Every finding on record at Collinwood Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to ensure staff followed established infection control policies and procedures for enhanced barrier precautions and facility surveillance for multidrug-resistant organisms. The facility must establish and 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. This deficient practice affected 1 (Resident #1) of 3 residents reviewed for infection control. The facility failed to maintain an effective infection prevention and control program, including failure to follow its own enhanced barrier precautions policies and procedure for infection control and train nursing home staff in putting on and taking off personal protective equipment required for enhanced barrier precautions. This failure placed all residents and staff at risk for the development and transmission of communicable diseases and infections from multidrug-resistant organisms. Findings included: Record review of Resident #1's facility face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with the following diagnosis: metabolic encephalopathy (overall brain disfunction), major depression, neurogenic bladder (loss of bladder function due to brain injury), anxiety disorder, stroke, Alzheimer's disease, and unspecified dementia. Review of Resident #1's quarterly MDS dated [DATE] revealed Section C - Cognitive Patterns documented a BIMS score of 7 that revealed severe cognitive impairment. Section GG - Functional Abilities documented maximum assistance was required by one to two staff members for ADLs. The resident completed none of the tasks. A Hoyer lift was required for transfers from bed to wheelchair. Section H - Bowel and Bladder revealed the resident had an indwelling catheter for neurogenic bladder and incontinent of bowel function. Section M - Skin Conditions revealed stage four (most severe type) un-healed pressure injury to the sacrum (lower back). Record review of comprehensive care plan dated 03/16/2025 revealed: I have (1) pressure ulcer or potential for pressure ulcer development r/t Immobility Stage IV to sacrum. Date Initiated: 10/21/2025. I have a condition that requires Enhanced Barrier Precautions due to an indwelling catheter and wound care. Staff must don gown and gloves after entering the room to provide high contact resident care activities such as dressing, bathing/showering, transfers, providing hygiene, changing linens, toileting/brief changes, device care, med administration by enteral tube or central line, trach care and wound care. Record review of comprehensive care plan dated 03/16/2026 for Resident #1 revealed enhanced barrier precautions and interventions were planned as an infection control intervention for wound care and incontinent care to reduce the transmission of multidrug-resistant organisms. Intervention revealed Staff must don a gown and gloves after entering the room to provide high contact resident care activities such as dressing, bathing/showering, transfers, providing hygiene, changing linens, toileting/brief changes, device care, med administration and wound care. Review of physician order dated 03/16/2026 for Resident #1 revealed the resident was placed on enhanced barrier precautions for wound care and urinary catheter care. PPE was to be put on by staff inside the resident room prior to providing care. Wound care treatment order: Honey, Calcium Alginate for stage four pressure injury; cleanse with normal saline, pat dry, apply honey and calcium alginate, cover with dry dressing daily and as needed. Interview on 05/18/2026 at 9:00 AM a message was left for the physician for Resident #1 to return the call for an interview. During an observation on 05/28/2026 at 9:11 AM, Resident #1 was in her bed. CNA A and CNA B prepared to reposition the resident. They washed their hands and put on clean gloves but no gown per facility Infection Control/EBP policy. A small storage container with gowns, gloves, masks, and hand sanitizer was noted to be inside Resident #1's room. CNA A and CNA B proceeded to reposition the resident to her right side. During an interview with CNA B on 05/18/2026 at 9:15 AM, she worked here for approximately six months. She was unable to describe the current facility infection control/enhanced barrier precautions policy or procedures. She could not give an example of a high contact resident activity identified in the EBP policy such as dressing, bathing, toileting, transferring, providing hygiene, changing linens, and wound care. She said she would ask her charge nurse. She did not understand the meaning of multidrug-resistant organisms associated with enhanced barrier precautions and the spread of infection identified in the Infection Control/EBP policy. She could not remember when the last in-service for EBP was provided. She said D.O.N. was the facility Infection Preventionist. During an interview with CNA E on 05/18/2026 at 9:30 AM, she has worked here for ten years. She said she did not understand the current facility infection control/enhanced barrier precautions policy or procedures. She could not give an example of a high contact resident activity identified in the facility EBP policy. She said she would ask her charge nurse. She did not understand the meaning of multidrug-resistant organisms associated with enhanced barrier precautions and the spread of infection. She could not remember when the last in-service for EBP was provided. She said she would ask her charge nurse. She said she did not know who the facility Infection Preventionist was or what it was for. During an interview with CNA D on 05/18/2026 at 10:40 AM, he has worked here for four years. He said he did not know the current facility infection control/enhanced barrier precautions policy or procedures. He could not give an example of a high contact resident activity identified in the facility EBP policy. He did not understand the meaning of multidrug-resistant organisms associated with enhanced barrier precautions and the spread of infection. He said he couldn't remember when the last in-service for EBP was provided. He said D.O.N. was the facility Infection Preventionist. During an interview with CNA C 05/18/2026 at 11:17 AM, she has worked here for four years. She was unable to describe the current facility enhanced barrier precautions policy or procedures. She could not give an example of a high contact resident activity identified in the facility EBP policy. She did not understand the meaning of multidrug-resistant organisms associated with enhanced barrier precautions and the spread of infection. She said she couldn't remember when the last in-service for EBP was provided. She said D.O.N. was the facility Infection Preventionist. During an interview with RN F on 05/18/2026 at 11:31 AM, she has worked here for three years. She said a high contact resident activity would be providing wound care. An example of a multidrug resistant organism would be MRSA. She said she couldn't remember when the last in-service for EBP was provided. She said, We are all the Infection Preventionist, but the D.O.N. was over the Infection Control program for the facility. In an interview with LVN G on 05/18/2026 at 11:44 AM, it was revealed she worked here ten years. She was one of the two nurses in charge on the 6:00 AM to 2:00 PM shift. She said she observed her CNA staff to ensure they put on PPE before providing care for residents on enhanced barrier precautions. She said she couldn't remember when the last in-service for EBP was provided. She said D.O.N. was the facility Infection Preventionist. In an observation on 05/18/2026 at 1:30 PM, RN F and CNA B entered Resident #1's room to provide wound care. Both staff washed hands and put on a gown and gloves. Wound care supplies were gathered using aseptic techniques. The resident was told what staff were going to do; and her pain level was assessed. The resident denied being in pain. Resident #1 was repositioned in preparation for wound care by both staff. RN F removed the old wound dressing. The wound bed of the pressure injury was clean and dry with no signs of infection present. The wound to the lower back matched documented measurements of 6.01 cm long; 2.73 cm wide; 0 cm deep. RN F changed gloves and used alcohol rub for hand hygiene. She put on clean gloves. Wound cleaned with normal saline solution. RN F took off her right glove and put on another clean