less than as determined by the group. The date, time, and location of the meetings are noted on the Activity Calendar.the activity director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and other staff members.names of residents in attendance, follow-up from previous meetings, issues discussed, recommendations from group to facility staff, and names of staff members, speakers, and other guest present in the meeting.the facility shall act upon concerns and recommendations of the council, makes attempts to accommodate recommendations to the extent practicable and communicate its decisions to the council.scheduling of meetings and meeting topics, upon request by the council.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 4 of 21 residents reviewed for care plans. (Resident #63, Resident #45, Resident #5, Resident #28) 1. The facility failed to develop the comprehensive person-centered care plan for Resident #63 by not documenting their use of a psychotropic (Quetiapine Fumarate Oral Tablet 100 MG) medication. 2. The facility failed to develop a person-centered care plan for Resident #5's psychotropic medication Seroquel 150 mg every evening prescribed on 4/2/2026. 3.The facility failed to develop a person-centered care plan for Resident #28's psychotropic medication Zyprexa 5 mg every day and Zyprexa 7.5 mg every evening prescribed on 11/26/2025. 4.The facility failed to develop a person-centered care plan for Resident #45's admission to Hospice Care on 5/15/2026. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services 1. Record review of Resident #63's face sheet, dated 04/09/26, revealed a [AGE] year old female admitted on [DATE] with diagnoses including Alzheimer's Disease (Alzheimer's is a progressive, irreversible brain disorder and the most common cause of dementia), Major Depressive Disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and an inability to function normally), and Anxiety Disorder (Anxiety disorders involve persistent, excessive worry or fear that is disproportionate to the situation and interferes with daily life). Record review of physician's orders for Resident #63, dated 05/30/26, indicated an order for Quetiapine Fumarate Oral Tablet 100 MG. Order shows that mediation was to be administered 1 tablet by mouth at bedtime. Record review of Resident #63's admission MDS assessment, dated 04/21/26, indicated Resident #63 was understood and understood others. The MDS indicated a BIMS of 08 indicating moderate cognitive impairment for Resident #63. The MDS indicated Resident #63 used psychotropic medication. Record review of Resident #63's care plan, dated 4/14/26, revealed there was no care planning or documentation regarding the use of Quetiapine Fumarate Oral Tablet 100 MG. During an interview on 6/3/26 at 12:00 p.m., the Director of Nurses said that antipsychotic medication use should be care planned. She said it was the responsibility of nursing staff to ensure that care plans were developed properly. She said that residents could be placed at risk of not receiving proper care if their care plans were not sufficiently documented. During an interview on 6/3/26 at 12:05 p.m., the Administrator said he expected nursing staff develop residents care plans to encompass all aspects of residents' care including psychotropic medications. He said that residents could be placed at risk if their care plans were not completed as staff may not meet all of a resident's needs. 2. Record review of Resident #5's Face sheet, dated 6/2/2026, indicated an [AGE] year-old female readmitted [DATE]. Resident #5 had diagnoses which included fracture of right femur, vascular dementia (a decreased blood flow, which can damage brain tissue), paranoid personality disorder (a mental health condition marked by pervasive distrust and suspicion of others without sufficient reason) and delusions (a type of mental health condition in which a person can't tell what's real from what's imagined). Record review of Resident #5's Significant change in condition MDS assessment, dated 4/7/2026, indicated she was able to make self-understood and was able to understand others. Resident #5 had a BIMS score of 3 indicating she was severely cognitively impaired. Resident #5 was dependent with toileting, bathing, and dressing upper and lower body. The MDS care area indicated Resident #5 was on psychotropic medication triggering a care area. Record review of Resident #5's Care plan, initiated on 11/14/2025, indicated Resident #5 resided on the secure memory care unit due to elopement risk. Resident #5's care plan also indicated she had impaired cognitive function, dementia, or impaired thought processes. Interventions included administration of medications as ordered, monitor/document for side effects, ask yes/no questions to determine the resident needs. Resident #5's care plan did not address psychotropic medications. Record review of a physician order, dated 6/3/2026, indicated Resident #5 was ordered to have Seroquel 100 mg tablet every evening and Seroquel 50 mg tablet every evening to equal 150 mg daily for behavioral hallucinations. The physician order summary also included behavioral monitoring related to antipsychotics such as mania (an abnormally elevated, energetic, or irritable mood that lasts at least a week and severely impacts daily functioning), auditory hallucinations (the perception of hearing a sound-such as a voice, music, or environment noise- when no actual external source exists), visual hallucinations (involve seeing things that do not actually exist), delusions (a fixed, false belief that is firmly held despite clear evidence to the contrary), paranoia (an intense, irrational feeling of suspicion and distrust without a solid basis), biting, danger to self, danger to others, smearing feces, kicking, extreme fear, or striking out. Interventions included activity, adjusting room temperature, changing positions, administration of fluids or foods, redirect, or toileting. Record review of MAR/TAR, dated 5/1/2026-5/31/2026, indicated Resident #5 was prescribed Seroquel 100 mg by mouth at bedtime and Seroquel 50 mg by mouth every evening to equal 150 mg at bedtime related to behavioral hallucinations. The TAR indicated monitoring of behaviors such as mania, auditory hallucinations, visual hallucinations, delusions, paranoia, biting, danger to self, danger to others, smearing feces, kicking, extreme fear, or striking out. Interventions included activity, adjusting room temperature, changing positions, administration of fluids or foods, redirect, or toileting. 3. Record review of Resident #28's Face sheet, dated 6/2/202,6 indicated an [AGE] year-old male admitted [DATE]. Resident #28 had diagnoses which included vascular dementia (a decreased blood flow, which can damage brain tissue), chronic systolic congestive heart failure (a serious condition where the heart's ability to pump blood efficiently is impaired over time, primarily affecting the left ventricle), and delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined.). Record review of Resident #28's quarterly MDS assessment, dated 5/12/2026, indicated he was able to make self-understood and was able to understand others. Resident #28 had a BIMS score of 7 indicating he was severely cognitively impaired. Resident #28 was dependent with toileting, bathing, and required moderate to substantial assistance with dressing lower body. The quarterly MDS did not indicate Resident #28 had any behaviors and he had a psychotic disorder. The MDS indicate Resident #28 was on psychotropic medication. Record review of Resident #28's Care plan, revised on 2/2/2026, indicated Resident #28 resided on the secure memory care unit due to exit seeking and constant wandering. Resident #28's care plan also indicated he had impaired cognitive function, dementia, or impaired thought processes. Interventions included asking yes/no questions to determine the resident needs, communicating with Resident #28/RP/caregivers regarding Resident #28's capabilities and needs, and keep Resident #28's routine consistent and trying to provide consistent care givers as much as possible. Resident #28's care plan did not address psychotropic medications. Record review of a physician order, dated 6/3/2026, indicated Resident #28 was ordered Zyprexa 5 mg every day and Zyprexa 7.5 mg every evening for behaviors on 11/26/2025 with side effect monitoring for behaviors included restlessness, pacing, continuous crying for help, afraid/panic, repetitious movements, verbalization of anxiety. The physician order summary indicated interventions such as activity, adjust room temperature, backrub, change in position, administer fluids, offer food, redirect, and remove resident from environment. Record review of MAR/TAR dated 5/1/2026-5/31/2026 indicated Resident #28 was prescribed Zyprexa 5 mg every day and Zyprexa 7.5 mg every evening for behaviors. The MAR/TAR indicated Resident #28 was monitored for side effects and behaviors including restlessness, pacing, continuous crying for help, afraid/panic, repetitious movements (any physical action, task, or movement that is performed continuously or frequently over time), and verbalization of anxiety. Interventions on the MAR/TAR were 1 on 1 activity, adjust room temperature, backrub, change in position, offer fluids, offer food, redirect, or remove from environment. 4. Record review of Resident #45's Face sheet, dated 6/3/2026, indicated an [AGE] year-old male w readmitted [DATE]. Resident #45 had diagnoses which included acute posthemorrhagic anemia (a condition caused by blood loss, leading to reduced red blood cells and hemoglobin), vascular dementia (a decreased blood flow, which can damage brain tissue), hypertension (a common condition where the force of blood against the artery walls are consistently too high) and malignant neoplasm of the prostate (uncontrolled growth of cells in the prostate, a gland in the male reproductive system). Record review of Resident #45's significant MDS assessment, dated 5/28/2026, indicated he was able to make self-understood and was able to understand others. Resident #45 had a BIMS score of 5 indicating he was severely cognitively impaired. The quarterly MDS also indicated Resident #45 had verbal behavioral symptoms directed toward others and required moderate assistance with toileting, bathing, and dressing upper body. The MDS indicated Resident #45 was admitted to Hospice while a resident. Record review of Resident #45's Care plan, revised o5/13/2026, indicated Resident #45 resided on the secure unit due to elopement risk. Resident #45's care plan also indicated he used psychotropic medications related to disease process of vascular dementia with behaviors and delusional disorder. Interventions included administration of psychotropic medications as ordered by physicians. The care plan included intervention to observe for and report to the nurse any side effects and effectiveness. The Care plan did not indicate Resident #45 was on Hospice Care. Record review of a physician order, dated 6/3/2026, indicated Resident #45 had an order indicating he could be admitted to Hospice Care on 5/18/2026. During an interview on 6/3/2026 at 12:17 PM, LVN D said psychotropic medications should be on the care plan. LVN D reviewed Resident #5 and Resident #28's care plan and said there were no care plans for the psychotropic medications. LVN D said psychotropic medications should have their own care plan with specific interventions for the medications. LVN D said Resident #45 did not have a care plan for Hospice Care. LVN D said Resident #45 was admitted to Hospice on 5/15/2026. LVN D said DON and MDS nurse were responsible for adding the psychotropic medications to resident's care plans. LVN D said the MDS nurse and the DON should update in the morning meeting. LVN D said it could negatively impact residents if the staff did not know what side effects or interventions were if a resident took psychotropic medications and a resident might not receive the care or interventions that needed to be monitored. During an interview on 06/03/2026 at 1:25 PM, the ADON said she did not enter the care plan. The ADON said the MDS nurse or the nurse entered the care plan. The ADON said the care plan should be individualized for each resident. The ADON said the care plan should be updated within the next couple of days if a resident was admitted to Hospice or had a psychotropic medication. The ADON said it was important for all medications to be on the care plan so the staff would know how to treat the residents. The ADON said it would not impact the residents because the facility staff would not do anything without a Physician order. During an interview on 6/3/2026 at 1:36 PM, the MDS nurse said she oversees the care plans. MDS nurse said the IDT met every morning and discussed anything new to care plans or any updates. MDS nurse reviewed Resident #5, Resident #28 and Resident #45's care plan. The MDS nurse said Resident #5 and Resident #28 did not have a care plan for psychotropic medications. The MDS nurse did not have an explanation why the care plan was not updated with the psychotropic medications. The MDS nurse said she had been in her new role for about 3 months. The MDS nurse said Resident #45 should have a care plan for Hospice Care and she had Resident #45 marked on her white board in her office indicating his admission date of 5/15/2026. The MDS nurse said she did not care plan hospice. The MDS nurse said she had about 14 days and usually does it right when she was made aware. The MDS nurse said she was responsible for ensuring the care plans were updated. The MDS nurse said it was important so the staff would know what was going on with the residents. The MDS nurse said it could negatively impact the residents because the care plan was a way for the staff to know what care to provide for the residents. During an interview on 6/3/2026 at 2:03 PM, the DON said she expected the psychotropic medications to be on the care plan because they were required. The DON said the nurse management (DON, ADON, and MDS nurse) were responsible for care planning psychotropic medications and Hospice care plan. The DON said she did not know any negative effect on the residents. During an interview on 06/03/2026 at 2:25 PM, the ADM said the care plan should be updated by the DON or IDT. The ADM said he would want the clinical team to update the care plan if a resident was placed on Hospice Care and if a resident was prescribed a psychotropic medication. The ADM said there was potential for the care plan to not be followed and have a negative impact on the residents but did not elaborate on what could occur. Record review of a facility policy titled, Comprehensive Care Plan, dated 3/1/2026, indicated .it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and ALL services that are identified in the resident's comprehensive assessment.Person-centered care.to focus on the resident as the focus of control and support the resident in making their own choices.Policy Explanation and Compliance guidelines.1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal preferences.2.will be developed within 7 days after the completion of the comprehensive MDS assessment.3.will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her rights.c. any specialized services.d.resident's goals for admission and desired outcomes.e. Discharge plans.f.specific interventions that reflect the resident's needs and preferences.g. Individualized interventions for trauma services.4. The comprehensive care plan will be prepared by an interdisciplinary team.a.attending physician or non-physician practitioner designee.b. registered nurse with responsibility for the resident.c. nurse aide.d.a member of the food and nutrition services.e. The resident and the resident's representative.5.reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment.6.will include measurable objectives and timeframes to meet the resident's needs.7. The physician, other practitioner, or professional will inform the resident and resident representative of risk and benefits of proposed care, of treatment and alternatives.8. Qualified staff responsible for carrying out interventions specified in the care plan.

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 diseases and infections for 3 of 16 residents (Resident #2, Resident #26 and Resident #13) reviewed for infection control practices. 1. The facility failed to ensure LVN D donned a gown when prior to administering medications via G-tube (gastrostomy tube) (a medical device inserted through the abdomen directly into the stomach) for Resident #2 on enhanced barrier precautions on 6/2/26. 2. The facility failed to ensure LVN D donned a gown prior to administering Resident #26's Daptomycin (a powerful, intravenous, cyclic lipopeptide antibiotic) intravenously via PICC line (peripherally inserted central catheter) (a long, thin, flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart). 3.The facility failed to ensure CNA A and CNA B donned a gown before performing catheter care on Resident #13 who was on EBP. These failures could place residents at risk for cross contamination and the spread of infection. Findings include: 1.Record review of Resident #2's face sheet dated 6/3/26 reflected a [AGE] year-old male who was initially admitted on [DATE] and was readmitted to the facility on [DATE]. Resident #2 had diagnoses which included: diffuse traumatic brain injury with loss of consciousness of 30 minutes or less (widespread damage caused when rapid acceleration, deceleration, or rotational forces twist and tear the brain's long connecting nerve fibers), quadriplegic (a medical condition involves the partial or total loss of motor), cognitive communication deficit, gastrostomy status (having a surgically created opening in the stomach (a G-tube) and need for assistance with personal care. Record review of Resident #2's MDS assessment, dated 5/28/26, reflected Resident #2 sometimes understood and usually understood by others. There was no BIMS assessment conducted for Resident #2. Resident #2 was dependent on ADLs. Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's care plan dated 5/1/26 reflected Resident #2 has an abrasion to right wrist. The intervention: provide wound care per treatment order. Resident review of Resident #2 care plan date 7/15/25 reflected Resident #2 has impaired cognitive function or impaired thought process related to traumatic brain injury. Record review of Resident #2's care plan dated 10/16/24 reflected Resident #2 had impaired cognitive function. The intervention: encourage resident to participate in simple, structured activities. Record review of Resident #2's order summary report reflected, clean right wrist wound with wound cleanser, pat dry, and apply Leptospermum honey. Cover with dry dressing. Change every day and as needed, every day shift for wound care, dated 5/20/26. Record review of Resident #2's order summary report reflected, Resident #2 on enhanced barrier precautions due to peg tube (a flexible feeding tube surgically placed through the abdominal wall directly into the stomach), dated 3/31/26. Record review of Resident #2's order summary report reflected, may cocktail meds, dated 10/3/24. During an observation on 6/2/26 at 8:18 AM, LVN D prepared and administered Resident #2 medications via peg tube. LVN D did not donn a gown prior to administering the resident's medication. Resident #2 had an enhanced barrier precaution sign upon entry of room. During an interview on 6/2/26 at 8:50 AM LVN D stated Resident #2 was on enhanced barrier precautions. She stated it was a personal preference if staff wanted to wear the PPE to protect themself. She stated if the staff had something going on such as sickness, they should wear the PPE. She stated a negative effect was spreading infection to the next person. She stated she had been in-serviced over enhanced Barrier Precautions before. During an interview on 6/2/26 at 10:27 AM the Assistant Director of Nursing stated, the nurses were supposed to be wearing PPE during incontinent care, transferring and giving medications via gastrostomy tube when a resident was on enhanced barrier precautions. She stated she was the Infection Control Preventionist and she and the Director of Nursing were both responsible for ensuring the nurses wore PPE. She stated she has done an in-service on applying PPE for residents on enhanced barrier precautions with staff on 6/2/26. She stated a negative effect of enhancement barrier precautions not followed was that staff does not know if the residents have bacteria on them and staff could spread it to others. 2.Record review of Resident #26's face sheet dated 6/3/26 reflected a [AGE] year-old male who was initially admitted on [DATE] and readmitted to the facility on [DATE]. Resident #26 had diagnoses which included: other chronic osteomyelitis (aa persistent, progressive bone infection lasting longer than four weeks), osteomyelitis of vertebra (a serious, potentially debilitating infection of the spine bones) and acquired absence of left leg above knee. Record review of Resident #26's MDS assessment, dated 4/26/26, reflected Resident #26 understood and understood by others. Resident #26 required maximal assistance with ADLs. Record review of Resident #26's care plan dated 3/31/26 reflected Resident #26 has an infection of the lumbar spine Resident #26 has a PICC line and receiving IV antibiotics Vancomycin.Record review of Resident #26's care plan dated 4/8/25 reflected Resident #26 has diabetic chronic ulcer to right 4th toes. Resident #26 requires enhanced barrier precautions due to his wound. Record review of Resident #26's order summary report reflected, Daptomycin Intravenous Solution Reconstituted 500 mg (Daptomycin) use 850 mg intravenously one time a day for osteomyelitis until 6/19/26 2:59 PM to give in 50 ml Normal Saline at 100 ml/hr., start dated 6/2/26. Record review of Resident #26's order summary report reflected, PICC Line Dressing and cap change weekly using sterile technique per protocol one time a day every Monday for wound care treatment, dated 4/27/26. Record review of Resident #26's order summary report reflected, Resident on enhanced barrier precautions due to wound, dated 3/31/26. During an observation on 6/2/26 at 2:39 PM, LVN D prepared Resident #26's Daptomycin and administered the medication via IV. LVN D did not donn gown prior to administering the IV medication, the resident had an enhanced barrier precaution sign on door. During an interview on 6/2/26 at 2:45 PM, LVN E stated she was supposed to apply the gown which was her PPE. She stated she was nervous about administering the medication. She stated she was responsible for applying for the PPE before she gave the medication, because he has a PICC line and a wound. She stated she was just in-serviced over enhanced barrier precautions, but she was just nervous. She stated a negative effect was the blood from the PICC line could spread germs. During an interview on 6/3/26 at 12:51 PM, LVN E stated the importance for enhanced barrier precautions for a foley, intravenous and gastrostomy tube was splashing. She stated all staff were responsible for themselves and the residents. She stated a negative effect of improper EBP was exposure to bacteria for the staff and the residents. 3.Record review of Resident #13's undated face sheet indicated she was a [AGE] year-old female that originally admitted [DATE] with a readmission date of 1/30/26. Record review of the physician's orders dated 6/2/26 indicated Resident #13 had diagnoses that included: Paraplegia (partial or complete loss of motor and sensory function in the lower half of the body, including both legs), metabolic encephalopathy (temporary or permanent brain dysfunction caused by chemical imbalances or underlying systemic diseases rather than a direct head injury), other specified sepsis (extreme life threatening response to an infection). Record review of Resident #13's quarterly MDS dated [DATE] indicated she had a BIMS of 14 meaning she was cognitively intact. The MDS indicated she required substantial/maximal assistance to roll to the left and to the right and was dependent on staff for a chair to bed or bed to chair transfer. Resident #13 had an indwelling catheter (a flexible, sterile rubber or plastic tube inserted through the urethra into the bladder to drain urine.) Record review of Resident #13's care plan with a revised date of 4/1/26 indicated she required the use of EBP due to her foley (brand of catheter) catheter and wound. The care plan indicated she had an indwelling catheter related to neurogenic bladder (when nerve damage disrupts the signals between your brain and bladder, requiring careful treatment to prevent kidney damage). During an interview and observation on 6/01/2026 at 9:28 AM, Resident #13 was in bed brushing her teeth. Water was on her bedside table. She said she was just back from the hospital with a UTI. She had a catheter and the bag was covered. She said she was paralyzed from the waist down, so she had no symptoms of a UTI. She said staff was very kind to her and everyone loved her. There was an EBP sign on her door that indicated: Stop. Enhanced Barrier Precautions, everyone must: Clean their hands, including before entering and leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line (long flexible tube inserted into the chest, neck, arm, or groin), urinary catheter, feeding tube, tracheostomy, Wound care: any opening requiring a dressing. Written on the sign was B-bed which was Resident #13's bed. During an observation on 6/02/2026 at 10:27 AM, this surveyor, CNA A and CNA B entered Resident #13's room. A sign on the door indicated Enhanced Barrier Precautions. Near the door to the room was a container with drawers that contained PPE including gowns. CNA A and CNA B performed catheter care for Resident #13. CNA A and CNA B did not donn gowns in preparation for or during catheter care. During an interview on 6/02/2026 at 10:40 AM CNA A said she forgot to put on a gown and she knew she was supposed to, because she just had an in-service on EBP precautions. She said not wearing a gown could cause infection to staff and residents. During an interview on 6/02/2026 at 10:41 AM, CNA B said she was supposed to put on a gown before performing catheter care to protect herself, other staff, and residents from infection. She said she had just had an in-service on wearing PPE for EBP, but she had forgotten. During an interview on 06/03/2026 at 12:00 PM, the ADON, said the importance of EBP and using PPE was, per CMS, that staff must assume there was bacteria in any type of resident tubing, whether a g-tube (gastrostomy tube, a medical device inserted directly through the abdomen into the stomach), IV (intravenous, a medical technique to deliver fluids, medications, or nutrients directly into a person's bloodstream), or a catheter that staff was unaware of which presented a danger of infection to staff and residents. She said an infection could be spread to staff, residents, or both. Wearing a gown would help to prevent infection transmission. During an interview on 06/03/2026 at 12:05 PM, the DON said Residents that were on EBP were at higher risk for MDRO's. She said when performing care on a resident that was on EBP, staff should wear a gown and gloves. She said PPE was used to protect staff and residents from transmitting infection. Record review of an Enhanced Barrier Precautions Policy, dated 3/1/26, provided by the DON indicated: Policy:It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: 'Enhanced Barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 1.Prompt recognition of need:a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high risk activities and common organisms that require enhanced barrier precautions. c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Record review of Enhanced Barrier Precautions (EBP)-What Do I Need to Know? In-service dated 6/2/26 indicated: What is EBP?-Wear gown and gloves during specific resident care activities-Used to reduce the spread of multidrug-resistant organisms (MDRO's) When is EBP used? -An MDRO.-A wound and/or indwelling medical device (regardless of MDRO status). Wear Gown and Gloves for High-Contact Care Activities such as: -dressing, bathing, or showering-Transferring/resident lifting-changing linens-toileting/incontinence care-wound care -Device care (urinary catheter, feeding tube, trach (small hole in the front of the neck and directly into the windpipe), IV/PICC (Peripherally Inserted Central Catheter), etc.- Assisting with hygiene. What is not required?-Gown and gloves are not required for casual contact, social activities, or simply entering the room unless performing a high-contact care activity. This in-service was signed by CNA A, CNA B, and LVN D on 6/2/26.

Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities and to ensure the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it in response to the pharmacist report for 1 of 3 residents (Resident #5) reviewed for (MRR) Medication Regimen Review. 1. The facility failed to act on signed GDR orders to decrease Seroquel (Quetiapine) (an atypical antipsychotic medication used to treat schizophrenia, bipolar disorder and depressive disorder) from 150 mg to 125 mg for Resident #5 on 3/31/2026. These failures could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for adverse consequences related to medication therapy.Findings included: 1. Record review of Resident #5's Face sheet dated 6/2/2026 indicated an [AGE] year-old female who was readmitted to the facility on [DATE]. Diagnoses included fracture of right femur (a break or a crack in the right thighbone, the largest and strongest bone in the body), vascular dementia (a decreased blood flow, which can damage brain tissue), paranoid personality disorder (a mental health condition marked by pervasive distrust and suspicion of others without sufficient reason) and delusions (a type of mental health condition in which a person can't tell what's real from what's imagined). Record review of Resident #5's Significant change in condition MDS dated [DATE], indicated she was able to make self-understood and was able to understand others. Resident #5 had a BIMS score of 3 indicating she was severely cognitively impaired. Resident #5 was dependent with toileting, bathing, and dressing upper and lower body. Record review of Resident #5's Care plan, initiated on 11/14/2025 indicated Resident #5 resided on secure memory care unit due to elopement risk. The care plan indicated she had impaired cognitive function, dementia or impaired thought processes. Interventions included administration of medications as ordered, monitor/document for side effects, ask yes/no questions to determine the resident needs. The care plan did not indicate Resident #5 was on a psychotropic medication. Record review of a physician order, dated 6/3/2026, indicated Resident #5 was ordered to have Seroquel (Quetiapine) 100 mg tablet every evening and Seroquel (Quetiapine) 50 mg tablet every evening to equal 150 mg daily for behavioral hallucinations. The physician order summary also included behavioral monitoring related to antipsychotics such as mania, auditory hallucinations, visual hallucinations, delusions, paranoia, biting, danger to self, danger to others, smearing feces, kicking, extreme fear, or striking out. Interventions included activity, adjusting room temperature, changing positions, administration of fluids or foods, redirect, or toileting. Record review of MAR/TAR dated 3/1/2026-3/31/2026 indicated Resident #5 was administered Seroquel (Quetiapine) 100 mg by mouth at bedtime and Seroquel (Quetiapine) 50 mg by mouth every evening to equal 150 mg for behavioral hallucinations starting on 2/20/2026. The TAR indicated monitoring of behaviors such as mania, auditory hallucinations, visual hallucinations, delusions, paranoia, biting, danger to self, danger to others, smearing feces, kicking, extreme fear, or striking out. Interventions included activity, adjusting room temp, changing positions, administration of fluids or foods, redirect, or toileting. Record review of MAR/TAR dated 4/1/2026-4/30/2026 indicated Resident #5 was prescribed Seroquel (Quetiapine) 100 mg by mouth every evening and Seroquel (Quetiapine) 50 mg every evening to equal 150 mg at bedtime related to behavior and hallucinations. The MAR/TAR indicated monitoring of behaviors such as mania, auditory hallucinations, visual hallucinations, delusions, paranoia, biting, danger to self, danger to others, smearing feces, kicking, extreme fear, or striking out. Interventions included activity, adjusting room temp, changing positions, administration of fluids or foods, redirect, or toileting. Record review of MAR/TAR dated 5/1/2026-5/31/2026 indicated Resident #5 was prescribed Seroquel (Quetiapine) 100 mg by mouth at bedtime and Seroquel (Quetiapine) 50 mg by mouth every evening to equal 150 mg at bedtime related to behavioral hallucinations. The MAR/TAR indicated monitoring of behaviors such as mania, auditory hallucinations, visual hallucinations, delusions, paranoia, biting, danger to self, danger to others, smearing feces, kicking, extreme fear, or striking out. Interventions included activity, adjusting room temp, changing positions, administration of fluids or foods, redirect, or toileting.Record review of MAR/TAR dated 6/1/2026-6/30/2026 indicated Resident #5 was prescribed Seroquel (Quetiapine) 100 mg by mouth at bedtime and Seroquel (Quetiapine) 50 mg by mouth every evening to equal 150 mg at bedtime related to behavioral hallucinations. The MAR/TAR indicated monitoring of behaviors such as mania, auditory hallucinations, visual hallucinations, delusions, paranoia, biting, danger to self, danger to others, smearing feces, kicking, extreme fear, or striking out. Interventions included activity, adjusting room temp, changing positions, administration of fluids or foods, redirect, or toileting. Record review of Resident #5's Consultant Pharmacist/Physician Communications, dated MRR Date 3/20/2026 indicated: .Resident is receiving the following antipsychotic medication (s) which is due for review.CMS regulations, please evaluate resident for trial dose reduction .Medication: Quetiapine 150 mg Daily.Suggest change.Quetiapine 125 mg DailyThe Physician/Prescriber Response was written to decrease Quetiapine 125 mg daily and signed on 3/31/2026. During an interview on 6/3/2026 at 12:13 PM, LVN D said GDR orders were placed in the EMR by the nurse. LVN D said if she received an order, she would place the order in the EMR immediately. LVN D said she was not aware of Resident #5's GDR for Seroquel (Quetiapine) was reduced by the physician. LVN D said the DON was responsible for entering the orders. LVN D said the resident may not have a therapeutic effect on the resident. During an interview on 6/3/2026 at 1:11 PM, the ADON said the GDR should have been entered into the EMR if the order was signed. The ADON said she was the nurse sending out the GDR recommendations to the physician and once the order is signed, she would enter the new order into the EMR. The ADON said she and the DON were responsible for the orders. The ADON said she had been working the floor and the facility had Covid (a contagious disease caused by the coronavirus) in the building during that time. The ADON said it was an oversight. The ADON said a resident could negatively be impacted causing the resident to be overly sedated. The ADON said if the resident was stable on the current dose, she was not sure it would have a negative impact. During an interview on 6/3/2026 at 2:06 PM, the DON said she and the ADON were responsible for updating the orders for the GDR. The DON said it was missed and it has been completed now. The DON said Resident #5 was not overmedicated. The DON said was trying to GDR because the State makes us. The DON said she did not think there was a risk but not following the Physician order could negatively impact the resident. The DON did not elaborate on how it could impact the residents. During an interview on 06/03/2026 at 2:22 PM, the ADM said the clinical team was responsible for GDR and 3713. The ADM said he expected the medication to be decreased if the physician signed the order and the order should be put in right then. The ADM said there was a potential for a negative effect if orders are not being followed and would not elaborate.Requested GDR policy on 6/3/2026 at 2:06 PM. No policy received. Record review of the facility's policy titled, Use of Psychotropic Medication (s) dated 3/1/2026 indicated Policy.it is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Definitions: Adequate indications for use .refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition.For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication of use is inadequate. Policy explanation.1.affects brain activities associated with mental processes and behaviors.2.to be used only when a practitioner determined that the medication is appropriate to treat a resident's specific, diagnosed and documented condition.3.medications not classified as antipsychotic, antidepressant, antianxiety, or hypnotic medications but can affect brain activity.4.when a medication is used that can affect brain activity and central nervous system agents for use in conditions such as seizures, mood disorders.5.indications for initiating, maintaining, or discontinuing medication (s) as week as the use of non-pharmacological approaches.6. Non-pharmacological approaches must be attempted.7.medical record shall include documentation of this evaluation and rationale.8.the attending physician will assume leadership in medication management.9. Prior to initiating or increasing psychotropic medication, the resident, family and resident representative must be informed of the benefit, risk and alternatives.12.shall receive gradual dose reduction, unless clinically contraindicated in effort to discontinue these drugs.14.effects of the psychotropic drugs shall receive on resident's physical, mental and psychological well-being will be evaluated on an ongoing basis.15.resident response to the medication(s), including progress towards goals and presence/absence of adverse consequences.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 3 of 21 residents reviewed for assessments. (Resident #1, #10, and #65) 1.The facility failed to ensure the MDS was appropriately coded for bed rails/restraints for Resident #1. She did not have bed rails. 2.The facility failed to ensure the MDS was appropriately coded for insulin for Resident #10. She did not take insulin. 3.The facility to ensure Resident #65's MDS assessment accurately reflected he was discharged with return anticipated. This failure could place residents at risk for decreased quality of care due to inaccuracy of assessments. 1.Record review of Resident #1's face sheet, dated 6/2/26, indicated she was a [AGE] year-old female, with an original admission date ofadmitted [DATE]. She had diagnoses that included: Alzheimer's Disease with early onset (a progressive, irreversible brain disorder destroying memory, cognitive abilities and the ability to carry out daily tasks), Dementia (decline in cognitive abilities-such as memory, reasoning, and communication severe enough to interfere with daily life), Rheumatoid Arthritis (autoimmune disease where the body's immune system attacks the lining of the joints), and chronic pain. Record review of the quarterly MDS assessment, dated 3/22/26, indicated Resident #1 had clear speech, understood others, and was understood by others. She had a BIMS score of 15 indicating she was cognitively intact. Resident #1 was independent with a bed to chair or chair to bed transfer. Section P/Restraints and Alarms, of the MDS indicated she had a bed rail/restraint. Record review of the undated care plan indicated Resident #1 had acute and chronic pain, impaired cognitive function/dementia or impaired thought processes. The care plan indicated she had side rails to promote independence. During an interview and observation on 6/1/26 at 9:17 AM, Resident #1 was in her room in her wheelchair. She had a lot of personal items in her room. She wore a toboggan on her head. She said staff treated her well, kindly and professionally. She said the food was excellent and the portion sizes were good. She said she got her shower when she was supposed to. She had enabler bars on her bed. She said she did most things herself. She said she had not been and was not restrained in any way. 2.Record review of Resident #10's face sheet, dated 6/3/26, indicated she was a [AGE] year-old female that admitted [DATE]. She had diagnoses that included: Hemiplegia and Hemiparesis following cerebral infarction affecting left dominant side (due to a stroke a blood vessel in the brain is blocked or narrowed causing complete or partial paralysis on one side due to damage in parts of the brain that control voluntary muscle movement), seizures (uncontrolled burst of electrical activity in the brain), and Diabetes Mellitus type 2 with polyneuropathy ( the body resists insulin or cannot produce enough with prolonged high blood sugar that damages peripheral nerves). Record review of the quarterly MDS assessment, dated 4/8/26, indicated Resident #10 had clear speech, understood others, and was understood by others. She had a BIMS score of 14 indicating she was cognitively intact. Section N-Medications N0300.-Injections: indicated Resident #10 received injections 7 of 7 days. Section N-Insulin N0350 indicated Resident #10 received insulin 7 of 7 days. Record review of the undated care plan indicated Resident #10 had an unstable blood glucose level, and Diabetes Mellitus. Diabetes medications should be taken per doctor's orders. The Care plan indicated Resident #10 had a Cerebral Vascular accident (CVA/stroke) affecting non dominant side related to disease processes and seizures. Record review of the physician's orders, dated 6/2/26, indicated Resident #10 did not take insulin. She had orders for: 9/24/24 Check blood glucose level once weekly, one time a day every Friday. 9/18/24 Metformin tab 500 mg, give 1 tablet by mouth two times a day related to Type 2 Diabetes Mellitis without complications. During an interview and observation on 6/01/2026 at 9:38 AM, Resident #10 was dozing in her bed with her glasses on. She had coffee on her overbed table. She said her favorite was to order off the menu for lunch. She said staff treated her okay. During an interview on 6/1/26 at 12:07 PM, LVN F said Resident #10 had never taken insulin as far as she knew. During an interview on 6/1/26 at 1:43 PM, Resident #10 said she had not ever taken insulin. 3.Record review of Resident #65's face sheet, dated 6/3/26, indicated he was an [AGE] year-old man that admitted [DATE]. He had diagnoses that included: Acute on Chronic Systolic (Congestive) Heart Failure (the heart muscle is too weak or stiff to pump blood efficiently), Ventricular Tachycardia (a fast abnormal heart rhythm originating in the heart's lower chambers/ventricles), and a cardiac defibrillator (a medical device used to treat life-threatening heart rhythms and sudden cardiac arrest). Record review of the quarterly MDS assessment, dated 3/18/26, indicated Resident #65 had clear speech, usually understood others and was usually understood by others. He had a BIMS of 10 indicating he had moderate cognitive impairment. Record review of an MDS Nursing home Discharge, dated 5/20/26, indicated Resident #65 was discharging return not anticipated. The MDS indicated it was an unplanned discharge, and he had discharged to a Short-Term General Hospital. Record review of a MDS Nursing Home and Swing Bed Tracking Item Set, dated 5/21/26, indicated Resident #65 had entered the facility on 5/21/26 from a Short-Term General Hospital. Record review of Resident #65's care plan dated 5/28/26 indicated he had impaired cognitive function or impaired thought processes and oxygen therapy related to Congestive Heart Failure. During an interview and observation on 6/01/2026 at 10:31 AM, Resident #65 was lying in bed resting. Resident #65 stated that no one had been mean or abusive to him. He said Tthe food was fair. He said he got his medication on time and showersshowered 3 times per week. Resident #65 stated Sstaff responded to his call light timely. During an interview on 6/01/2026 at 1:26 PM, the MDS nurse said Resident #1 had never had bed rails and she should not have been marked for bed rails/restraints. She said she was unsure who had done the MDS, but she would check. She said she did not remember Resident #10 ever being on insulin. She said if Resident #10 was marked for taking insulin, it must have been a mistake, and she would check on that, too. She said she would modify both those MDS's. During an interview on 6/01/2026 at 1:32 PM, the MDS nurse said she marked the MDS wrong for Resident #10. She said on section N/Medications of the MDS, on 4/10/26 she marked Resident #10 for receiving insulin 7 of 7 days and marked she had injections for 7 of 7 days. She said that was incorrect and she would modify the MDS now. She said she wouldwill check on the MDS for Resident #1. During an interview and record review on 6/1/26 at 1:45 PM, the MDS nurse showed this surveyor a sheet indicating she had exported MDS modifications for Resident #10 for her assessment on 3/22/26 and Resident #1 for her MDS dated [DATE]. During an interview on 6/01/2026 at 1:50 PM, the MDS nurse said she had modified Resident #1's MDS to show she did not have bedrails. She said Resident #1 never had restraints or a bed rail, and it must have been a technical error because she did not intentionally mark that. During an interview on 6/3/26 at 10:25 AM, the MDS nurse said Resident #65's MDS dated [DATE] should not have been marked discharged with a return not anticipated. She said he had gone to the emergency room, and she knew he was coming back. She said it must have been a technical error. She said it was an easy fix and she would do a modification to show discharged , return anticipated. During an interview on 6/03/2026 at 12:00 PM, the ADON said she did not know much about MDS's. She said they would not want to lie or misrepresent a resident. The ADON said Ifif the care plan was done from the MDS and the MDS was wrong, they could be thinking an issue was there for a resident that was not. She said as nurses they would look at the orders and be able to see what was going on with a resident. During an interview on 6/03/2026 at 12:05 PM, the DON said Resident #10 being marked for insulin when she was not on insulin and Resident #1 being marked for bedrails when she did not have them presented an inaccurate picture and inaccurate assessment of those residents. She said Resident #65 should not have been marked discharged , return not anticipated because that would give CMS an inaccurate picture of those residents. During an interview on 6/03/2026 at 12:18 PM, the ADM said Resident #65's MDS being marked discharged , return not anticipated was a communication issue. He said for Resident #1 being marked for bedrails could have thrown off the reimbursementthe reimbursement rate. The ADM said Resident #10 being marked for receiving insulin when she did not, could cause confusion regarding continuity of care. Record review of a Conducting an Accurate Resident Assessment, dated 3/1/26, provided by the DON indicated: Policy:The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the residents' status at the time of the assessment, by staff qualified to assess relevant care areas. Definition: Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status). Policy Explanation and Compliance Guidelines: 1.The Administrator will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 2.Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 3.The appropriate, qualified health professional will correctly document the residents medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 21 residents reviewed for ADLs (Residents #20.) The facility did not clean or trim Resident #20's fingernails. This failure could place residents at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.Findings included: Record review of Resident #20s face sheet, dated 01/20/2026, revealed Resident #20 was a [AGE] year-old male admitted [DATE] and re-admitted [DATE] with diagnoses including Cerebral Infarction (A cerebral infarction, commonly known as an ischemic stroke, occurs when a blood vessel in the brain is blocked or narrowed), Seizures (A seizure is a sudden, uncontrolled burst of electrical activity in the brain), and Urticaria (a skin reaction characterized by raised, itchy, red or skin-colored welts). Record review of Resident #20's quarterly MDS assessment, dated 03/05/2026, revealed a BIMS score of 13, which indicated resident #20's cognition was intact. The MDS also revealed, Resident #20, required total dependance with personal hygiene. Resident #20 required one-person physical assistance with personal hygiene, including nail hygiene. Record review of Resident #20's care plan problem, dated 1/31/2025, revealed that Resident #20 had a self-care deficit: bathing, dressing, and feeding. Interventions included staff were to check nail length, trim, and clean on bath day and as necessary andreport any changes to the nurse. During an interview and observation on 6/1/26 at 10:00 a.m., Resident #20 was observed with long black and brown fingernails. His nails were approximately a half inch long. There was a black and brown substance underneath the nails. He said that he could not cut his own nails as he did not have use of his left arm. He said that a staff cuts and cleans his nails. He said that it bothered him that his nails were in the condition they were in and wanted them cut. He said that it was well over a week since his nails were cut. During an interview and observation on 6/03/26 at 9:55 a.m., Resident #20 said his nails had not been cut all week. He said that he was still waiting for his nails to be cut. He said that no staff had offered to cut his nails. Resident #20's nails were approximately half an inch and had black and brown substances underneath the nail bed. During an interview on 6/03/26 at 10:05 a.m., CNA C said that it was the responsibility of CNAs or any nursing staff to cut residents' fingernails. She said that Resident #20 was dependent on care. She said he couldn't use his left arm, and he said he could not cut his nails on his own. She said that she did not know why his nails had not been cut for so long, but she did not usually work in this hall. She said today she was working the hall with Resident #20 and she noticed his nails were long and dirty. She said she offered to cut his nails and he agreed. She said she had not cut his nails yet because she was waiting for when she had free time. She said that it could be unsanitary if residents did not have their nails trimmed and cleaned regularly. During an interview on 6/3/26 at 12:00 p.m., the Director of Nurses said that it was the responsibility of nursing staff to ensure residents who were dependent for ADLs had their needs met including cutting and cleaning of their nails. She said failure to do so could place residents at risk of infection. During an interview on 6/3/26 at 12:05 p.m., the Administrator said that it was the responsibility of nurses to cut and clean nails of residents. He said that residents could be placed at risk of infection if they did not have their nails cleaned. Record review of the facility policy titled, Activities of Daily Living, dated 3/1/2026, revealed that the purpose of this policy was to: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 16 residents (Resident #40) reviewed for resident call system. The facility failed to ensure Resident #40 had a call light button attached to the call light system. Resident #40 did not have a call light available on [DATE]. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.Findings include: Record review of Resident #40's face sheet, dated [DATE], reflected an [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #40 had diagnoses which included: vascular dementia (a decline in thinking and memory skills caused by restricted blood flow and oxygen to the brain), encounter for palliative care and chronic kidney disease (the progressive loss of kidney function over time, impairing the body's ability to filter waste and excess fluid from the blood). Record review of Resident #40's MDS assessment, dated [DATE], reflected Resident #40 was usually understood and usually understood by others. Resident #40's BIMS score was a 3, which indicated severe cognitive impairment. Resident #40 dependent with all ADLs. Resident #40 was always incontinent to bowel and bladder. Record review of Resident #40's care plan, dated [DATE], reflected Resident #40 has impaired thought processes related to dementia. During an observation on [DATE] at 10:05 AM, Resident #40 was lying in bed looking around. Resident #40 did not have a call light button attached to the call light system. During an observation on [DATE] at 12:45 PM, Resident #40 was lying in bed resting. Resident #40 did not have a call light button attached to the call light system. During an interview on [DATE] at 3:19 PM, the Maintenance Supervisor stated he fixed the call light in Resident #40's room that morning. He stated he put a double plate on the wall, so that there would be two call light cords instead of one. He stated before he replaced the plate that morning there was only one call light cord in the room and Resident #40's roommate had it. He stated there was another call light connection behind the television, because the staff moved the resident's bed around. He stated the staff notified him about adding the call light Friday, but he fixed it that morning. He stated every resident should have a call light in case they need to call for assistance or help. During an attempted interview on [DATE] at 8:02 AM, with Resident #40 he was asked if he could use the call light, but Resident #40 did not respond. During an interview on [DATE] at 8:05 AM, LVN E stated Resident #40 could use his call light. She stated he did not use it very often and usually his wife would get on the call light for him. She stated all staff were responsible for ensuring a resident had a call light accessible and within reach. She stated a negative effect was Resident #40 not being able to get the help he needed. During an interview on [DATE] at 1:02 PM, the Director of Nursing stated she expected all residents to have call light. She stated all staff were responsible for ensuring the residents had call light. She stated a negative effect of not having a call light accessible was that a resident would not be able to call for assistance. During an interview on [DATE] at 1:11 PM, the Administrator stated he expected all residents to have a call light accessible. He stated the maintenance team were responsible for ensuring the call lights were installed and operating properly. He stated the CNAs were responsible for ensuring the call light was within reach. He stated a negative effect was that Resident #40 did not have the ability to voice his needs or wants. Record review of the facility's policy Call Lights: Accessibility and Timely Response dated [DATE], indicated . The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to staff member or centralized location to ensure appropriate response. 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alterative solutions until the problem can be remedied .