glove without cleaning her hands per facility infection control policy. She continued to provide wound care. The dressing with honey and calcium alginate was applied with a clean gauze. Dated, dry dressing was applied. The resident was repositioned, asked about her pain level, which was zero on a scale of zero to ten. In an interview on 05/18/2026 at 2:00 PM with CNA A, it was revealed she did not know the current facility enhanced barrier precautions policy or procedures. She could not give an example of a high contact resident activity identified in the facility EBP policy. She did not understand the meaning of multidrug-resistant organisms associated with enhanced barrier precautions and the spread of infection. She said she couldn't remember when the last in-service for EBP was provided. She did not know the person or understand the role of Infection Preventionist.In an interview with CNA H on 05/18/2026 at 2:17 PM, it was revealed she did not know the current facility enhanced barrier precautions policy or procedures. She could not give an example of a high contact resident activity. She did not understand the meaning of multidrug-resistant organisms associated with enhanced barrier precautions and the spread of infection. She said she couldn't remember when the last in-service for EBP was provided. She did not know the person or role of the facility Infection Preventionist. In an interview on 05/18/2026 at 3:30 PM with D.O.N., it was revealed he worked here for almost one year. He said the most current in-service on enhanced barrier precautions was provided in February 2026. He said the infection control policies and procedures have been reviewed for 2026 and the Medical Director had signed approval. He said he observed staff daily to ensure resident care was being provided and care plans were followed. He could not identify if an MDRO was currently tracked in the facility. He could not identify the plan he used for evidence-based surveillance criteria as required by the CDC (e.g., CDC NHSN Long-Term Care or revised McGeer Criteria) to define infections and the use of a data collection tool. He stated the facility had not established/implemented an Infection Control surveillance plan based on a facility assessment. The DON said he provided an in-service for infection control and enhanced barrier precautions in February 2026, and his expectations were for all staff to follow facility policy and procedure. A copy of the EBP in-service was not provided for review. Review of infection control policy dated 12/2025 revealed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms otherwise known as MDRO that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. High contact resident activities include but are not limited to dressing, bathing, toileting, transferring, providing hygiene, changing linens, and wound care. Hand hygiene policy and procedure included in the 12/2025 infection control policy revealed: Hand hygiene for 20 seconds with alcohol hand sanitizer or washing hands with soap and water: c. before handling clean or soiled dressings, gauze pads, etc. f. before moving from a contaminated body site to a clean body site during resident care; h. after handling used dressings contaminated equipment; j. removing gloves. During an interview with the Administrator on 05/18/2026 at 4:00 PM, revealed it was his expectation the D.O.N. will in-service all nursing staff on infection control and enhanced barrier precautions and his expectations of the administrative nursing staff was better monitoring of facility wide infection control measures. On 05/18/2026 at 4:15 PM, the physician for Resident #1 did not return the phone call requested at 9:00 AM today.

Based on observation, interview, and record review, the facility failed to establish and 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 infection for 2 (Resident #1 and Resident#2) of 4 residents reviewed for infection control. The facility failed on 02/27/26 to ensure infection control procedures were followed when the ADON, the PRN-TN and CNA A provided wound care to Resident #1, who was on enhanced barrier precautions, without appropriate PPE.The facility failed on 02/27/26 to ensure infection control procedures were followed when CNA A provided peri care, transferred and changed linens for Resident #1, who was on enhanced barrier precautions, without appropriate PPE.The facility failed on 02/27/26 to ensure infection control procedures were followed when the ADON and PRN-TN provided wound care to Resident #2, who was on enhanced barrier precautions, without appropriate PPE.The facility failed on 02/27/26 to ensure infection control procedures were followed when CNA B provided peri care to Resident #2, who was on enhanced barrier precautions, without appropriate PPE.This failure could place residents at risk of infection. Findings included: Record review of Resident #1's face sheet, dated 02/27/26 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with but not limited to vascular Dementia (decreased b blood flow to areas of the brain), mild with other behavioral disturbance, other lack of coordination, scabies (contagious skin infestation caused by tiny mites) (10/02/25), dermatitis and legally blind as defined in USA. Record review of Resident #1's MDS, dated [DATE] reflected, his BIMS score was 14 which indicated no cognition impairment. Record review of Resident #1's care plan, undated, reflected Resident#1 required Provide wound care treatment order.Record review of Resident#1'onorders, dated 02/13/26 reflected, Wound Care Treatment Order: Xeroform, Type - Non pressure wound Stage - N/A Treatment Directions -Right upper back non pressure wound: Cleanse with NS pat dry, apply Xeroform, Calcium then cover with dry dressing three times a week an PRN. Every evening shifts every Tue, Thu, Sat for Wound. If anything, abnormal noted with the wound notify.Record review of Resident #2's face sheet, dated 02/27/26 reflected she was a [AGE] year-old female who was admitted on [DATE] and diagnosed with but not limited to active primary progressive multiple sclerosis (steady worsening of neurological function without distinct relapses or remissions), acute upper respiratory infection and other nonspecific skin eruption. Record review of Resident #2's MDS, dated [DATE] reflected, his BIMS score was 15 which indicated no cognition impairment. Record review of Resident #2's care plan, undated, reflected Resident #2's condition required Enhanced Barrier Precautions. EBP related to Urinary Catheter, Wound Care.Goal reflected, Infection control intervention to reduce the transmission of multidrug-resistant organisms.Resident #2's intervention included Staff must don gown and gloves after entering the room to provide high contact resident care activities such as dressing, bathing/showering, transfers, providing hygiene, changing linens, toileting/brief changes, device care, med administration via enteral tube or central line, trach care and wound care.Record review of Resident #2's order, dated 01/25/26 reflected, Clean the wound to Sacrum with NS, pat dry apply, Collagen, calcium alginate, and cover with Dry dressing daily and PRN. every evening shift for pressure wound. During an observation on 02/27/26 at 3:25 PM, Surveyor observed an enhanced barrier sign on Resident#1's and Resident#2's doors which reflected, a stop signs with the following instructions: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities. DressingBathing/showeringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice Care use: central line, urinary catheter, feeding tube, tracheostomy.Wound care: any skin opening requiring a dressing.During an observation on 02/27/26 at 3:30 PM, the ADON asked Resident #2 if she was ok with wound care being provided now. Resident #2 stated yes and she wanted to be changed first. CNA B walked in the room and stated she would change Resident #2. The surveyor observed no gowns were in Resident #2's room or outside the door.During an observation on 02/27/26 at 3:40 PM, the surveyor observed an enhanced barrier sign outside of Resident #1's door. Surveyor knocked on Resident #1's door and as surveyor entered observed CNA A providing peri care with no PPE gown. The ADON, PRN-TN and surveyor entered the room. The ADON stood behind Resident #1, PRN-TN provided wound care to Resident #1 back while CNA A stood behind Resident #1 