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 2 of 16 residents reviewed for storage of drugs and biologicals (Resident #2 and Resident #30). 1.The facility failed to securely store wound care chemicals for Resident #2. 2. The facility failed to ensure Hydrocortisone 1% anti-itch liquid was properly stored and locked in accordance with currently accepted professional standards for Resident #30. This failure could place residents at risk for adverse reactions, reduced therapeutic effects of medications and supplies, risk of having access to unauthorized medication and/or lead to harm. Findings included: 1.Record review of Resident #2's face sheet dated 6/3/26 reflected a [AGE] year-old male who was initially admitted on [DATE] and was readmitted to the facility on [DATE]. Resident #2 had diagnoses which included: diffuse traumatic brain injury with loss of consciousness of 30 minutes or less (widespread damage caused when rapid acceleration, deceleration, or rotational forces twist and tear the brain's long connecting nerve fibers), quadriplegic (a medical condition involves the partial or total loss of motor), cognitive communication deficit and need for assistance with personal care. Record review of Resident #2's MDS assessment, dated 5/28/26, reflected Resident #2 sometimes understood and usually understood by others. There was no BIMS assessment conducted for Resident #2. Resident #2 was dependent on ADLs. Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's care plan dated 5/1/26 reflected Resident #2 has an abrasion to right wrist. The intervention: provide wound care per treatment order.Resident review of Resident #2 care plan date 7/15/25 reflected Resident #2 has impaired cognitive function or impaired thought process related to traumatic brain injury.Record review of Resident #2's care plan dated 10/16/24 reflected Resident #2 had impaired cognitive function. The intervention: encourage resident to participate in simple, structured activities. Record review of Resident #2's order summary report reflected, clean right wrist wound with wound cleanser, pat dry, and apply Leptospermum honey. Cover with dry dressing. Change every day and as needed, every day shift for wound care, dated 5/20/26. During an observation on 6/2/26 at 8:29 AM, the surveyor observed wound cleanser on the shelf in Resident #2's bathroom on a shelf. During an interview and observation 6/2/26 at 1:32 PM, the surveyor took the Assistant Director of Nursing to Resident #2's bathroom and showed her the wound cleanser on the shelf in the bathroom. The Assistant Director of Nursing stated sometimes the staff left wound cleanser in the resident's drawers in their rooms, but staff did not leave the wound cleanser in the bathroom. She stated the wound cleanser was not the facility product, she stated hospice probably left the wound cleanser there. She stated the negative effect was that anyone could wander into the resident's bathroom and use the wound cleanser and use it inappropriately. During an interview on 6/3/26 at 8:05 AM, LVN E stated whether the resident had a wound or not the wound cleanser should not have been left in the bathroom. She stated everybody was responsible for ensuring the wound cleanser was not in Resident #2's bathroom. She stated a negative effect of an improper stored medication was that a resident could use the wound cleanser inappropriately. During an interview on 6/3/26 at 1:02 PM, the Director of Nursing stated she expected the wound cleanser not to be accessible to the residents in the facility. She stated the wound cleanser should be stored properly. She stated staff in and out of the rooms were responsible for ensuring the wound cleanser was not in Resident #2's bathroom. She stated a negative effect of the improper storage of medications could be a severe effect if a resident got a hold to the wound cleanser. During an interview on 6/3/26 at 1:11 PM, the Administrator stated he expected all medications to be properly stored. He stated the clinical team were responsible for ensuring all medications were stored properly. He stated a negative effect was that a resident could potentially consume or administer the wound cleanser and that could cause an issue. 2.Record review of Resident #30's face sheet dated 6/3/2026 indicated Resident #30 was [AGE] year-old female admitted on [DATE] with diagnoses including Vascular Dementia (a decreased blood flow, which can damage brain tissue), centrilobular emphysema (a common form of COPD that primarily damages the central portions of the lung lobules, especially in the upper lobes, and is strongly associated with long-term smoking), hypertension (a common condition where the force of blood against the artery walls is consistency too high), and osteoporosis (a condition that weakens bones and increases the risk of fractures). Record review of Quarterly MDS dated [DATE] indicated Resident #30 was unable to complete the BIMS assessment due to resident was rarely/never understood and was severely cognitively impaired. The MDS indicated Resident #30 required set-up assistance with toileting, bathing, dressing upper and lower body. Record review of Resident #30's Care Plan revised on 4/23/2025 indicated Resident #30 resided on a secure memory unit with interventions which included: A structured environment will be provided to create a stress-free lifestyle, elopement assessment will be conducted upon initial admission to the facility and weekly x 4 weeks, and physician order will be obtained for the resident to reside on the memory care unit. Record review of the facility's medication record dated 6/1/2026-6/30/2026 indicated Resident #30 did not have an order for Hydrocortisone 1% anti-itch liquid. During an interview and observation on 6/1/2026 at 9:26 AM, Resident # 30 was sitting on her bed and had her side table drawer open. Resident #30 had Hydrocortisone 1% anti-itch liquid in the top drawer with her name on it. Resident #30 could not tell what the Hydrocortisone liquid was for, and she did not indicate it was used. During an interview and observation on 6/2/2026 at 1:56 PM, CNA H [NAME] said residents should not have any topical medications in their rooms. CNA H said if medications were identified in a room, she would turn medication into the nurse. CNA H said the residents could take too much of the medication or eat the topical medication or put it in their eyes causing them to go blind. CNA H said the CNAs were responsible there were no medications in the resident room and she would give the medication to the charge nurse. CNA said the CNAs checked rooms every 2 hours. CNA H said a family member brought that medication to her. CNA H went to Resident #30's room and the medication remained on her bedside table. CNA H said Resident #30's family must have brought up the medication and removed the Hydrocortisone medication. During an interview on 6/3/2026 at 11:48 AM, CNA B said residents on the secure unit should not have medications or topical medications in their rooms. CNA B said residents' visitors have brought medication in and was not always caught due to Resident #30 hiding items. CMA B said they go through the drawers weekly. CNA B said the CNAs; CMAs were responsible for checking rooms weekly and sometimes more. CNA B said a resident could drink the medication or use the medication in a way not intended. CNA B said it could make the residents sick or cause them harm if the residents got it in their eyes. During an interview on 06/03/2026 at 12:01 PM, CNA G said residents should not have medications in room. CNA G said a resident could get sick and it may not be their medication. CNA G said the residents should not have ointments, and it may not be for them. CNA G said the CNAs check the rooms every other day. CNA G said another resident could get a hold of a medication they are not supposed to have. CNA G said the nurse and CMA were responsible for making sure the residents do not have medications in room. During an interview on 06/03/2026 at 12:13 PM, LVN D said residents should not have medications in their room including ointments and creams. LVN D said the CNAs were responsible for checking daily medications while they were getting the residents ready for the day. LVN D said families bring things such as ointments that the staff were not aware of. LVN D said anything could happen. LVN D said a resident could get an ointment and get it in their eyes. LVN D said the nurses were responsible for ensuring all medications were stored properly. During an interview on 06/03/2026 at 1:29 PM, the ADON said medication should not be in a resident room. The ADON said we tell the family not to bring in medications. The ADON said the staff had been instructed to make sure medication brought in was not in the resident room within their reach. The ADON said the resident could put ointment in her eyes if her eye itched. She could put the medication in places that were not intended for. The ADON said every staff member was responsible for ensuring medications were secured. During an interview on 6/3/2026 at 1:54 PM, the DON said Resident #30 should not have cream or ointments in her room. The DON said all staff were responsible for ensuring the medications were stored and secure. The DON said it could be harmful to the resident if they ingested the medication or if another resident got the medication. The DON said a resident could have a reaction or nothing could happen. During an interview on 06/03/2026 at 2:28 PM, the ADM said he expected the medication to be locked up and secure including ointments. The ADM said if there was no order for the medication, the resident could have an allergic reaction to the ointment. The ADM said the clinical team was responsible for making sure the medication were locked up. Review of a facility policy titled Medication Storage last revised in March 1, 2026 indicated It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse from a visitor for 1 of 3 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse on 05/17/26 when Visitor A was found with his hand down Resident #1's pants. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 05/17/26 and ended on 05/17/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious adverse psychosocial outcome such as fear, anxiety, shame or guilt, depression, withdrawal from activities, helplessness, low self-worth, and post-traumatic responses such as flashbacks, nightmares, or increased startle responses.The findings included: Record review of the face sheet, dated 05/26/26, reflected Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of vascular dementia (decline in thinking and reasoning skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients) and generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday issues). Record review of the quarterly MDS assessment, dated 04/16/26, reflected Resident #1 had clear speech, was understood by others, and was able to understand others. Resident #1 had a BIMS score of 6, which indicated severe cognitive impairment. Resident #1 required setup assistance with eating, oral and toileting hygiene, and bed mobility. She required supervision or touching assistance with bathing, dressing, personal hygiene, and transfers. Record review of the comprehensive care plan, dated 01/21/25, reflected Resident #1 had impaired cognitive functioning and impaired thought processes related to dementia. The interventions included: cue, reorient, and supervise as needed and keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Record review of Resident #1's nursing progress note electronically signed by LVN E on 05/17/26 at 11:30 a.m., reflected [CNA B] called [LVN E] reports a male visitor that was visiting another resident was sitting on the couch and throw blanket was covering [Resident #1] and [Visitor A]. [CNA B] reports she then pulled throw blanket off of [Resident #1] and [Visitor A] was observed with his hand placed inside [Resident #1's] brief. [CNA B] immediately removed [Resident #1] from couch and away from [Visitor A]. [CNA B] confronted white male on his actions. [Visitor A] then left memory care unit and [CNA B] alerted [LVN E], [Visitor A] proceeded to walk past [LVN E] at [nurses' station]. [LVN E] attempted to stop and question [Visitor A] he [continued] to leave the building. [RN F] made aware of incident. [RN F] and [LVN E] proceeded to follow [Visitor A] as he [continued] fleeing to parking lot and left facility. DON, [Administrator], [Medical Director] notified of incident. [Resident #1's responsible party] notified of incident involving [Resident #1] and police being notified and [Resident #1's responsible party] verbalized she is in agreement with this plan of care. [Local police department] notified. Head to toe assessment completed on [Resident #1] no trauma or injury noted to vaginal opening. No bleeding or redness is observed. Trauma assessment completed at this time on [Resident #1]. [Resident #1] questioned with no recall of [Visitor A]. No emotional distress or trauma observed from [Resident #1] at this time. [Vital signs] - 97.8 [temperature], 60 [pulse], 18 [respiratory rate], 134/68 [blood pressure] [respirations] even and non-labored skin [warm/dry] color [within normal limits] no distress noted. Record review of CNA B's witness statement, dated 05/17/26, reflected While giving care to [another resident]. [Resident #2] had a visit and I cleaning [another resident] up the man went and sit on the couch with [Resident #1] and when I walk over there and told [Resident #1] it was time for lunch and I pulled the covers back and he had his hands in her pants. And he jump off the couch and ran out of here.[sic] Record review of MA C's witness statement, dated 05/17/26, reflected [Resident #2] had a visitor to whom when over and sat by [Resident #1]. Meantime me and another CNA was busy cleaning up another resident, when finished the other CNA went over to get [Resident #1] up because she felt uneasy about [Visitor A], she discovered that the visitor had pulled the blanket that the resident had over his lap also. When CNA pulled the blanket off, we saw that the visitor had his hand in her brief. [sic] Record review of RN F's witness statement, dated 05/17/26, reflected Tall, white older male with dark hair walked toward nurses' station, leaving facility. He greeted us and proceeded down hallway toward front door. We received a phone call from the cove (memory care unit) answered by [LVN E], advising this visitor was caught with his hand down the front of a resident's pants. Nurse asked visitor to wait but was told he needed to get his medicine from his truck. This nurse and [LVN E] followed visitor to parking lot, where the visitor proceeded to get into his truck and leave the parking lot. This nurse took a pictures of his license plate and video of his truck. Record review of LVN E's witness statement, dated 05/17/26, reflected [NAME] male approached [nurses' station] asked to see [Resident #2] a resident that resides in memory care unit. This nurse instructed [white male] to head down hall 200 to memory care unit code provided. This nurse was called to [memory care unit] to render aide to another resident. [NAME] male was observed on the couch next to [Resident #1]. This nurse then exited [memory care unit] back to [nurses' station]. Call received from [CNA B] in [memory care unit] reports that [white male] had his hand in [Resident #1's] brief when she pulled the throw blanket off [Resident #1's] lap. [White male] passing [nurses' station] this nurse immediately followed [white male] asked him to stop that I had questions for him. [White male continued] to exit building with urgency. This nurse and [RN F] followed [white male] out of building. [White male] proceeded to get in truck and leave, this nurse stood in driveway with hand up gesturing to stop, [white male continued] to drive off, this nurse moved out of driveway (to avoid being hit). [RN F] was able to video license plate [number]. Record review of the skin check, dated 05/17/26, reflected Resident #1's skin was warm and dry, skin color was within normal limits, and turgor was normal. No new skin issues were identified. Record review of the trauma informed care assessment, dated 05/17/26, reflected Resident #1 indicated she had not experienced an event that was unusually or especially frightening, horrible, or traumatic. Record review Resident #1's orders report, dated 05/17/26, reflected a new order was started for the following:1. Monitor every shift for signs or symptoms of emotional distress for three days.2. Refer to social services one time only for three days. Record review of the Abuse/Neglect Policy in-service training report, dated 05/17/26, reflected all staff were provided education on the abuse and neglect policy to include the following: abuse occurring by anyone including visitors, types of abuse, and reporting abuse or suspected abuse to the Abuse Coordinator (Administrator) immediately. There were 58 staff signatures. Record review of the The Cove - Door Code Instructions in-service training report, dated 05/17/26, reflected all staff were provided education on the secured unit door code being changed. The in-service informed staff the code was not to be given out to visitors. The visitors were to be escorted in and out of the secured unit by a staff member. There were 42 staff signatures. Record review of the Sexual Abuse in-service training report, dated 05/17/26, reflected all staff were provided education on the types of sexual abuse, to include unwanted touching and signs and symptoms of sexual abuse to include emotional and physical trauma. There were 58 staff signatures. Record review of the Visitor A - Not allowed on property in-service training report, dated 05/17/26, reflected all staff were provided education and description of Visitor A not being allowed on the property and to notify the police department and Administrator immediately if seen. There were 44 staff signatures. Record review of the Visitor Sign In - Kiosk in-service training report, dated 05/17/26, reflected all staff were provided education on making sure visitors check in on the kiosk located in the front lobby. The visitors were to wear the sticker at all times while visiting. The staff were instructed if a visitor did not have a sticker, to escort them to the front and assist them with signing in. There were 57 staff signatures. Record review of the Resident #1's progress note electronically signed and dated by the Social Worker on 05/18/26 at 8:33 a.m., reflected Emotional distress assessment completed following report. [Resident #1] reported she was 'fine' emotionally and denied feelings of sadness, anxiety, loneliness, anger, or being overwhelmed. [Resident #1] denied any current emotional distress, suicidal ideation, or homicidal ideation. [Resident #1] stated she feels safe at this time and declined need for social services, family involvement, or additional supportive services. [Resident #1] unable to recall details related to prior incident. During assessment, [Resident #1] appeared calm, pleasant, well-groomed, and cooperative with conversation. No acute signs of emotional distress or behavioral concerns noted. [Resident #1] rated emotional distress [0 out of 10]. [Resident #1] reported difficulty with sleep, stating she is unable to fall asleep until approximately 2 - 3 a.m., and expressed interest in medication to assist with sleep. For safety and potential psychosocial impact, referral will be placed to [counseling services] for further in-depth psychosocial evaluation and risk assessment. Record review of Resident #1's orders report, dated 05/18/26, reflected a new order was started for counseling services to evaluate and treat as indicated one time only for psychiatric services. Record review of resident safe surveys, dated 05/18/26, reflected Resident's #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 were interviewed. The residents denied anyone being abusive, knowing about any abuse, and all verbalized they felt safe in the facility. Record review of the Quality Assurance Committee Meeting Agenda form, dated 05/18/26, reflected the Administrator, DON, ADON, MDS Coordinator, Social Worker, Business Office Manager, Dietary Manager, Director of Rehabilitation, Housekeeping Supervisor, Transportation Aide, Maintenance Director, Activity Director, and Medical Director met to discuss Resident #1 being subjected to sexual abuse. Record review of Resident #1's counseling diagnostic assessment, dated 05/19/26, reflected Resident #1 was re-admitted for services following a confirmed incident of inappropriate touching by another resident's family member. This assessment was conducted through Telehealth (digital technology to access healthcare services using computer, smartphone, and the internet). Resident #1 had no recollection of any type of inappropriate touching and could not recall anything of any nature occurring that she found distressing. Resident #1 confirmed feeling safe and properly care for in this facility and stated that all of her needs were currently met. Resident #1's conversation reflected short-term and long-term memory loss over situational confusion. During an observation on 05/26/26 at 8:35 a.m., there was signage inside the front door indicating visitor sign-in was required on the kiosk. There was a small kiosk stand in the hallway with a stop sign that stated STOP: Visitors Must Sign-In During an interview on 05/26/26 at 9:00 a.m., the DON stated the code to the secured unit had changed. During an observation and interview on 05/26/26 at 9:15 a.m., Resident #1 was sitting on the couch in the secured unit, which was placed against the wall. The couch was visible from all areas of the dining room and living areas. Resident #1's hair was combed neatly and her face was clean. Resident #1 stated the staff treated her well and she had no issues with any of the male staff or male visitors. Resident #1 stated she felt safe at the facility. Resident #1 was unable to remember the incident with Visitor A. During an interview on 05/26/26 at 9:37 a.m., Resident #1's family member stated she was notified Visitor A had his hands down Resident #1's pants on 05/17/26. She stated the staff acted immediately and appropriately. She stated the police were involved. She said that Resident #1 had dementia and did not remember the incident. She stated if Resident #1 was in her right mind, she would have slugged the man and would have been mortified. She stated Resident #1 had no previous history of trauma in her life. During an interview on 05/26/26 at 10:16 a.m., CNA B stated she normally worked the 2-10 shift, but on 05/17/26 she had picked up a morning shift. She stated another resident had thrown up and she assisted him down the hallway to get him changed. She stated she assisted the other resident back up the hallway, she noticed Visitor A, who was visiting Resident #2, was sitting on the couch next to Resident #1. She said she thought it was strange, so she sat the other resident down and then played like it was time for lunch. She said she told Resident #1 it was time for lunch and then pulled the blanket off her lap. She said Visitor A's hand was down her pants. She stated Visitor A was struggling to get his hands out of her pants and she immediately tried to get Resident #1 off the couch. She said she kept asking Visitor A why his hands were in her pants, but he would not answer the questions. She said Visitor A then became very nervous and ran off the secured unit. CNA B stated she called LVN E to report the incident. She stated Resident #1 seemed sad and distressed immediately after the incident and stated, I didn't tell him to put his hands in my pants, he just did it. CNA B stated Resident #1 did not remember the incident later on. CNA B stated the police were notified and she had to write a statement about what happened. She stated the code to the secured unit was changed and the furniture was re-arranged. She stated Visitor A was no longer allowed on the property and if he tried to visit, they were instructed to notify the police and administration. During an interview on 05/26/26 at 10:34 a.m., MA C stated Visitor A had come to the facility to visit Resident #2. She stated another resident got sick during that time and started throwing up. She stated she was cleaning up the vomit, and Visitor A was standing behind her and kept saying You missed a spot. She stated Visitor A walked off toward the couch and she finished cleaning, then started caring for another resident in the dining room. She stated CNA B returned to the living area and noticed Visitor A was sitting by Resident #1 on the couch. She stated when CNA B lifted Resident #1's covers off her lap; Visitor A's hand was observed down her pants. MA C stated CNA B immediately moved Resident #1 off the couch and Visitor A quickly got up and left. She stated a housekeeper on the other side of the doors let Visitor A off the secured unit. She stated he was running down the hallway. MA C stated Resident #1 stated I don't know why he put his hands in my pants he just did. MA C stated she initially seemed distressed and nervous but then quickly forgot about the incident. She stated LVN E called the police and they arrived at the facility right away. She stated LVN E and RN F assessed Resident #1 and she had no injuries or evidence of trauma. During an interview on 05/26/26 at 11:03 a.m., LVN E stated Visitor A had come into the building as asked her about visiting Resident #2. She said she instructed him toward the memory care unit and gave him the code. She stated Visitor A had visited before with no issues. LVN E said not long after that encounter, she received a call from the secured unit about another resident who was sick. LVN E stated as they were assisting the other resident to be cleaned, Visitor A was observed sitting on couch next to Resident #1 and she did not think anything about it. LVN E stated she did not see Resident #1 and Visitor A under the blanket together or she would have said something. LVN E stated she walked back to the nurses' station to document. She stated CNA B called her not too long after that to report Visitor A was found with his hand down Resident #1's pants. CNA B had reported she had confronted Visitor A, who then got up to leave. She said a housekeeper had let him off the secured unit. LVN E stated she tried to stop Visitor A but he was walking briskly. She stated Visitor A kept saying he needed to go to truck for medication. LVN E stated she and RN F followed Visitor A outside. She stated that he started driving down the driveway and she stood in the road holding her hand up to try and stop him, but he kept driving. She stated RN F got the vehicle information and they notified the police department, DON, Administrator, family member, and Medical Director. There were no new orders given. She stated a head to toe assessment and trauma assessment were completed and negative for findings. She stated Resident #1 did not recall what happened by the time she was assessed. She stated the code to the secured unit was changed, the furniture was rearranged, and Visitor A was banned from the facility. She was instructed to notify police and administration immediately if he attempted to come back. During an interview on 05/26/26 at 11:18 a.m., RN F stated she was standing at the nurses' station, when Visitor A walked down the hallway. Visitor A stated Hope yall have a nice day. She stated about that time the phone rang, and LVN E was notified Visitor A was caught with hand down Resident #1's pants. She stated Visitor A started walking faster. She stated she and LVN E followed him to parking lot. She said he kept saying he needed medication out of his truck. She said LVN E stood in parking lot with her hand up and she videoed the truck as he drove past and took off. RN F stated the police were notified along with the Administrator, DON, family, and doctor. She said Resident #1 was assessed head to toe, no physical injuries or evidence of trauma. A trauma assessment was completed with no negative findings. RN F stated Resident #1 did not remember anything due to dementia. She stated the police arrived and statements were provided. During interviews on 05/26/26 between 11:27 a.m. and 12:35 p.m., Housekeeper K, Housekeeper M, DA U, Dietary Manager, CNA B, CNA D, CNA L, CNA Q, CNA R, CNA S, CNA T, MA C, MA G, LVN E, RN F, COTA N, PTA P, ST O, Maintenance Supervisor H, and Activity Director verbalized in-service education was provided after the incident with Resident #1. The staff stated they were provided education on sexual abuse to include types of sexual abuse, signs and symptoms of sexual abuse, reporting allegations of sexual abuse immediately to the Administrator (Abuse Coordinator). The staff were provided pictures of Visitor A and his vehicle. They were instructed he was not allowed on the property and if he was noticed on the property to notify the police and administration immediately. The staff were in-served on the visitor sign-in procedure. They were able to verbalize all visitor were to sign-in at the front using the kiosk. The staff said the visitor were to wear a sticker badge visible at all times while visiting. The staff stated if a visitor did not have a sticker badge, then they were to escort them to the front and assist them with getting one. The staff stated the secured unit code was changed and was not to be given to visitors. The staff were instructed to escort visitors to and from the secured unit. During an interview on 05/26/26 at 12:29 p.m., the DON stated on 05/17/26 she received a call from the facility that Visitor A was found with his pants down Resident #1's pants. She stated she was told the staff had try to stop him from leaving but he took off. LVN E and RN F followed him outside and was able to get a license plate number. She stated she instructed the nurses to call the police and she called the Administrator, who was the abuse coordinator, and the Regional Compliance Nurse. She stated LVN E and RN F completed a head to toe skin assessment and a trauma assessment, which was negative for findings. She stated the family and Medical Director were notified. The Administrator completed the self-report to the state. The DON stated she started in-service education on the abuse and neglect policy, sexual abuse, visitor sign-in, changed code of the secured unit, and Visitor A being banned from the facility, which included pictures. She stated the staff rearranged the furniture of the secured unit. The management staff conducted an ad hoc quality assurance meeting. Safe surveys were conducted and there were no other issues identified. During an interview on 05/26/26 at 12:40 p.m., the Administrator stated the DON called him on 05/17/26 to report the incident with Visitor A and Resident #1. He stated they immediately contacted their regional supervisors and decided to report the incident to the state and complete an investigation. He said the facility had already been notified to contact the police. He said Visitor A had left the building, and the cops responded to the facility. They obtained statements from the nursing staff. He said Resident #1 was assessed by nursing staff with no negative findings. He stated Resident #1 had no recollection of the incident. He stated he started in-service education on the abuse and neglect policy, sexual abuse, secured unit code, visitor sign-in process, and Visitor A being banned from the facility. He stated safe surveys were conducted with other residents and no other issues were identified. He stated Visitor A had been in the facility before with no other incidents or suspicions. Record review of the Abuse, Neglect, Exploitation, & Misappropriation Policy, dated September 2024, reflected Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. 1. Protects residents from abuse. by anyone including but no necessarily limited to: . Family members. visitors. Or any other individual. The noncompliance was identified as PNC. The noncompliance began on 05/17/26 and ended on 05/17/26.

Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to ensure the daily staffing needs were followed according to the facility assessment. This failure could place residents at risk of inadequate care or treatment and a decreased quality of life. Findings included: During a confidential group meeting on 04/22/2025 at 10:30 AM, the group reported getting bed baths instead of showers, call lights not being answered timely, and the CNAs telling them they were short staffed so if they did not respond to a call light timely or were taking too long to assist them that was the reason why they were taking so long. The group reported it made them feel like they should not request assistance from the CNAs. During an interview Anonymous Staff Member #1 said the CNAs often did not show up to work, and the on-call nurse and head CNA tried to fill in. Anonymous Staff Member #1 said when the CNAs did not show up to work, they were not always replaced. Anonymous Staff Member #1 said they worked shorthanded frequently. Anonymous Staff Member #1 said for sure on Sunday, 04/20/2025, they were short CNAs on the 2 PM- 10 PM shift. Anonymous Staff Member #1 said they had been at the facility until 6 PM and nobody from management showed up to assist due to the staffing shortage. Anonymous Staff Member #1 said the DON and RN K were notified of the CNA shortage on 04/20/2025. Anonymous Staff Member #1 said management was aware they had been having to work short. Anonymous Staff Member #1 said management rarely helped to cover the CNAs, if management worked, they were covering a nurse position so they could not do the CNAs job. Anonymous Staff Member #1 said lately they had been working short a lot. Anonymous Staff Member #1 said not having enough staff to provide care to the residents could affect their care because they would not get toileted on tie or they would have to wait long periods of times to be changes, and this could result in an increased risk for skin breakdown. During an interview Anonymous Staff Member #2 said they were short CNAs almost every day. Anonymous Staff Member #2 said nurse management did not help to cover the CNAs when a CNA did not show up to work. Anonymous Staff Member #2 said when a CNA that was scheduled to work did not show up, management told them they had to work with what they had. Anonymous Staff Member #2 said not having enough staff could affect the residents because they would not get the care they deserved. During an interview, Anonymous Staff Member #3 said they had been short CNAs and management told them they were trying to get help, but they never did. Anonymous Staff Member #3 said when they were short CNAs, they were not able to provide all the showers, and they had to clean the residents with towels instead. Anonymous Staff Member #3 said management did not help when they were short staffed. Anonymous Staff Member #3 said the weekend RN supervisor did not help the CNAs when they were short. Anonymous Staff Member #3 said the nurses and the medication aides did not help the CNAs when they were short. Anonymous Staff Member #3 said not having enough staff could affect the residents because they would not receive the care they needed. During an interview on 04/23/2025 at 3:33 PM, RN K said she was the weekend RN supervisor. RN K said if the CNAs did not show up to work or called off, they tried to find someone to fill the position and she notified the ADON or the DON. RN K said they were not always able to fill the position and they try to pitch in together and take care of the residents. RN K said on 04/20/2025 she was told as she was going out of the door that one of the CNAs had called off. RN K said she was told that it had been covered, but she did not remember who told her. RN K said if there was not enough staff the residents would not receive the proper care that they should be getting. During an interview on 04/23/2025 at 3:57 PM, LVN L said sometimes they were short, and they tried to call in other staff members, notified the ADON and DON, and if it was the weekend they notified the weekend RN. LVN L said sometimes they were told to do the best they could. LVN L said recently they had started using agency staff to fill in. LVN L said if they did not have enough staff, it could affect the residents because they would not receive proper/timely care. During an interview on 04/24/2025 at 10:34 AM, the DON said if the staff called off nurse management worked or got somebody to work. The DON said they all together worked to take care of the residents. The DON said there were a lot of times that they had not been able to fill the gaps. The DON said the staff had told her that they were unable to complete all their daily tasks. The DON said on 04/17/2025 they started using a staffing agency to help with the staffing shortage. The DON said she could not replace somebody when they called off last minute. The DON said not having enough staff placed the residents at risk of their care not being provided efficiently. During an interview on 04/24/2025 at 11:06 AM, the Administrator said they tried to hire PRN staff to cover when staff did not show up to work, and the DON or ADON and the CNAs also helped to cover the shifts. The Administrator said they also started using a staffing agency to help with the staffing issues. The Administrator said a lot of times he did not know until the middle of the night and then the ball gets dropped, but they tried to do their best to get more people to the facility. The Administrator said typically the charge nurses reported to him that they were short, and it was also reported to him that the CNAs were not able to get to all the showers. The Administrator said he was aware that they had been staffing less than the requirements per the facility assessment. The Administrator said the staff were not supposed to tell the residents they were short staffed. The Administrator said there could be a negative effect on the quality of care the residents received if the facility was not adequately staffed. Record review of the Facility assessment dated [DATE] indicated, Facility-Wide Daily Staffing Needs Including Evening, Nights, Weekends, and Holidays: DON RN- 1 full time, 1st shift Staff Registered Nurses- 2 Part Time, 1st shift LVNs- 2 full time, 1st and 2nd shift CNAs- 7 full time 1st shift, 6 full time 2nd shift, 3 full time 3rd shift MAs- 1 full time 1st shift, 1 part time 2nd shift MDS/RAI Coordinator (RN)- 1 full time 1st shift Record review of time sheets dated 04/01/2025 indicated only 2 CNAs worked the entire 8 hour second (2:00 p.m.-10:00 p.m.) shift. Record review of time sheets dated 04/05/2025 indicated only 2 CNAs worked the entire 8 hour second (2:00 p.m.-10:00 p.m.) shift. Record review of time sheets dated 04/07/2025 indicated only 1 CNA worked the entire 8 hour second (2:00 p.m.-10:00 p.m.) shift. Record review of time sheets dated 04/15/2025 indicated only 1 CNA worked the entire 8 hour third (10:00 p.m.-6:00 a.m.) shift. Record review of time sheets dated 04/16/2025 indicated only 2 CNAs worked the entire 8 hour second (2:00 p.m.-10:00 p.m.) shift and only 2 CNAs worked the entire 8 hour third (10:00 p.m.-6:00 a.m.) shift. Record review of time sheets dated 04/17/2025 indicated only 1 CNA worked the entire 8 hour second (2:00 p.m.-10:00 p.m.) shift and only 2 CNAs worked the entire 8 hour third (10:00 p.m.-6:00 a.m.) shift. Record review of time sheets dated 04/20/2025 indicated only 4 CNAs worked the entire 8 hour first (6:00 a.m.-2:00 p.m.) shift, 2 CNAs worked the entire 8 hour second (2:00 p.m.-10:00 p.m.) shift and no CNAs worked the entire 8 hour third (10:00 p.m.-6:00 a.m.) shift. Record review of the facility's policy, Staffing, Sufficient and Competent Nursing, revised August 2022, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 1. Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c. assessing, evaluating, planning and implementing resident care plans; and d. responding to resident needs . Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment .

Based on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information from 04/20/2025-04/24/2025. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census. The findings included: During an observation and interview on 04/24/2025 at 11:32 AM, the daily staffing posting was hanging at the nurse's station, and it was dated 04/19/2025. LVN D said the daily staffing was completed by the night shift nurse. LVN D said the daily staffing posting should be completed daily so that everyone knew how much staff was supposed to be in the facility to care for the residents. During an interview on 04/24/2025 at 11:42 AM, the DON said the night shift nurses completed the daily staffing posting. The DON said the ADON usually checked to ensure the daily staffing was posted. The DON said the daily staffing should be posted to keep up with the number of staff in the building. During an interview on 04/24/2025 at 11:44 AM, the ADON said the night shift nurse was responsible for completing the daily staffing posting. The ADON said she presumed it was not completed since 04/19/2025 because they had a temporary nurse working at night. The ADON said she normally checked it. The ADON said the daily staffing should be posted so anybody that went to the facility, including the nurses and visitors, knew the census and the staffing hours. During an attempted interview on 04/24/2025 at 11:55 AM, LVN M, night shift nurse, did not answer the phone. During an attempted interview on 04/24/2025 at 11:57 AM, LVN N, night shift nurse, did not answer the phone. Record review of the facility's policy titled, Staffing, Sufficient and Competent Nursing, revised August 2022, indicated, .Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift .

Based on observations, interviews and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 4 of 21 residents (Resident #8, Resident #9, Resident #51, and Resident #11) reviewed for privacy and confidentiality. 1.LVN C failed to ensure she closed the EMR of Resident #8, Resident #9, and Resident #51 before entering residents' room to obtain a blood sugar check and administer medications on 04/21/2025. 2. The facility failed to ensure MA G closed Resident #11's EMR before entering her room to administer her pain medication on 04/21/25. These failures could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medication administration record being accessible to others. Findings included: 1.Record review of a face sheet dated 04/23/2025, revealed Resident # 8 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of respiratory symptoms in individuals with COPD, typically involving increased shortness of breath, cough, and/or sputum production), type 2 diabetes mellitus with hyperglycemia ( person diagnosed with type 2 diabetes has persistently high blood sugar levels), and chronic respiratory failure with hypoxia ( a condition where the body's tissues don't receive enough oxygen due to a chronic inability of the lungs to adequately exchange oxygen and carbon dioxide), Record review of the quarterly MDS assessment dated [DATE], indicated Resident #8 understood and could make herself understood by others. Resident #8 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period. 2. Record review of a face sheet dated 04/23/2025, revealed Resident # 9 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of vascular dementia (a form of dementia caused by reduced blood flow to the brain, leading to cognitive decline), bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, including both manic (elevated mood) and depressive (low mood) periods), and mild cognitive impairment of uncertain or unknown etiology(memory and thinking problems that are more pronounced than normal aging but don't meet the criteria for dementia). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #9 understood and could make herself understood by others. Resident #9 had a BIMS score of 09 which indicated moderate cognitive impairment. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period. 3. Record review of a face sheet dated 04/23/2025, revealed Resident # 51 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of type 2 diabetes mellitus with hyperglycemia ( a person diagnosed with type 2 diabetes has persistently high blood sugar levels), chronic respiratory failure with hypoxia ( a condition where the body's tissues don't receive enough oxygen due to a chronic inability of the lungs to adequately exchange oxygen and carbon dioxide), and essential (primary) hypertension ( the most common type of high blood pressure). Record review of the quarterly MDS assessment dated [DATE], indicated Resident #51 understood and could make herself understood by others. Resident #51 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS indicated he received insulin injections 7 out of the 7 days of the look back period. During an observation and interview on 04/21/2025 at 11:45 a.m., LVN C was observed going into Resident #51's room to check a blood sugar and left the EMR open with Resident #51, Resident #8, and Resident # 9's information visible. LVN C stated it was her responsibility to close the EMR before going into a room. LVN C stated it was important to ensure the residents medical information was confidential. LVN C stated the failure was a HIPPA violation. 46928 4. Record review of Resident #11's face sheet dated 04/23/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included diabetes (a group of diseases that result in too much sugar in the blood), cerebral infarction (stroke), irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), and need for assistance with personal care. Record review of Resident #11's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. Resident #11 had a BIMS score of 15, which indicated her cognition was intact. Resident #11 was dependent on staff with toileting, lower body dressing, and putting on/taking off footwear. Resident #11 received scheduled pain medication. Record review of Resident #11's comprehensive care plan dated 10/28/24, indicated she had acute pain. The care plan interventions indicated to administer pain medications as ordered. Record review of Resident #11's order summary report dated 04/23/25, indicated she had an order for acetaminophen-codeine (narcotic pain medication) 300mg-60mg tablet give one tablet by mouth three times a day for pain with an order start date of 01/14/25. Record review of Resident #11's medication administration record dated 04/01/25-04/30/25, indicated she had received an acetaminophen-codeine 300mg-60mg tablet three times a day. During an observation and interview on 04/21/25 at 10:08 AM the 200-hall medication cart was on the 200 hall and had a laptop on top with the screen open to Resident #11's information. Staff and residents were noted to be walking next to the medication cart. MA G exited Resident #11's room and said she should not have left screen up because someone could come by and take all of Resident #11's information. MA G said she forgot to lock the screen because she was in a hurry to administer Resident #11 her medication. MA G said it was her responsibility in ensuring the screen was locked when leaving it unattended. During an interview on 04/24/25 at 09:03 AM, the DON said it was a HIPPA violation leaving the screen up with resident information. The DON said she expected the screen to be locked or pulled down when leaving it unattended. The DON said it was the responsibility of the person on the cart to ensure the resident's information was kept confidential. During an interview on 04/24/25 at 09:58 AM, the Administrator said he expected resident information to me kept confidential and not visible to unauthorized persons. He said there was a potential for the resident's information to be seen by leaving the screen up. The Administrator said it was the responsibility of the person on the cart to ensure the resident information was kept confidential. Record review of the facility's policy Resident Rights revised February 2021, indicated . Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . t. privacy and confidentiality . Record review of the facility's policy Confidentiality of Information and Personal Privacy revised October 2017, indicated . Our facility will protect and safeguard resident confidentiality and personal privacy. 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 21 (Resident #2, Resident #6, and Resident #9) residents reviewed for care plans. 1. The facility failed to develop a plan of care for Resident #2's smoking and use of a vape (an electronic cigarette). 2. The facility failed to develop a plan of care specific to Resident #6's use of clozapine (antipsychotic medication used to treat mental/mood disorders) The facility failed to develop a plan of care to indicate Resident #6 was considered by the PASRR process to have serious mental illness and an intellectual disability. 3. The facility failed to care plan Resident #9 was in the memory care unit. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (blood flow to the brain affected with weakness and paralysis of left side of the body), type 2 diabetes mellitus with diabetic neuropathy (insulin resistance, with or without insulin deficiency that induces organ dysfunction) progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers), and anxiety disorder. Record review of Resident #2's Comprehensive MDS assessment dated [DATE] indicated she understood others and was understood. Resident #2's BIMS score was a 15, which indicated her cognition was intact. The MDS assessment indicated Resident #2 was dependent on staff for showering/bathing, toileting, dressing, and personal hygiene. The MDS assessment indicated Resident #2 used tobacco. Record review of Resident #2's care plan with a target date of 02/09/2025 did not indicate she used a vape or smoked. During an observation and interview on 04/21/2025 starting at 9:20 AM, Resident #2 had a vape on her over bed table. Resident #2 said she used the vape. During an interview on 04/22/2025 at 4:12 PM, LVN B said when Resident #2 got out of bed she went to smoke sometimes. LVN B said Resident #2 used a vape device. During an interview on 04/23/2025 at 1:20 PM, the MDS Coordinator said the care plans were completed by therapy, dietary activities, the DON, and social services. The MDS Coordinator said the care plan was initiated on admission. The MDS Coordinator said she was responsible for care planning Resident #2's use of a vape and that she smoked. The MDS Coordinator said she was aware Resident #2 smoked, and she used a vape. The MDS Coordinator said she did not know why it was not included in her care plan. The MDS Coordinator said it should have been care planned because Resident #2 required someone with her when she smoked. The MDS Coordinator said it was important for smoking and the use of a vape to be included in the residents' care plans so people could look at the care plan and see how to manage the residents' care. 2. Record review of a face sheet dated 04/23/2024 indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior) and mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). Record review of Resident #6's Comprehensive MDS assessment dated [DATE] indicated she was considered by the PASRR process to have serious mental illness and an intellectual disability. Record review of Resident #6's Quarterly MDS assessment dated [DATE] indicated she was understood, and she understood others. The MDS assessment indicated Resident #6 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #6 received an antipsychotic. Record review of Resident #6's Order Summary Report dated 04/23/2025 indicated clozapine 100 mg give 3.5 tablets orally two times a day with a start date of 09/19/2024. Record review of Resident #6's care plan with a target date of 12/01/2024 indicated, Focus The resident uses psychotropic medications (SPECIFY medications) r/t. There were no interventions. The care plan did not include Resident #6's use of clozapine and interventions related to the use of clozapine. The care plan did not address that Resident #6 was considered by the PASRR process to have serious mental illness and an intellectual disability. During an interview on 04/24/2025 at 10:11 AM, the DON said the responsibilities of the care plans were shared between the DON, social worker, and the MDS Coordinator. The DON said any of them could have care planned Resident #2's smoking and vape use. The DON said Resident #6's positive PASRR status and services should have been care planned by the IDT. The DON said Resident #2's use of a vape and smoking and Resident #6's PASRR positive status and services were not care planned due to the change in ownership that occurred October 2024. The DON said it was important for the residents' care plans to include all their needs and services to ensure they knew how to take care of the resident. 47612 3.Record review of Resident #9's face sheet dated 04/23/2025, revealed Resident # 9 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of vascular dementia (a form of dementia caused by reduced blood flow to the brain, leading to cognitive decline), bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, including both manic (elevated mood) and depressive (low mood) periods), and mild cognitive impairment of uncertain or unknown etiology(memory and thinking problems that are more pronounced than normal aging but don't meet the criteria for dementia). Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 understood and could make herself understood by others. Resident #9 had a BIMS score of 09 which indicated moderate cognitive impairment. The MDS revealed Resident #9 had no behaviors or refusal of care. Record review of Resident #9's comprehensive care plan, dated 11/01/2024, indicated a risk for wondering and elopement. Goals: the resident will not leave the facility unattended. Interventions: clearly identify resident's room and bathroom. Identify if there was a certain time of day the resident's wandering and elopement attempts. The care plan did not address the memory care unit. During an interview on 04/24/2025 at 9:09 a.m., the MDS Coordinator stated she was the one responsible for completing the residents' care plans. The MDS Coordinator stated the care plan should be done on admission, quarterly, and with a change in condition. The MDS Coordinator said Resident #9 residing on the memory care unit should have been included in her care plan. The MDS Coordinator said Resident #6's use of clozapine should have been included in her care plan. The MDS Coordinator said Resident #6's PASRR positive status should have been in her care plan. The MDS Coordinator stated because of the changeover things had been missed. The MDS Coordinator stated if the residents do not have a care plan, there would be a possibility of confusion about the care to be provided or the care would be not provided at all. During an interview on 04/24/2025 at 10:44 AM, the Administrator said his expectations for the residents' care plans were for the care plans to reflect the services the residents were receiving. The Administrator said the IDT was responsible for ensuring the residents' care plans included all the services they received. The Administrator said there was a potential, if the residents care plan did not reflect everything, that they may miss out on services or orders they needed. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions arc derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 3 resident (Resident #41) reviewed for enteral nutrition. The facility failed to ensure Resident #41's physician's order for her enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) indicated the type of feeding she was supposed to have been receiving. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #41's face sheet dated 04/23/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), epilepsy (seizures), hypertension (high blood pressure), and gastrostomy status (surgical opening in stomach to provide nutrition and medications). Record review of Resident #41's quarterly MDS assessment dated [DATE], indicated Resident #41 was usually understood and usually understood others. Resident #41 had a BIMS score of 2, which indicated her cognition was severely impaired. Resident #41 was dependent on staff with toileting, showering, and personal hygiene. The MDS indicated Resident #41 had a feeding tube and had not had any weight loss/gain of 5% or more in the last month or 10% or more in the last 6 months. Record review of Resident #41's comprehensive care plan dated 04/04/25, indicated Resident #41 required a feeding tube related to dysphagia (difficulty swallowing), medical condition of cerebral palsy, swallowing problem, and required gastrostomy tube to aide in her nutritional needs. The care plan interventions indicated to assist with administration of tube feeding and water flushes per MD order. The care plan did not specify the type of feeding Resident #41 required. Record review of Resident #41's order dated 01/01/25, indicated to give one can (237ml) bolus feeding via gastrostomy tube 5 times a day for supplement. The order did not indicate the type of feeding Resident #41 required. Record review of Resident #41's nursing MAR dated 04/01/25-04/30/25, indicated Resident #41 received one can of bolus feeding via her gastrostomy tube 5 times a day at 2:00 AM, 07:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM. The MAR did not indicate the type of feeding Resident #41 was supposed to receive. During an observation on 04/21/25 at 10:45 AM, Resident #41 had an 8-ounce carton of Jevity 1.5 cal sitting on her nightstand. During an observation on 04/21/25 at 2:22 PM, Resident #41 continued to have the 8-ounce carton of Jevity 1.5 cal sitting on her nightstand. During an interview on 04/22/25 at 2:48 PM, LVN C said Resident #41 received Jevity 1.5 cal five times a day. LVN C said since Resident #41's enteral feeding order did not specify the type of feeding she could receive any type of formula. She said this could cause Resident #41 to have an adverse reaction. LVN C said the nurse was responsible for ensuring the order was accurate with the specific enteral feeding to be administered. During an interview on 04/24/25 at 09:03 AM, the DON said the specific enteral feeding to be used should be on the order. The DON said failure to specify the feeding to be administered could place the resident at risk to receive the wrong feeding. The DON said it was the ADON's and her responsibility to ensure the orders were accurately transcribed. The DON said she reviewed orders daily during morning meeting. The DON said she was unsure of how the order was missed. During an interview on 04/24/25 at 09:58 AM, the Administrator said he expected Resident #41's order to specify the enteral feeding she required. The Administrator said it was the nurse's responsibility to ensure the correct feeding was being administered to Resident #41. He said by not specifying the feeding required placed Resident #41 at risk for receiving the wrong feeding. Record review of the facility's policy Enteral Nutrition revised February 2018, indicated . Adequate nutritional support through enteral nutrition is provided to residents as ordered . 11. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. the enteral nutrition product .

Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 of 3 staff (MA G, MA F, and LVN C) reviewed for competencies. The facility failed to ensure MA G, MA F, and LVN C were competent in medication administration. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections. Findings included: 1. Record review of Resident #41's face sheet dated 04/23/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), epilepsy (seizures), hypertension (high blood pressure), and gastrostomy status (surgical opening in stomach to provide nutrition and medications). Record review of Resident #41's quarterly MDS assessment dated [DATE], indicated Resident #41 was usually understood and usually understood others. Resident #41 had a BIMS score of 2, which indicated her cognition was severely impaired. The MDS indicated Resident #41 had an active diagnosis of hypertension. Record review of Resident #41's comprehensive care plan dated 01/13/25, indicated Resident #41 had hypertension. The care plan interventions indicated to give antihypertensive medications as ordered. Record review of Resident #41's order summary report dated 04/24/25, indicated she had an order for metoprolol tartrate 100mg give one tablet enterally one time a day related to hypertension with a start date of 01/01/25. The order indicated to hold if SBP less than 110 or DBP is less than 65. Record review of Resident #41's Nursing MAR dated 04/01/25-04/30/25, indicated Resident #41 had an order for metoprolol 100mg tablet give one tablet in the morning with instructions to hold for SBP less than 110 or DBP less than 65. On 04/13/25 at 08:00 AM, Resident #41's blood pressure was 104/72. The MAR had a check mark which indicated Resident #41 was administered a metoprolol 100 mg tablet outside the parameters by LVN C. On 04/16/25 at 08:00 AM, Resident #41's blood pressure was 97/59. The MAR had a check mark which indicated Resident #41 was administered a metoprolol 100 mg tablet outside the parameters by LVN C. On 04/21/25 at 08:00 AM, Resident #41's blood pressure was 106/81. The MAR had a check mark which indicated Resident #41 was administered a metoprolol 100 mg tablet outside the parameters by LVN C. During an interview on 04/22/25 at 3:41 PM, LVN C said a check mark on the medication administration record indicated the medication was administered. LVN C reviewed Resident #41's MAR and said Resident #41's received the metoprolol tablet on 04/13/25, 04/16/25, and 04/21/25 when her blood pressure was outside of the ordered parameters. LVN C said according to Resident #41's parameters the metoprolol should have been held. LVN C said it was the nurse's responsibility to ensure medications were being administered as per the physician's orders. LVN C said she had been checked off on medication administration competency. 2. Record review of a face sheet dated 04/23/2025 indicated Resident #23 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and essential primary hypertension (high blood pressure). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #23 was understood by others and understood others. The MDS assessment indicated Resident #23 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #23 was dependent for toileting and showering/bathing self, independent for eating, and required partial to moderate assistance with ADLs. Record review of Resident #23's care plan with a target date of 11/17/2024 indicated she had hypertension, and the goal was for her blood pressure to be within normal limits with an intervention to evaluate blood pressure. Record review of Resident #23's Order Summary Report dated 04/23/2025 indicated, she had an order for metoprolol tartrate 25 mg give 0.5 tablet by mouth two times a day for hypertension hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60 with a start date of 10/26/2024. Record review of Resident #23's April 2025 MAR indicated metoprolol tartrate 25 mg give 0.5 tablet by mouth two times a day hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60. o On 04/07/2025 Resident #23's blood pressure was 104/59 the MAR indicated Resident #23's metoprolol was documented as administered by MA G. o On 04/20/2025 Resident #23's blood pressure was 106/74 the MAR indicated Resident #23's metoprolol was documented as administered by MA F. 3. Record review of a face sheet dated 04/23/2025 indicated Resident #31 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included end stage heart failure (heart's ability to pump blood effectively is severely impaired, leading to progressive symptoms and a reduced quality of life) and essential primary hypertension (high blood pressure). Record review of Resident #31's Quarterly MDS assessment dated [DATE] indicated, he was understood by others and understood others. The MDS assessment indicated Resident #31 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #31 required substantial/maximal with toileting, showering/bathing, and set-up or cleanup assistance with personal hygiene. Record review of Resident #31's care plan revised 04/11/2025, indicated he was at risk for decreased cardiac output related to a diagnosis of hypertension with a goal for his blood pressure would be within normal limits and an intervention to evaluate his blood pressure. Record review of Resident #31's Order Summary Report dated 04/23/2025 indicated, he had an order for metoprolol tartrate 25 mg give 0.5 tablet by mouth two times a day for hypertension hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60 with a start date of 10/17/2024. Record review of Resident #31's April 2025 MAR indicated metoprolol tartrate 25 mg give 0.5 tablet by mouth hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60. o On 04/02/2025 Resident #31's blood pressure was 109/62 the MAR indicated Resident #31's metoprolol was documented as administered by MA F. o On 04/08/2025 Resident #31's blood pressure was 101/63 the MAR indicated Resident #31's metoprolol was documented as administered by MA F. o On 04/20/2025 Resident #31's blood pressure was 104/64 the MAR indicated Resident #31's metoprolol was documented as administered by MA F. During an interview on 04/22/2025 at 1:34 PM, MA F said blood pressure medication should be held for blood pressure less than 100/60. MA F said she was not sure if she had administered Resident #23's and Resident #31's blood pressure medications when their blood pressure was out of parameters, but she thought she had not. MA F said when a medication was documented as administered on the MAR it indicated it was administered. MA F said if the medication was held the medication would not be documented as administered. MA F said giving a blood pressure medication when the blood pressure was not within parameters could result in heart failure and death. During an attempted phone interview on 04/22/2025 at 2:00 PM, MA G did not answer the phone. During an attempted phone interview on 04/23/2025 at 3:28 PM, MA G did not answer the phone. During an interview on 04/24/2025 at 10:11 AM, the ADON said she was still looking for the nurse competencies because they were under the previous facility. During an interview on 04/24/2025 at 10:14 AM, the DON said the nurse or medication aide should be checking the parameters of blood pressure medications when they administered them. The DON said correct administration of medications was being monitored by competency check offs and if they were notified of an issue, they conducted another check off. The DON said the ADON and herself reviewed the MARs and they had not noticed any discrepancies. The DON said it was hard for them to review the MARs, when they had to work the floor. The DON said if blood pressure medication was administered with the blood pressure being too low it could lower the blood pressure, but she could not speculate on what could happen to the residents. During an interview on 04/24/2025 at 10:20 AM, the ADON said when she reviewed the MARs, she had noticed some medications not documented as administered, but as far as the medications being administered with the blood pressure out of parameters, she had not noticed any issues. The ADON said if a resident received blood pressure medication when their blood pressure was low, their blood pressure could be lowered more, and they could pass out from the low blood pressure or fall. During an interview on 04/24/2025 at 10:44 AM, the Administrator said if a resident's blood pressure was out of parameters, he expected the staff to re-check the residents blood pressure. The Administrator said the nurses and medication aides were responsible for ensuring the residents' blood pressures were within parameters before administering blood pressure medications to them. The Administrator said if they noticed there was an issue with medication administrator nursing and himself were responsible for ensuring the medication aides and nurses were doing their job appropriately. The Administrator said to his knowledge there was not an accountability system in place for monitoring that the residents were receiving medications appropriately. The Administrator said if you were giving medications that were designed for a specific purpose and it was outside of the parameters it could have a negative impact on a person's health. During an interview on 04/24/2025 at 12:32 PM, the Administrator said they did not have any competency checks for the nurses and medication aides, so they would not be able to produce them. During an interview on 04/24/2025 at 12:39 PM, the Administrator said they had not completed any competency checks for the nurses and medication aides through their current company, and he did not have a file with them from the previous company. The Administrator said he took responsibility for not having the competency checks. The Administrator said the competency checks were necessary to ensure the staff was competent. During an interview on 04/24/2025 at 1:00 PM, the DON said nursing administration was responsible for ensuring the competency checks for the nurses and medication aides were completed. The DON said competency checks were completed with the previous company, but they did not have them. The DON said the medication pass audit completed by the pharmacist was the facility's competency check for the medication aides because who better to do it than the pharmacist. The DON said if the competency checks were not completed, they could not say the staff performed skills correctly. The DON said competency checks were supposed to be completed as needed and upon hire. Record review of a Medication Pass Audit for MA F, completed by the pharmacist, dated 01/23/2024 indicated, she did not administer medications in accordance with current physician orders, did not check each medication package against the MAR before administering medications to the resident, and did not ensure the medication cart was locked while she was in the room. She did check blood pressure prior to medication administration when appropriate, and she charted administration of medications or charted held or refused meds immediately after medication administration. Record review of a Medication Pass Audit for MA G, completed by the pharmacist, dated 03/22/2024 indicated, she administered medications in accordance with current physician orders, blood pressure was taken prior to medication administration when appropriate, the medication cart was locked at all times, and she charted administration of medications or charted held or refused meds immediately after medication administration. Record review of the facility's policy, Staffing, Sufficient and Competent Nursing, revised August 2022, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment .1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas . j. Medication management . Competency requirements and training for nursing staff are established and monitored by nursing leadership. Record review of the Facility Assessment, dated 01/15/2025, indicated, .Staff Competency . competency demonstrations, certifications, educational and training requirements, etc., are reviewed/verified, as appropriate, at the time of hire, before position changes, annually, and/or as needed. We measure staff competence through knowledge, skills, abilities, behaviors, and other characteristics that staff need to perform work roles or occupational functions successfully as determined by the care needs of our resident population. Documentation of these reviews are maintained as part of our facility's employment history records .