and assisted with pushing Resident #1 forward so PRN-TN could provide care to his wound. CNA A and PRN-TN transferred Resident #1 into bed. CNA A stated he changed Resident #1's linens. Surveyor observed no gowns in Resident#1 room or outside the door. CNA A, the PRN-TN, and the ADON wore gloves and washed their hands. The ADON, PRN-TN and CNA A did not put on disposable gowns while care was provided to Resident #1.During an observation on 02/27/26 at 4:00 PM, the surveyor observed the CNA B and the ADON put on gloves. The ADON and the PRN-TN provided wound care to Resident #2'S sacrum with no PPE gown. The PRN-TN and the ADON wore gloves and washed their hands. The ADON and the PRN-TN did not put on disposable gowns while care was provided to Resident #2.During an interview on 02/27/26 at 4:15 PM, CNA B stated she changed Resident #2 without the yellow gown. CNA B stated the gown was not in the room and she usually wore the gown.During an interview on 02/27/26 at 4:20 PM, PRN-TN stated she did wound care for 4 days. The PRN-TN stated staff wore gowns if the resident had covid, cough, or any kind of upper respiratory condition. The TN-PRN stated she was trained on infection control. The PRN-TN stated staff can transmit different germs/infections to other residents on our clothes and make residents sick. During an interview on 02/27/26 at 4:30 PM, CNA A stated he changed Resident #1's brief and changed his linens without a gown because the resident did not have a contagious infection/virus at this time. CNA A stated he was trained in infection control and did not think a gown needed to be worn. CNA A stated staff always wash hands and put on gloves when care was provided to residents. During an interview on 02/27/26 at 4:35 PM, the ADON stated gowns for residents with indwelling catheters, G-tubes, MDRO, wounds and Covid. The ADON stated gowns are worn to protect residents from cross contamination. The ADON stated all staff are responsible for following infection control policy. During an interview on 02/27/26 at 4:40 PM, Resident #2 stated staff usually wear the gowns when wound care and peri care was provided. Resident #2 stated she believed CNA B was rushed and forgot.During an interview and observation on 02/27/26 at 4:50 PM, the DON showed the surveyor three closets that had disposable gowns. The DON stated carts with PPE were placed outside the resident's door to be used when residents are in isolation. The DON stated the staff had access to the gowns in the closet to use. The DON stated gowns should have been used during wound care to prevent cross contamination. The DON stated the TN ensured PPE was available to staff and the TN was on vacation. The DON completed in service with nursing staff at 4:35 pm which reflected, Enhanced barrier precaution (EBP) a set of infection control measures on nursing homes designed to reduce the spread of multi drug resistive organism before surveyor exited. During an interview on 02/27/26 at 5:15 PM, the Admin stated the TN was out for the past week and the usual staff were not here. The Admin stated the facility does work hard to provide the best care to the residents.Record review of the facility policy, titled Infection Control Guidelines for All Nursing Procedures, revised 11/23 reflected, .2. EBPs employ targeted gown and gloves use during high contact resident care activities when contract precautions do not otherwise apply.3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: a)dressing .e) changing linens;.f) changing briefs or assisting toileting; g)device care or use (central line, urinary catheter, feeding tube, etch); wound care(any skin opening requiring a dressing).

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 500 - hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10).Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 500 - hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10). The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10, were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 08/05/25 at 10:42 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark dirt stains between the vents. The bathroom floor had white and grayish stains on it. A wall near an assist rail in the bathroom had a brown stain going down the wall. An observation on 08/05/25 at 10:47 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark stains on and between the vents. The toilet in the bathroom had brownish stains on a visible plastic bolt attached to the toilet seat, and the bolt attaching the toilet to the floor. A mini fridge in the room had red stains and dark dried up food particles inside. An observation on 08/05/25 at 10:59 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark stains on and between the vents. The bathroom floor had white paste around the toilet. A piece of tissue was used to determine if it was able to be cleaned and the substance came up. The top of the cover of the toilet seat had brownish spot stains. The faucet on the sink had thick blue and green soap scum build up. An observation on 08/05/25 at 11:04 AM of resident room [ROOM NUMBER] reflected the air condition vents had dark stains on and between the vents. The faucet on the sink had thick blue and green soap scum build up and the faucet had cracks. The toilet in the bathroom had brownish stains on a visible bolt attaching the toilet to the floor. An observation on 08/05/25 at 11:12 AM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. The toilet in the bathroom had brownish stains on the base of the toilet. An observation on 08/05/25 at 11:17 AM of resident room [ROOM NUMBER] reflected the faucet on the sink had thick blue and green soap scum build up. The bathroom floor had white and grayish stains around the toilet and corners of the floor. An observation on 08/05/25 at 11:20 AM of resident room [ROOM NUMBER] reflected the toilet in the bathroom had brownish stains on the base of the toilet. An observation on 08/05/25 at 11:23 AM of resident room [ROOM NUMBER] reflected the toilet in the bathroom had brownish stains near the top of the toilet seat cover. The faucet on the sink had thick blue and green soap scum build up. An observation on 08/05/25 at 11:28 AM of resident room [ROOM NUMBER] reflected the bathroom sink had light and dark stains on the inside of the sink. An observation on 08/05/25 at 11:30 AM of resident room [ROOM NUMBER] reflected the faucet on the sink had thick blue and green soap scum build up. The bathroom floor had white and grayish stains around the toilet and corners of the floor. The air condition vents had [NAME] stains on and between the vents. In an interview on 08/07/2025 at 9:23 AM, Housekeeping P stated she was responsible for cleaning the rooms on the 500-hall. She was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10. She stated housekeeping was responsible for cleaning those areas identified. She stated she tried to clean the faucets, but they could not get the dirt build up off. She stated the dried-up soap scum was hard to clean. She stated not cleaning the resident rooms thoroughly could result in residents getting sick. In an interview on 08/07/2025 at 9:33 AM, the Housekeeping Director stated she had been at the facility for 36 years. She stated the cleaning staff were to clean all areas of the resident rooms and bathrooms. She was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10. She stated the areas identified should have been cleaned by her cleaning staff. She stated they had tried to clean the faucets, but they had not been successful. She stated not cleaning resident rooms thoroughly could result in some residents having respiratory problems. In an interview on 08/07/2025 at 10:00 AM, the Administrator was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10. He stated his expectation was for housekeeping to clean resident rooms thoroughly every day. He stated the leadership had to do a better job inspecting what they expect. He stated the concerns with the faucets was that it could cause leaks and be a fall risk for the resident. He stated he really did not see any other risk for the residents. He stated the air condition vents not being thoroughly cleaned could impact the resident's air quality. Record review of the facility's policy on Cleaning and Disinfection of Environmental Surfaces dated June 2009, reflected Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.

Based on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #7) reviewed for ADL care provided to dependent residents. Based on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #7) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #7 received any of her scheduled showers based on records reviewed for July 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #7's face sheet, dated 08/06/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included rash and other non-specific skin eruption. Record review of Resident #7's Comprehensive MDS Assessment, dated 07/29/25, reflected the resident was unable to complete the interview for a BIMS score. The Comprehensive MDS Assessment reflected the resident required extensive assistance with ADL care. Record review of Resident #7's Comprehensive Care Plan dated 06/10/25, reflected the resident refused showers and had skin tears in multiple areas. Interventions included encouraging showers and keeping the resident's skin clean and dry. Record review of Resident #7's Comprehensive Care Plan, dated 07/16/25, reflected the resident was incontinent of urine and bowel. One of the approaches was for hygiene as needed after every incontinent episode to maintain dignity. Record review of Resident #7's Bath/Shower Sheets for the month of July 2025, reflected the resident had one shower sheet on file dated 07/24/25, which indicated the resident had refused a shower. Record review of Resident #7's progress notes for the month of July 2025, reflected no notes indicating the resident refusing showers nor were there any notes indicating any attempts to contact the resident's responsible party regarding the resident's refusal to take a shower. In an interview on 08/05/2025 at 10:29 AM, Resident #7 was asked if she was receiving her showers and she stated she wanted a shower. The resident was asked if she refused showers or received bed baths but did not respond. In an interview on 08/06/25 at 10:45 AM the ADON stated the CNAs were to complete a shower sheet for all residents, whether they received a shower or refused a shower. She stated if a resident refused a shower, the CNA was to notify the hall nurse and advise them of the refusal so the nurse could attempt to persuade the resident to shower, and if they were unsuccessful, the nurse was to contact the responsible party to see if they could convince the resident to take a shower. She was advised that Resident #7 had only 1 shower sheet on file for the month of July 2025, which indicated the resident had refused a shower. She stated the resident was scheduled to receive her showers during the 2 PM to 10 PM shift on Tuesday, Thursday, and Saturday. She stated the resident had a history of refusing showers and it was care planned. She stated a shower sheet indicating a refusal to shower should have been completed each time she was scheduled for a shower. She stated not providing the resident her scheduled showers could result in skin break down. In an interview on 08/06/25 at 1:32 PM with Resident #7, the ADON, and the Receptionist, Resident was asked if she wanted a shower in Spanish by the Receptionist and she said yes and she was taken to get a shower. In an interview on 08/06/25 at 2:20 PM CNA A, stated she had been at the facility for 9 months. She stated most of the times she provided Resident #7 bed baths. She stated they were supposed to complete a shower sheet for all residents, even if they refused a shower. She stated she did provide the residents bed baths but did not complete the shower sheets for the resident. She stated she did not always work the 500- hall and only worked with the resident a few times. She stated they were to document the refusal and notify the hall nurse. She stated she did notify the hall nurse but failed to document it. She stated if the resident did not receive their scheduled showers, she could get sick. In an interview on 08/06/25 at 2:29 PM, LVN D stated he had been at the facility more than 4 years. He stated he was the nurse for the 500-hall. She stated Resident #7 sometimes refused showers, so they tried to give her bed baths. He stated CNAs were required to complete shower sheets for the resident, whether she received a shower or refused. He stated if the resident refused a shower, the CNA was to notify him, and he would attempt to persuade the resident and notify family to assist. He was made aware that Resident #7 only had one shower sheet in the binder, and he stated she should have had a shower sheet for all scheduled days. He stated the resident was scheduled for showers on Tuesday, Thursday, and Saturday during the 2 PM-10 pm shift. He stated if the resident did not receive showers she could have a skin impairment. In an interview on 08/07/25 at 9:02 AM, the DON stated he had just started with the facility on 08/04/25. He stated the ADON had made him aware of Resident #7 not receiving her scheduled showers. He stated his expectation was for all residents to receive their scheduled showers by the CNA and if the resident refused, they were to notify the floor nurse, and the floor nurse would try to persuade the resident to take a shower. He stated if the resident still refused to take a shower, they were to contact the Responsible party to try and get them to take a shower. The DON stated that staff had to complete a shower sheet whether the resident took a shower or refused, and the refusal should be documented in the progress notes. He stated the risk of the resident not getting her scheduled showers could result in skin breakdown. He stated he completed an in-service on showers with his staff on 08/06/25. Record review of the facility's policy on Shower/Tub bath, dated December 2024, revealed The purposes of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The following information should be recorded on the resident's ADL record and/or in the resident's medical record: The date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Notify the supervisor if the resident refuses the shower/tub bath.

Based observation, interview, and record review the facility failed to establish and 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 one (Resident #37) of five residents reviewed for infection control. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene when providing incontinence care to Resident #37 on 08/05/2025.These failures could place residents at risk of cross-contamination and development of infections.Findings included:Record Review of Resident #37's Face Sheet, dated 08/05/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #37 had diagnoses which included dysarthria (slow or slurred speech that can be hard to understand), personal history of traumatic brain injury, hypertension (high blood pressure), and type 2 diabetes (the body does not use insulin effectively).Record review of Resident #37's Quarterly MDS Assessment, dated 05/29/2025, reflected the resident had severely impaired cognition with a BIMS score of 03. Section G (functional status) reflected Resident #37 required the assistance of one staff member with toileting needs. Record review of Resident #37's Comprehensive Care Plan, dated 06/30/2025, reflected bladder incontinence related to immobility. The goal reflected to remain free from skin breakdown due to incontinence and brief use. One intervention was to change the resident every two hours and as needed. During an observation and interview on 08/05/2025 at 1:25 PM, CNA B was providing incontinence care to Resident #37. Resident #37 was lying in bed on her left side. CNA B stated she had just finished cleaning Resident #37. CNA B removed the soiled brief and barrier pad from under Resident #37 and dropped the items in a bag on the floor. CNA B did not change gloves or use hand sanitizer. CNA B placed a clean brief and barrier bad under Resident #37 and assisted Resident #37 to lie flat. CNA B pressed buttons on the resident's bed controller to adjust the bed. CNA B moved to the opposite side of the bed, assisted Resident #37 to turn to her right side, and straightened the barrier pad and brief under the resident. CNA B assisted Resident #37 to lie flat and secured the tabs on each side of her brief. CNA B covered up the resident with a sheet. CNA B removed her gloves but did not use hand sanitizer or wash her hands before leaving the room. CNA B took the bag of soiled items to another room in the hall to dispose of, and after exiting the room, CNA B used hand sanitizer from a pump on the wall in the hall to sanitize her hands. When asked about hand hygiene, CNA B stated she should have removed the gloves and washed her hands or used sanitizer after removing the soiled brief. CNA B stated she should not have touched the clean brief and the resident's bed controller with soiled gloves. CNA B stated she should have cleaned her