Based on interview and record review the facility failed to ensure that residents were free of significant medication errors for 3 of 10 residents reviewed for pharmacy services. (Resident #'s 23, 31 and 41) 1. The facility failed to ensure Resident #41's metoprolol (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters on 04/13/2025, 04/16/2025, and 04/21/2025. 2. The facility failed to ensure MA G and MA F did not administer Resident #23's metoprolol (blood pressure medication) on 04/07/2025 and 04/20/2025, when her blood pressure was not within the required parameters per the physician's order. 3. The facility failed to ensure MA F did not administer Resident #31's metoprolol (blood pressure medication) on 04/02/2025, 04/08/2025, and 04/20/2025, when his blood pressure was not within the required parameters per the physician's order. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #41's face sheet dated 04/23/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), epilepsy (seizures), hypertension (high blood pressure), and gastrostomy status (surgical opening in stomach to provide nutrition and medications). Record review of Resident #41's quarterly MDS assessment dated [DATE], indicated Resident #41 was usually understood and usually understood others. Resident #41 had a BIMS score of 2, which indicated her cognition was severely impaired. The MDS indicated Resident #41 had an active diagnosis of hypertension. Record review of Resident #41's comprehensive care plan dated 01/13/25, indicated Resident #41 had hypertension. The care plan interventions indicated to give antihypertensive medications as ordered. Record review of Resident #41's order summary report dated 04/24/25, indicated she had an order for metoprolol tartrate 100mg give one tablet enterally one time a day related to hypertension with a start date of 01/01/25. The order indicated to hold if SBP was less than 110 or DBP was less than 65. Record review of Resident #41's Nursing MAR dated 04/01/25-04/30/25, indicated Resident #41 had an order for metoprolol 100mg tablet give one tablet in the morning with instructions to hold for SBP less than 110 or DBP less than 65. o On 04/13/25 at 08:00 AM, Resident #41's blood pressure was 104/72. The MAR had a check mark which indicated Resident #41 was administered a metoprolol 100 mg tablet outside the parameters by LVN C. o On 04/16/25 at 08:00 AM, Resident #41's blood pressure was 97/59. The MAR had a check mark which indicated Resident #41 was administered a metoprolol 100 mg tablet outside the parameters by LVN C. o On 04/21/25 at 08:00 AM, Resident #41's blood pressure was 106/81. The MAR had a check mark which indicated Resident #41 was administered a metoprolol 100 mg tablet outside the parameters by LVN C. During an interview on 04/22/25 at 3:41 PM, LVN C said a check mark on the medication administration record indicated the medication was administered. LVN C reviewed Resident #41's MAR and said Resident #41's received the metoprolol tablet on 04/13/25, 04/16/25, and 04/21/25 when her blood pressure was outside of the ordered parameters. LVN C said failure to hold her blood pressure medication placed Resident #41 at risk for her blood pressure dropping. LVN C said according to Resident #41's parameters the metoprolol should have been held. LVN C said it was the nurse's responsibility to ensure medications were being administered as per the physician's orders. LVN C said she had been checked off on medication administration competency. 46892 2. Record review of a face sheet dated 04/23/2025 indicated Resident #23 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and essential primary hypertension (high blood pressure). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #23 was understood by others and understood others. The MDS assessment indicated Resident #23 had a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #23's care plan with a target date of 11/17/2024 indicated she had hypertension, and the goal was for her blood pressure to be within normal limits with an intervention to evaluate blood pressure. Record review of Resident #23's Order Summary Report dated 04/23/2025 indicated, she had an order for metoprolol tartrate 25 mg give 0.5 tablet by mouth two times a day for hypertension hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60 with a start date of 10/26/2024. Record review of Resident #23's April 2025 MAR indicated metoprolol tartrate 25 mg give 0.5 tablet by mouth two times a day hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60. On 04/07/2025 Resident #23's blood pressure was 104/59, the MAR indicated Resident #23's metoprolol was documented as administered by MA G. On 04/20/2025 Resident #23's blood pressure was 106/74, the MAR indicated Resident #23's metoprolol was documented as administered by MA F. 3. Record review of a face sheet dated 04/23/2025 indicated Resident #31 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included end stage heart failure (heart's ability to pump blood effectively is severely impaired, leading to progressive symptoms and a reduced quality of life) and essential primary hypertension (high blood pressure). Record review of Resident #31's Quarterly MDS assessment dated [DATE] indicated, he was understood by others and understood others. The MDS assessment indicated Resident #31 had a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #31's care plan revised 04/11/2025, indicated he was at risk for decreased cardiac output related to a diagnosis of hypertension with a goal for his blood pressure would be within normal limits and an intervention to evaluate his blood pressure. Record review of Resident #31's Order Summary Report dated 04/23/2025 indicated, he had an order for metoprolol tartrate 25 mg give 0.5 tablet by mouth two times a day for hypertension hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60 with a start date of 10/17/2024. Record review of Resident #31's April 2025 MAR indicated metoprolol tartrate 25 mg give 0.5 tablet by mouth hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60. On 04/02/2025 Resident #31's blood pressure was 109/62, the MAR indicated Resident #31's metoprolol was documented as administered by MA F. On 04/08/2025 Resident #31's blood pressure was 101/63, the MAR indicated Resident #31's metoprolol was documented as administered by MA F. On 04/20/2025 Resident #31's blood pressure was 104/64, the MAR indicated Resident #31's metoprolol was documented as administered by MA F. During an interview on 04/22/2025 at 1:34 PM, MA F said blood pressure medication should be held for blood pressure less than 100/60. MA F said she was not sure if she had administered Resident #23's and Resident #31's blood pressure medications when their blood pressure was out of parameters, but she thought she had not. MA F said when a medication was documented as administered on the MAR it indicated it was administered. MA F said if the medication was held the medication would not be documented as administered. MA F said giving a blood pressure medication when the blood pressure was not within parameters could result in heart failure and death. During an attempted phone interview on 04/22/2025 at 2:00 PM, MA G did not answer the phone. During an attempted phone interview on 04/23/2025 at 3:28 PM, MA G did not answer the phone. During an interview on 04/24/2025 at 10:14 AM, the DON said the nurse or medication aide should be checking the parameters of blood pressure medications when they administered them. The DON said correct administration of medications was being monitored by competency check offs and if they were notified of an issue, they conducted another check off. The DON said the ADON and herself reviewed the MARs and they had not noticed any discrepancies. The DON said it was hard for them to review the MARs, when they had to work the floor. The DON said if blood pressure medication was administered with the blood pressure being too low it could lower the blood pressure, but she could not speculate on what could happen to the residents. During an interview on 04/24/2025 at 10:20 AM, the ADON said when she reviewed the MARs, she had noticed some medications not documented as administered, but as far as the medications being administered with the blood pressure out of parameters, she had not noticed any issues. The ADON said if a resident received blood pressure medication when their blood pressure was low, their blood pressure could be lowered more, and they could pass out from the low blood pressure or fall. During an interview on 04/24/2025 at 10:44 AM, the Administrator said if a resident's blood pressure was out of parameters, he expected the staff to re-check the residents blood pressure. The Administrator said the nurses and medication aides were responsible for ensuring the residents' blood pressures were within parameters before administering blood pressure medications to them. The Administrator said if they noticed there was an issue with medication administrator nursing and himself were responsible for ensuring the medication aides and nurses were doing their job appropriately. The Administrator said to his knowledge there was not an accountability system in place for monitoring that the residents were receiving medications appropriately. The Administrator said if you were giving medications that were designed for a specific purpose and it was outside of the parameters it could have a negative impact on a person's health. Record review of a Medication Pass Audit for MA F, completed by the pharmacist, dated 01/23/2024 indicated, she did not administer medications in accordance with current physician orders and did not check each medication package against the MAR before administering medications to the resident. She did check blood pressure prior to medication administration when appropriate, and she charted administration of medications or charted held or refused meds immediately after medication administration. Record review of a Medication Pass Audit for MA G, completed by the pharmacist, dated 03/22/2024 indicated, she administered medications in accordance with current physician orders, blood pressure was taken prior to medication administration when appropriate, and she charted administration of medications or charted held or refused meds immediately after medication administration. Record review of the facility's policy Medication and Treatment Orders revised July 2016, indicated . Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 21 residents (Resident #'s 55 and 10), 1 of 5 medication carts (200 hall medication cart), and 1 of 1 medication storage rooms reviewed for drugs and biologicals. 1. The facility did not ensure Resident #55's Rexall (pain/ fever relief), Purzee (sleep supplement), and Melatonin (sleep aid) were properly safe and secured on 04/23/2025. 2. The facility failed to ensure a lock box in the Medication Room refrigerator with 2 bottles of Lorazepam (controlled medication for anxiety) was permanently affixed. 3. The facility failed to ensure Resident #10's clobetasol cream (used to reduce swelling, redness, itching, and rashes caused by skin conditions) was properly secured and not left on his nightstand on 04/21/25 and 04/22/25. 4. The facility failed to ensure MA G secured the 200 hall Medication Cart when she left it unattended on 04/21/25. 5. The facility failed to ensure MA F secured the 200 hall Medication Cart when she turned away from it on 04/22/25. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: 1.Record review of Resident #55's face sheet dated 04/23/2025, revealed Resident # 55 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of metabolic encephalopathy ( a brain dysfunction caused by underlying metabolic disorders or conditions that disrupt the brain's energy supply or chemical balance), type 2 diabetes mellitus with hyperglycemia ( a person diagnosed with type 2 diabetes has persistently high blood sugar levels), essential (primary) hypertension ( the most common type of high blood pressure). Record review of Resident #55's comprehensive MDS assessment dated [DATE] indicated Resident #55 understood and could make herself understood by others. Resident #55 had a BIMS of 13 which indicated cognitive function intact. Record review of Resident #55's care plan dated 03/25/2025 indicated Resident #55's Goal: would be free of pain and discomfort. Interventions: elevate pain, utilize non-medication intervention for pain relief. Focus: risk for insomnia. Goal: resident will achieve and maintain a consistent sleep pattern. Interventions: establish bedtime routine with resident, evaluate for history of sleep-disordered breathing (periods of apnea, prior Use of CPAP/BiPAP), evaluate for respiratory distress when lying flat or while sleeping, evaluate medication schedule and possible pharmacologic causes of insomnia. During an observation and interview on 04/23/2025 at 9:34 a.m., revealed a bottle of Rexall, Purzee and Melatonin were on Resident #55's bedside table. Resident #55 stated a family member brought him the medication to take when he needed help sleeping. Record review of the order summary report dated 04/23/2025 did not address the use of Rexall (pain/ fever relief), Purzee (sleep supplement), and Melatonin. During an interview on 04/23/2025 at 11:40 a.m., MA F stated she saw the medication on the bedside table on 04/22/2025 and told LVN C. MA F stated the resident should not have medication at the bedside. MA F stated it was important for the resident to not have the medication because he could take too much or take it at any time. MA F stated the failure was the resident could take too much medication or another resident could take the medication. During an attempted interview on 04/23/2025 at 2:15 p.m., the surveyor attempted to contact LVN C by phone. During an interview on 04/23/2025 at 4:16 p.m., LVN D stated she did not know Resident #55 had medication on his bedside table. LVN D went into Resident #55's room and removed the medication. LVND stated it was important to know what the resident was taking so he did not overdose or have a adverse reaction. LVN D stated the failure was his roommate could have taken the medication. 2.During an observation of the Medication Room and interview with the DON on 04/23/2025 at 3:53 p.m., revealed a lock box was in the medication refrigerator. The DON took the clear plastic lock box out of the refrigerator, and there were 2 bottles of Lorazepam inside the lock box. The lock box was not affixed to the refrigerator. The DON stated she thought they had it locked correctly. The DON stated it was her and the charge nurse's responsibility to make sure the narcotic was locked. The DON stated it was important to make sure the narcotics were lock because they were controlled substance and did not want a drug diversion. The DON stated the failure was the narcotics could be taken just like any other medication could be. During an interview on 04/24/2025 at 10:00 a.m., the DON stated she did not know the narcotic lock box had to be affixed to the refrigerator. The DON stated it was her and responsibility to ensure the lock box was affixed to the refrigerator. The DON stated the failure was a possible drug diversion. During an interview on 05/24/2025 at 10:46 a.m., the Administrator stated lock boxes containing controlled medications should be affixed. The Administrator stated the DON was responsible for ensuring the lock boxes were affixed. The Administrator stated it was important for the lock boxes with controlled medications to be affixed so they were not removed easily from the facility or that room because they were a controlled substance. 46928 3. Record review of Resident #10's face sheet dated 04/23/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hypertension (high blood pressure), right upper arm muscle wasting and atrophy (loss of muscle mass and strength), and right-hand contracture. Record review of Resident #10's quarterly MDS assessment dated [DATE], indicated he was sometimes understood and sometimes understood others. Resident #10 had short term/long term memory problems and his cognition was severely impaired. Record review of Resident #10's comprehensive care plan dated 11/11/24, indicated Resident #10 was at risk for impaired skin integrity. The care plan interventions included to evaluate skin areas for blanching or redness and provide skin care per facility guidelines. Record review of Resident #10's order summary report dated 04/23/25, indicated he had an order for clobetasol cream 0.05% apply to dry patchy areas of skin topically as needed with a start date of 09/18/24. Record review of Resident #10's treatment administration record dated 04/01/25-04/30/25, indicated Resident #10 had an order for clobetasol cream 0.5% apply to dry, patchy areas of skin topically as needed. The treatment administration record indicated Resident #10 had only received the clobetasol cream on 04/09/25. During an observation on 04/21/25 at 09:47 AM, revealed Resident #10 had a Clobetasol propionate cream on his nightstand. During an observation on 04/21/25 at 1:42 PM, revealed Resident #10 continued to have the Clobetasol propionate cream on his nightstand. During an observation on 04/22/25 at 08:34 AM, revealed Resident #10 continued to have the Clobetasol propionate cream on his nightstand. During an observation on 04/22/25 at 2:20 PM, revealed Resident #10 continued to have the Clobetasol propionate cream on his nightstand. During an interview on 04/22/25 at 2:48 PM, LVN C said Resident #10 should not have medications at bedside because the resident or another resident could get ahold of it. LVN C said anyone who cared for the resident was responsible for ensuring the medications were properly secured. 4. During an observation on 04/21/25 at 10:08 AM revealed the 200-hall medication cart was unattended and unlocked. Staff and residents were noted to be walking next to the unlocked medication cart. MA G exited a resident's room and said she should not have left the medication cart unlocked. MA G said she forgot to lock the medication cart because she was in a hurry to administer the resident her medication. MA G said someone could get medication out of the unlocked medication cart. MA G said it was her responsibility in ensuring the medication carts were locked when leaving them unattended. 5. During an observation interview on 04/22/25 at 09:21 AM, revealed MA F went into a resident's room to administer her routine medications. MA F left the 200-hall medication cart unlocked with the keys attached to the narcotic drawer. MA F turned her back to the cart. MA F said she thought it was okay to leave the cart unlocked if it was facing the room. MA F said she should not have left the keys attached to cart because someone could get into it. MA F said it was her responsibility to ensure the cart was locked when turning her back to it and keeping the keys in her possession. During an interview on 4/23/25 at 2:17 PM, LVN D said the keys should not be left on the cart or the cart unlocked when going in a resident's room because it not was not within the view of the person responsible for the medication carts. LVN D said anyone passing by could get into the cart and obtain medication. LVN D said the person administering the medications was responsible for ensuring the cart was kept locked and the keys in their possession. During an interview on 04/24/24 at 09:03 AM, the DON said she expected medication carts to be to be locked when stepping away and medications to be properly secured. The DON said there was a potential for a drug diversion or someone getting in the medication cart by not locking the medication cart. The DON said there should not have been medications at bedside unless the residents were able to safely administer their medications. She said she currently did not have any residents at the facility that were deemed safe to administer their own medications. The DON said by not properly securing medications placed the residents at risk for potentially taking the medication. The DON said it was the medication aide and nurse's responsibility in ensuring the carts were locked and medications were properly stored. During an interview on 04/24/25 at 09:58 AM, the Administrator said he expected medication carts to be to be locked when stepping away and for medications to be properly secured. He said failure to lock the medication carts was a potential for someone to get into the cart and obtain something that did not belong to them. He said by not properly securing medications could place the residents at risk for potentially taking the medication without appropriate orders. The Administrator said it was the medication aide and nurses' responsibility in ensuring the carts were locked and medications were properly stored. Record review of the facility's policy Storage of Medications revised November 2020, indicated . The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended . Record review of the facility's policy titled, Controlled Substance, revised 11/2022 indicated Controlled Substance are separately locked in a permanently affixed compartment

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable for 1 of 3 meals observed on 4/22/2025 (lunch) meal. The failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record review of the menu indicated the lunch meal items on 4/22/2025 included chicken enchiladas, Spanish rice, refried beans, and churro bites. During an interview on 04/21/2025 beginning at 09:39 a.m., Resident # 29 stated sometimes the food was good and sometimes the food was bad. Resident #29 stated the food was a hit and miss. During an interview on 04/21/25 at 12:05 p.m., Resident #26 stated the food was not good. Resident #26 stated the food was not good because of the taste and sometimes she received the food cold. During an interview on 04/21/25 at 09:46 a.m., Resident #56 stated his eggs were cold most of the time. During a confidential group meeting on 04/22/2025 beginning at 10:30 AM, the resident group said the food had a lot of herbs and the food was cold. During an observation and tasting of the lunch meal on 4/22/2025 at 12:20 p.m., the Dietary Manager stated the chicken enchiladas were good in flavor; the Spanish rice was bland and not hot, but lukewarm; the refried beans had a good temp; and the churros were bland tasting. The Dietary Manager stated she was not sure how the churros were supposed to taste. During observation and tasting of lunch meal on 4/22/25 at 12:20 p.m., five Surveyors stated the chicken enchiladas were good in flavor; the Spanish rice was bland and not hot; the refried beans had a good temp; the churros were bland tasting and did not have the cinnamon sugar taste. During an interview on 4/23/25 at 2:22 p.m., the dietary manager stated she had been the dietary manager for 2 years. The Dietary Manager stated she oversaw the dietary staff at the facility. The Dietary Manager stated the Administrator was her manager. The Dietary Manager stated she tasted the foods in the kitchen once a week. The Dietary Manager stated she made sure staff were following the recipe book by making sure staff looked at the recipe book so that staff knew what ingredients to use. The Dietary Manager stated staff was last in-service on the recipe book on 3/10/25. The Dietary Manager stated she handled food complaints from the residents by talking to the residents that complained about the food and addressing the food complaints while also letting the residents know that it would not happen again. The Dietary Manager stated it was important that food was palatable, attractive, and appetizing to the residents for the residents health. Record review of the Dietary staff in-services indicated following the recipe in-service was last completed on 3/10/25. During an interview on 4/24/25 at 8:44 a.m., the Administrator stated he had been employed at the facility since 8/1/22. The Administrator stated he oversaw the Dietary Manager. The Administrator stated yes, he tried to order test trays a few times a month but would love to order a test tray a few times a week, but he got busy. The Administrator stated the residents did complain about the food at the facility. The Administrator stated food complaints were handled as such by offering alternative meals to the residents. The Administrator stated, I got as many food complaints as I got for raises at the facility. The Administrator stated, You can never please everyone when it comes to food; the facility has the best food. The Administrator stated he did not know when the in-services on the following the recipe book had been last completed. The Administrator stated the Dietary Manager conducted rounds every month and she did the in-services monthly with the dietary staff. A policy on following the recipes was not received prior to exit on 4/24/25 at 8:44 a.m.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen and 1 of 4 halls (Hall 400) reviewed for dietary services, in that: 1) The dietary staff failed to label and date all food items. 2) The dietary staff failed to discard expired food items. 3)CNA A did not sanitize her hands in between passing meal trays on the 400 hall. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation of Freezer #1 with the Dietary Manager on [DATE] at 9:02 a.m., the following was observed: -(1) container of cranberry juice had no prep date and had a use by date of [DATE]. -(1) 5-pound container of sour cream had an open date of [DATE] and expiration date of [DATE]. - (1) ,d+[DATE]-quart container of orange juice was not labeled and had no preparation date or expiration date. - (1) container of Kool aide had a no preparation date and had an expiration date of [DATE]. - (1) container of unsweet tea had no preparation date and had an expiration date of [DATE]. -(1) package of salami lunch meat had an open date of [DATE] and an expiration date of [DATE]. During an observation of the dry storage area with the Dietary Manager on [DATE] at 9:17 a.m., the following was observed: -(1) 5 liters of rotini pasta was not labeled and had no open date and no expiration date. During an observation of the kitchen area with the Dietary Manager on [DATE] at 9:21 a.m., the following was observed: -(1) 4.25 ounce of cilantro had an open date of [DATE] and an expiration date of [DATE]. During an interview on [DATE] at 2:34 p.m., the Dietary Manager stated she had been the Dietary Manager for 2 years. The Dietary Manager stated she oversaw the dietary staff at the facility. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manager stated all food items in the refrigerator were to be labeled, dated with the receive date, open date and expiration date. The Dietary Manager stated staff completed in-services on labeling and dating all food items on [DATE]. The Administrator stated she conducted a daily walk through in the kitchen. The Dietary Manager stated the Administrator conducted weekly walk throughs in the kitchen. The Dietary Manager stated it was important to ensure staff were labeling, dating and discarding expired refrigerator and kitchen food items to make sure food was within reasonable date so that the food would not cause any danger to the residents like salmonella. During an interview on [DATE] at 8:48 a.m., the Administrator stated he had been employed at the facility since [DATE]. The Administrator stated he oversaw the Dietary Manager. The Administrator stated all food items in the refrigerator were to be labeled, dated with receive date, open date and expiration date. The Administrator stated in-services on labeling, dating, and discarding expired food items was last completed this week. The Administrator stated he conducted walk throughs in the kitchen once a week at least and most of the week was more than one time a week. The Administrator stated he was made aware of expired food item food in the kitchen from the Dietary Manager this week. The Administrator stated he did expect the Dietary Manager to report issues found in the kitchen to him. The Administrator stated, It was important to ensure staff were labeling, dating and discarding expired refrigerator and frozen food items because we can't give expired food products in our recipe and cannot give expired food to the residents. Record Review of the Dietary staff in-services indicated following the food labeling and dating in-service was last completed on [DATE]. 2)During an interview and observation on [DATE] at 12:15 p.m., revealed CNA A did not sanitize between passing meal trays on the 400 hall. CNA A stated she had the hand sanitizer in her pocket and had forgot to sanitize her hands in between passing the meal trays on the 400 hall. During a phone interview on [DATE] at 2:15p.m., CNA A stated she had been employed at the facility for [AGE] years. CNA A stated her job title was CNA. CNA A stated she worked the 6 a.m. to 2 p.m. shift at the facility. CNA A stated she completed hand washing in-services a few weeks ago, maybe a month ago. CNA A stated the facility went over hand washing very frequently. CNA A stated she was supposed to sanitize her hands in between passing out the meal trays. CNA A stated her nerves was the reason she did not hand sanitize her hands in between passing meal trays. CNA A stated she kept a bottle of hand sanitizer in her pockets. CNA A stated the charge nurse oversaw her. CNA A stated it was important to ensure she was sanitizing her hands in between passing meal trays for infection control. During an interview on [DATE] at 2:38 p.m. LVN B stated she oversaw CNA A when she worked the floor. LVN B stated she worked the 6 a.m. to 6 p.m. shift. LVN B stated she had been employed at the facility for 2 years. LVN B stated she was not made aware of CNA A not sanitizing her hands in between passing the meal trays. LVN B stated staff were to sanitize their hands in between passing meal trays. LVN B stated she did not remember when the last in-service was last completed on hand hygiene. LVN B stated the DON oversaw her. LVN B stated she ensured staff sanitized their hands by making sure hand sanitation was available and by reminding staff to use the hand sanitation. LVN B stated it was important to ensure staff was sanitizing their hands in between passing meal trays because of infection control and to prevent cross contamination. During an interview on [DATE] at 8:34 a.m., the DON stated she oversaw the nurses at the facility. The DON stated she had been employed at the facility since [DATE]. The DON stated she was made aware of CNA A not sanitizing her hands in between passing meals on the 400 hall until the surveyor had told her. The DON stated staff were to sanitize their hands in between passing meal trays. The DON stated she did not know when the last in-service on hand sanitation was last completed by all staff at the facility. The DON stated CNA A was in-serviced on hand sanitation on the same day she was made aware of this incident. The DON stated the Administrator oversaw her at the facility. The DON stated she ensured staff were sanitizing their hands in between passing meal trays by completing in-services and monitoring the dining room. The DON stated it was important to ensure staff were sanitizing their hands in between passing meal trays for safety of the resident. During an interview on [DATE] at 8:41 a.m., the Administrator stated he oversaw the DON. The Administrator stated he had been employed at the facility since [DATE]. The Administrator stated he was made aware by the DON of CNA A not sanitizing her hands in between passing meals on the 400 hall on [DATE]. The Administrator stated staff were to sanitize their hands in between passing meal trays. The Administrator stated he did not know when the last in-service on hand sanitation was completed. The Administrator stated, He ensured staff were sanitizing their hands in between passing meal trays because that's our protocol; I expect them to follow protocol. The Administrator stated it was important to ensure staff were sanitizing their hands in between passing meal trays to prevent cross contamination and infection control. Record review of hand hygiene policy dated [DATE] indicated, Policy Statement: I. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infec tions to other personnel, residents, and visitors; 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Record review of food receiving, and storage policy revised dated on ,d+[DATE] indicated, (1) All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Record Review of food policy dated [DATE] indicated, Refrigerators: (a). All refrigerated foods are stored per state and federal guidelines; (e) All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old are discarded.

Based on interviews and record review, the facility failed to ensure the right of the residents to be free from abuse for 2 of 4 residents (Resident #2, Resident #3) reviewed for abuse. The facility failed to protect other residents from being kicked by Resident #1, when Resident #1 kicked Resident #3's feet when he walked by him on 1/12/25 at 5:20 am. The facility failed to recognize and put measures in place for Resident #1's increased behaviors from 01/09/2025 through 01/12/2025, which resulted in Resident #1 choking Resident #2. An Immediate Jeopardy (IJ) was identified on 02/27/2025 at 1:40 PM. The IJ template was provided to the facility on [DATE] at 1:06 p.m. While the IJ was removed on 02/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 02/27/2025 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including depression, hypercholesterolemia (high blood cholesterol that limits blood flow), hypertension (high blood pressure), delusional disorders (mental illness that causes people to have false beliefs), and dementia (degenerative brain disease - loss of memory, language). Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS score of 0 and was severely cognitively impaired. Resident #1's MDS indicated wandering behavior was exhibited, and physical and verbal behaviors towards others. Resident #1 was not assessed due to medical condition or safety concerns for eating, toileting, showering, dressing and personal hygiene, ambulation, or transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #1 had an order for behavior monitoring for Diazepam,(medication used to treat anxiety, muscle spasms, and seizures) Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly), bipolar disorder (mood swings) and depression), Trazodone (medication used to treat depression) , and Wellbutrin (medication used to treat depression). Document number of times the resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 09/25/2024. Record review of the care plan with a revision date of 01/15/2024 indicated Resident #1 had the potential to be physically aggressive related to dementia with the following interventions Administer medications as ordered after attempting non-medical approaches, analyze times of day, places, circumstances, triggers and what de-escalates behavior, anticipate needs such as food, water, toileting, if behavior is threat to self or others immediately call for assistance. If signs of agitation shown - intervene before it escalates: remain calm, stand out of reach, listen and respond with empathy, engage in conversation. If response is aggressive, team member to calmly walk away, ask others to leave, ensure everyone is safe, immediately report this to nurse. Record review of the facilities Incident and Accidents Report dated 10/01/2024 - 01/26/2025 indicated no reported incidents involving Resident #1 and Resident #3. Record review of a progress note dated 01/09/2025 at 2:07 PM by LVN A, indicated Resident #1 had behaviors with 2 other residents without physical contact. Record review of a progress noted dated 01/09/2025 at 08:38 PM by LVN B, indicated Resident #1 snatched a cover off another resident in the commons area of the secured unit. Resident #1 swung at staff when approached. Record review of progress noted dated 01/09/2025 at 08:40 PM by LVN B, indicated Resident #1 was going into other resident's rooms. Resident #1 raised his hand to the nurse and then walked out of the room. Record review of progress note dated 01/09/2025 at 09:09 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor. Resident #1 was given a pillow and covered with a blanket. Record review of progress note dated 01/09/2025 at 09:19 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor then got up and started pacing from door to door, shaking the doors. The ADON and the DON were notified of the behaviors. Record review of progress noted dated 01/12/2025 at 01:42 AM by LVN F, indicated Resident #1 was exit seeking, restless, and in and out of other resident's rooms. Resident #1 removed his pants in the commons area in the secured unit. Record review of progress note dated 01/12/2025 at 05:20 AM by LVN F, indicated Resident #1 (as he walked by) kicked Resident #3's feet while he was sitting in his wheelchair. Resident #1 was going in other resident rooms and pacing the secured unit. Record review of progress noted dated 01/12/2025 at 07:00 AM by LVN C, indicated Resident #1 was up and pacing. Resident #1 was grabbing other resident's wheelchairs and attempting to move them. Resident #1 was crawling in hallway. Resident #1 continued to disturb other residents. Record review of progress noted dated 01/12/2025 at 08:40 AM by LVN C, indicated Resident #1 was entering rooms, busting in doors, combative with staff, required assistance by two staff members to remove from room. Resident #1 continued to push and pulled on other resident's wheelchairs. Resident was unable to be redirected. The MA reported Resident #1 continued to refuse his medications with multiple approaches. Resident #1 shoved LVN C in the chest then knocked the medication cup from LVN C. LVN C notified the Administrator, the DON, and the ADON of unable to control/redirect Resident #1, and the escalating behaviors. LVN C then notified Resident #1's family. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN C indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. Immediate notification made for 911 services. The family was notified of escalating behaviors and transfer and agreed to the transfer. Record review of a face sheet dated 02/27/2025 indicated Resident #2 was a 75 -year-old female, admitted to the facility on [DATE], with diagnoses including neuralgia (pain associated with nerves), weakness, age related physical debility, dementia (degenerative brain disease - loss of memory, language), and anxiety (intense, excessive worry). Record review of the comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS score of 3 and was severely cognitively impaired. Resident #2's MDS indicated she required set up assistance with eating, partial assistance with personal hygiene, and substantial assistance with toileting, dressing, and showering. Resident #2's MDS indicated she was independent with ambulation. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident 2 had an order to monitor for pain every shift. During an interview with the DON on 2/27/2025 at 10:10 AM , a copy of the Resident's #2 care plan was requested and not received prior to exiting the facility. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN A indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. CNA E was summoned to Resident #2's room and escorted Resident #2 from the room. Resident #2 was taken to a chair in the commons area of the memory care unit. Resident #2 was upset and crying. Assessment completed with vital signs within normal limits, oxygen saturation at 97%, no redness or bruising noted, and no petechia observed to bilateral eyes. Police officer and EMT arrived at the facility. The EMT completed a full assessment of Resident #2 until Resident #2 stopped the EMT and stated' I am fine. Resident #2 assured the EMT she was safe and could return to her room. Resident #2's family member arrived at the facility and took Resident #2 via private care to the hospital emergency room for evaluation. The Administrator and the DON were made aware of reportable to state. Record review of hospital discharge paperwork dated 01/12/2025 indicated Resident #2 was discharged with unremarkable findings. Record review of a face sheet dated 02/27/2025 indicated Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including hypoglycemia (low blood sugar), type 2 diabetes mellitus (chronic disease when the body does not make insulin properly) mixed hyperlipidemia (causes high levels of cholesterol in the blood), hypertension (high blood pressure), and Alzheimer's disease (a progressive disease that destroys memory and other mental functions). Record review of the discharge MDS dated [DATE] indicated Resident #3 had a BIMS score of 0 and was severely cognitively impaired. Resident #3's MDS indicated wandering behavior was exhibited, physical and verbal behaviors towards others. The MDS indicated Resident #3 required set up assistance for eating. The MDS indicated Resident #3 required partial/moderate assistance for oral and toileting hygiene, partial assistance for shower, dressing, personal hygiene, ambulation, and transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #3 had an order for behavior monitoring for Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly) Document number of times resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 01/06/2025. During an interview with the DON on 2/27/25 at 10:10 AM, a copy of the Resident #3's care plan was requested and not received prior to exiting the facility. Record Review of Resident #3's progress notes dated 01/12/2025 indicated no incidents or assessments completed. Attempted interview on 02/25/2025 at 11:32 AM with Resident #2, she was not interview able. During an interview on 02/26/2025 at 09:30 AM, LVN C stated she had worked at the facility for approximately 2 years. LVN C stated Resident #1 was an elopement risk from another facility and required the secured unit. LVN C stated on 01/12/25 at 08:50 AM she received a telephone call from CNA E, to come to the secured unit to Resident #2's room. LVN C stated upon arrival CNA D had restrained Resident #1 on the floor. CNA E had removed Resident #2 to the commons area of the secured unit. LVN C stated she notified 911 for assistance. LVN C stated upon arrival of the police and the EMT, Resident #1 was transferred out of the facility. LVN C stated she completed an assessment on Resident #2. LVN C stated Resident #2 was upset and crying but then stated she was fine and declined any further care. LVN C stated Resident #2's family arrived and transported her to the emergency room via a private car. LVN C stated Resident #1's behaviors had escalated from the start of her shift at 06:00 AM. LVN C stated Resident #1 disturbed other residents by pulling on wheelchairs, walked with a rapid pace, crawled on the floors. LVN C stated she had not notified the physician of the increase of behaviors. LVN C stated she had contacted Resident #1's family at 08:40 AM. LVN C stated she contacted the ADON and the DON regarding Resident #1's escalated behaviors at 08:40 AM. LVN C stated, I guessed the ADON and DON were working to have the resident transferred out. LVN C stated she was not sure who was making the transfer arrangements at that time. LVN C stated she had reached out to the ADON and the DON via text message and neither were in the facility at that time. LVN C stated she could not recall what exactly she had been told by the ADON and the DON other than redirect Resident #1, but she would have charted the instructions received if she had received any. LVN C stated everything was happening very quickly and she had not delegated any 1 to 1 intervention because the facility did not have the staff. LVN C stated Resident #1 should have been transferred out to a behavioral unit due to escalating behaviors. LVN C stated 1 to 1 intervention could have prevented the choking incident between Resident #1 and Resident #2 but there was not enough staff. LVN C stated Resident #1 was not adequately monitored during the escalated behaviors that resulted in Resident #2 being choked while she was asleep in her bed. During an interview on 02/26/2025 at 10:21 AM, CNA E said Resident #1 had escalated behaviors on 1/12/2025 and was more difficult to redirect and was disturbing the other residents. CNA E said she had reported to LVN C several behaviors since the start of her shift at 6:00 AM. CNA E said Resident #1 was sitting at the table with her and CNA D and appeared settled at that moment. CNA E said she left the secured unit to retrieve the breakfast trays while CNA D was providing care with another resident. Upon returning to the secured unit, she heard CNA D hollering to get help. CNA E said upon entering resident #2's room, CNA D was attempting to restrain Resident #1 from going at Resident #2. CNA E said she removed Resident #2 to the commons area at the front of the secured unit. CNA E said she alerted LVN C by the phone located in the commons area of the secured unit to come and assist CNA D. CNA E said they continued to keep Resident #1 from other residents until the EMT arrived to transport Resident #1. During an interview on 02/26/2025 at 01:15 PM, CNA D said during her shift on 1/12/2025. she noticed Resident #1 was not in the commons area or his room after she finished providing care to another resident. CNA D stated while she looked for Resident #1, she faintly heard Resident #2 call for help. CNA D said when she entered Resident #2's room, Resident #1 was leaning over Resident #2 with both hands around her neck. CNA D said she had to pry Resident #1's hands and fingers from Resident #1's neck. CNA D said she got him down in a sitting position on the floor and placed his hands behind his back as Resident #1 continued to try to go at Resident #2. CNA D stated CNA E arrived back on the secured unit, and she yelled for her. CNA E removed Resident #2 from the room and notified LVN C by the phone located in the commons area of the secured unit. CNA D stated she continued to restrain Resident #1 until the police arrived. LVN C entered the room and then contacted 911. CNA D said the EMTs, and police assisted to transport Resident #1 out of the building to the hospital. During an interview on 02/26/2025 at 03:41 PM, the social worker stated she had not worked on a transfer for Resident #1 until 01/15/2025 after Resident #1 had transferred from the facility. The social worker stated she could not recall any conversation or text messages regarding Resident #1 until after he had left from the facility. The social worker stated escalated behaviors were addressed by putting the care plan interventions in place. When those interventions failed, the facility would transfer the resident with escalating behaviors out of the facility to a behavior unit. The social worker defined escalated behaviors as a change from the resident's baseline behavior such as increased agitation, crawling on floors, no longer able to distract the resident. The social worker said these failures could resulted in harm to residents such as death. During an interview on 02/26/2025 at 07:11 PM, LVN F said Resident #1's behavior had changed. LVN F stated Resident #1 could usually be redirected. LVN F stated that she reported to the ADON and the DON on 01/11/2025 that Resident #1 was more difficult to redirect. LVN F stated she was instructed to continue to redirect the resident and give medications as ordered. LVN F stated Resident #1 took off his pants in the commons area which he had never done anything like that before. LVN F stated the CNA reported to her that Resident #1 kicked Resident #3. LVN F stated she failed to complete the incident report and report the incident to the ADON, the DON, or the Administrator. LVN F stated the incident should have been investigated due to being a resident-to-resident altercation. LVN F stated it was at change of shift and although she had reported the incident to the oncoming shift, an incident report should have been completed by her at the time the incident had occurred. LVN F stated the physician should have been notified as well as the families of the residents involved. LVN F stated reporting should be completed for investigation and to protect the residents from abuse. During an interview on 02/26/2025 at 07:59 PM, LVN G stated Resident #1 experienced escalated behaviors on 01/09/2025. LVN G reported to the ADON and the DON that Resident #1 was crawling around and laying on the floor with his eyes closed. LVN G stated she was instructed by the ADON to give a pillow and blanket and ensure Resident #1 was warm and leave on the floor to sleep. LVN G stated she did not contact the physician for a change of condition related to increased behaviors. LVN G stated Resident #1 was pacing more often and faster. Resident #1 was blocking the doors and shaking the door handles to the secured unit which made it difficult for staff to get through. LVN G recalled Resident #1 took a swing at one of the CNAs. Resident #1 was entering in another resident's rooms and the staff had to coax Resident #1 out and attempted to detour him from going into another resident's rooms. LVN G stated Resident #1 raised his hand at her when she attempted to redirect Resident #1 from another resident's rooms. LVN G stated the CNA reported Resident #1 had jerked covers off of another resident in the commons area of the secured unit. LVN G said when the previous interventions were not effective, she should have also contacted the physician for orders. LVN G said as the charge nurse she was responsible for reporting the change of condition. LVN G said the residents were in harms way such as the choking or death. During an interview on 02/27/2025 at 10:10 AM, the DON identified escalating behaviors as increased agitation, loudness/screaming, and showing signs of aggression. The DON stated Resident #1 was at his baseline and was not showing signs of escalating behaviors. The DON did not respond to the state surveyor when asked if the charted behaviors reported to her through 01/09/2025 - 01/12/2025 describe the definitions as she had identified above as escalated behaviors of Resident #1. The DON said the behaviors exhibited by Resident #1 were typical behaviors of a resident with dementia. The DON said when the staff notified her of the incident with Resident #1 choking Resident #2, she told the staff (CNA E and LVN C) via text message that Resident #1 needed to be sent out because the facility did not provide 1 to 1 care. The DON stated the physician was notified as well as the families after the incident occurred. The DON said there was no way to know the choking incident was going to happen prior to the incident taking place. The DON said the incident with Resident #1 kicking Resident #3 could have been an accident while Resident #1 walked by Resident #3. The DON stated, we don't care what the residents do to the staff - residents hit staff all the time and it did not mean the behaviors were escalated. The DON said they educated the staff on better resident approaching strategies to prevent residents hitting staff. The DON later said when Resident #1 kicked Resident #3 feet, it was considered a resident-to-resident altercation and should have been reported as an incident and investigated to rule out abuse. During an interview on 02/27/2025 at 10:30 AM, the ADON stated Resident #1 exhibited behaviors of a dementia patient and she had not considered the behaviors to be escalated between the dates of 01/09/2025 - 01/12/2025. The ADON described an escalated behavior as something different from their typical baseline behavior and that varied between each individual resident. The ADON stated staff had reported Resident #1 jerking the blanket off another Resident but Resident #1 could have thought that was his blanket. The ADON stated she had told the staff to give Resident #1 the pillow and blanket and ensure resident was warm because he was sleeping and settled/safe on the floor. The ADON said it had not been reported except during the time of 01/09/2025 - 01/12/2025 of Resident #1 pulling/jerking covers from other residents or crawling/laying/sleeping in the floors. The ADON said it was not unusual for dementia residents to wander in and out of room rooms. The ADON stated that was why Resident #1 was in the secured unit due to wandering. The ADON said the incident when Resident #1 hit Resident #3 should have been reported as an incident and the physician, family, the abuse coordinator should have been notified for further investigation. The ADON said abuse allegations should be investigated to protect all residents from abuse. During an interview on 02/27/2025 at 10:50 AM, the Administrator stated behaviors were often unpredictable and predictable to a point. The Administrator said the facility and staff do their best to minimize behaviors and keep all residents safe. The Administrator said, it was not the best ideal to take eyes off of Resident #1 during the 10-minute time frame that the incident occurred within. The Administrator stated he expected staff to report incidents of suspected abuse including suspected resident to resident altercations so that the incident was then followed up on by him with a thorough investigation. The Administrator stated all staff were responsible for ensuring that no resident was subject to any type of abuse. The Administrator said the choking incident and failure of reporting incidents appropriately placed residents at a potential risk of abuse by physical or emotional trauma. The facility policy titled Abuse, Neglect Exploitation, & Misappropriation Policy dated 09/2024 indicated: .The resident has the right to be free of abuse, neglect, exploitation, and misappropriation of resident property and other reportable incidents that affect the Health and Safety of the resident .Physical Abuse includes slapping, biting .5. Abuse toward a resident can occur as: a. resident to resident abuse; . The Administrator was notified on 02/27/2025 at 01:04 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 02/27/2025 at 1:06 PM. The facility's Plan of Removal was accepted on 02/27/2025 at 06:30 PM. and included: Tag F-600: Systemic Approach 1. Resident 1 was transferred to The Local Hospital's Emergency Department where he was admitted to the Behavioral Health Hospital on 1/12/2025. As indicated on SRI #556297, the resident is not to return to the facility to eliminate the risk of behavior happening again. 