hands before exiting the resident's room. CNA B stated she normally put on three pair of gloves at the beginning of incontinence care and removed a pair after they became soiled. CNA B stated it was important to prevent cross-contamination when providing incontinence care. During an interview on 08/05/2025 at 1:30 PM, RN A stated it was important to use proper hand hygiene for infection control. She stated when CNA B's hands or gloves were dirty, and touching other items, she was spreading germs to other surfaces. She stated she would talk to CNA B to ensure she understood the importance of infection control measures when providing resident care. During an interview on 08/05/2025 at 1:55 PM, the DON stated it was important to change gloves and use hand sanitizer appropriately during incontinence care and avoid touching the resident or surfaces with soiled gloves. He stated it was important to prevent cross contamination and potentially spreading infection. He stated staff should wash their hands before leaving the residents' room and going to the next resident. He stated staff would be provided in-service about infection control. Review of the facility's policy Handwashing/Hand Hygiene, revised August 2015, reflected the policy statement This facility considers hand hygiene the primary means to prevent the spread of infection. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #10) of 4 residents reviewed for care plan review and revision.The facility failed to review and revise Resident #10's care plan interventions after he fell on [DATE] and sustained injuries that did not require transfer to the hospital for treatment. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls. The findings included: Record review of Resident #10's Face Sheet, dated 08/07/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #10 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), cognitive communication deficit (impacts how a person processes and conveys information), and unsteadiness on feet.Record review of Resident #10's Quarterly MDS (tool used to measure health status) Assessment, dated 07/13/2025, reflected moderately impaired cognition with a BIMS (tool used to assess cognition) score of 08. Section G (functional status) indicated Resident #10 required limited assistance of one staff member for activities of daily living. Record review of Resident #10's Comprehensive Care Plan, dated 05/12/2025, reflected the resident was at risk for falls related to generalized weakness and indicated the resident had a fall on 3/31/25 with no injury and a fall on 06/22/25 which caused an abrasion to the left elbow and a laceration on the face. This focus was initiated on 02/22/2025 and revised on 06/25/2025. An intervention to prevent a future fall was not added to the care plan after the resident fell on [DATE]. Record review of Resident #10's Incident Report, dated 06/22/2025, reflected The resident had a witnessed fall near to nurse station while ambulating to his room. Staff nurse observed while resident walking suddenly lost balance and fell forward. Resident hit his head and on assessment abrasion to right side eyebrow observed. The incident report reflected a head to toe assessment was completed, vital signs obtained, and neuro checks initiated. Record review of Resident #10's Fall Risk Evaluation, dated 06/22/2025, reflected his fall risk score was 16. The Fall Risk Evaluation reflected If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The clinical suggestion included on the fall risk evaluation, dated 06/22/2025, reflected rubber-soled shoes or nonskid slippers worn for ambulation. This intervention was not reflected in the resident's care plan. During an interview on 08/07/2025 at 10:03 AM, the ADON looked at the resident's medical record and stated the fall date was added to the focus of the resident's fall risk care plan but an intervention to prevent a future fall was not added. She stated it was important to update the care plan to help prevent another fall. She stated if the interventions the resident had before did not work, it was important to find a new intervention. During an observation and interview on 08/07/2025 at 10:47 AM, Resident #10 was lying in bed on top of the blanket. He was dressed and wearing shoes with rubber soles. Resident #10 stated he did not remember falling. During an interview on 08/07/2025 at 10:50 AM, the DON stated an intervention should have been added to the care plan after Resident #10 fell on [DATE]. He stated it was important to update the care plan and interventions after a resident fell. He stated most likely the interventions in place did not work and it was important to update the care plan and interventions to try to avoid a future fall. During an interview with the Administrator on 08/08/2025 at 2:40 PM, he stated Resident #10's fall risk care plan should have been updated with an intervention to help prevent a future fall. He stated the DON and ADON were responsible for ensuring any acute change was added or updated in the resident's care plan. Record review of the facility's policy Care Plan, Comprehensive reviewed December 2024, reflected the 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.10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (Resident #2) of six residents reviewed for behavioral health services. 1. The facility failed to ensure Resident #2 was not roommates with another resident who affect her diagnoses of anxiety and PTSD, when she told staff she felt anxious about the new roommate, Resident #1. 2. The facility failed to ensure Resident #2 was immediately provided behavioral health services or put interventions in place after having suicidal ideations and threatening to harm herself. An Immediate Jeopardy was identified on 05/21/2025. The IJ template was provided to the facility on [DATE] at 4:38 PM. While the immediacy was removed on 05/22/2025 at 1:35 PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could put residents at risk of not receiving behavioral health services and a decline in quality of life. Finding Included: Record review of Resident #2's face sheet, dated 05/20/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #2 had diagnoses of Dementia (decline in memory, thinking, and reasoning), Major Depressive Disorder (serious mental illness with low mood, loss of interest in activities, and sleep disturbance), Post Traumatic Stress Disorder (mental health condition that develops after experiencing or witnessing a traumatic event, which can be triggered by violence or abuse), and Anxiety Disorder (persistent and excessive worry or fear). The face sheet reflected Resident #2 discharged from the facility on 05/17/25. Record review of Resident #2's electronic record, reflected a hospital document, titled, Discharge Clinical and Scripts, dated 08/27/24, and it reflected Resident #2 was admitted to the hospital for suicidal ideations on 08/02/24 from another facility. The document noted Resident #2 tried to use a knife to cut her neck. It noted Resident #2 told staff at the previous facility that she was going to kill herself. Record review of Resident #2's Quarterly MDS Assessment, dated 03/26/25, reflected Resident #2 had a BIMS score of 9, which meant Resident #2's cognition was moderately impaired. Record review of Resident #2's Care Plan, with an initial date of 09/03/24, did not address suicidal ideations, and no interventions were noted regarding suicidal ideations. In a received email on 05/21/25 at 10:06 AM, the Administrator stated the following: The incident this past weekend with (Resident #2) resulted in her being sent to the hospital for evaluation and treatment. It started with her being confused as to the time and was thinking staff 'hadn't given her the medications she needed. She called the police, and staff explained the time and administered her medications as scheduled. She was at the nurse's station, and they were in the process of sending her to the hospital when she wheeled herself to the receptionist area and locked the door behind her keeping staff out. She grabbed the stapler and wanted everyone to leave her alone. Staff were able to get inside the door when the receptionist returned. The EMTs were here and assisted with this. The receptionist had gone to get a resident some water and was just returning. I spoke with her by phone and was encouraging her to go with them, reminding her they were only here to help. She was still refusing to go and eventually allowed them to take her to the hospital. The staff did everything they could in this situation to protect her. They removed the scissors and were in the process of sending her to the hospital for treatment. This is the first time Resident #2 has given any indication of self-harm. She has expressed her wishes that she would die but has never done anything to facilitate this. The staff ensured she did not hurt herself and assisted the EMTs in her transportation to the hospital. No in-services or investigations were done during this time. Record review of Resident #2's progress notes reflected the following: 09/26/24 11:45 AM Signed by ADON Resident by therapy door crying this nurse asked the resident why is she crying and resident stated I want to go heaven, I am tired of this place. This nurse called resident's daughter and notified. Daughter said she will be come shortly. Resident cont. on Sertraline 100mg daily, Clonazepam 0.5mg BID and Quetiapine 25mg BID. Psych Dr. called and left a voice message with call back # awaiting for call back. Resident in her room sitting in her wheel chair water provided by the CNA and resident is drinking at this time. [sic] Record review of Resident #2's electronic record reflected Resident #2 did not receive any psychiatric, psychological, or behavioral assessment immediately following the staff noting the suicidal ideations on 09/24/24. 