2. The Medical Director was immediately notified by the Director of Nurses on 2/27/2025 at 2:11pm and the Chief Operating Officer at 1:07pm of the Immediate Jeopardy. 3. Administrator review of the following facility policy on 2.27.2025: a. Abuse, Neglect, Exploitation, & Misappropriation Policy b. Resident to Resident Altercations 4. An immediate in-service to be provided by Regional Nurse Consultant to Administrator, DON and staff at facility with the subject of Recognizing Escalating Behaviors and Effective Measures to Put in Place to Protect Residents on 2/27/2025 at 2:20pm. a. Main takeaways from training include: the use of interventions which include 1:1 monitoring, redirecting, social services department visits and using calming music. 5. An Immediate in-service of the facility's Abuse policy to be conducted for all staff. Employees not present at building will be called via phone and provided in-service information. Inservice of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. A questionnaire will be created from the abuse policy. Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON are responsible for conducting the training. 6. An immediate QAPI meeting to be held by IDT on 2.27.2025 a. Review of incident b. Establish areas of improvement c. Create plan to monitor and manage areas of improvement 7. Safe Surveys were conducted at the time of the incident. Results from the survey can be found with supportive documents provided to State surveyor and in SRI folder administrator keeps on hand. Safe survey results indicated no other residents were in need of additional supervision. 8. Monitoring: a. Admin or DON will conduct weekly random questionnaires of the abuse policy for a period of 4 weeks to ensure staff retain knowledge from the Abuse Policy. 9. Root Cause Analysis was conducted on 2/27/2024 identifying issues related to incidents on 1/12/2025. It was established that employees need more education of the abuse policy and aware of effective ways to de-escalate resident behaviors. This education was immediately provided on 2/27/2025. 10. Quality Assurance a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective. O2/28/2025, the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy by: Record Review of in-service dated 02/27/2025 provided by the Regional Nurse to the Administrator, the DON, and the ADON with the following topics: A. Abuse, Neglect, Exploitation, & Misappropriation Policy B. Resident to Resident Altercations Record Review of the in-service dated 02/27/2025 at 2:20 PM provided by the Regional Nurse Consult to the Administrator, the DON, and the staff at the facility with the subject topic of: Recognizing Escalating Behaviors and effective measure to put in place to protect the residents such as intervention of 1:1 monitoring, redirecting, social services departments visit, and using calming music. Record review of in-service dated 02/27/2025 of the facility's Abuse policy conducted for all staff. (Employees not present at the building will be called via phone and provided in-service information. In-service of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. ) Record review of a questionnaire created from the abuse policy with 25 employee/staff correctly completed on 02/28/2025. (Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON were responsible for conducting the training) Record review of signed QAPI Committee Meeting completed on 2/27/2025 at 2:20 PM addressed the following: a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective. Interviews of nursing staff on 2/28/2025 from 09:49 AM - 11:55 AM (6 AM - 6 PM Shift) DON, ADON, MDS Nurse, LVN C, CNA D, CNA E, CNA L, MA P, LVN Q, LVN W, LVN A, CNA AA, (6PM - 6AM) MA X, LVN Y, LVN Z, CNA BB, CNA CC, CNA DD, CNA EE, Administrator, Dietary Manager, Assistant Dietary Manager, Housekeeping Supervisor, Social Worker, Maintenance Supervisor, Director Business Development, Medical Records, Dietary Aide H, Housekeeper K, Housekeeper M, Housekeeper N, Director of Rehabilitation, PTA U, OT V, Activities Assistant. During these interviews staff were able to correctly identify types of abuse such as physical, sexual, verbal and resident to resident altercations; who to notify if abuse was suspected - such as the abuse coordinator, physician, families; proper documentation in resident charts, incident reports and care plans; recognizing escalated behaviors such as increased screaming and agitation and notifying the physician immediately of escalating behaviors; ways to de-escalate behaviors 1 to 1 monitoring, redirecting, separating residents, removing residents from the environment, calming music, and social services. On 02/28/2025 at 12:00 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facilities need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 2 of 3 residents (Resident #2 and Resident #3) reviewed for accidents and supervision. The facility failed to increase supervision and implement interventions when Resident #1 displayed increased behaviors beginning on 1/9/25 to prevent resident to resident altercations. The facility failed to ensure Resident #1 received adequate supervision to prevent escalating behaviors towards other residents. The facility failed to ensure Resident #1 received adequate supervision after displaying increased behaviors beginning on 1/9/25 which resulted in Resident #1 choking Resident #2. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 1:40 PM on 02/27/2025. While the IJ was removed on 02/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of accidents, injury, or death. Findings included: Record review of a face sheet dated 02/27/2025 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including depression, hypercholesterolemia (high blood cholesterol that limits blood flow), hypertension (high blood pressure), delusional disorders (mental illness that causes people to have false beliefs), and dementia (degenerative brain disease - loss of memory, language). Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS score of 0 and was severely cognitively impaired. Resident #1's MDS indicated wandering behavior was exhibited, and physical and verbal behaviors towards others. Resident #1 was not assessed due to medical condition or safety concerns for eating, toileting, showering, dressing and personal hygiene, ambulation, or transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #1 had an order for behavior monitoring for Diazepam,(medication used to treat anxiety, muscle spasms, and seizures) Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly), bipolar disorder (mood swings) and depression), Trazodone (medication used to treat depression) , and Wellbutrin (medication used to treat depression). Document number of times the resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 09/25/2024. Record review of the care plan with a revision date of 01/15/2024 indicated Resident #1 had the potential to be physically aggressive related to dementia with the following interventions Administer medications as ordered after attempting non-medical approaches, analyze times of day, places, circumstances, triggers and what de-escalates behavior, anticipate needs such as food, water, toileting, if behavior is threat to self or others immediately call for assistance. If signs of agitation shown - intervene before it escalates: remain calm, stand out of reach, listen and respond with empathy, engage in conversation. If response is aggressive, team member to calmly walk away, ask others to leave, ensure everyone is safe, immediately report this to nurse. Record review of the facilities Incident and Accidents Report dated 10/01/2024 - 01/26/2025 indicated no reported incidents involving Resident #1 and Resident #3. Record review of a progress note dated 01/09/2025 at 2:07 PM by LVN A, indicated Resident #1 had behaviors with 2 other residents without physical contact. Record review of a progress noted dated 01/09/2025 at 08:38 PM by LVN B, indicated Resident #1 snatched a cover off another resident in the commons area of the secured unit. Resident #1 swung at staff when approached. Record review of progress noted dated 01/09/2025 at 08:40 PM by LVN B, indicated Resident #1 was going into other resident's rooms. Resident #1 raised his hand to the nurse and then walked out of the room. Record review of progress note dated 01/09/2025 at 09:09 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor. Resident #1 was given a pillow and covered with a blanket. Record review of progress note dated 01/09/2025 at 09:19 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor then got up and started pacing from door to door, shaking the doors. The ADON and the DON were notified of the behaviors. Record review of progress noted dated 01/12/2025 at 01:42 AM by LVN F, indicated Resident #1 was exit seeking, restless, and in and out of other resident's rooms. Resident #1 removed his pants in the commons area in the secured unit. Record review of progress note dated 01/12/2025 at 05:20 AM by LVN F, indicated Resident #1 (as he walked by) kicked Resident #3's feet while he was sitting in his wheelchair. Resident #1 was going in other resident rooms and pacing the secured unit. Record review of progress noted dated 01/12/2025 at 07:00 AM by LVN C, indicated Resident #1 was up and pacing. Resident #1 was grabbing other resident's wheelchairs and attempting to move them. Resident #1 was crawling in hallway. Resident #1 continued to disturb other residents. Record review of progress noted dated 01/12/2025 at 08:40 AM by LVN C, indicated Resident #1 was entering rooms, busting in doors, combative with staff, required assistance by two staff members to remove from room. Resident #1 continued to push and pulled on other resident's wheelchairs. Resident was unable to be redirected. The MA reported Resident #1 continued to refuse his medications with multiple approaches. Resident #1 shoved LVN C in the chest then knocked the medication cup from LVN C. LVN C notified the Administrator, the DON, and the ADON of unable to control/redirect Resident #1, and the escalating behaviors. LVN C then notified Resident #1's family. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN C indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. Immediate notification made for 911 services. The family was notified of escalating behaviors and transfer and agreed to the transfer. Record review of a face sheet dated 02/27/2025 indicated Resident #2 was a 75 -year-old female, admitted to the facility on [DATE], with diagnoses including neuralgia (pain associated with nerves), weakness, age related physical debility, dementia (degenerative brain disease - loss of memory, language), and anxiety (intense, excessive worry). Record review of the comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS score of 3 and was severely cognitively impaired. Resident #2's MDS indicated she required set up assistance with eating, partial assistance with personal hygiene, and substantial assistance with toileting, dressing, and showering. Resident #2's MDS indicated she was independent with ambulation. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident 2 had an order to monitor for pain every shift. During an interview with the DON on 2/27/2025 at 10:10 AM , a copy of the Resident's #2 care plan was requested and not received prior to exiting the facility. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN A indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. CNA E was summoned to Resident #2's room and escorted Resident #2 from the room. Resident #2 was taken to a chair in the commons area of the memory care unit. Resident #2 was upset and crying. Assessment completed with vital signs within normal limits, oxygen saturation at 97%, no redness or bruising noted, and no petechia observed to bilateral eyes. Police officer and EMT arrived at the facility. The EMT completed a full assessment of Resident #2 until Resident #2 stopped the EMT and stated' I am fine. Resident #2 assured the EMT she was safe and could return to her room. Resident #2's family member arrived at the facility and took Resident #2 via private care to the hospital emergency room for evaluation. The Administrator and the DON were made aware of reportable to state. Record review of hospital discharge paperwork dated 01/12/2025 indicated Resident #2 was discharged with unremarkable findings. Record review of a face sheet dated 02/27/2025 indicated Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including hypoglycemia (low blood sugar), type 2 diabetes mellitus (chronic disease when the body does not make insulin properly) mixed hyperlipidemia (causes high levels of cholesterol in the blood), hypertension (high blood pressure), and Alzheimer's disease (a progressive disease that destroys memory and other mental functions). Record review of the discharge MDS dated [DATE] indicated Resident #3 had a BIMS score of 0 and was severely cognitively impaired. Resident #3's MDS indicated wandering behavior was exhibited, physical and verbal behaviors towards others. The MDS indicated Resident #3 required set up assistance for eating. The MDS indicated Resident #3 required partial/moderate assistance for oral and toileting hygiene, partial assistance for shower, dressing, personal hygiene, ambulation, and transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #3 had an order for behavior monitoring for Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly) . Document number of times resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 01/06/2025. During an interview with the DON at 2/27/25 at 10:10 AM, a copy of the Resident #3's care plan was requested and not received prior to exiting the facility. Record Review of Resident #3's progress notes dated 01/12/2025 indicated no incidents or assessments completed. Attempted interview on 02/25/2025 at 11:32 AM with Resident #2, she was not interview able. During an interview on 02/26/2025 at 09:30 AM, LVN C stated she had worked at the facility for approximately 2 years. LVN C stated Resident #1 was an elopement risk from another facility and required the secured unit. LVN C stated on 01/12/25 at 08:50 AM she received a telephone call from CNA E, to come to the secured unit to Resident #2's room. LVN C stated upon arrival CNA D had restrained Resident #1 on the floor. CNA E had removed Resident #2 to the commons area of the secured unit. LVN C stated she notified 911 for assistance. LVN C stated upon arrival of the police and the EMT, Resident #1 was transferred out of the facility. LVN C stated she completed an assessment on Resident #2. LVN C stated Resident #2 was upset and crying but then stated she was fine and declined any further care. LVN C stated Resident #2's family arrived and transported her to the emergency room via a private car. LVN C stated Resident #1's behaviors had escalated from the start of her shift at 06:00 AM. LVN C stated Resident #1 disturbed other residents by pulling on wheelchairs, walked with a rapid paced crawled on the floors. LVN C stated she had not notified the physician of the increase of behaviors. LVN C stated she had contacted Resident #1's family at 08:40 AM. LVN C stated she contacted the ADON and the DON regarding Resident #1's escalated behaviors at 08:40 AM. LVN C stated, I guessed the ADON and the DON were working to have the resident transferred out. LVN C stated she was not sure who was making the transfer arrangements at that time. LVN C stated she had reached out to the ADON and the DON via text message and neither were in the facility at that time. LVN C stated she could not recall what exactly she had been told by the ADON and DON other than redirect Resident #1, but she would have charted the instructions received if she had received any. LVN C stated everything was happening very quickly and she had not delegated any 1 to 1 intervention because the facility did not have the staff. LVN C stated there was not enough staff to do 1 to 1 supervision with Resident #1. LVN C stated lack of staff for the 1 to 1 supervision of Resident #1 resulted in another resident being harmed. During an interview on 02/26/2025 at 10:21 AM, CNA E said Resident #1 had escalated behaviors on 1/12/2025 and was more difficult to redirect and was disturbing the other residents. CNA E said she had reported to LVN C several behaviors since the start of her shift at 6:00 AM. CNA E said Resident #1 was sitting at the table with her and CNA D and appeared settled at that moment. CNA E said she left the secured unit to retrieve the breakfast trays while CNA D was providing care with another resident. Upon returning to the secured unit, she heard CNA D hollering to get help. CNA E said upon entering resident #2's room, CNA D was attempting to restrain Resident #1 from going at Resident #2. CNA E said she removed Resident #2 to the commons area at the front of the secured unit. CNA E said she alerted LVN C by the phone located in the commons area of the secured unit to come and assist CNA D. CNA E said she should have stayed on the unit and prevented the incident, but she had left the unit to get the trays for the other residents because there was no other staff to do so at that time. CNE E said she had notified the charge nurse and she thought she had sent a text message to the DON and ADON about Resident #1 behaviors and was told to continue to monitor and distract Resident #1. CNA E said the lack of supervision during Resident #1's escalating behaviors resulted in Resident #2 being choked in her room. During an interview on 02/26/2025 at 01:15 PM, CNA D said during her shift on 1/12/2025. she noticed Resident #1 was not in the commons area or his room after she finished providing care to another resident. CNA D stated while she looked for Resident #1, she faintly heard Resident #2 call for help. CNA D said when she entered Resident #2's room, Resident #1 was leaning over Resident #2 with both hands around her neck. CNA D said she had to pry Resident #1's hands and fingers from Resident #1's neck. CNA D said she got him down in a sitting position on the floor and placed his hands behind his back as Resident #1 continued to try to go at Resident #2. CNA D stated CNA E arrived back on the secured unit, and she yelled for her. CNA E removed Resident #2 from the room and notified LVN C by the phone located in the commons area of the secured unit. CNA D stated she continued to restrain Resident #1 until the police arrived. LVN C entered the room and then contacted 911. CNA D said the EMTs, and police assisted to transport Resident #1 out of the building to the hospital. CNA D said Resident #1 should not have been left alone. CNA D said Resident #1 was out of control. CNA D said the charge nurse had been notified previously through out the morning. CNA D said lack of supervision resulted in Resident #2 being choked. During an interview on 02/26/2025 at 03:41 PM, the social worker stated she had not worked on a transfer for Resident #1 until 01/15/2025 after Resident #1 had transferred from the facility. The social worker stated she could not recall any conversation or text messages regarding resident #1 until after he had left from the facility. The social worker stated when the care plan interventions failed, Resident #1 should have been placed on 1 to 1 supervision for all resident safety including the safety of Resident #1 and transferred from the facility. The social worker stated the physician should have been notified by the clinical staff and new orders should have been received. During an interview on 02/26/2025 at 07:11 PM, LVN F said Resident #1's behavior had changed LVN F stated Resident #1 could usually be redirected. LVN F stated that she reported to the ADON andthe the DON on 01/11/2025 that Resident #1 was more difficult to redirect. LVN F stated she was instructed to continue to redirect the resident and give medications as ordered. LVN F stated Resident #1 took off his pants in the commons area which he had never done anything like that before. LVN F stated the CNA reported to her that Resident #1 kicked Resident #3. LVN F stated she failed to complete the incident report and report the incident to the ADON, the DON or the Administrator. LVN F stated the incident should have been investigated due to being a resident-to-resident altercation. LVN F stated it was at change of shift and although she had reported the incident to the oncoming shift, an incident report should have been completed by her at the time the incident had occurred. LVN F stated the physician should have been notified as well as the families of the residents involved. LVN F stated reporting should be completed for investigation and to protect the residents from abuse. During an interview on 02/26/2025 at 07:59 PM, LVN G stated Resident #1 experienced escalated behaviors on 01/09/2025. LVN G reported to the ADON and the DON that Resident #1 was crawling around and laying on the floor with his eyes closed. LVN G stated she was instructed by the ADON to give a pillow and blanket and ensure Resident #1 was warm and leave on the floor to sleep. LVN G stated she did not contact the physician for a change of condition related to increased behaviors. LVN G stated Resident #1 was pacing more often and faster. Resident #1 was blocking the doors and shaking the door handles to the secured unit which made it difficult for staff to get through. LVN G recalled Resident #1 took a swing at one of the CNAs. Resident #1 was entering in another resident's rooms and the staff had to coax Resident #1 out and attempted to detour him from going into another resident's rooms. LVN G stated Resident #1 raised his hand at her when she attempted to redirect Resident #1 from another resident's rooms. LVN G stated the CNA reported Resident #1 had jerked covers off of another resident in the commons area of the secured unit. LVN G stated she should have contacted the physician and received new orders regarding Resident #1's change in escalating behaviors to ensure the other residents were not placed in harm or danger of Resident #1. During an interview on 02/27/2025 at 10:10 AM, the DON identified escalating behaviors as increased agitation, loudness/screaming, and showing signs of aggression. The DON stated Resident #1 was at his baseline and was not showing signs of escalating behaviors. The DON did not respond to the state surveyor when asked if the charted behaviors reported to her through 01/09/2025 - 01/12/2025 describe the definitions as she had identified above as escalated behaviors of Resident #1. The DON said the behaviors exhibited by Resident #1 were typical behaviors of a resident with dementia. The DON said when the staff notified her of the incident with Resident #1 choking Resident #2, she told the staff (CNA E and LVN C) via text message that Resident #1 needed to be sent out because the facility did not provide 1 to 1 care. The DON stated the physician was notified as well as the families after the incident occurred. The DON said there was no way to know the choking incident was going to happen prior to the incident taking place. The DON said the incident with Resident #1 kicking Resident #3 could have been an accident while Resident #1 walked by Resident #3. The DON stated, we don't care what the residents do to the staff - residents hit staff all the time and it did not mean the behaviors were escalated. The DON said they educated the staff on better resident approaching strategies to prevent residents hitting staff. The DON later said when Resident #1 kicked Resident #3 feet, it was considered a resident-to-resident altercation and should have been reported as an incident and investigated to rule out abuse. The DON said there was no just no way to know that Resident #1 was going to harm another resident prior to the incident occurring. During an interview on 02/27/2025 at 10:30 AM, the ADON stated Resident #1 exhibited behaviors of a dementia patient and she had not considered the behaviors to be escalated between the dates of 01/09/2025 - 01/12/2025. The ADON described an escalated behavior as something different from their typical baseline behavior and that varied between each individual resident. The ADON stated staff had reported Resident #1 jerking the blanket off another Resident but Resident #1 could have thought that was his blanket. The ADON stated she had told the staff to give Resident #1 the pillow and blanket and ensure resident was warm because he was sleeping and settled/safe on the floor. The ADON said it had not been reported except during the time of 01/09/2025 - 01/12/2025 of Resident #1 pulling/jerking covers from other residents or crawling/laying/sleeping in the floors. The ADON said it was not unusual for dementia residents to wander in and out of room rooms. The ADON stated that was why Resident #1 was in the secured unit due to wandering. The ADON said the incident when Resident #1 hit Resident #3 should have been reported as an incident and the physician, family, the abuse coordinator should have been notified for further investigation. The ADON said abuse allegations should be investigated to protect all residents from abuse. The ADON said when escalated behavior begin, the charge nurse should notify the physician for new orders and interventions. If those intervention and new orders are not effective, the charge nurse should be communicated to the physician to transfer the resident out of the facility to protect other residents as well as the resident with the behavioral changes. During an interview on 02/27/2025 at 10:50 AM, the Administrator stated behaviors were often unpredictable and predictable to a point. The Administrator said the facility and staff do their best to minimize behaviors and keep all residents safe. The Administrator said, it was not the best ideal to take eyes off of Resident #1 during the 10-minute time frame that the incident occurred within. The Administrator stated he expected staff to report incidents of suspected abuse including suspected resident to resident altercations so that the incident was then followed up on by him with a thorough investigation. The Administrator stated all staff were responsible for ensuring that no resident was subject to any type of abuse. The Administrator said the choking incident and failure of reporting incidents appropriately placed residents at a potential risk of abuse by physical or emotional trauma. The Administrator said the clinical staff was responsible for reporting and notifying the physician for changes of condition such as escalating behaviors to protect all the residents from any type of potential harm. The facility policy titled Abuse, Neglect Exploitation, & Misappropriation Policy dated 09/2024 indicated: .The resident has the right to be free of abuse, neglect, exploitation and misappropriation of resident property and other reportable incidents that affect the Health and Safety of the resident .Physical Abuse includes slapping, biting .5. Abuse toward a resident can occur as: a. resident to resident abuse; . The Administrator was notified on 02/27/2025 at 01:04 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 02/27/2025 at 1:06 PM. The facility's Plan of Removal was accepted on 02/27/2025 at 06:30 PM. and included: Tag F-689: Systemic Approach 1. Resident 1 was transferred to The Local Hospital's Emergency Department where he was admitted to the Behavioral Health Hospital on 1/12/2025. As indicated on SRI #556297, the resident is not to return to the facility to eliminate the risk of behavior happening again. 2. The Medical Director was immediately notified by the Director of Nurses on 2/27/2025 at 2:11pm and the Chief Operating Officer at 1:07pm of the Immediate Jeopardy. 3. Administrator review of the following facility policy on 2.27.2025: a. Abuse, Neglect, Exploitation, & Misappropriation Policy b. Resident to Resident Altercations 4. An immediate in-service to be provided by Regional Nurse Consultant to Administrator, DON and staff at facility with the subject of Recognizing Escalating Behaviors and Effective Measures to Put in Place to Protect Residents on 2/27/2025 at 2:20pm. a. Main takeaways from training include: the use of interventions which include 1:1 monitoring, redirecting, social services department visits and using calming music. 5. An Immediate in-service of the facility's Abuse policy to be conducted for all staff. Employees not present at building will be called via phone and provided in-service information. Inservice of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. A questionnaire will be created from the abuse policy. Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON are responsible for conducting the training. 6. An immediate QAPI meeting to be held by IDT on 2.27.2025 a. Review of incident b. Establish areas of improvement c. Create plan to monitor and manage areas of improvement 7. Safe Surveys were conducted at the time of the incident. Results from the survey can be found with supportive documents provided to State surveyor and in SRI folder administrator keeps on hand. Safe survey results indicated no other residents were in need of additional supervision. 8. Monitoring: a. Admin or DON will conduct weekly random questionnaires of the abuse policy for a period of 4 weeks to ensure staff retain knowledge from the Abuse Policy. 9. Root Cause Analysis was conducted on 2/27/2024 identifying issues related to incidents on 1/12/2025. It was established that employees need more education of the abuse policy and aware of effective ways to de-escalate resident behaviors. This education was immediately provided on 2/27/2025. 10. Quality Assurance a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective. O2/28/2025, the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopard by: Record Review of in-service dated 02/27/2025 provided by the Regional Nurse to the Administrator, the DON and the ADON with the following topics: A. Abuse, Neglect, Exploitation, & Misappropriation Policy B. Resident to Resident Altercations Record Review of the in service dated 02/27/2025 at 2:20 PM provided by the Regional Nurse Consult to Administrator,the DON and the staff at the facility with the subject topic of: Recognizing Escalating Behaviors and effective measure to put in place to protect the residents such as intervention of 1:1 monitoring, redirecting, social services departments visit and using calming music. Record review of in-service dated 02/27/2025 of the facility's Abuse policy conducted for all staff. (Employees not present at the building will be called via phone and provided in-service information. Inservice of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. ) Record review of a questionnaire created from the abuse policy with 25 employee/staff correctly completed on 02/28/2025. (Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON were responsible for conducting the training) Record review of signed QAPI Committee Meeting completed on 2/27/2025 at 2:20 PM addressed the following: a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective'. Interviews of nursing staff: on 2/28/2025 from 09:49 AM - 11:55 AM for( 6 AM - 6 PM shift) - DON, ADON, MDS Nurse, LVN C, CNA D, CNA E, CNA L, MA P, LVN Q, LVN W, LVN A, CNA AA (6PM - 6AM shift) - MA X, LVN Y, LVN Z, CNA BB, CNA CC, CNA DD, CNA EE Administrator, Dietary Manager, Assistant Dietary Manager, Housekeeping Supervisor, Social Worker, Maintenance Supervisor, Director Business Development, Medical Records, Dietary Aide H, Housekeeper K, Housekeeper M, Housekeeper N, Director of Rehabilitation, PTA U, OT V, Activities Assistant During these interviews staff were able to correctly identify types of abuse such as physical, sexual, verbal and resident to resident altercations; who to notify if abuse was suspected - such as the abuse coordinator, physician, families; proper documentation in resident charts, incident reports and care plans; recognizing escalated behaviors such as increased screaming and agitation and notifying the physician immediately of escalating behaviors; ways to de-escalate behaviors 1 to 1 monitoring, redirecting, separating residents, removing residents from the environment, calming music, and social services. On 02/28/2025 at 12:00 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facilities need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote the healing of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. (Resident # 37) The facility did not follow wound care ordered by the wound care specialist (NP) from 01/08/2024 to 02/20/2024 by dressing the wound with medical honey instead of the calcium alginate ordered by the wound care nurse practioner. The facility did not ensure Resident #37's alternating pressure mattress (LAL) was working properly to promote healing to her Stage III pressure ulcer and prevent the worsening of the wound. Resident #37 did not have the MD ordered alternating pressure mattress on the bed for 2 of 3 days observed. The facility failed to ensure off loading of the pressure ulcer occured by failing to ensure medical equipment of alternating pressure mattress (LAL) was plugged in, resulting in Resident #37 observed lying on a deflated mattress through which the metal bed frame could be felt. The facility failed to ensure a system was in place to have staff designated to track weekly wound care reports, order changes, and weekly wound measurments by the wound care specialist. These failures could place residents at risk for new development or worsening of existing pressure ulcers, pain, infection, decreased quality of life, and hospitalization . Findings included: 1.Review of a face sheet dated 02/27/2024 indicated Resident #37 was an [AGE] year-old female, admitted on [DATE] with the diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), contractures (occurs when muscles, tendons, joints, or other tissue tighten/ shorten causing deformity), and hypothyroidism (when thyroid gland does not make enough thyroid-hormones to meet the body's needs). Review of the quarterly MDS assessment dated [DATE] indicated Resident #37 had no BIMS completed. Resident #37 was rarely/never understood. Resident #37 required dependent assistance with ADLs. Resident #37 had (1) Stage II pressure ulcer and (1) unstageable pressure ulcer. Resident #37 had daily treatments, pressure relieving device to chair and pressure reduction mattress noted on the MDS. Review of Resident #37's care plan last updated 11/23/2023 indicated Resident #37 had an open area to left buttock. The wound care orders were to cleanse area with wound cleanser, pat dry, apply collagen and cover with calcium alginate, apply dry dressing, and change daily. The intervention included providing treatment as ordered. Review of wound care specialist's progress notes included the following: 09/11/2023- Resident #37 again referred to wound management services for pressure ulcer to sacrum measuring 0.6 cm x 0.3 cm x 0.1 (Stage III). The wound had eschar and dry skin of peri wound (area surrounding wound). The wound was free of signs and symptoms of infection. No odor. Cleansed with (cleaning) solution, collagen applied to wound and secured with border foam dressing. 10/23/2023- Wound improved measuring 0.4cm x 0.6 cm x 0.3 cm. Peri wound area pink. Wound scrubbed vigorously with moist 4x4 (gauze). Collagen applied to wound base. Covered with calcium alginate and secured with border foam dressing. 11/13/2023- Wound has improved measuring 0.5 cm x 0.4 cm x 0.1 cm. Collagen placed to wound. Covered with calcium alginate and secured with foam border dressing. 12/04/2023-Wound appeared better, peri wound area had improved, however, due to satellite lesions wound is much larger. Wound cleansed, collagen applied to wound base, covered with calcium alginate, and secured with border foam gauze. 12/18/2023- No notable change to wound. Peri wound pink and fragile, instructed (RN U) for barrier cream to be applied to peri wound. Wound to be cleansed with wound cleanser, collagen applied to wound base. Covered with calcium alginate and secured with border foam dressing. Resident is bed/chair bound and unable to turn self. Educate staff to keep resident on a regular turning schedule. Verbalized understanding. 01/08/2024- Resident (#37) lying in bed on arrival, wound deteriorated measuring 1.8cm x 1.3cm x 0.1 cm. Wound now with centrally located slough. Wound debrided with minimal bleeding controlled with light pressure. Discussed resident offloading with RN and protein intake. Discussed the need for use of overlay or air mattress for offloading and prevention of further skin breakdown. Wound cleansed and dressed per orders, calcium alginate with foam dressing to cover. 01/22/2024- Wound deteriorating measures 2.0cm x 1.6 cm x 0.1 cm. Wound with deep purple/ dark red peri wound. Scrubbed with moist gauze to remove nonviable tissue. Collagen applied to wound bed, covered with calcium alginate, and secured with border foam dressing. 02/05/2024- Resident (#37) was not offloaded at this time. Wound with deterioration measuring 1.8 cm x 1.1 cm x 0.1 cm. Peri wound area very red and fragile with skin breakdown noted. No sign of infection. Wound scrubbed vigorously with moist gauze to remove nonviable tissue. Collagen applied to wound, covered with calcium alginate, and secured with bordered foam dressing. 02/12/2024- No off loading at this time. Encouraged staff to turn regularly with staff verbalizing understanding. Wound 1.5 cm x 2.5 cm x 0.1cm. Wound developed adjacent, connecting sacral and coccyx wound. Peri wound fragile. Erythema noted. No signs of infection. Wound scrubbed with moist gauze to remove nonviable tissue. Collagen applied to wound. Covered with calcium alginate and secured with bordered foam dressing. 02/19/2024- Offloaded in right lateral recumbent position with wedge. Wound with severe deterioration. 6.5cm x 4.9 cm x 0.3 cm. Peri wound area deep purple and dark red with linear area of black tissue. Wound debrided with use of curette to remove nonviable tissue. Medical honey had been used to wound. Encouraged staff to not use medical honey due to moisture and it not being the correct order. Understanding verbalized. Wound cleansed with wound cleanser, collagen applied to wound base. Covered with calcium alginate, secured with border foam dressing. Resident (#37) was not on an alternating pressure air mattress as previously discussed. It is reported the previous mattress kept going flat and that may have contributed to deterioration of wound. Review of wound care specialist progress notes dated 01/08/2024 to 02/19/2024 indicate the orders for the treatment of the stage III coccyx wound were to cleanse with wound cleanser, pat dry, apply collagen, cover with calcium alginate, cover with foam border dressing, and change daily and prn. Review of Resident #37's consolidated orders for 01/10/2024 to 02/20/2024 indicated the orders for the treatment of the stage III coccyx wound were to cleanse with wound cleanser, pat dry. Apply medical honey to slough adhered to wound bed and cover with foam dressing. Change daily and as needed. Review of Resident #37's consolidated orders for 02/20/2024 to present were to cleanse open area to coccyx with wound cleanser, pat dry, apply barrier cream to periwound area. Apply activated moisten collagen sheet or poweder to wound bed. Cover with calcium alginate dressing, then cover with foam dressing. Change daily and as needed. Review of the TARs dated January and February of 2024, indicated Resident #37's coccyx ulcer was treated daily. The treatment was for the wound to be cleansed with wound cleanser, pat dry, apply medical honey to slough adhered to wound bed, cover with foam dressing, and change daily and as needed. During an interview and /observation on 02/25/2024 at 3:00 p.m., RN U revealed Resident #37's coccyx wound had declined over the past 2-4 weeks. RN U stated the nurse assigned to the 200 hall was responsible for all treatments assigned to 200 hall residents. She stated there was not a designated treatment nurse for the facility. RN U performed wound care for Resident #37 following MD orders and failed to follow aseptic technique. RN U failed to wash her hands prior to beginning the treatment and between cleaning the wound and applying the clean dressing. RN U stated there was a wound care doctor that visited the facility on Mondays. RN U stated she spoke with him a few weeks ago and he was concerned he had not ordered medical honey for Resident #37's wound because she had moist skin from incontinence and overall skin condition, but he continued to find medical honey in her wound each Monday. RN U stated Resident #37 was not on a low air loss mattress at the time, because it kept going flat which may have contributed to the worsening of her wound. RN U stated Resident #37's ulcer started on her left sacral area and grew to include her coccyx. RN U stated proper treatment, offloading with a low air loss mattress, and proper nutrition were important to heal a wound. RN U stated not having all of those items could halt healing and lead to infection and death. During a phone interview on 02/26/2024 at 4:00 p.m., the wound care NP stated Resident #37 had the potential to have healed wounds if the facility would keep Resident #37 off loaded, dry, and do the treatments that had been ordered by him. He stated he did rounds every Monday morning and often Resident #37's skin was macerated from being overly moist from incontinence. He stated he had found medical honey in the wound of Resident #37 for the last 3- 4 weeks each week and he had talked to staff (RN U) about his concerns. The wound care specialist stated he never ordered medical honey for Resident #37 because it added moisture to wounds. He explained Resident #37's skin was already moist because she was incontinent at all times, and she had clammy skin. He stated he requested Resident #37 get a new LAL mattress over a week prior when he was told by RN U, Resident #37's LAL mattress was going flat, and she was still on a standard mattress. The wound care NP stated her measurements on 02/25/2024 had improved very little since the previous week because she had been left wet over the weekend when he came in on Monday to measure her wounds. He stated the new measurements were 6.1 cm x 4.5 cm x 0.3 cm, as of 02/25/2024. During an observation on 02/27/2024 at 4:30 a.m., Resident #37 was in bed asleep. Resident #37 was clean and dry with no odor, laying on her right side on an unplugged deflated LAL mattress. The cord for the LAL mattress was wrapped with a zip tie in plastic around it lying on the floor at the foot of the bed. The LAL mattress was completely flat, and the metal frame of the bed was felt under Resident #37's right hip. During an interview on 02/27/2024 at 7:00 a.m., LVN E came into Resident #37's room and stated she was unaware the LAL mattress for Resident #37 was unplugged. LVN E stated she felt it must have come unplugged when the night shift preformed incontinent care last, but there was no way to know for sure. LVN E stated Resident #37 laying directly on the frame could have worsen her wound and would not promote wound healing. LVN E plugged the bed in at this time. During an interview on 02/27/2024 at 11:20 a.m., the DON stated she was made aware the LAL mattress for Resident #37 was unplugged this morning on rounds. The DON stated she plugged the LAL mattress into the wall the prior night around 6 p.m., prior to leaving the facility for the day. The DON stated the facility did not have a weekly wound care report and no one was designated to do weekly measurements of pressure ulcers. The DON stated the facility used the measurements from the wound care specialist (NP) that visited each week. The DON stated she did not agree with the wound care NP's progress notes because she felt that his communication was poor and she was certain he had not talked to her staff about the treatment or Resident #37's care. The DON stated it was her responsibility to read the progress notes the wound care specialist emailed to her each Tuesday after his Monday visit. The DON admitted that she did not always read his progress notes. And was not sure why she had not been reading them other than she had been busy. The DON stated she was unaware the treatment of medical honey from 01/10/2024 to 02/20/2024 was not what the wound care specialist (NP) wanted to use. The DON stated RN U had not communicated the wound care specialist's concerns to her. The DON stated it was her expectation that the floor nurses follow the orders of the wound care specialist and report to her any concerns the wound care specialist had during rounds. The DON stated not following the Medical Director's orders, not having the resident on LAL mattress, and not keeping the resident off loaded could lead to worsening of the wound, development of new wounds, infection, and even death. During an interview on 02/27/2024 at 11:45 a.m., the Administrator stated he wanted the DON to monitor all of the systems she was responsible for and report any concerns she had to him. The Administrator stated he wanted the nurses to do skin assessments, wound care as ordered, and make sure the resident's had all they needed to maintain a healthy life. Review of a policy titled Wound Care Protocol, purpose: 1. To ensure optimal healing of wounds. 2. To identify type of wound in order to provide proper wound care. Expectations: 1. Wounds are to be measured each week and should be measured by the same Registered Nurse / NP clinician for consistency. Measure the wound weekly and provide oversite and direction for the LPN/LVN. Re-evaluate wounds with changes in condition and report to the physician wound status. Revise plan of care with treating physician.

Based on observation, interview, and record review the facility failed to ensure they implemented their abuse policy to ensure residents had the right to be free from abuse or neglect for 4 of 7 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, and Resident #4) The facility failed to follow their policy and ensure Resident #4 was not verbally abuse by LVN D and mental abused and harassed for the remainder of the night on 5/28/23. The facility failed to follow their policy and identify harassment, and intimidation for Resident #1, Resident #2, and Resident #3 when they reported CNA A had intentionally tried to intimidate them. The facility failed to follow their policy when Resident #3 said CNA A intentionally caused her pain. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for [AGE] years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. The Plan of Removal for: [Tag F-607: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o Surveys will be completed by the following department heads: Social Services BOM Dietary Supervisor MDS Coordinator Director of Rehabilitation LVN, ADON If concerns arise from safe survey, statements will be taken from residents. If an allegation of abuse is noted, statements will be taken from all possible sources. In-service has already been provided targeting the importance of reporting as soon as possible and NOT allowing the abuse to continue. An in-service will be provided on behavior training for staff on how to deescalate resident behaviors. This in-service will be completed by DON/Admin by the end of 12/29/2023. An in-service will be provided for treating residents with dignity and respect. To be completed by DON/Admin by the end of 12/29/2023. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting The new Policy was completed by Administrator. Policy was completed 12/28/2023 at 10:00am New policy is more comprehensive and inclusive. The past policy has a collection of 3 different documents. New policy displays definitions of abuse at the very beginning where old policy was displayed on Abuse and Neglect - Clinical Protocol Policy. The definitions on the new policy include Involuntary seclusion, mental abuse, physical abuse, and verbal abuse where the old policies did not specifically specify these types of abuse. A read and sign of the abuse policy will be initiated for every employee working at Windsor Place Nursing Center. Employees may not return to work unless they have read and signed the abuse policy. Staff members started reviewi [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse or neglect for 3 of 7 residents reviewed for abuse. (Resident #1, Resident #3, and Resident #4) The facility failed to ensure Resident #4 was not verbally abused mentally abused, and harassed for the remainder of the night on 5/28/23 by LVN D The facility failed to educate staff on the de-escalation of an agitated or aggressive resident. The facility failed to identify harassment and intimidation as abuse for Resident #1 and Resident #3 when they complained about the care CNA A was providing. The facility failed to identify abuse when Resident #3 said CNA A intentionally caused her pain. CNA A was allowed to continue to intimidate and harass Resident #1 by going into her room and the shower room when she was receiving a shower. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for [AGE] years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. Plan of Removal for [Tag F-600: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o Surveys will be completed by the following department heads: Social Services BOM Dietary Supervisor MDS Coordinator Director of Rehabilitation ADON o Non-interviewable residents will have skin assessment completed once a week, for 3 months to be reviewed monthly in QA. Documented daily rounds to determine if non-interviewable residents are free from abuse to be completely 3 times a week for 3 months and reviewed in monthly QA. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting The new Policy was completed by Administrator. Policy was completed 12/28/2023 at 10:00am New policy is more comprehensive and inclusive. The past policy has a collection of 3 different documents. New policy displays definitions of abuse at the very beginning where old policy was displayed on Abuse and Neglect - Clinical Protocol Policy. The definitions on the new policy include Involuntary seclusion, mental abuse, physical abuse, and verbal abuse where the old policies did not specifically specify these types of abuse. A read and sign of the abuse policy will be initiated for every employee working at Windsor Place Nursing Center. Employees may not return to work unless they have read and signed the abuse policy. A questionnaire will be provided at random to ensure retention of policy. Employees are required to answer questionnaires over policy. Any employee answering questions wrong will receive more education. Staff members started reviewing and signing the new policy. All staff members availa [TRUNCATED]

Based on observation, interview, and record review the facility failed to have evidence violations were thoroughly investigated to prevent further abuse for 4 of 7 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, and Resident #4) The facility failed to ensure a thorough investigation when Resident #4 was not verbally abuse by LVN D and mental abused and harassed for the remainder of the night on 5/28/23. The facility failed to ensure a thorough investigation was conducted when residents complained of harassment, and intimidation for Resident #1, and Resident #3 when they reported CNA A had intentionally tried to intimidate them. The facility failed to complete a thorough investigation on abuse when Resident #3 said CNA A intentionally caused her pain. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for [AGE] years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. The Plan of Removal for: [Tag F-610: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o Surveys will be completed by the following department heads: Social Services BOM Dietary Supervisor MDS Coordinator Director of Rehabilitation ADON o Non-interviewable residents will have skin assessment completed once a week, for 3 months to be reviewed monthly in QA. Documented daily rounds to determine if non-interviewable residents are free from abuse to be completely 3 times a week for 3 months and reviewed in monthly QA. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting The new Policy was completed by Administrator. Policy was completed 12/28/2023 at 10:00am New policy is more comprehensive and inclusive. The past policy has a collection of 3 different documents. New policy displays definitions of abuse at the very beginning where old policy was displayed on Abuse and Neglect - Clinical Protocol Policy. The definitions on the new policy include Involuntary seclusion, mental abuse, physical abuse, and verbal abuse where the old policies did not specifically specify these types of abuse. o New policy states allegations for abuse must be investigated and efforts to prevent the continuation of alleged abuse to be removed as soon as possible. A read and sign of the abuse policy will be initiated for every employee working at Windsor Place Nursing Center. Employees may not return to work unless they have read and signed the abuse policy. A questionnaire will be provided at random to ensure retention of policy. Employees are required to answer questionnaires over policy. Any employee answering questions wrong will receive more education. Staff members [TRUNCATED]

Based on interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 4 residents reviewed for elopement. (Resident #1) The facility did not prevent Resident #1, who had underlying health conditions which placed him at risk of infection, from eloping from the facility during a global COVID 19 outbreak (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older and people of any age with serious underlying medical problems) Due to the outbreak, residents were to be monitored and checked every two hours for changes in their health. Resident #1 was gone from the facility for more than 7 hours and flew to Portland Oregon before staff realized he was missing. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for illness, injury, or death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged on [DATE]. The face sheet indicated he had [DIAGNOSES REDACTED]. The face sheet indicated Resident #1 was not his own responsible party and the resident's mother had durable financial power of attorney (allows someone else to manage finances if the resident becomes incapacitated). During an interview on [DATE] at 4:41 p.m., Resident #1's mother said she was Resident #1's guardian. She said Resident #1 lived in Oregon with his partner and in [DATE] she traveled to Oregon and brought Resident #1 to Texas. She said Resident #1 was confused, weighed less than 120 pounds, was diagnosed with [REDACTED].#1's partner was abusing him. She said when she admitted Resident #1 to the facility, she expressed her concerns about Resident #1 trying to get in contact with his partner and asked staff not to provide him access to phones. Resident #1's mother said she told staff that she was concerned that Resident #1 would elope from the facility and staff assured her he would not elope. During an interview on [DATE] at 12:27 p.m., Resident #1's physician said Resident #1 was gravely ill before he admitted to the facility. He said Resident #1 was living in Oregon and had been diagnosed with [REDACTED].#1's mother moved Resident #1 closer to her and he was admitted to the facility. He said Resident #1's mother said she was Resident #1's guardian. He was unaware that Resident #1 was no longer living in the facility. A nursing note dated [DATE] at 5:45 p.m. indicated Resident #1 was upset that he had to stay at the facility. The nurse notified the oncoming nurse to watch the resident for possible elopement but noted Resident #1 made no attempt on 2:00 p.m. to 10:00 p.m. shift to elope. An elopement risk assessment dated [DATE] for Resident #1 was initiated but it was not completed and did not indicate if Resident #1 was an elopement risk. A social service note dated [DATE] indicated Resident #1 said he was admitted to the facility for panic attacks and he denied having a stroke. Resident #1 would rather be home but understood that medically he needed to be in the facility. Resident #1 was in an abusive relationship and the stroke affected his short-term memory. A citation on notice of temporary guardianship dated [DATE] and provided by Resident #1's mother, indicated she filed an application for temporary guardianship of Resident #1. A care plan last revised on [DATE] indicated Resident #1 had an altered immune system and staff were to follow universal precautions, monitor every two hours and report signs of infection, and provide a private room. The care plan did not address Resident #1's elopement risk. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said after her son was admitted , she gave the business office manager a copy of the court ordered guardianship and the business office manager said she would scan the guardianship paperwork into Resident #1's file. During an interview on [DATE] at 11:38 a.m., the business office manager said in [DATE], Resident #1's mother told her that she was trying to obtain guardianship of Resident #1, but she did not provide guardianship paperwork. She said Resident #1's mother signed Resident #1's admission paperwork and signed it as his power of attorney. During an interview on [DATE] at 1:16 p.m., the sheriff's deputy said he went to the facility on [DATE] and served Resident #1 with guardianship papers. He said the guardianship paperwork indicated that Resident #1's mother was Resident #1's guardian. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said a few weeks after she secured the guardianship, she received a call from the facility and was told that the sheriff's department was serving the guardianship paperwork to Resident #1 and Resident #1 was upset. She said her husband went to the facility and calmed Resident #1 down. She said she spoke to Resident #1 on the phone and he understood that she had guardianship over him. A letter of temporary guardianship dated [DATE] provided by Resident #1's mother indicated she was appointed guardian of Resident #1. The temporary guardianship expired on [DATE]. On [DATE] the temporary guardianship was extended until 30 days after [DATE] due to the COVID-19 pandemic. Physician orders [REDACTED].#1 was ordered Dascovy ,[DATE] mg ([MEDICAL CONDITION] to [MEDICAL CONDITION].once a day between 8:00 a.m. and 12:00 p.m., Tivicay 50 mg ([MEDICAL CONDITION] to [MEDICAL CONDITION].once a day between 8:00 a.m. and 12:00 p.m., [MEDICATION NAME] multivitamin ,[DATE] mg-mcg once a day between 8:00 a.m. and 12:00 p.m., [MEDICATION NAME] propionate nasal spray 50 mcg/actuation 2 sprays once a day between 8:00 a.m. and 10:00 a.m., and Bactrim DS ,[DATE] mg (antibiotic) once a day between 8:00 a.m. and 10:00 a.m. to prevent pneumocystis. A social service note dated [DATE] indicated Resident #1 would rather be at home (Oregon) or in his own home but was not ready medically or financially. Resident #1 said he liked it at the facility but felt somewhat controlled or restricted by his mother. Resident #1 wanted to have more freedom, but he could leave the facility with family and friends. A Minimum (MDS) data set [DATE] indicated Resident #1 had intact cognition, made his needs known, and understood others. He had no physical, verbal, or wandering behaviors during the review period. Resident #1 was independent with most ADLs. He was continent of bowel and bladder. A care plan last revised on [DATE] indicated Resident #1 had an altered immune system and staff were to follow universal precautions, monitor every two hours and report signs of infection, and provide a private room. The care plan did not address Resident #1's elopement risk. A social service note dated [DATE] indicated Resident #1 wanted to reside in an apartment on his own and staff were working on a discharge plan to get him ready to reside in the community. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said the facility restricted visitors in [DATE] due to COVID-19 but Resident #1 called her during the middle of March and said staff were trying to help him to get out of the facility. Resident #1's mother said she called the facility, but the administrative staff had already left for the day and she spoke to CNA C. She said CNA C confirmed that the facility was trying to find an apartment for Resident #1. Resident #1's mother said she told staff that her son could not live independently. A nursing note dated [DATE] at 11:30 a.m. indicated staff were unable to locate Resident #1 in the facility. The administrator, DON, and the resident's mother were notified. Resident #1 was contacted by cell phone and he said he was safe, and he was headed home to Portland Oregon. Resident #1 said this was what he wanted, and this would make him happy. A Medication Administration Record [REDACTED]. A social service note dated [DATE] at 1:35 p.m. indicated Resident #1 had a desire to leave the facility and get an apartment of his own or return to Oregon and stay with his friend. The note indicated staff were working on a discharge plan and the next step was to assist Resident #1 with getting a disability check, so he would have an income. The social service note indicated that there was a discussion with Resident #1 about traveling or flying at this time and they told him he was at high risk due to COVID-19. Resident #1 left the faciity on [DATE] without staff knowledge and returned to Oregon. Resident #1 told staff his desire was to return to Oregon and he was safe. The social service note indicated Resident #1 was mentally capable of making that decision for himself. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said on [DATE] at 12:02 p.m. an unknown staff from the facility called and asked if Resident #1 was with her because he was not in the facility. She said the staff said Resident #1 was last seen around 3:30 a.m., and at 11:30 a.m. staff realized he was not in the facility. She said staff told her that they found the window in Resident #1's room open and the screen was pushed out. She said Resident #1 missed his morning medications. She said she spoke to Resident #1 a few hours later and he said he was back in Oregon. She said Resident #1 did not have money or a phone, but he somehow was able to get in contact with his partner and flew back to Oregon. During an observation on [DATE] at 8:53 a.m., a sign was noted on the front door that visitation was restricted. During an interview on [DATE] at 2:28 p.m., LVN E said Resident #1 was alert and independent with ADLs. She said she last saw Resident #1 on [DATE] around 3:30 a.m. at the nursing station which was normal for him. She said Resident #1 was usually up during the night and would go to the conference room and call his partner on the facility's phone. LVN E said Resident #1's mother did not want Resident #1 talking to his boyfriend but there was no court order, so he could talk to anyone he wanted. She said Resident #1 would say he wanted to go home every day. She said on the morning of [DATE], Resident #1 did not say anything about wanting to go home. She said after Resident #1 was at the nursing station for a little bit then said he was tired, and he was going to his room. She said that was the last time she saw Resident #1. She said she did not hear any door alarms go off the rest of her shift. LVN E said the facility restricted visitors for about a month and required staff to wear masks in the facility. The said appropriate PPE was worn when assisting residents. She said residents were assessed daily for respiratory symptoms and their temperature was checked. She said residents ate their meals in their rooms and spent most of their time in their rooms. She said they monitored residents when they were in common areas to ensure they were a safe distance apart. She said staff had their temperature checked and answered questions regarding symptoms before they were allowed to start their shift. During an interview on [DATE] at 2:46 p.m., CNA C said she and Resident #1 were close. She said Resident #1 told her all the time he was going back to Oregon. She said on [DATE] around 1:00 p.m. she said she called Resident #1 and he said he was going home. She said Resident #1 told her he left the facility through the window in his room and a cab took him to the airport. She said Resident #1's mother told staff she had guardianship over Resident #1 and she did not want Resident #1 talking to his partner. She said she heard there was no guardianship paperwork. She said Resident #1 was alert and independent with ADLs but needed assistance with showers. She said the social worker was finding an apartment for Resident #1 and she said she offered to go to the apartment and assist Resident #1 with showers. During an interview on [DATE] at 10:51 a.m., the social worker said Resident #1 was alert and independent with his care. He said Resident #1's cognition had improved since his admission and he was able to make his own decisions. He said Resident #1's mother said she was trying to get guardianship of Resident #1 but did not provide the facility with any paperwork. He said he had 2 discharge care plan meetings with Resident #1 because Resident #1 wanted to live independently in an apartment. The social worker said Resident #1 did not want his mother to know he wanted to discharge from the facility. He said residents were staying in their rooms most of the time during the COVID-19 restrictions. He said residents ate in their rooms and kept an acceptable distance from other residents when in common areas. He said all staff and essential visitors wore masks in the facility. He said all staff and residents had their temperature checked daily. During an interview on [DATE] at 3:03 p.m., CNA D said Resident #1 always said he wanted to go back home to Oregon. She said he was alert and independent with most ADLs. She said she was not sure if Resident #1's mother had guardianship of Resident #1. She said Resident #1 did not have a cell phone, but he would go to the conference room and use the phone. During an interview on [DATE] at 11:20 a.m., LVN B said Resident #1 was alert and did not want to be at the facility. She said Resident #1 said he wanted to get an apartment locally but had no idea that he would leave the facility on his own. She said the last time she saw Resident #1 was the day before he left the facility and he did not say anything about leaving the facility. During an interview on [DATE] at 1:47 p.m., CNA F said she worked on [DATE] and she took Resident #1's breakfast tray to his room between 8:00 a.m. and 8:30 a.m. She said Resident #1 was not in his room. CNA F said it was normal for Resident #1 not to be in his room because he was independent with ADLs and smoked without supervision. She said she noticed Resident #1's window was open but did not think Resident #1's would have gone out the window. She said she did not report the window being open. She said she left Resident #1's breakfast tray in the room and left. She said if Resident #1 needed anything he would tell staff and she did not check on him like she checked on residents that required ADL assistance. During an interview on [DATE] at 1:25 p.m., LVN A said she worked on [DATE] and went to Resident #1's room to administer his medications about 9:00 a.m. She said Resident #1 was not in his room and his bed looked like it had been slept in. She said it was normal for Resident #1 to be out of his room. She said MA H said she had not seen him. LVN A said she returned to Resident #1's room about 10:30 a.m. and she thought Resident #1 was in his bathroom. She said she went back to Resident #1's room about 11:00 a.m. to 11:30 a.m. and Resident #1's bathroom door was still closed. She said she opened the bathroom door and the bathroom was empty. She said she could not find Resident #1 and she called Resident #1's mother and determined he was not with her. She said the RN supervisor called police. She said when police arrived she walked around the facility with police and noticed Resident #1's window was open and the screen was pushed out. She said when police called Resident #1, he said he was at the airport in Oregon. LVN A said Resident #1's mother told the facility that Resident #1 should not have any contact with his abuser/partner. She said Resident #1 was able to make his own decisions and she was not aware Resident #1's mother had guardianship paperwork. She said residents were assessed daily for respiratory symptoms and had their temperature checked. She said the front door was locked and staff entered the facility through the door where the enclosed smoking area was located. She said staff had their temperature checked and answered a few questions about symptoms before they were allowed to start their shift. She said residents stayed in their rooms most of the time and staff wore masks while in the facility and wore appropriate PPE when working with residents. During an interview on [DATE] at 11:13 a.m., MA H said she worked on [DATE] but did not see Resident #1. She said Resident #1 left the facility sometime before 6:00 a.m. She said Resident #1 was alert and usually was not in his room. She said she heard that he went out the window in his room and called a cab. During an interview on [DATE] at 12:27 p.m., Resident #1's physician said Resident #1 was alert and had improved significantly since he was admitted , but he did not feel that the resident was cognitively intact enough to live independently. He said Resident #1's immune system was weakened due to his diagnoses. During an interview on [DATE] at 9:56 a.m., the administrator said they spoke to Resident #1 on [DATE] and he was safe. She said Resident #1 was his own responsible party and they had been working on discharging the resident into the community. She said Resident #1's mother said she was trying to get guardianship of Resident #1 but did not provide any paperwork to the facility. She said Resident #1 was alert and independent with his own care and staff monitored Resident #1 as staff should for independent residents. She said she did not expect LVN A to open the bathroom door when she though Resident #1 was in the bathroom. She said they reviewed video footage and Resident #1 did not walk out any exit door because he was not seen on video. The administrator said the facility was not a prison. She said the facility began restricting visitors in early [DATE]. She said they posted signs on the front door indicating that visitors were restricted and kept the door locked. She said staff entered and exited the facility through the exit door that led to the enclosed smoking area. The administrator said residents were assessed daily for respiratory symptoms and had their temperature checked. She said they did not have any residents with a temperature of respiratory symptoms. She said staff had their temperature checked and answered a series of questions about travel and symptoms before they were allowed to begin their shift. She said staff were required to wear a mask while in the facility and appropriate PPE when interacting with residents. The administrator said medical and pharmacy suppliers would meet staff outside to ensure no unnecessary visitors came into the facility. She said laboratory services came to the facility on ce a week and obtained all laboratory draws during the visit. The administrator said residents ate their meals in their rooms and staff were monitoring to ensure there was a safe distance between residents. She said staff were in-serviced on infection control, handwashing, and PPE. During a telephone interview on [DATE] at 12:58 p.m., Resident #1 said on [DATE] at 4:00 a.m. he left the facility. He said he walked out the door near the smoking area and a cab picked him up from the facility and took him to a local airport. He said he flew to Dallas and then flew to Oregon. He said his partner in Oregon bought his plane tickets a week prior to him leaving. He said he was able to get his medications through a resource in Portland Oregon. Resident #1 said his mother did not have guardianship over him. A police report dated [DATE] indicated local police were dispatched at 12:11 p.m. to the facility regarding a missing person. LVN A said Resident #1 was last seen in the facility on [DATE] at 3:30 a.m. by nursing staff. It is believed that Resident #1 left the facility through his room window. The report indicated Resident #1 left the facility to return to Oregon. Resident #1 was no longer considered a missing person on [DATE]. The administrator and DON were notified on [DATE] at 9:58 a.m., an IJ situation had been identified due to the above failures. The IJ template was provided to the administrator by email on [DATE] at 10:12 a.m. The facility's Plan of Removal was accepted on [DATE] at 12:08 p.m. and included: 1. All residents have the potential to be affected by this. 2. All current residents have been accounted for. 3. All current residents will have an updated elopement risk assessments completed by close of business [DATE] 4. The Administrator or designee will re-inservice all nursing staff regarding: a. Abuse/neglect b. making rounds to ensure residents are accounted every 2 hours if a CNA cannot account for a residents location they are to notify the charge nurse immediately. If the charge nurse cannot account for a resident's where about they are to notify the administrator and DON immediately. c. Licensed nurses will be re-inserviced on completing an elopement risk assessment on admission d. The MDS Coordinator will complete an elopement risk assessment annually, quarterly and with significant change. All inservicing will be completed by close of business [DATE] 5. The DON/ADON/Administrator or designee will review documentation of every 2 hour checks daily. To begin [DATE] and ongoing. The investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by: During an interview on [DATE] at 9:14 a.m., the DON said all staff were in-serviced on abuse, neglect, and ensuring residents were accounted for every 2 hours. If a CNA could not locate a resident, they would notify the charge nurse immediately. If the charge nurse could not locate the resident, they would notify the administrator and DON immediately. She said licensed nurses were in-serviced on completing elopement assessments on admission. She said all residents were assessed for elopement risk on [DATE]. She said she was reviewing the documentation that staff were visually accounting for residents every 2 hours. During interviews on [DATE], 6 CNAs and 1 MA (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m.) said they were in-serviced on abuse, neglect, and elopement procedures. They were able to define and give examples of abuse and neglect. They said they would make rounds on all residents every 2 hours and ensure every resident was accounted for. They said if a resident could not be located they would notify the charge nurse. During interviews on [DATE], 4 charge nurses (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m.) said they were in-serviced on abuse, neglect, and elopement procedures. They were able to define and give examples of abuse and neglect. They said they would make rounds on all residents every 2 hours and ensure every resident was accounted for. They said if a resident could not be located they would notify the administrator or DON. During an interview on [DATE] at 10:12 a.m. the MDS nurse said she reviewed resident's elopement risk assessments and there were no changes in resident's elopement risks. She said residents that resided in the general population were not wanderers or exit seeking. Elopement risk assessments were reviewed for 43 residents and all assessments were completed. On [DATE] at 10:32 a.m., the DON was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to implement their written policies and procedures to prevent neglect for 1 of 4 residents reviewed for neglect. (Resident #1) The facility did not report to the state when Resident #1, who had underlying health conditions which placed him at risk of infection, eloped from the facility during a global COVID 19 outbreak (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older and people of any age with serious underlying medical problems). Due to the outbreak, residents were to be monitored and checked every two hours for changes in their health. Resident #1 was gone from the facility for more than 7 hours and flew to Portland Oregon before staff realized he was missing. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for neglect. Findings included: The facility's undated abuse prevention program policy indicated residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility's undated abuse investigation and reporting policy indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source were to be promptly report to local, state, and federal agencies and thoroughly investigated by facility management. Alleged abuse, neglect, exploitation or mistreatment that did not result in serious bodily injury the report were required to be reported within 24 hours. A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged on [DATE]. He had [DIAGNOSES REDACTED]. The face sheet indicated Resident #1 was not his own responsible party and the resident's mother had durable financial power of attorney. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said she was Resident #1's guardian. She said Resident #1 lived in Oregon with his partner and in [DATE] she traveled to Oregon and brought Resident #1 to Texas. She said Resident #1 was confused, weighed less than 120 pounds, was diagnosed with [REDACTED].#1's partner was abusing him. She said when she admitted Resident #1 to the facility, she expressed her concerns about Resident #1 trying to get in contact with his partner and asked staff not to provide him access to phones. Resident #1's mother said she told staff that she was concerned that Resident #1 would elope from the facility and staff assured her he would not elope. During an interview on [DATE] at 12:27 p.m., Resident #1's physician said Resident #1 was gravely ill before he admitted to the facility. He said Resident #1 was living in Oregon and had been diagnosed with [REDACTED].#1's mother moved Resident #1 closer to her and he was admitted to the facility. He said Resident #1's mother said she was Resident #1's guardian. A nursing note dated [DATE] at 5:45 p.m. indicated Resident #1 was upset that he had to stay at the facility. The nurse notified the oncoming nurse to watch the resident for possible elopement but noted Resident #1 made no attempt on 2:00 p.m. to 10:00 p.m. shift to elope. An elopement risk assessment dated [DATE] for Resident #1 was initiated but it was not completed and did not indicate if Resident #1 was an elopement risk. A social service note dated [DATE] indicated Resident #1 said he was admitted to the facility for panic attacks and he denied having a stroke. Resident #1 would rather be home but understood that medically he needed to be in the facility. Resident #1 was in an abusive relationship and the stroke affected his short-term memory. A citation on notice of temporary guardianship dated [DATE] and provided by Resident #1's mother, indicated she filed an application for temporary guardianship of Resident #1. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said after her son was admitted , she gave the business office manager a copy of the court ordered guardianship and the business office manager said she would scan the guardianship paperwork into Resident #1's file. During an interview on [DATE] at 11:38 a.m., the business office manager said in [DATE], Resident #1's mother told her that she was trying to obtain guardianship of Resident #1, but she did not provide guardianship paperwork. She said Resident #1's mother signed Resident #1's admission paperwork and signed it as his power of attorney. During an interview on [DATE] at 1:16 p.m., the sheriff's deputy said he went to the facility on [DATE] and served Resident #1 with guardianship papers. He said the guardianship paperwork indicated that Resident #1's mother was Resident #1's guardian. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said a few weeks after she secured the guardianship, she received a call from the facility and was told that the sheriff's department was serving the guardianship paperwork to Resident #1 and Resident #1 was upset. She said her husband went to the facility and calmed Resident #1 down. She said she spoke to Resident #1 on the phone and he understood that she had guardianship over him. A letter of temporary guardianship dated [DATE] provided by Resident #1's mother indicated she was appointed guardian of Resident #1. The temporary guardianship expired on [DATE]. On [DATE] the temporary guardianship was extended until 30 days after [DATE] due to the COVID-19 pandemic. A social service note dated [DATE] indicated Resident #1 would rather be at home (Oregon) or in his own home but was not ready medically or financially. Resident #1 said he liked it at the facility but felt somewhat controlled or restricted by his mother. Resident #1 wanted to have more freedom, but he could leave the facility with family and friends. Physician orders [REDACTED].#1 was ordered Dascovy ,[DATE] mg ([MEDICAL CONDITION] to [MEDICAL CONDITION].once a day between 8:00 a.m. and 12:00 p.m., Tivicay 50 mg ([MEDICAL CONDITION] to [MEDICAL CONDITION].once a day between 8:00 a.m. and 12:00 p.m., [MEDICATION NAME] multivitamin ,[DATE] mg-mcg once a day between 8:00 a.m. and 12:00 p.m., [MEDICATION NAME] propionate nasal spray 50 mcg/actuation 2 sprays once a day between 8:00 a.m. and 10:00 a.m., and Bactrim DS ,[DATE] mg (antibiotic) once a day between 8:00 a.m. and 10:00 a.m. to prevent pneumocystis. A Minimum (MDS) data set [DATE] indicated Resident #1 had intact cognition, made his needs known, and understood others. He had no physical, verbal, or wandering behaviors during the review period. Resident #1 was independent with most ADLs. He was continent of bowel and bladder. A care plan last revised on [DATE] indicated Resident #1 had an altered immune system and staff were to follow universal precautions, monitor every two hours and report signs of infection, and provide a private room. The care plan did not address Resident #1's elopement risk. A social service note dated [DATE] indicated Resident #1 wanted to reside in an apartment on his own and staff were working on a discharge plan to get him ready to reside in the community. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said the facility restricted visitors in [DATE] due to COVID-19 but Resident #1 called her during the middle of March and said staff were trying to help him to get out of the facility. Resident #1's mother said she called the facility, but the administrative staff had already left for the day and she spoke to CNA C. She said CNA C confirmed that the facility was trying to find an apartment for Resident #1. Resident #1's mother said she told staff that her son could not live independently. A nursing note dated [DATE] at 11:30 a.m. indicated staff were unable to locate Resident #1 in the facility. The administrator, DON, and the resident's mother were notified. Resident #1 was contacted by cell phone and he said he was safe, and he was headed home to Portland Oregon. Resident #1 said this was what he wanted, and this would make him happy. A Medication Administration Record [REDACTED]. A social service note dated [DATE] at 1:35 p.m. indicated Resident #1 had a desire to leave the facility and get an apartment of his own or return to Oregon and stay with his friend. The note indicated staff were working on a discharge plan and the next step was to assist Resident #1 with getting a disability check, so he would have an income. The social service note indicated that there was a discussion with Resident #1 about traveling or flying at this time and they told him he was at high risk due to COVID-19. Resident #1 left the faciity on [DATE] without staff knowledge and returned to Oregon. Resident #1 told staff his desire was to return to Oregon and he was safe. The social service note indicated Resident #1 was mentally capable of making that decision for himself. During an interview on [DATE] at 4:41 p.m., Resident #1's mother said on [DATE] at 12:02 p.m. an unknown staff from the facility called and asked if Resident #1 was with her because he was not in the facility. She said the staff said Resident #1 was last seen around 3:30 a.m., and at 11:30 a.m. staff realized he was not in the facility. She said staff told her that they found the window in Resident #1's room open and the screen was pushed out. She said Resident #1 missed his morning medications. She said she spoke to Resident #1 a few hours later and he said he was back in Oregon. She said Resident #1 did not have money or a phone, but he somehow was able to get in contact with his partner and flew back to Oregon. During an interview on [DATE] at 2:28 p.m., LVN E said Resident #1 was alert and independent with ADLs. She said she last saw Resident #1 on [DATE] around 3:30 a.m. at the nursing station which was normal for him. She said Resident #1 was usually up during the night and would go to the conference room and call his partner on the facility's phone. LVN E said Resident #1's mother did not want Resident #1 talking to his boyfriend but there was no court order, so he could talk to anyone he wanted. She said Resident #1 would say he wanted to go home every day. She said on the morning of [DATE], Resident #1 did not say anything about wanting to go home. She said after Resident #1 was at the nursing station for a little bit then said he was tired, and he was going to his room. She said that was the last time she saw Resident #1. She said she did not hear any door alarms go off the rest of her shift. During an interview on [DATE] at 1:47 p.m., CNA F said she worked on [DATE] and she took Resident #1's breakfast tray to his room between 8:00 a.m. and 8:30 a.m. She said Resident #1 was not in his room. CNA F said it was normal for Resident #1 not to be in his room because he was independent with ADLs and smoked without supervision. She said she noticed Resident #1's window was open but did not think Resident #1's would have gone out the window. She said she did not report the window being open. She said she left Resident #1's breakfast tray in the room and left. She said if Resident #1 needed anything he would tell staff and she did not check on him like she checked on residents that required ADL assistance. During an interview on [DATE] at 1:25 p.m., LVN A said she worked on [DATE] and went to Resident #1's room to administer his medications about 9:00 a.m. She said Resident #1 was not in his room and his bed looked like it had been slept in. She said it was normal for Resident #1 to be out of his room. She said MA H said she had not seen him. LVN A said she returned to Resident #1's room about 10:30 a.m. and she thought Resident #1 was in his bathroom. She said she went back to Resident #1's room about 11:00 a.m. to 11:30 a.m. and Resident #1's bathroom door was still closed. She said she opened the bathroom door and the bathroom was empty. She said she could not find Resident #1 and she called Resident #1's mother and determined he was not with her. She said the RN supervisor called police. She said when police arrived she walked around the facility with police and noticed Resident #1's window was open and the screen was pushed out. She said when police called Resident #1, he said he was at the airport in Oregon. LVN A said Resident #1's mother told the facility that Resident #1 should not have any contact with his abuser/partner. She said Resident #1 was able to make his own decisions and she was not aware Resident #1's mother had guardianship paperwork. During an interview on [DATE] at 11:13 a.m., MA H said she worked on [DATE] but did not see Resident #1. She said Resident #1 left the facility sometime before 6:00 a.m. She said Resident #1 was alert and usually was not in his room. She said she heard that he went out the window in his room and called a cab. During an interview on [DATE] at 12:27 p.m., Resident #1's physician said Resident #1 was alert and had improved significantly since he was admitted , but he did not feel that the resident was cognitively intact enough to live independently. He said Resident #1's immune system was weakened due to his diagnoses. During a telephone interview on [DATE] at 12:58 p.m., Resident #1 said on [DATE] at 4:00 a.m. he left the facility. He said he walked out the door near the smoking area and a cab picked him up from the facility and took him to a local airport. He said he flew to Dallas and then flew to Oregon. He said his partner in Oregon bought his plane tickets a week prior to him leaving. He said he was able to get his medications through a resource in Portland Oregon. Resident #1 said his mother did not have guardianship over him. During an interview on [DATE] at 9:56 a.m., the administrator said they spoke to Resident #1 on [DATE] and he was safe. She said Resident #1 was his own responsible party and they had been working on discharging the resident into the community. She said Resident #1's mother said she was trying to get guardianship of Resident #1 but did not provide any paperwork to the facility. She said Resident #1 was alert and independent with his own care and staff monitored Resident #1 as staff should for independent residents. She said she did not expect LVN A to open the bathroom door when she though Resident #1 was in the bathroom. She said they reviewed video footage and Resident #1 did not walk out any exit door because he was not seen on video. The administrator said the facility was not a prison. During an interview on [DATE] at 3:03 p.m., CNA D said Resident #1 always said he wanted to go back home to Oregon. She said he was alert and independent with most ADLs. She said she was not sure if Resident #1's mother had guardianship of Resident #1. She said Resident #1 did not have a cell phone, but he would go to the conference room and use the phone. During an interview on [DATE] at 11:20 a.m., LVN B said Resident #1 was alert and did not want to be at the facility. She said Resident #1 said he wanted to get an apartment locally but had no idea that he would leave the facility on his own. She said the last time she saw Resident #1 was the day before he left the facility and he did not say anything about leaving the facility. A police report dated [DATE] indicated local police were dispatched at 12:11 p.m. to the facility regarding a missing person. LVN A said Resident #1 was last seen in the facility on [DATE] at 3:30 a.m. by nursing staff. It is believed that Resident #1 left the facility through his room window. The report indicated Resident #1 left the facility to return to Oregon. Resident #1 was no longer considered a missing person on [DATE]. The administrator and DON were notified on [DATE] at 9:58 a.m., an IJ situation had been identified due to the above failures. The IJ template was provided to the administrator by email on [DATE] at 10:12 a.m. The facility's Plan of Removal was accepted on [DATE] at 12:08 p.m. and included: 1. All residents have the potential to be affected by this. 2. All current residents have been accounted for. 3. All current residents will have an updated elopement risk assessments completed by close of business [DATE] 4. The Administrator or designee will re-inservice all nursing staff regarding: a. Abuse/neglect b. making rounds to ensure residents are accounted every 2 hours if a CNA cannot account for a residents location they are to notify the charge nurse immediately. If the charge nurse cannot account for a resident's where about they are to notify the administrator and DON immediately. c. Licensed nurses will be re-inserviced on completing an elopement risk assessment on admission d. The MDS Coordinator will complete an elopement risk assessment annually, quarterly and with significant change. All inservicing will be completed by close of business [DATE] 5. The DON/ADON/Administrator or designee will review documentation of every 2 hour checks daily. To begin [DATE] and ongoing. The investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by: During an interview on [DATE] at 9:14 a.m., the DON said all staff were in-serviced on abuse, neglect, and ensuring residents were accounted for every 2 hours. If a CNA could not locate a resident, they would notify the charge nurse immediately. If the charge nurse could not locate the resident, they would notify the administrator and DON immediately. She said licensed nurses were in-serviced on completing elopement assessments on admission. She said all residents were assessed for elopement risk on [DATE]. She said she was reviewing the documentation that staff were visually accounting for residents every 2 hours. During interviews on [DATE], 6 CNAs and 1 MA (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m.) said they were in-serviced on abuse, neglect, and elopement procedures. They were able to define and give examples of abuse and neglect. They said they would make rounds on all residents every 2 hours and ensure every resident was accounted for. They said if a resident could not be located they would notify the charge nurse. During interviews on [DATE], 4 charge nurses (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m.) said they were in-serviced on abuse, neglect, and elopement procedures. They were able to define and give examples of abuse and neglect. They said they would make rounds on all residents every 2 hours and ensure every resident was accounted for. They said if a resident could not be located they would notify the administrator or DON. During an interview on [DATE] at 10:12 a.m. the MDS nurse said she reviewed resident's elopement risk assessments and there were no changes in resident's elopement risks. She said residents that resided in the general population were not wanderers or exit seeking. Elopement risk assessments were reviewed for 43 residents and all assessments were completed. On [DATE] at 10:32 a.m., the DON was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and based on the comprehensive assessment and care plan for 1 of 4 residents reviewed for assessments. (Resident #1) The facility did not immediately provide emergency care for Resident #1 when he experienced several sudden significant changes in condition involving stroke like symptoms for approximately 16 hours. Resident #1 had a history of [REDACTED].