12/11/24 13:56 (1:56 PM) Signed by LPN A Resident was having crying outbursts. She stated- 'I want to die' and it would be better if I weren't here. She also said that her daughter committed suicide. She was crying. Resident got a new roommate and feels anxious about it. Physician gave verbal order to give 1 mg Clonazepam now and increase scheduled dose from .5 mg to 1 mg BID. Gave Stat dose. updated order, Record review of Resident #2's electronic record reflected Resident #2 did not receive any psychiatric, psychological, or behavioral assessment immediately following the staff noting the suicidal ideations on 12/11/24. 01/03/25 22:02 (10:02 PM) Signed by LPN I Resident got up around 8:45 Pm , and tried to exit the building . She wanted to talk to her Pastor but did not know his name or his phone number . Resident grabbed a lamp in the lobby and wanted to hurt herself . This nurse asked resident if she would like to talk to one of our chaplains , then this nurse called Pastor (Pastor Name) and they talked for about one hour and then resident calmed down and she was able to go to sleep . The Chaplain promised resident that he will come to visit her tomorrow afternoon . Scissors which were in her room have been removed and kept in 400 hall cart . Family member (Family Member name) called but was not able to answer the phone call. Per the Progress Notes, Resident #2 did see a Psychiatrist on 01/03/25 at 00:02 (1:02 AM) on 01/03/25. Resident #2 did not receive any psychiatric, psychological, or behavioral assessment immediately following the staff noting the suicidal ideations that occurred on 01/03/25. Per the Progress Notes, Resident #2 did see a Psychiatrist on 01/03/25 at 00:02 (1:02 AM) on 01/03/25. Resident #2 did not receive any psychiatric, psychological, or behavioral assessment immediately following the staff noting the suicidal ideations that occurred on 01/03/25. 05/17/25 9:33 AM Sign by LPN J right after breakfast about 8 am charge nurse summone this nurse stating that resident was calling the police when spoke to resident she was saying that last night they didn't give her medication she has to wait a long time to get it. try to explain that this is morning and will give her all her med personally. and did administer her am meds including clonazepam and spoke with the officer that she will be calming after a while instead after they left while trying to get a hold of her daughter resident came to nursing station with scissor on hand pointing it to her neck stating I am going to do it the other nurses took away her scissor from her hand contacted MD on call and received an order to send resident to ER for evaluation. Resident is at nursing station. [sic] 05/17/25 9:44 AM Signed by LPN J Resident locked her self in receptionist room holding a stapler saying she want to be left alone at this time EMT has been notified and able to open the door and get resident, when EMT arrived resident refuse to go with them (City Name) police department were involved. Resident insist speaking with (Administrator name) (Administrator) and he spoke with her. Even then she refuse to go with them after police spoke with their chief since she was threatening to harm herself and disrupting the facility they lifted her to the stretcher and took her to (Hospital Name). EMT personal said they will take her to (facility name) facility but if they have to use sedation then they have to take her to (hospital name). called daughter and notified her. and told her exactly what the EMT told me. administrator, DON, ADON notified. [sic] Record review of Resident #2's electronic record reflected the resident saw the Behavioral Health Doctor on 01/02/25, but per the doctor's notes, Resident #2 denied any suicidal or homicidal ideations. The treatments listed on the document were: Psychosocial & Supportive Interventions Referral to Counseling/Therapy: Arrange for a counselor to provide regular one-on-one sessions to address her loneliness, potential family dysfunction, and coping skills. Staff Education: Encourage staff to respond promptly to her call light, ensure her immediate requests are met when feasible to reduce triggers for agitation. Activity Engagement: Suggest low-impact group or one-on-one recreational therapy to increase social interaction and reduce idle time. Medication Review Current Regimen: She is on multiple agents (sertraline, quetiapine, clonazepam) for mood/anxiety/psychosis. Continue to monitor sedation, cognitive impact, and overall efficacy. Possible Adjustments: If depression persists, consider evaluating the dose of sertraline (currently 100 mg daily) for potential titration, or add a mood stabilizer carefully if indicated. In an interview on 05/20/25 at 4:27 PM, Nurse Aide C stated Resident #1 was always needed her privacy and always fought with people. She stated Resident #1 got aggressive with staff at times and they would have to work with her to calm her down. Nurse Aide C stated Resident #2 was the same way as Resident #1, and she stated it was hard to work with both of them when they were roommates. She stated she let the DON know whenever she had a hard time with either resident. She stated staff were trained to let the DON or Administrator know if any resident had suicidal ideations. In an interview on 05/20/25 at 4:37 PM, the MDS Nurse stated the DON and ADON were responsible for putting interventions in place for suicidal ideation concerns. She stated the nursing staff were the ones responsible for the more acute situations like suicidal ideations. In an interview on 05/20/25 at 5:01 PM, the ADON stated certain interventions would be updated by the nursing staff, such as herself or the DON, but certain interventions, like adding interventions to the care plan was the responsibility of the MDS Nurse. The ADON stated her nursing staff were monitoring Resident #2 for behaviors. In a telephone interview on 05/20/25 at 5:12 PM, LPN A stated she did not feel comfortable discussing the incident over the phone, that the State did not normally make telephone calls during an investigation, and she did not feel safe to discuss the incident with Surveyor. She stated she was not able to meet in person and did not feel comfortable discussing a resident via email. In an interview on 05/20/25 at 5:32 PM, the Administrator stated he was aware of the incident with the scissors, but he stated he was not aware of any incident where Resident #2 picked up a lamp to harm herself. He stated he did not recall a time where she actually harmed herself. He stated she refused to go to the hospital on a few occasions. The Administrator stated he refused her medications at time. He stated with putting interventions in place, it was a collaborative effort between the ADON, DON, the Social Worker, and the MDS Nurse. He stated they usually worked together. The Administrator stated he will revisit exactly whose duty it was when it came to putting interventions in place. The Administrator stated there were risks of not having interventions in place for Resident #2, and that was the staff, nurses, and caregivers not being alerted on behaviors and knowing what to look for to report to management. In an interview on 05/21/25 at 11:29 AM, the Social Worker stated her primary responsibilities were MDS admission assessments, care plans, discharges, coordination of services like transportation and insulary things like seeing specialists. She stated Resident #1 and Resident #2 were good roommates as first. She stated they got along well together. She stated something changed, and Resident #2 was moved to another room. The Social Worker stated she is not sure how long the two were roommates, but it was not long. The Social Worker stated, regarding suicidal ideations, that would be added to the care plan by the nurses. Record review of the facility's undated policy, titled, Suicide Prevention, reflected the following: The facility designs and implements processes that strive to provide physical and psychosocial services that adequately care for all residents/patients admitted to the facility. In an attempt to identify and prevent psychosocial dysfunction, the staff will observe the physical and functioning psychosocial of the resident/patient. This process allows the staff to detect early warning signs of major mood changes and/or possible suicidal ideation and obtain and provide appropriate interventions. 