#1 exhibited left sided weakness, a decreased level of consciousness that required a sternal rub (the application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) and, a decline in swallowing, and communication. At approximately 8:30 p.m. Resident #1 experienced left sided weakness and a decreased level of consciousness. At approximately 1:00 a.m., on 6/25/19 Resident # 1 had rapid respirations with pursed lip breathing, elevated blood pressure and pulse, inability to move his left side, and his right side was rigid he was transferred to the hospital where he was diagnosed with [REDACTED]. He was discharged from the hospital back to the nursing facility in terminal condition on hospice services. An Immediate Jeopardy (IJ) situation was identified on 6/28/19 due to the above failures related to Resident #1. While the IJ was removed on 7/1/19, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents who experienced a change in condition at risk for not receiving care and services to meet their needs, and/or death. Findings included: Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. A physician telephone order dated 6/27/19 indicated Resident #1 admitted to hospice services for [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 sometimes made himself understood, usually understood others, and his cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The MDS also indicated the resident had no impairment to his upper and lower extremities. The MDS indicated Resident #1 had an active [DIAGNOSES REDACTED]. The care plan updated on 4/23/19 did not address Resident #1's history of [MEDICAL CONDITION]. The care plan indicated Resident #1 was alert and oriented to self, and staff would notify the physician and primary contact of any noted changes in cognitive status. The care plan indicated Resident #1 had visual impairment but was able to follow staff with his eyes, had impaired communication but was able to communicate if time was given, and the resident had no problem with chewing or swallowing. The clinical record for Resident #1 did not have nursing notes for 6/24/19. A vitals report dated from 6/1/19 to 6/28/19 indicated Resident #1's blood pressure and pulse was taken on 6/24/19 at 11:29 a.m. (blood pressure 137/79, pulse 69) and 5:01 p.m. (blood pressure 144/73, pulse 64). There were no additional vital signs documented on 6/24/19. A nursing note dated 6/25/19 at 5:24 a.m., indicated Resident #1 was transferred to the emergency room for increased blood pressure, increased pulse, unable to talk, left sided weakness, right side muscle tension, and heavy, increased respirations with pursed lip breathing. A history and physical from the hospital dated 6/25/19 indicated Resident #1 presented to the emergency room with altered mental status and was unresponsive when he was evaluated in the emergency room and on the medical floor. The history and physical indicated Resident #1 had past medical history of [REDACTED].#1 had an MRI (a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body in both health and disease) and the impression was a [MEDICAL CONDITION]. Resident #1's active [DIAGNOSES REDACTED]. The history and physical indicated Resident #1 was transferred to the ICU (intensive care unit) on 6/25/19. A hospital discharge summary dated 6/27/19 indicated Resident #1 was discharged from the hospital back to the nursing facility on hospice services with a grim prognosis. The hospital discharge summary indicated Resident #1's [DIAGNOSES REDACTED]. During an observation on 6/28/19 at 11:10 a.m., Resident #1 was lying in bed, asleep, with oxygen on via nasal cannula. During an interview on 6/28/19 at 11:12 a.m., MA B said Resident #1 was alert and responsive prior to 6/24/19. MA B said Resident #1 had not been responsive and was on hospice services for [DIAGNOSES REDACTED]. During a telephone interview on 6/28/19 at 11:43 a.m., Resident #1's responsible party said he was not notified of any changes in Resident #1's condition until he was sent to the emergency room . During an interview on 6/28/19 at 11:50 a.m., MA [NAME] said on 6/24/19 Resident #1 was out of it that morning between approximately 9:00 a.m. to 10:00 a.m. MA [NAME] said Resident #1 had decreased responsiveness and she did not administer his medications because she did not feel safe. MA [NAME] said she felt like Resident #1 was at risk for choking on his medications if they were administered. MA [NAME] said she reported Resident #1's decreased responsiveness and not administering his medications to RN F. MA [NAME] said Resident #1 was assisted to lay down after he was noticed to have decreased responsiveness. MA [NAME] said Resident #1 was responsive and more like himself later in the evening on 6/24/19. During an interview on 6/28/19 at 12:03 p.m., CNA C said on 6/24/19 between approximately 10:30 a.m. and 11:00 a.m., Resident #1 was sitting in his wheelchair in the sitting area in front of the television. CNA C said Resident #1 appeared to choke while having a sucker in his mouth. CNA C said Resident #1 was looking toward the right side, not focusing his eyes which was not his normal. CNA C said Resident #1 was not hollering per his usual and had a decreased level of consciousness. CNA C said she notified RN F about Resident #1's change in condition. CNA C said Resident #1 had left sided weakness and was unable to squeeze her hand with his left hand but was able to squeeze with his right hand. CNA C said Resident #1 previously could squeeze both hands equally. CNA C said RN F checked Resident #1's vital signs and they were normal, then Resident #1 was assisted to lay down in his bed. During an interview on 6/28/19 at 12:08 p.m., RN F said on 6/24/19 at approximately 10:00 a.m. Resident #1 had a decreased level of consciousness while he was sitting in front of the television in his wheelchair. RN F said staff reported Resident #1 appeared to choke on his sucker and was not his normal self. RN F said approximately 20 minutes before the decreased level of consciousness was noticed, Resident #1 was his normal self. RN F said he checked Resident #1's vital signs and they were normal. RN F said he consulted with the DON about Resident #1's decreased level of consciousness and the DON told him Resident #1 had done this before, was sent out and was sent right back. RN F said he checked Resident #1's vital signs every 15 to 20 minutes for one hour and after approximately one-hour Resident #1 was back to normal. RN F said he checked on Resident #1 a couple of times after lunch until 2:00 p.m. and Resident #1 was normal. RN F said he did not chart anything on 6/24/19 and did not have a reason for not charting. During a telephone interview on 6/28/19 at 12:36 p.m., LVN A said Resident #1 was asleep when her shift began on 6/24/19 at 10:00 p.m. LVN A said she did not receive anything in the shift change report on 6/24/19 from the ADON about Resident #1. LVN A said on 6/24/19 between approximately 1:00 a.m. and 1:30 a.m., the night shift CNAs reported there was a change with Resident #1. LVN A said Resident #1 had decreased level of consciousness and did not respond to painful stimuli. LVN A said Resident #1 had rapid respirations with pursed lip breathing, elevated blood pressure and pulse, he was unable to move his left side, and his right side was rigid. LVN A said she immediately called to transfer Resident #1 to the emergency room and he was out of the facility by 2:00 a.m. During an interview on 6/28/19 at 1:42 p.m., RN F said he did not notify Resident #1's physician of his change in condition because there was nothing to report. RN F said on 6/24/19 at approximately 10:00 a.m. he had a hard time getting Resident #1 to wake up and performed a sternal rub on Resident #1. RN F said Resident #1 barely opened his eyes and grunted when the sternal rub was performed. RN F said he did not assess Resident #1's left and right hand grips. RN F said he was close to sending Resident #1 out to the emergency room but did not send him since he came back to normal approximately an hour after he performed the sternal rub. RN F said he did not perform every 15 minute vital sign checks. RN F said he checked Resident #1's blood pressure three times during his shift on 6/24/19. RN F said Resident #1's blood pressure was 134/79 (Normal blood pressure is less than 120/80) before 10:00 a.m., 139/70 at 10:00 a.m., and 153/87 at 11:40 a.m. During an interview on 6/28/19 at 2:06 p.m., CNA G said on 6/24/19 at approximately 8:45 p.m., Resident #1 had a decreased level of consciousness, was not using his left arm per usual, and was not making noise like he normally did when care was being provided. CNA G said she notified the ADON of the resident's change of condition, the ADON checked his blood pressure and pulse which were normal. CNA G said Resident #1 was left in bed to sleep. During a telephone interview on 6/28/19 at 2:32 p.m., CNA D said on 6/24/19 at approximately 1:00 a.m. Resident #1 was not responsive, his breathing was different and rapid, and he had left sided weakness. CNA D said CNA G told her in shift change report to keep an eye on Resident #1 because he was not himself. During an interview on 6/28/19 at 2:48 p.m., the ADON said on 6/24/19 a day shift CNA reported a concern about Resident #1 not opening his eyes. The ADON said Resident #1 was normal and there was no change of condition on 6/24/19. The ADON said she went to Resident #1's room on 6/24/19 at approximately 8:30 p.m. to assess him. The ADON said Resident #1 would not open his eyes but his vital signs were normal. The ADON said she did not chart anything about Resident #1 or her assessment because she did not think there was a change of condition. During an interview on 6/28/19 at 2:55 p.m., the DON said she assessed Resident #1 on 6/24/19 and he had no change of condition. The DON said Resident #1 did not want to wake up for lunch and the CNAs asked her to check on Resident #1. The DON said she checked Resident #1's vital signs, they were normal, and he did get up for lunch. The DON said she was not aware of Resident #1's decreased level of consciousness that required RN F to perform a sternal rub or Resident #1's left sided weakness on the morning of 6/24/19 at approximately 10:00 a.m. During a telephone interview on 7/1/19 at 9:54 a.m., Resident #1's physician did not recall if he was notified of Resident #1's change of condition. Resident #1's physician said if Resident #1 had decreased level of consciousness, required a sternal rub, and had left sided weakness, he should have been notified and Resident #1 sent to the emergency room . Resident #1's physician said he expected to be notified of changes in condition. An undated Change in a Resident's Condition or Status policy indicated .the nurse will notify the resident's Attending Physician or physician on call when there has been a .significant change in the resident's physical/emotional/mental condition .need to alter the resident's medical treatment significantly .need to transfer the resident to a hospital/treatment center .unless otherwise instructed by the resident, a nurse will notify the resident's representative when .there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center . The CDC website at <https://www.cdc.gov/stroke/signs_symptoms.htm> accessed 7/2/19 indicated .During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women *Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body *Sudden confusion, trouble speaking, or difficulty understanding speech *Sudden trouble seeing in one or both eyes *Sudden trouble walking, dizziness, loss of balance, or lack of coordination *Sudden severe headache with no known cause Call 9-1-1 right away if you or someone else has any of these symptoms . The DON was notified on 6/28/19 at 5:03 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The DON was provided the IJ template on 6/28/19 at 5:40 p.m. The facility's Plan of Removal was accepted on 6/28/19 at 8:41 p.m. and included: 1. All residents have the potential to be affected by this. 2. Current residents experiencing a change in condition will be assessed by the DON, ADON and an RN from another facility beginning immediately and to be completed by 8:00 p.m. 06/28/19. 3. All residents not already identified as having a change of condition will be assessed to ensure no current change of condition has been missed by the DON, ADON and an RN from another facility beginning immediately and to be completed by 8:00 p.m. 06/28/19. 4. An RN from another facility will re-inservice DON and ADON regarding signs [MEDICAL CONDITION] changes in condition, assessments, transfer of a resident during a change of condition, physician notification of change of condition, what and when to notify, (see attached policy). Training will begin immediately. Once training completed with DON and ADON, DON and ADON will complete training with all other nursing staff; training will be completed by close of business 06/29/19 or they will be taken off the schedule until the training is received. No nursing staff will be allowed to clock in for their next shift without first receiving the training. 5. The DON/ADON/Administrator or designee will make walking rounds daily to identify any changes in condition not already identified by nursing staff and take immediate action to ensure proper assessment and treatment beginning immediately. 6. The DON/ADON/Administrator or designee will review documentation of residents experiencing a change of condition daily to ensure proper assessments are being conducted. To begin 06/28/2019 ongoing. Inconsistencies will be addressed with the assessing nurse. 7. The DON/ADON/Administrator will report results of daily reviews to the QA team each morning during the morning meeting beginning 07/01/2019. 8. The Medical Director was consulted and has reviewed the plan of removal and has approved of the above plan. On 7/1/19 surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: The ADON said she was in-serviced by an RN from another facility on symptoms of a stroke and changes in condition. The ADON said if a resident experienced symptom of a stroke or any other change in condition, the resident's physician would be notified and the resident would be sent to the emergency room . The DON said she was in-serviced by an RN from another facility on symptoms of a stroke and changes in condition. The DON said if a resident experienced symptom of a stroke or any other change in condition, the resident's physician would be notified and the resident would be sent to the emergency room . Six CNAs (on all 3 shifts) and four medication aides (6 a.m. to 2 p.m. shift, 2 p.m. to 10 p.m. shift), said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident experienced symptom of a stroke or any other change in condition, they would report it to the resident's charge nurse. They said if the charge nurse did not respond to the change in condition, they would report it to the DON, ADON, or administrator. They said if administrative staff were unavailable or did not respond, they would call 911 themselves if the resident was having symptoms of a stroke or needed immediate medical attention for any other change in condition. Five nurses (on all 3 shifts) said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident presented with symptoms of a stroke or any other change in condition which required immediate medical attention, they would send the resident to the hospital and notify the physician. On 7/1/19 at 1:00 p.m., the administrator, DON, and ADON were informed the IJ was removed; however, the facility out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately consult with the resident's physician and responsible party when there was a need to alter treatment for 1 of 4 residents reviewed for assessments. (Resident #1) The facility did not immediately notify the physician or responsible party for Resident #1 when he experienced several significant changes in condition involving stroke like symptoms including left sided weakness, a decreased level of consciousness that required a sternal rub (the application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli), a decline in swallowing, and communication for approximately 16 hours. Resident #1 exhibited stroke like symptoms on 6/24/19 at approximately 10:00 a.m. and again on 6/25/19 at approximately 1:00 a.m. Resident #1 was discharged from the hospital back to the nursing facility in terminal condition on hospice services An Immediate Jeopardy (IJ) situation was identified on 6/28/19 due to the above failures related to Resident #1. While the IJ was removed on 7/1/19, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents who experienced a change in condition at risk for not receiving care and services to meet their needs, and/or death. Findings included: Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. A physician telephone order dated 6/27/19 indicated Resident #1 admitted to hospice services for [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 sometimes made himself understood, usually understood others, and his cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The MDS also indicated the resident had no impairment to his upper and lower extremities. The MDS indicated Resident #1 had an active [DIAGNOSES REDACTED]. The care plan updated on 4/23/19 did not address Resident #1's history of [MEDICAL CONDITION]. The care plan indicated Resident #1 was alert and oriented to self, and staff would notify the physician and primary contact of any noted changes in cognitive status. The care plan indicated Resident #1 had visual impairment but was able to follow staff with his eyes, had impaired communication but was able to communicate if time was given, and the resident had no problem with chewing or swallowing. The clinical record for Resident #1 did not have nursing notes for 6/24/19. A vitals report dated from 6/1/19 to 6/28/19 indicated Resident #1's blood pressure and pulse was taken on 6/24/19 at 11:29 a.m. (blood pressure 137/79, pulse 69) and 5:01 p.m. (blood pressure 144/73, pulse 64). There were no additional vital signs documented on 6/24/19. A nursing note dated 6/25/19 at 5:24 a.m., indicated Resident #1 was transferred to the emergency room for increased blood pressure, increased pulse, unable to talk, left sided weakness, right side muscle tension, and heavy, increased respirations with pursed lip breathing. A history and physical from the hospital dated 6/25/19 indicated Resident #1 presented to the emergency room with altered mental status and was unresponsive when he was evaluated in the emergency room and on the medical floor. The history and physical indicated Resident #1 had past medical history of [REDACTED].#1 had an MRI (a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body in both health and disease) and the impression was a [MEDICAL CONDITION]. Resident #1's active [DIAGNOSES REDACTED]. The history and physical indicated Resident #1 was transferred to the ICU (intensive care unit) on 6/25/19. A hospital discharge summary dated 6/27/19 indicated Resident #1 was discharged from the hospital back to the nursing facility on hospice services with a grim prognosis. The hospital discharge summary indicated Resident #1's [DIAGNOSES REDACTED]. During an observation on 6/28/19 at 11:10 a.m., Resident #1 was lying in bed, asleep, with oxygen on via nasal cannula. During an interview on 6/28/19 at 11:12 a.m., MA B said Resident #1 was alert and responsive prior to 6/24/19. MA B said Resident #1 had not been responsive and was on hospice services for [DIAGNOSES REDACTED]. During a telephone interview on 6/28/19 at 11:43 a.m., Resident #1's responsible party said he was not notified of any changes in Resident #1's condition until he was sent to the emergency room . During an interview on 6/28/19 at 11:50 a.m., MA [NAME] said on 6/24/19 Resident #1 was out of it that morning between approximately 9:00 a.m. to 10:00 a.m. MA [NAME] said Resident #1 had decreased responsiveness and she did not administer his medications because she did not feel safe. MA [NAME] said she felt like Resident #1 was at risk for choking on his medications if they were administered. MA [NAME] said she reported Resident #1's decreased responsiveness and not administering his medications to RN F. MA [NAME] said Resident #1 was assisted to lay down after he was noticed to have decreased responsiveness. MA [NAME] said Resident #1 was responsive and more like himself later in the evening on 6/24/19. During an interview on 6/28/19 at 12:03 p.m., CNA C said on 6/24/19 between approximately 10:30 a.m. and 11:00 a.m., Resident #1 was sitting in his wheelchair in the sitting area in front of the television. CNA C said Resident #1 appeared to choke while having a sucker in his mouth. CNA C said Resident #1 was looking toward the right side, not focusing his eyes which was not his normal. CNA C said Resident #1 was not hollering per his usual and had a decreased level of consciousness. CNA C said she notified RN F about Resident #1's change in condition. CNA C said Resident #1 had left sided weakness and was unable to squeeze her hand with his left hand but was able to squeeze with his right hand. CNA C said Resident #1 previously could squeeze both hands equally. CNA C said RN F checked Resident #1's vital signs and they were normal, then Resident #1 was assisted to lay down in his bed. During an interview on 6/28/19 at 12:08 p.m., RN F said on 6/24/19 at approximately 10:00 a.m. Resident #1 had a decreased level of consciousness while he was sitting in front of the television in his wheelchair. RN F said staff reported Resident #1 appeared to choke on his sucker and was not his normal self. RN F said approximately 20 minutes before the decreased level of consciousness was noticed, Resident #1 was his normal self. RN F said he checked Resident #1's vital signs and they were normal. RN F said he consulted with the DON about Resident #1's decreased level of consciousness and the DON told him Resident #1 had done this before, was sent out and was sent right back. RN F said he checked Resident #1's vital signs every 15 to 20 minutes for one hour and after approximately one-hour Resident #1 was back to normal. RN F said he checked on Resident #1 a couple of times after lunch until 2:00 p.m. and Resident #1 was normal. RN F said he did not chart anything on 6/24/19 and did not have a reason for not charting. During a telephone interview on 6/28/19 at 12:36 p.m., LVN A said Resident #1 was asleep when her shift began on 6/24/19 at 10:00 p.m. LVN A said she did not receive anything in the shift change report on 6/24/19 from the ADON about Resident #1. LVN A said on 6/24/19 between approximately 1:00 a.m. and 1:30 a.m., the night shift CNAs reported there was a change with Resident #1. LVN A said Resident #1 had decreased level of consciousness and did not respond to painful stimuli. LVN A said Resident #1 had rapid respirations with pursed lip breathing, elevated blood pressure and pulse, he was unable to move his left side, and his right side was rigid. LVN A said she immediately called to transfer Resident #1 to the emergency room and he was out of the facility by 2:00 a.m. During an interview on 6/28/19 at 1:42 p.m., RN F said he did not notify Resident #1's physician of his change in condition because there was nothing to report. RN F said on 6/24/19 at approximately 10:00 a.m. he had a hard time getting Resident #1 to wake up and performed a sternal rub on Resident #1. RN F said Resident #1 barely opened his eyes and grunted when the sternal rub was performed. RN F said he did not assess Resident #1's left and right hand grips. RN F said he was close to sending Resident #1 out to the emergency room but did not send him since he came back to normal approximately an hour after he performed the sternal rub. RN F said he did not perform every 15 minute vital sign checks. RN F said he checked Resident #1's blood pressure three times during his shift on 6/24/19. RN F said Resident #1's blood pressure was 134/79 (Normal blood pressure is less than 120/80) before 10:00 a.m., 139/70 at 10:00 a.m., and 153/87 at 11:40 a.m. During an interview on 6/28/19 at 2:06 p.m., CNA G said on 6/24/19 at approximately 8:45 p.m., Resident #1 had a decreased level of consciousness, was not using his left arm per usual, and was not making noise like he normally did when care was being provided. CNA G said she notified the ADON of the resident's change of condition, the ADON checked his blood pressure and pulse which were normal. CNA G said Resident #1 was left in bed to sleep. During a telephone interview on 6/28/19 at 2:32 p.m., CNA D said on 6/25/19 at approximately 1:00 a.m. Resident #1 was not responsive, his breathing was different and rapid, and he had left sided weakness. CNA D said CNA G told her in shift change report to keep an eye on Resident #1 because he was not himself. During an interview on 6/28/19 at 2:48 p.m., the ADON said on 6/24/19 a day shift CNA reported a concern about Resident #1 not opening his eyes. The ADON said Resident #1 was normal and there was no change of condition on 6/24/19. The ADON said she went to Resident #1's room on 6/24/19 at approximately 8:30 p.m. to assess him. The ADON said Resident #1 would not open his eyes but his vital signs were normal. The ADON said she did not chart anything about Resident #1 or her assessment because she did not think there was a change of condition. During an interview on 6/28/19 at 2:55 p.m., the DON said she assessed Resident #1 on 6/24/19 and he had no change of condition. The DON said Resident #1 did not want to wake up for lunch and the CNAs asked her to check on Resident #1. The DON said she checked Resident #1's vital signs, they were normal, and he did get up for lunch. The DON said she was not aware of Resident #1's decreased level of consciousness that required RN F to perform a sternal rub or Resident #1's left sided weakness on the morning of 6/24/19 at approximately 10:00 a.m. During a telephone interview on 7/1/19 at 9:54 a.m., Resident #1's physician did not recall if he was notified of Resident #1's change of condition. Resident #1's physician said if Resident #1 had decreased level of consciousness, required a sternal rub, and had left sided weakness, he should have been notified and Resident #1 sent to the emergency room . Resident #1's physician said he expected to be notified of changes in condition. An undated Change in a Resident's Condition or Status policy indicated .the nurse will notify the resident's Attending Physician or physician on call when there has been a .significant change in the resident's physical/emotional/mental condition .need to alter the resident's medical treatment significantly .need to transfer the resident to a hospital/treatment center .unless otherwise instructed by the resident, a nurse will notify the resident's representative when .there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center . The CDC website at <https://www.cdc.gov/stroke/signs_symptoms.htm> accessed 7/2/19 indicated .During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women *Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body *Sudden confusion, trouble speaking, or difficulty understanding speech *Sudden trouble seeing in one or both eyes *Sudden trouble walking, dizziness, loss of balance, or lack of coordination *Sudden severe headache with no known cause Call 9-1-1 right away if you or someone else has any of these symptoms . The DON was notified on 6/28/19 at 5:03 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The DON was provided the IJ template on 6/28/19 at 5:40 p.m. The facility's Plan of Removal was accepted on 6/28/19 at 8:41 p.m. and included: 1. All residents have the potential to be affected by this. 2. Current residents experiencing a change in condition will be assessed by the DON, ADON and an RN from another facility beginning immediately and to be completed by 8:00 p.m. 06/28/19. 3. All residents not already identified as having a change of condition will be assessed to ensure no current change of condition has been missed by the DON, ADON and an RN from another facility beginning immediately and to be completed by 8:00 p.m. 06/28/19. 4. An RN from another facility will re-inservice DON and ADON regarding signs [MEDICAL CONDITION] changes in condition, assessments, transfer of a resident during a change of condition, physician notification of change of condition, what and when to notify, (see attached policy). Training will begin immediately. Once training completed with DON and ADON, DON and ADON will complete training with all other nursing staff; training will be completed by close of business 06/29/19 or they will be taken off the schedule until the training is received. No nursing staff will be allowed to clock in for their next shift without first receiving the training. 5. The DON/ADON/Administrator or designee will make walking rounds daily to identify any changes in condition not already identified by nursing staff and take immediate action to ensure proper assessment and treatment beginning immediately. 6. The DON/ADON/Administrator or designee will review documentation of residents experiencing a change of condition daily to ensure proper assessments are being conducted. To begin 06/28/2019 ongoing. Inconsistencies will be addressed with the assessing nurse. 7. The DON/ADON/Administrator will report results of daily reviews to the QA team each morning during the morning meeting beginning 07/01/2019. 8. The Medical Director was consulted and has reviewed the plan of removal and has approved of the above plan. On 7/1/19 surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: The ADON said she was in-serviced by an RN from another facility on symptoms of a stroke and changes in condition. The ADON said if a resident experienced symptom of a stroke or any other change in condition, the resident's physician would be notified and the resident would be sent to the emergency room . The DON said she was in-serviced by an RN from another facility on symptoms of a stroke and changes in condition. The DON said if a resident experienced symptom of a stroke or any other change in condition, the resident's physician would be notified and the resident would be sent to the emergency room . Six CNAs (on all 3 shifts) and four medication aides (6 a.m. to 2 p.m. shift, 2 p.m. to 10 p.m. shift), said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident experienced symptom of a stroke or any other change in condition, they would report it to the resident's charge nurse. They said if the charge nurse did not respond to the change in condition, they would report it to the DON, ADON, or administrator. They said if administrative staff were unavailable or did not respond, they would call 911 themselves if the resident was having symptoms of a stroke or needed immediate medical attention for any other change in condition. Five nurses (on all 3 shifts) said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident presented with symptoms of a stroke or any other change in condition which required immediate medical attention, they would send the resident to the hospital and notify the physician. On 7/1/19 at 1:00 p.m., the administrator, DON, and ADON were informed the IJ was removed; however, the facility out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately consult with the resident's physician and responsible party when there was a need to alter treatment for 1 of 8 residents reviewed for change of condition. (Resident #1) The facility did not immediately notify Resident #1's physician or responsible party when Resident #1 experienced a significant change of condition of stroke (right sided weakness) like symptoms that started on [DATE] and continued until [DATE]. The facility did not send Resident #1 to the hospital until 7:15 p.m., on [DATE] approximately 24 hours after Resident #1 presented with stroke-like symptoms. Resident #1 was diagnosed at the hospital with a likely stroke, was discharged from the hospital to another nursing facility in terminal condition and died three days later. An Immediate Jeopardy (IJ) situation was identified on [DATE] due to the above failures related to Resident #1. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place other residents with a change in condition at risk for not receiving care and services to meet their needs, and death. Findings included: Physician orders [REDACTED].#1's closed clinical record indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1's cognition was moderately impaired. Resident #1 had delusions, physical and verbal behaviors, rejection of care, wandering, and other behaviors not affecting others. Resident #1 independently performed most ADLs, including walking. The care plan last revised [DATE] did not address Resident #1's history of stroke. A hospital discharge summary dated [DATE] indicated Resident #1 presented to the emergency room with worsening mental status after a fall. Resident #1 was noted with a new-onset of right-sided weakness and was diagnosed with [REDACTED].#1 initially because the MRI and ultrasound were not available during the weekend. After the weekend, Resident #1 became more encephalopathic, was not even alert to person, was not following commands, and experienced cooperation issues. Due to the resident's cooperation issues, an MRI was unable to be obtained. It was noted an acute stroke was considered very likely given the residents symptoms. Resident #1 was discharged from the hospital to another nursing facility on hospice services in terminal condition. A nursing note dated [DATE] at 2:45 p.m., indicated Resident #1 was laying in the floor next to her bed. She had redness to the back of her right shoulder. She appeared to have difficulty raising her right arm. The resident's physician and family were notified, and the doctor ordered an x-ray for Resident #1's right arm. During an interview on [DATE] at 10:22 a.m., LVN A said on [DATE] Resident #1 was in bed most of the day and did not feel well. He said during shift change with LVN B around 2:15 p.m., Resident #1 decided to get up, but fell as she got herself out of bed. He said Resident #1 was able to get around independently before that day. LVN A said after the fall, Resident #1 had trouble moving her right arm and experienced general right sided weakness. LVN A said he left the facility around 2:30 or 3:00 p.m. that day and LVN B sent Resident #1 to the hospital after he left. LVN A said he did not know how long it took for LVN B to send Resident #1 to the hospital, but he would have sent her immediately because of Resident #1's symptoms. There were no nursing notes for Resident #1 on [DATE] between 3:00 p.m. and 5:11 p.m. A speech therapy evaluation report dated [DATE] indicated Resident #1 was referred to speech therapy after Resident #1 exhibited a sudden overall decline after falling the afternoon of [DATE]. A decline was noted in Resident #1's auditory comprehension as evidenced by her inability to follow directions, in verbal expression as evidenced by her inability to verbally communicate her wants and needs, in motor skills as evidenced by her alternating ability to initiate motor tasks such as moving her legs, moving her arms, moving her articulators for speech, and adequate swallowing. Resident #1 also exhibited deficits in problem solving and was agitated by continuous trying to move herself and repeatedly making the same errors such as picking up a glass and dropping it. Due to the resident's sudden decline and alternating motor skills, especially on the right side, the speech therapist recommended Resident #1 be sent to the hospital for additional medical assessment. During an interview on [DATE] at 11:41 a.m., the speech therapist said on [DATE] at 4:45 p.m., CNA C came to her very concerned for Resident #1's change in condition and said the resident was sliding down in her chair, could not use the right side of her arm, and was spilling her cup. The speech therapist said CNA C reported to her that CNA C reported her concerns to the administrator, who did not respond to her concern. The speech therapist said she was very concerned for Resident #1's decline because the resident was able to move herself independently, did not have a history of dropping things, her trunk control was not previously impaired, and she was previously able to communicate if she was given time to express herself. The speech therapist said Resident #1 was in the dining room in a wheelchair. She said Resident #1 was leaning to the right side of her chair, her right arm was limp, she had right sided weakness to both her lower and upper extremities, she was experiencing right sided facial weakness, she was having trouble speaking, and she was pocketing her food as she was eating. The speech therapist said Resident #1 sometimes had previous trouble with communication but was still usually very vocal and able to communicate if given time. However, when the speech therapist assessed Resident #1 on [DATE], the resident had a significant decline in her communication ability and her comprehension was significantly worse. The speech therapist said around 5:30 p.m., she reported her concerns regarding Resident #1 to LVN B and told LVN B she felt Resident #1 should be sent to the hospital. The speech therapist said she clocked out on [DATE] at 6:40 p.m. and Resident #1 had not been sent to the hospital at that time. The speech therapist said Resident #1 should have been sent to the hospital sooner. A nursing note dated [DATE] at 5:12 p.m., indicated Resident #1 continues to be noted to have no use or control of the right side of her body. Resident #1 had both upper and lower extremity weakness. Speech therapy noted during the assessment that the right side of Resident #1's mouth was not operating properly while eating and drinking. The note indicated a chest x-ray was ordered related to the resident's wheezing. It was not noted that the physician or responsible party was notified of the residents change in condition. During an interview on [DATE] at 1:33 p.m., LVN B said on [DATE] around 2:45 p.m., Resident #1 was still moving her right extremities. LVN B said Resident #1 experienced a fall around 2:45 p.m. and had difficulty raising her right arm after the fall. LVN B said she contacted the physician, who ordered an x-ray of the resident's right arm. LVN B said around 4:30 p.m., the speech therapist came to her and told her Resident #1 was holding food in her mouth without swallowing, was falling in her chair, and was drooling. She said the resident was unable to use or control the right side of her body. LVN B said she called the physician around 5:00 p.m. and explained to the physician the resident's symptoms, including the resident experiencing increased right-sided weakness and the resident wheezing. She said the physician thought the resident was just dehydrated and ordered intravenous (IV) antibiotics for the resident and ordered a chest x-ray. LVN B said she suspected Resident #1 was experiencing a TIA (mini-stroke). LVN B said the doctor should have ordered for the resident to be sent to the hospital when she notified him of Resident #1's symptoms around 5:00 p.m. A nursing note dated [DATE] at 6:31 p.m., indicated Resident #1 continued to have difficulty with her speech and ambulation. An order was received to give two liters of normal saline via a saline lock. One liter of normal saline was administered before Resident #1 dislodged the IV. It was not noted that the physician or responsible party was notified of the residents right sided weakness or inability to use or control the right side of her body. A nursing note dated [DATE] at 6:50 p.m., indicated emergency medical services (EMS) was notified to transport the resident based on the .resident's difficulties . and the sons request. A nursing note dated [DATE] at 7:15 p.m., indicated EMS arrived to transport the resident. Resident #1 was agitated, but her speech was not clear and was random. It was noted the son and nurse practitioner were notified. A nursing note dated [DATE] at 7:40 p.m., indicated EMS departed the building with Resident #1 at 7:20 p.m., but did not leave the property until 7:40 p.m. During an interview on [DATE] at 1:33 p.m., LVN B said on [DATE] the nurse practitioner took over call for Resident #1's physician sometime between 5:00 and 6:00 p.m. She said she notified the nurse practitioner around 6:30 p.m. of Resident' #1's continued symptoms and of the negative results of the chest x-ray, and the nurse practitioner ordered for Resident #1 to be sent out to the hospital. LVN B said EMS was contacted around 6:50 p.m., arrived around 7:20 p.m., and left the facility around 7:40 p.m. During an interview on [DATE] at 3:18 p.m., Resident #1's son said he was not notified of Resident #1's change on [DATE] until around 6:30 p.m., when he requested Resident #1 be sent out to the hospital. He said around 6:30 p.m., LVN B informed him that Resident #1 was trying to eat and was dropping her cup while holding it, was not able to talk, and was experiencing right sided weakness. Resident #1's son said he was told the residents symptoms had been ongoing for a couple of hours after Resident #1 had a fall earlier in the day. He said LVN B said she was getting in touch with the DON about what to do. Resident #1's son said he was concerned because Resident #1 had a history of [REDACTED].