1. Report any of the following warning signs immediately to your immediate supervisor: a. Resident/patient expresses feelings of worthlessness, hopelessness or helplessness b. Outbursts of anger, mood swings, and drastic changes in behavior c. Experienced a recent significant loss d. Direct and indirect statements such as, I wish I were dead, I'm going to kill myself, I'm useless, and I can't go on living like this 2. Provide a quiet, calm atmosphere to decrease anxiety/agitation. 3. Express care and concern while allowing resident/patient to express emotions. 4. Evaluate resident/patient's environment for safety and remove and store objects which could be used for self-harm. 9. Initiate a Plan of Care meeting and determine the appropriate interventions and goals. The Administrator and ADON were notified of an Immediate Jeopardy (IJ) on 5/21/25 at 4:25 PM, due to the above failures and the IJ Template was provided at 4:38 PM. The facility's Plan of Removal (POR) was accepted on 5/22/25 at 1:35 PM and included: (Facility Name) F-742 Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 5/22/25). All staff were educated by, Dr. (doctor name), a Licensed Clinical Social Worker (LCSW), who specializes in mental health and behavior management, on suicide, self-harm, and recognizing triggers/indicators of resident distress. The LCSW provided detailed education to all social services staff members on conducting resident suicide screenings/assessments successfully. The DON/ADON educated nursing staff on meeting the resident's behavioral health and psychosocial needs based upon current standards of practice, the principals of person-centered care, and the resident's goals. Social Service Director to meet with resident two times weekly indefinitely, to assess for suicidal ideation, intent, and/or plan. Resident #2 is no longer in the facility All charts were audited the Administrator, ADON, MDS, and Social Worker, to ensure that care plan interventions were in place for any residents with mood, behavior, or psychosocial indicators. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/22/25). All facility policies and procedures regarding behavioral health services, and suicide assessment and prevention, were reviewed by the department managers as well as all care staff. All nursing and social services staff members were educated by the ADON regarding facility policy and procedures on behavioral health services, and suicide assessment and prevention. Changes in resident mood and behavior will be discussed by the IDT at the daily stand-up meeting. Interventions will be developed, care planned, and implemented with front line staff involvement. The facility has contracted with a new mental health company that employs Psychiatrists who make facility visits. This will improve medication management for residents with mental illnesses and behavioral health needs. The Social Services Director will conduct chart audits to continually ensure that care plan interventions are in place for any residents with mood, behavior, or psychosocial indicators. Audits occur: o Weekly for 4 weeks and then. o Monthly for 3 months and then. o Quarterly The Social Services Director implemented a QAPI PIP to gather and process information from the audits. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 5/22/25 On 5/22/25 at 1:35 PM, the investigator began monitoring to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy: In an interview on 05/22/25 at 1:39 PM, RN D stated she received in-services today, suicidal ideations, and reporting of suicidal ideations. In an interview on 05/22/25 at 1:55 PM, the ADON stated she and the Administrator facilitated the in-services with the staff, on abuse and neglect, resident rights, resident-to-resident aggression, and care planning. She stated she and the Administrator received in-services on those subjects and it was facilitated by the VP from their corporate office. She stated there was an additional in-services on psych services and suicidal ideations facilitated by the behavioral health doctor on site today. On 05/22/25 at 1:58 PM, an in-service on behavioral health, suicidal ideations, and suicide was observed with over 20 staff members present in the in-service, which was conducted by the Behavioral Health Physician, in the dining hall. In an interview on 05/22/25 at 2:02 PM, RN E stated she received in-services that started yesterday and covered abuse, neglect, today on suicidal ideations, and reporting when a resident had suicidal ideations. She stated the abuse coordinator was the Administrator. In an interview on 05/22/25 at 2:18 PM, LVN F stated he received in-services today that covered, abuse and neglect and suicidal ideations. In an interview on 05/22/25 at 3:09 PM, Nurse Aide G stated she was in the behavioral health in-service today, reporting incidents and behaviors of residents to the nursing staff, suicidal ideations heard from residents, suicide attempts, and residents fighting with each other. In an interview on 05/22/25 at 4:01 PM, Nurse Aide H stated she received training today on reporting of suicidal ideations by residents. She stated she would report that to the Administrator, who was the abuse coordinator. In an interview on 05/22/25 at 4:22 PM, with Spanish Interpreter 2633, the Housekeeper stated she received in-services today on changes with residents, reporting any issues like behavior or abuse to the nurses or the Administrator. She stated the was in the behavioral health in-service. She stated her in-services are usually given to her in Spanish, so she can understand everything. She stated her supervisor interprets it for her. The Housekeeper stated there was always someone present to interpret the trainings for her. In an interview on 05/22/25 at 4:41 PM, the Dietary Manager stated she was trained this week on resident suicide, suicidal ideations, behavioral issues and concerns with residents, resident changes, and reporting of allegations. She stated if she witnessed anything she would immediately tell the Administrator. She stated she in-serviced her staff on all of those subjects this week, and she stated all of her staff attended the in-service on behavioral health today. In an interview on 05/2/25 at 4:47 PM, the Receptionist stated she received in-services on changes in residents and reporting suicidal ideations. She stated she was getting the in-service on behavioral health after the other staff, because she had to cover the front desk during the larger in-service. In an interview on 05/22/25 at 5:02 PM, the ADON stated the DON was still on vacation, but she would be in-serviced by the VP of Clinical Services prior to her working again. She stated all other staff had received in-services on abuse, neglect, resident rights, behavioral health, care plans, suicide prevention, and medication administration. She stated she, the DON, and the Administrator would continue to do routine in-services and audits to ensure there were no more concerns with abuse and neglect in the facility. She stated the IDT was working together to ensure all residents with behavioral issues had interventions in place and the care that was needed to ensure their safety. In an interview on 05/22/25 at 5:10 PM, the VP of Clinical Services stated she in-serviced the Administrator and the ADON on abuse and neglect, resident rights, care planning, resident to resident altercations, medication administration, and managing residents. She stated she would in-service the DON prior to her returning to work from leave. She stated they started audits and will continue to routinely do audits to ensure the staff are following through with all the trainings, as well as the Administrator, ADON, and DON following through with continued training and auditing. In an interview on 05/22/25 at 5:18 PM, the Social Worker stated she attended the behavioral health in-service today. She stated she was helping the MDS Nurse audit the care plans today and on-going. She stated she was responsible for completing audits on suicidal ideations and anxiety. The Social Worker stated the residents with behaviors would be checked on twice a week for the next 6-8 weeks, then