#1 be sent to the hospital as soon as he was notified of her condition. He said Resident #1 should have been sent to the hospital when she first started showing symptoms of a stroke, and after the call around 6:30 p.m., it still took over 30 minutes for the ambulance to get to the facility. Resident #1's son said Resident #1 admitted to the hospital where they determined she had a stroke. He said the hospital tried everything they could, but Resident #1 could no longer get up on her own, could no longer speak, and could no longer use her right hand. Resident #1's son said Resident #1 admitted to another nursing facility on [DATE] on hospice. He said Resident #1 passed away from the stroke on [DATE]. During a telephone interview on [DATE] at 4:41 p.m., Resident #1's physician said he did not specifically recall being notified on [DATE] regarding Resident #1's fall, right-sided weakness, or any change in condition. Resident #1's physician said he received several calls a day regarding resident's falls, but did not remember each phone call made to him. He said the facility may have called and reported Resident #1's change in condition to him. Resident #1's physician said the nurses at the nursing facility had sent residents out in emergency situations and then notified him afterwards of the transfer. The physician said that would have been appropriate if a nurse suspected an acute stroke. The physician said slurred speech and right-sided weakness could be an indicator of a stroke, but also could have been related to the fall Resident #1 experienced earlier that day. The physician said he could have possibly ordered an x-ray for Resident #1 and told them to monitor for any changes, but if the nursing home staff recognized an acute problem, the nursing home should have evaluated the problem, notified him or the nurse practitioner depending who was on call, and the resident would have been sent out to the hospital. He said the nurses were trained to make decisions regarding emergency situations, and if a nurse would have recommended the resident be sent out, he would have no problem ordering for the resident to be sent out. During a telephone interview on [DATE] at 7:26 p.m., the nurse practitioner said he did not specifically recall being notified on [DATE] regarding Resident #1's change in condition and did not recall her being sent to the hospital. The nurse practitioner said if a resident presented with right sided weakness of the arms, legs, and mouth, and had a decreased ability to eat or swallow, it could be an indicator of a stroke or other neurological problem. He said if he had been contacted regarding Resident #1's symptoms and if he were informed those symptoms were not normal for Resident #1, he would have ordered to send Resident #1 to the emergency room immediately because it was potentially an emergency situation. The nurse practitioner said if the nurse only informed him of Resident #1's fall and a decreased ability to use her right arm, the situation would not present as an emergency situation and could potentially look like the resident needed an x-ray to rule out a fracture. During a telephone interview on [DATE] at 5:23 p.m., CNA C said she remembered Resident #1 was slouching in her chair in the dining room when she first got to the facility around 2:00 p.m. on [DATE]. CNA C said she did not recall Resident #1 having right sided weakness, but it had been two months ago and it was hard for her to remember exactly what happened. CNA C said she remembered she was concerned about Resident #1, so she stopped to report her concern to the administrator as the administrator was walking down the hall. CNA C said she was wearing a face mask at the time and she pulled her face mask down so the administrator could hear her as she spoke because CNA C had a soft-spoken voice. CNA C said the administrator was busy doing something else and must not have heard what she said because the administrator did not say anything to her when she reported the concern to her. CNA C said she saw the speech therapist immediately after that, and reported her concerns to the speech therapist. During an interview on [DATE] at 3:47 p.m., the administrator did not remember anyone reporting to her that Resident #1 experienced right-sided weakness. The administrator said she remembered Resident #1 was sent to the hospital but did not recall what for. The administrator said if it was reported to her that Resident #1 experienced right-sided weakness, she would have sent someone to assess Resident #1 or went to assess Resident #1 herself. During an interview on [DATE] at 4:13 p.m., the DON said she remembered being contacted regarding Resident #1's change in condition on [DATE], but she did not recall the timeframes and did not realize Resident #1 was not sent to the hospital immediately after her symptoms presented. The DON said she remembered the physician or nurse practitioner (whoever was on call) was contacted by LVN B regarding Resident #1's change in condition. The DON said the nurses were expected to follow the doctors' orders, but the doctor should have ordered to send Resident #1 to the hospital as soon as she started to experience having no control over the right side of her body and when it affected her swallowing. During an interview on [DATE] at 4:21 p.m., CNA D said she worked with Resident #1 the night before the resident was discharged to the hospital. ([DATE]) She said Resident #1 was normally able to transfer herself to her wheelchair, but on [DATE], she could not even pick her feet up. She said Resident #1 looked really drowsy, they had to pull her wheelchair backwards to keep the resident from falling out of the wheelchair, and it took 4 aides to get the resident in the bed. She said she reported the residents change of condition to LVN B. The CNA said she arrived to work the following day ([DATE]) around 2:00 p.m. She said Resident #1 had weakness on one side of her body, she was leaning in her wheelchair and was slouched. She said she could not hold a cup in her hand and kept dropping it and she was drooling. The CNA said all of those symptoms were changes for Resident #1, and she reported the resident's change in condition to LVN B. During a telephone interview on [DATE] at 4:27 p.m., CNA E said the day before Resident #1 was sent out to the hospital, Resident #1 had a change of condition. The CNA said Resident #1 could usually do for herself, but on [DATE] she was falling asleep in her wheelchair and one side of Resident #1's body seemed to be weak. The CNA said she did not recall which side. The CNA said Resident #1 usually got into bed herself, but on [DATE] between 7:30 p.m. and 9:00 p.m., it took four CNAs to get the resident into bed. The CNA suspected Resident #1 was having a stroke and reported the residents change of condition to LVN B. During an interview on [DATE] at 5:20 p.m. ,CNA F said Resident #1 was usually feisty, was able to move around independently, and could talk clearly. The CNA said during the evening of [DATE], Resident #1 was not speaking, was out of it, and was weak all over her body. He said it took four CNAs to get the resident into bed, when the resident could usually get into bed on her own. He said he was not assigned to Resident #1 and did not know if the change of condition was reported to the charge nurse. During an interview on [DATE] at 6:14 p.m., LVN B said she did not remember anyone reporting Resident #1's change of condition on [DATE]. She said if it had been reported to her, she would have went to assess Resident #1. She said sometimes Resident #1 would fall asleep in her wheelchair and appeared tired from having fits. She said usually Resident #1 was able to get in and out of bed on her own unless she acted helpless. She said it was obvious when the resident was acting, because she would close her eyes and grin. LVN B was not aware of Resident #1's change of condition on [DATE]. During a telephone interview on [DATE] at 6:43 p.m., LVN G said LVN B called her around 5:30 p.m. or 6:00 p.m. on [DATE] and reported to her Resident #1 had fallen earlier in the shift and was not responding well. LVN B reported to LVN G that Resident #1 had generalized weakness and was not able to stand. LVN G said LVN B described symptoms of a stroke, and she told LVN B she would have sent Resident #1 out at the beginning of the shift, and recommended she go assess Resident #1 again. An undated Change in a Resident's Condition or Status policy indicated .the nurse will notify the resident's Attending Physician or physician on call when there has been a .significant change in the resident's physical/emotional/mental condition .need to alter the resident's medical treatment significantly .need to transfer the resident to a hospital/treatment center .unless otherwise instructed by the resident, a nurse will notify the resident's representative when .there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center . The CDC website at <https://www.cdc.gov/stroke/signs_symptoms.htm> accessed [DATE] indicated .During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women *Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body *Sudden confusion, trouble speaking, or difficulty understanding speech *Sudden trouble seeing in one or both eyes *Sudden trouble walking, dizziness, loss of balance, or lack of coordination *Sudden severe headache with no known cause Call [DATE] right away if you or someone else has any of these symptoms . The administrator and ADON were notified on [DATE] at 4:14 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 6:35 p.m. and included: .1. All residents have the potential to be affected by this 2. Current residents experiencing a change in condition will be assessed by the ADON and Administrator beginning immediately and to be completed by 7:30 p.m. [DATE]. 3. All residents not already identified as having a change of condition will be assessed to ensure no current change of condition has been missed by the ADON and Administrator beginning immediately and to be completed by 7:30 p.m. [DATE]. 4. The Administrator or designee will re-inservice all nursing staff regarding signs [MEDICAL CONDITION] changes in condition, assessments, and transfer of a resident during a change of condition. Training will begin immediately. No nursing staff will be allowed to clock in for their next shift without first receiving the training. All nursing staff will receive the training by close of business [DATE] or they will be taken off the schedule until the training is received. 5. The DON/ADON/Administrator or designee will make walking rounds daily to identify any changes in condition not already identified by nursing staff and take immediate action to ensure proper assessment and treatment beginning immediately. 6. The DON/ADON/Administrator or designee will review documentation of residents experiencing a change of condition daily to ensure proper assessments are being conducted. To begin [DATE] ongoing. Inconsistencies will be addressed with the assessing nurse. 7. The DON/ADON/Administrator will report results of daily reviews to the QA team each morning during the morning meeting beginning [DATE]. 8. The Medical Director was consulted and has reviewed the plan of removal and hasapproved of the above plan . On [DATE] surveyor confirmed the facility implemented their plan of removal to sufficiently to remove the Immediate Jeopardy by: One nurse aide student (6 a.m. to 2 p.m. shift), six CNA's (on all shifts), two medication aides (6a.m. to 2 p.m. shift, 2 p.m. to 10 p.m. shift), the activity director, and the dietary supervisor said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident experienced symptoms of a stroke or any other change in condition, they would report it to the resident's charge nurse. They said if the charge nurse did not respond to the change in condition, they would report it to the DON, ADON, or adminisrator. They said if administrative staff were unavailable, they would call 911 themselves if the resident was having symptoms of a stroke or needed immediate medical attention for any other change in condition. Three nurses (6a.m. to 2 p.m. shift and 2p.m. to 10 p.m. shift) said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident presented with symptoms of a stroke or any other change in condition which required immediate medical attention, they would send the resident to the hospital and notify the physician. The ADON said on [DATE], she assessed every resident of the facility for a change in condition. The DON said she, the ADON, or administrator would make walking rounds in the facility Monday through Friday to identify any changes in condition not already identified by nursing staff, and the weekend RN's were going to be responsible for making walking rounds to assess for changes in condition during the weekend. One weekend RN was contacted and said she had been informed that when she was on duty, she was to make rounds of the entire facility to assess residents for changes in condition. On [DATE] at 11:35 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated . The facility was continuing to monitor and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care was provided in accordance with standards of practice and based on the comprehensive assessment and care plan for 1 of 8 residents reviewed for assessments. (Resident #1) The facility did not immediately provide emergency care for Resident #1 when a significant change of condition of stroke like symptoms (right sided weakness) that started on [DATE] and continued until [DATE]. The facility did not notify the physician and send Resident #1 to the hospital until 7:15 p.m., on [DATE] approximately 24 hours after Resident #1 presented with stroke-like symptoms. Resident #1 was diagnosed at the hospital with a likely stroke, was discharged from the hospital to another nursing facility in terminal condition and died three days later. An Immediate Jeopardy (IJ) situation was identified on [DATE] due to the above failures related to Resident #1. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents who experienced a change in condition at risk for not receiving care and services to meet their needs, and/or death. Findings included: Physician orders [REDACTED].#1's closed clinical record indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1's cognition was moderately impaired. Resident #1 had delusions, physical and verbal behaviors, rejection of care, wandering, and other behaviors not affecting others. Resident #1 independently performed most ADLs, including walking. The care plan last revised [DATE] did not address Resident #1's history of stroke. A hospital discharge summary dated [DATE] indicated Resident #1 presented to the emergency room with worsening mental status after a fall. Resident #1 was noted with a new-onset of right-sided weakness and was diagnosed with [REDACTED].#1 initially because the MRI and ultrasound were not available during the weekend. After the weekend, Resident #1 became more encephalopathic (disease or disorder of the brain), was not even alert to person, was not following commands, and experienced cooperation issues. Due to the resident's cooperation issues, an MRI was unable to be obtained. It was noted an acute stroke was considered very likely given the resident's symptoms. Resident #1 was discharged from the hospital to another nursing facility on hospice services in terminal condition. A nursing note dated [DATE] at 2:45 p.m., indicated Resident #1 was laying in the floor next to her bed. She had redness to the back of her right shoulder. She appeared to have difficulty raising her right arm. The resident's physician and family were notified, and the doctor ordered an x-ray for Resident #1's right arm. During an interview on [DATE] at 10:22 a.m., LVN A said on [DATE] Resident #1 was in bed most of the day and did not feel well. He said during shift change with LVN B around 2:15 p.m., Resident #1 decided to get up, but fell as she got herself out of bed. He said Resident #1 was able to get around independently before that day. LVN A said after the fall, Resident #1 had trouble moving her right arm and experienced general right sided weakness. LVN A said he left the facility around 2:30 or 3:00 p.m. that day and LVN B sent Resident #1 to the hospital after he left. LVN A said he did not know how long it took for LVN B to send Resident #1 to the hospital, but he would have sent her immediately because of Resident #1's symptoms. The clinical record for Resident #1 did not have nursing notes on [DATE] between 3:00 p.m. and 5:11 p.m. A speech therapy evaluation report dated [DATE] indicated Resident #1 was referred to speech therapy after Resident #1 exhibited a sudden overall decline after falling the afternoon of [DATE]. A decline was noted in Resident #1's auditory comprehension as evidenced by her inability to follow directions, in verbal expression as evidenced by her inability to verbally communicate her wants and needs, in motor skills as evidenced by her alternating ability to initiate motor tasks such as moving her legs, moving her arms, moving her articulators for speech, and adequate swallowing. Resident #1 also exhibited deficits in problem solving and was agitated by continuous trying to move herself and repeatedly making the same errors such as picking up a glass and dropping it. Due to the resident's sudden decline and alternating motor skills, especially on the right side, the speech therapist recommended Resident #1 be sent to the hospital for additional medical assessment. During an interview on [DATE] at 11:41 a.m., the speech therapist said on [DATE] at 4:45 p.m., CNA C came to her very concerned for Resident #1's change in condition and said the resident was sliding down in her chair, could not use the right side of her arm, and was spilling her cup. The speech therapist said CNA C reported to her that CNA C reported her concerns to the administrator, who did not respond to her concern. The speech therapist said she was very concerned for Resident #1's decline because the resident was able to move herself independently, did not have a history of dropping things, her trunk control was not previously impaired, and she was previously able to communicate if she was given time to express herself. The speech therapist said Resident #1 was in the dining room in a wheelchair. She said Resident #1 was leaning to the right side of her chair, her right arm was limp, she had right sided weakness to both her lower and upper extremities, she was experiencing right sided facial weakness, she was having trouble speaking, and she was pocketing her food as she was eating. The speech therapist said Resident #1 had previous trouble with communication but was still usually very vocal and able to communicate if given time. However, when the speech therapist assessed Resident #1 on [DATE], the resident had a significant decline in her communication ability and her comprehension was significantly worse. The speech therapist said around 5:30 p.m., she reported her concerns regarding Resident #1 to LVN B and told LVN B she felt Resident #1 should be sent to the hospital. The speech therapist said she clocked out on [DATE] at 6:40 p.m. and Resident #1 had not been sent to the hospital at that time. The speech therapist said Resident #1 should have been sent to the hospital sooner. A nursing note dated [DATE] at 5:12 p.m., indicated Resident #1 continues to be noted to have no use or control of the right side of her body. Resident #1 had both upper and lower extremity weakness. Speech therapy noted during the assessment that the right side of Resident #1's mouth was not operating properly while eating and drinking. The note indicated a chest x-ray was ordered related to the resident's wheezing. It was not noted that the physician or responsible party was notified of the residents change in condition. During an interview on [DATE] at 1:33 p.m., LVN B said on [DATE] around 2:45 p.m., Resident #1 was still moving her right extremities. LVN B said Resident #1 experienced a fall around 2:45 p.m. and had difficulty raising her right arm after the fall. LVN B said she contacted the physician, who ordered an x-ray of the resident's right arm. LVN B said around 4:30 p.m., the speech therapist came to her and told her Resident #1 was holding food in her mouth without swallowing, was falling in her chair, and was drooling. She said the resident was unable to use or control the right side of her body. LVN B said she called the physician around 5:00 p.m. and explained to the physician the resident's symptoms, including the resident experiencing increased right-sided weakness and the resident wheezing. She said the physician thought the resident was just dehydrated and ordered intravenous (IV) antibiotics for the resident and ordered a chest x-ray. LVN B said she suspected Resident #1 was experiencing a TIA. (mini-stroke) LVN B said the doctor should have ordered for the resident to be sent to the hospital when she notified him of Resident #1's symptoms around 5:00 p.m. A nursing note dated [DATE] at 6:31 p.m., indicated Resident #1 continued to have difficulty with her speech and ambulation. An order was received to give two liters of normal saline via a saline lock. One liter of normal saline was administered before Resident #1 dislodged the IV. It was not noted that the physician or responsible party was notified of the residents right sided weakness or inability to use or control the right side of her body. A nursing note dated [DATE] at 6:50 p.m., indicated emergency medical services (EMS) was notified to transport the resident based on the .resident's difficulties . and the sons request. A nursing note dated [DATE] at 7:15 p.m., indicated EMS arrived to transport the resident. Resident #1 was agitated, but her speech was not clear and was random. It was noted the son and nurse practitioner were notified. A nursing note dated [DATE] at 7:40 p.m., indicated EMS departed the building with Resident #1 at 7:20 p.m., but did not leave the property until 7:40 p.m. During an interview on [DATE] at 1:33 p.m., LVN B said on [DATE] the nurse practitioner took over call for Resident #1's physician sometime between 5:00 and 6:00 p.m. She said she notified the nurse practitioner around 6:30 p.m. of Resident #1's continued symptoms and of the negative results of the chest x-ray, and the nurse practitioner ordered for Resident #1 to be sent out to the hospital. LVN B said EMS was contacted around 6:50 p.m., arrived around 7:20 p.m., and left the facility around 7:40 p.m. During an interview on [DATE] at 3:18 p.m., Resident #1's son said he was not notified of Resident #1's change on [DATE] until around 6:30 p.m., when he requested Resident #1 be sent out to the hospital. He said around 6:30 p.m., LVN B informed him that Resident #1 was trying to eat and was dropping her cup while holding it, was not able to talk, and was experiencing right sided weakness. Resident #1's son said he was told the residents symptoms had been ongoing for a couple of hours after Resident #1 had a fall earlier in the day. He said LVN B said she was getting in touch with the DON about what to do. Resident #1's son said he was concerned because Resident #1 had a history of [REDACTED].#1 be sent to the hospital as soon as he was notified of her condition. He said Resident #1 should have been sent to the hospital when she first started showing symptoms of a stroke, and after the call around 6:30 p.m., it still took over 30 minutes for the ambulance to get to the facility. Resident #1's son said Resident #1 admitted to the hospital where they determined she had a stroke. He said the hospital tried everything they could, but Resident #1 could no longer get up on her own, could no longer speak, and could no longer use her right hand. Resident #1's son said Resident #1 admitted to another nursing facility on [DATE] on hospice. He said Resident #1 passed away from the stroke on [DATE]. During a telephone interview on [DATE] at 4:41 p.m., Resident #1's physician said he did not specifically recall being notified on [DATE] regarding Resident #1's fall, right-sided weakness, or any change in condition. Resident #1's physician said he received several calls a day regarding resident's falls but did not remember each phone call made to him. He said the facility may have called and reported Resident #1's change in condition to him. Resident #1's physician said the nurses at the nursing facility sent residents out in emergency situations and then notified him afterwards of the transfer. The physician said it would have been appropriate for a nurse to send a resident to the emergency room for treatment if an acute stroke was suspected. The physician said slurred speech and right-sided weakness could be an indicator of a stroke, but also could have been related to the fall Resident #1 experienced earlier that day. The physician said he could have possibly ordered an x-ray for Resident #1 and told them to monitor for any changes, but if the nursing home staff recognized an acute problem, the nursing home should have evaluated the problem, notified him or the nurse practitioner depending who was on call, and the resident would have been sent out to the hospital. He said the nurses were trained to make decisions regarding emergency situations, and if a nurse would have recommended the resident be sent out, he would have no problem ordering for the resident to be sent out. During a telephone interview on [DATE] at 7:26 p.m., the nurse practitioner said he did not specifically recall being notified on [DATE] regarding Resident #1's change in condition and did not recall her being sent to the hospital. The nurse practitioner said if a resident presented with right sided weakness of the arms, legs, and mouth, and had a decreased ability to eat or swallow, it could be an indicator of a stroke or other neurological problem. He said if he had been contacted regarding Resident #1's symptoms and if he were informed those symptoms were not normal for Resident #1, he would have ordered to send Resident #1 to the emergency room immediately because it was potentially an emergency. The nurse practitioner said if the nurse only informed him of Resident #1's fall and a decreased ability to use her right arm, the situation would not present as an emergency and could potentially look like the resident needed an x-ray to rule out a fracture. During a telephone interview on [DATE] at 5:23 p.m., CNA C said when she first got to the facility around 2:00 p.m. on [DATE], she remembered Resident #1 was slouching in her chair in the dining room. CNA C said she did not recall Resident #1 having right sided weakness, but it had been two months ago, and it was hard for her to remember exactly what happened. CNA C said she remembered she was concerned about Resident #1, so she stopped to report her concern to the administrator as the administrator was walking down the hall. CNA C said she was wearing a face mask at the time and she pulled her face mask down so the administrator could hear her as she spoke because CNA C had a soft-spoken voice. CNA C said the administrator was busy doing something else and must not have heard what she said because the administrator did not say anything to her when she reported the concern to her. CNA C said she saw the speech therapist immediately after that and reported her concerns to the speech therapist. During an interview on [DATE] at 3:47 p.m., the administrator indicated she did not remember anyone reporting to her that Resident #1 experienced right-sided weakness. The administrator said she remembered Resident #1 was sent to the hospital but did not recall why. The administrator said if it was reported to her that Resident #1 experienced right-sided weakness, she would have sent someone to assess Resident #1 or went to assess Resident #1 herself. During an interview on [DATE] at 4:13 p.m., the DON said she remembered being contacted regarding Resident #1's change in condition on [DATE], but she did not recall the timeframes and did not realize Resident #1 was not sent to the hospital immediately after her symptoms presented. The DON said she remembered the physician or nurse practitioner (whoever was on call) was contacted by LVN B regarding Resident #1's change in condition. The DON said the nurses were expected to follow the physician's orders [REDACTED].#1 to the hospital as soon as she started to experience having no control over the right side of her body and when it affected her swallowing. During an interview on [DATE] at 4:21 p.m., CNA D said she worked with Resident #1 the night before the resident was discharged to the hospital. ([DATE]) She said Resident #1 was normally able to transfer herself to her wheelchair, but on [DATE], she could not even pick her feet up. She said Resident #1 looked drowsy, they had to pull her wheelchair backwards to keep the resident from falling out of the wheelchair, and it took 4 aides to get the resident in the bed. She said she reported the residents change of condition to LVN B. The CNA said she arrived to work the following day around 2:00 p.m. She said Resident #1 had weakness on one side of her body, she was leaning in her wheelchair and was slouched. She said she could not hold a cup in her hand and kept dropping it and she was drooling. The CNA said all those symptoms were changes for Resident #1, and she reported the resident's change in condition to LVN B. During a telephone interview on [DATE] at 4:27 p.m., CNA E said the day before Resident #1 was sent out to the hospital, Resident #1 had a change of condition. The CNA said Resident #1 could usually do for herself, but on [DATE] she was falling asleep in her wheelchair and one side of Resident #1's body seemed to be weak. The CNA said she did not recall which side. The CNA said Resident #1 usually got into bed herself, but on [DATE] between 7:30 p.m. and 9:00 p.m., it took four CNAs to get the resident into bed. The CNA suspected Resident #1 was having a stroke and reported the residents change of condition to LVN B. During an interview on [DATE] at 5:20 p.m., CNA F said Resident #1 was usually feisty, was able to move around independently, and could talk clearly. The CNA said during the evening of [DATE], Resident #1 was not speaking, was out of it, and was weak all over her body. He said it took four CNAs to get the resident into bed, when the resident could usually get into bed on her own. He said he was not assigned to Resident #1 and did not know if the change of condition was reported to the charge nurse. During an interview on [DATE] at 6:14 p.m., LVN B said she did not remember anyone reporting Resident #1's change of condition on [DATE]. She said if it had been reported to her, she would have gone to assess Resident #1. She said sometimes Resident #1 would fall asleep in her wheelchair and appeared tired from having fits. She said usually Resident #1 was able to get in and out of bed on her own unless she acted helpless. She said it was obvious when the resident was acting, because she would close her eyes and grin. LVN B was not aware of Resident #1's change of condition on [DATE]. During a telephone interview on [DATE] at 6:43 p.m., LVN G said LVN B called her around 5:30 p.m. or 6:00 p.m. on [DATE] and reported to her Resident #1 had fallen earlier in the shift and was not responding well. LVN B reported to LVN G that Resident #1 had generalized weakness and was not able to stand. LVN G said LVN B described symptoms of a stroke, and she told LVN B she would have sent Resident #1 out at the beginning of the shift, and recommended she go assess Resident #1 again. An undated Change in a Resident's Condition or Status policy indicated .the nurse will notify the resident's Attending Physician or physician on call when there has been a .significant change in the resident's physical/emotional/mental condition .need to alter the resident's medical treatment significantly .need to transfer the resident to a hospital/treatment center .unless otherwise instructed by the resident, a nurse will notify the resident's representative when .there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center . The CDC website at <https://www.cdc.gov/stroke/signs_symptoms.htm> accessed [DATE] indicated .During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women *Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body *Sudden confusion, trouble speaking, or difficulty understanding speech *Sudden trouble seeing in one or both eyes *Sudden trouble walking, dizziness, loss of balance, or lack of coordination *Sudden severe headache with no known cause Call [DATE] right away if you or someone else has any of these symptoms . The administrator and ADON were notified on [DATE] at 4:14 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 6:35 p.m. and included: .1. All residents have the potential to be affected by this 2. Current residents experiencing a change in condition will be assessed by the ADON and Administrator beginning immediately and to be completed by 7:30 p.m. [DATE]. 3. All residents not already identified as having a change of condition will be assessed to ensure no current change of condition has been missed by the ADON and Administrator beginning immediately and to be completed by 7:30 p.m. [DATE]. 4. The Administrator or designee will re-inservice all nursing staff regarding signs [MEDICAL CONDITION] changes in condition, assessments, and transfer of a resident during a change of condition. Training will begin immediately. No nursing staff will be allowed to clock in for their next shift without first receiving the training. All nursing staff will receive the training by close of business [DATE] or they will be taken off the schedule until the training is received. 5. The DON/ADON/Administrator or designee will make walking rounds daily to identify any changes in condition not already identified by nursing staff and take immediate action to ensure proper assessment and treatment beginning immediately. 6. The DON/ADON/Administrator or designee will review documentation of residents experiencing a change of condition daily to ensure proper assessments are being conducted. To begin [DATE] ongoing. Inconsistencies will be addressed with the assessing nurse. 7. The DON/ADON/Administrator will report results of daily reviews to the QA team each morning during the morning meeting beginning [DATE]. 8. The Medical Director was consulted and has reviewed the plan of removal and has approved of the above plan . On [DATE] surveyor confirmed the facility implemented their plan of removal to sufficiently to remove the Immediate Jeopardy by: One nurse aide student (6 a.m. to 2 p.m. shift), six CNAs (on all 3 shifts), two medication aides (6 a.m. to 2 p.m. shift, 2 p.m. to 10 p.m. shift), the activity director, and the dietary supervisor said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident experienced symptom of a stroke or any other change in condition, they would report it to the resident's charge nurse. They said if the charge nurse did not respond to the change in condition, they would report it to the DON, ADON, or administrator. They said if administrative staff were unavailable, they would call 911 themselves if the resident was having symptoms of a stroke or needed immediate medical attention for any other change in condition. Three nurses (6 a.m. to 2 p.m. shift and p.m. to 10 p.m. shift) said they were in-serviced on symptoms of a stroke and changes in condition. They said if a resident presented with symptoms of a stroke or any other change in condition which required immediate medical attention, they would send the resident to the hospital and notify the physician. The ADON said on [DATE], she assessed every resident of the facility for a change in condition. The DON said she, the ADON, or administrator would make walking rounds in the facility Monday through Friday to identify any changes in condition not already identified by nursing staff, and the weekend RN's were going to be responsible for making walking rounds to assess for changes in condition during the weekend. One weekend RN was contacted and said she had been informed that when she was on duty, she was to make rounds of the entire facility to assess residents for changes in condition. On [DATE] at 11:35 a.m., the administrator and DON were informed the IJ was removed; however, the facility out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 1 of 4 residents reviewed for falls. (Resident #1) Resident #1 was at high risk for falls. Resident #1 was not supervised before and after her shower which resulted in two falls. She recieved a large hematoma a localized collection of blood outside of the blood vessels) and laceration to the right side of her head and forehead that required 5 sutures. This failure contibuted to Resident #1 recieving a hematoma and laceration to her head that required 5 sutures. This failure could place 57 residents who required assistance with bathing at risk for falls and injury. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1's cognitive status was severely impaired. She required extensive assistance with transfers, bed mobility, dressing and eating. Resident #1 was totally dependent with locomotion, toileting and personal hygiene. The most recent Fall Risk assessment dated ,[DATE], indicated Resident #1 was a high risk for falls. The most recent care plan dated 11/24/14, indicated Resident #1 had the potential for falls, history of falls associated with use of psychotropic drugs, incontinence and dementia. An Incident Report dated 2/11/15 at 4:56 p.m., indicated LVN A heard a "thump" she turned around and saw Resident #1 lying on the floor in front of her room. She was holding her head yelling "ouch, ouch". There was a shower chair beside her. The report indicated the resident must have leaned over to far and fell out. At 6:07 p.m., Resident #1 was taken from the shower and was sitting in shower chair in the hallway. The report indicated the resident must had gotten up and took a few steps. LVN A and the DON heard a noise and Resident #1 was lying on the floor with her head against the door frame, hollering "oh, oh." There was a laceration to the right side of her forehead with a large amount of blood. Emergency services were called. A nurse note dated 2/11/15 at 11:53 p.m., indicated Resident #1 returned from the hospital with 5 sutures to the right side of her forehead. During an observation on 2/21/15 at 11:10 a.m., Resident #1 was sitting in a geri chair. She was alert, but confused and unable to answer questions due to cognitive status. The healing laceration to her right forehead was approximately 3 inches long reddish, purple in color. There were no sutures. Resident #1's cheek bone had a dark red and purple discoloration. During an interview on 02/21/15 at 11:30 a.m., CNA B said she got Resident #1 up on the shower chair and made it to the hall when she had to leave the resident alone to assist another CNA. CNA B said when she returned she saw Resident #1 lying on the floor and she had a "knot" on the side of her head. CNA B said the nurse assessed the resident and she cotinued to assist Resident #1 with her shower. She said the nurse sat Resident #1 by her door in the hall after the shower and took her vital signs. She said the nurse walked away from Resident #1 to put the blood pressure cuff up. CNA B said there was another nurse on the hall. CNA B said she guessed the nurse did not see Resident #1 get up from the shower chair. She said Resident #1 had to take a couple of steps to get to the doorway, because she hit her head on the door frame causing a laceration. CNA B said should not have left her unattended. During an interview on 02/21/15 at 11:38 a.m., LVN A said she was on the hall passing medication when Resident #1 had her first fall on 2/11/15. She said she heard a "thump", turned around and saw Resident #1 on the floor with the shower chair beside her. She said Resident #1 said "ouch, ouch". LVN A said she did not see CNA B on the hall. LVN A said Resident #1 must had leaned over to far and fell off the shower chair. She said she assessed Resident #1 and she had a "goose egg" to the right side of her head. She said CNA B took the resident on to the shower. LVN A said she saw CNA B when she went around the corner taking Resident #1 back to her hall. LVN A said she and the DON was at the nursing station when they heard a "thump". She said when she looked up she saw an empty shower chair and Resident #1 on the floor. LVN A said she must had taken a couple of steps because she was lying in the door way with her head against the door frame with a large laceration to the right side of her forehead with a large amount of blood. LVN A said Resident #1 should had not been left unattended in the shower chair. During an interview on 02/21/15 at 2:10 p.m., LVN C said on 2/11/15, she was on the hall giving medication when Resident #1 fell the second time. She said she had her back to Resident #1. She said she heard a noise and when she turned around she saw Resident #1 on the floor with her head bleeding. During an interview on 02/21/15 at 12:00 p.m., the DON said Resident #1 fell twice off the shower chair on 2/11/15, because she was left alone. She said staff were not to leave Resident #1 unattended while up in a shower chair. During an interview on 2/21/15 at 12:00 p.m., the administrator said staff was in-serviced on not leaving residents alone on a shower chair following Resident #1's incident on 2/11/15. An in-service dated 2/16/15 indicated staff was to make sure the shower chair wheels were locked and not to ever leave a resident unattended on a shower chair. The undated Accident Report policy indicated the facility was to investigate incidents/accidents for trends which might indicate abuse. The CMS 672 dated 02/21/15 indicated 57 residents required assistance with bathing.