quarterly afterward. She stated she was working with the nursing team, and the MDS Nurse to ensure interventions were in place for residents with behavioral concerns. In an interview on 05/22/25 at 5:23 PM, the MDS Nurse stated she received an in-service on behavioral health, resident rights, abuse and neglect, care planning, resident altercations, and suicidal ideations. She stated he also received an in-services on reporting abuse, neglect, suicidal ideations. She stated she started auditing all resident MDS assessments to ensure all behaviors were addressed on the MDS, and she would do that for all in-coming residents as well. She stated she was working with other department heads like the Social Worker and ADON to ensure interventions were in place for residents with behavioral issues. In an interview on 05/22/25 at 5:58 PM, the Administrator stated he completed in-services this week on abuse and neglect, resident rights, behavioral health, resident altercations, care planning, medication administration, and reporting of anything concerning. He stated they have all started completing the audits and the audits would continue for a while according to the plan. The Administrator stated all department heads were working together to ensure the safety of all residents and to ensure their needs were met. Record review of the following: In-services on abuse and neglect, resident rights, behavioral health, care plans, medication administration, resident-to-resident altercations, reporting of abuse and neglect dated 05/21/25 and 05/22/25. Audit of all resident care plans dated 05/22/25 May Activity Report dated 05/22/25 MDS Nurse Audit of the MDS assessments of residents Audit report of incidents reported, grievances reported, and any allegations of abuse or neglect. An Immediate Jeopardy (IJ) was identified on 5/21/25 at 4:25 PM and an IJ Template was provided to the Administrator at 4:38 PM. While the IJ was removed on 5/22/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 2 (Resident #2 and Resident #3) of 3 residents reviewed for abuse. 1. The facility failed to ensure Resident #3 was free from abuse on 01/05/25, when Resident #1 told Resident #3 she would stab her. 2. The facility failed to ensure Resident #2 was free from abuse on 01/07/25, when Resident #1 walked into Resident #2's room and hit her repeatedly in the head, with a pole like object causing her to be sent to the hospital, where she was diagnosed with an eye injury, bruises, and abrasions. An Immediate Jeopardy was identified on 05/21/2025. The IJ template was provided to the facility on [DATE] at 4:38 PM. While the immediacy was removed on 05/22/2025 at 1:35 PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical or psychosocial harm from physical or verbal abuse. Findings included: Record review of Resident #1's face sheet, dated 05/20/25, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had diagnoses of Bipolar Disorder (mental health condition with extreme shifts in mood, energy, and activity levels), Major Depressive Disorder (serious mental illness with low mood, loss of interest in activities, and sleep disturbance), Anxiety Disorder (persistent and excessive worry or fear), and Cognitive Communication Deficit (cognitive function issues with memory and functioning) Record review of Resident #1's Quarterly MDS Assessment, dated 10/11/24, reflected Resident #1 had a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS noted Resident #1 had no issues with mood or behavior. Record review of Resident #1's Care Plan, with an initial date of 06/24/22, reflected the following: Initiated date 02/17/24- Resident is paranoid thinking everyone is against her Record review of Resident #2's face sheet, dated 05/20/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #2 had diagnoses of Dementia (decline in memory, thinking, and reasoning), Major Depressive Disorder (serious mental illness with low mood, loss of interest in activities, and sleep disturbance), Post Traumatic Stress Disorder (mental health condition that develops after experiencing or witnessing a traumatic event, which can be triggered by violence or abuse), and Anxiety Disorder (persistent and excessive worry or fear). The face sheet reflected Resident #2 discharged from the facility on 05/17/25. Record review of Resident #2's Quarterly MDS Assessment, dated 03/26/25, reflected Resident #2 had a BIMS score of 9, which meant Resident #2's cognition was moderately impaired. Record review of Resident #2's Care Plan, with an initial date of 09/03/24, did not address the incident where Resident #1 hit her. Record review of Resident #3's face sheet, dated 05/20/25, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #3 had diagnoses of Schizoaffective Disorder (combination of a brain disorder that affects thinking, feeling, and behavior along with a mood disorder), Major Depressive Disorder (serious mental illness with low mood, loss of interest in activities, and sleep disturbance), Cerebral Infarction (stroke), and Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness on one side of the body). Record review of Resident #3's Quarterly MDS Assessment, dated 03/22/25, reflected Resident #3 had a BIMS score of 03, which indicated Resident #3's cognition was severely impaired. Record review of Resident #3's Care Plan, with an initial date of 10/29/24, reflected the following: Resident #3 required 24-hour supervision by ensuring all of Resident #3's needs were met. Record review of the progress notes in Resident #1's electronic record reflected the following: 01/07/25 1:07 AM Late Entry with an original date of 01/05/25 20:30 (8:30 PM) Documented by LPN B This nurse went to resident's room to talk to resident about the C/O made against her by her roommate. Resident refuted all the allegations made against her by roommate. She denied ever touching her roommate and also denied making any threat of stabbing the roommate with any weapon. My supervisor and myself went back to resident room and the only thing we found was a hand held back scratcher which my supervisor took away from the room. [sic] 01/07/25 16:52 (4:52 PM) Documented by LPN A This nurse heard screams coming from hall 400. Ran to room [ROOM NUMBER] where I saw resident hitting resident who resides in room [ROOM NUMBER] 'lying' in the bed screaming 'my eye, my eye'. Resident was standing over resident in 410 hitting her repeatedly with a 'poll-like' object with a hood on the end of it. I immediately attempted to take the object from resident who would not let go. I examined the resident who resides in room and noticed her eye was red, around the eye was bruised, dorsal side of both hands were bruised. I called 911 for the police and paramedics. [sic] Record review of Resident #2's hospital record, dated 01/07/25, reflected Resident #2 was diagnosed with assault, abrasion of left cornea (clear domed-shaped front of the eye), and an abrasion of the face. Record review of the Employee Roster dated 05/20/25 reflected LPN A no longer worked at the facility. Record review of emails sent by the Administrator on 05/20/25, reflected the following: (Resident #2) - Both of them have psych issues and were arguing all the time. (Resident #2) was new so we moved her. (Resident #2) would throw stuff in the floor and (Resident #1) would complain about it and they would argue. (Resident #1) was hateful to (Resident #3) and complained about her all the time. It was escalating so we moved (Resident #3). (Resident #1) had a backscratcher she used and mentioned to staff she should hit (Resident #3) with it to shut her up. We moved (Resident #3) to avoid any escalation. I know (Resident #3) moved herself to (room number) on 12/15/2024. (Resident #2) moved to (room number) on 8/28/2024. It seems some of these moves were made at night by staff to de-escalate a situation, but we don't have specific information to be certain. The common denominator in all this was (Resident #1). She made it difficult for the staff and the other residents. When your census is low you are desperate for admissions and more times than not, you admit some you later regret admitting. It is never a dull moment, I can promise you that. A telephone interview with LPN B was attempted on 05/20/25 at 4:20 PM, but there was no answer and no return call during the investigation. In an interview on 05/20/25 at 4:27 PM, Nurse Aide C stated Resident #1 liked her privacy. She stated Resident #1 would always try to fight with staff. She stated Resident #1 would get a little aggressive, and the staff would have to work with her to calm her down. Nurse Aide C stated she was not at work the day Resident #1 hit Resident #2. She stated Resident #1 and Resident #2 had the same type of behaviors. Nurse Aide C stated it was hard when Resident #1 and Resident #2 were roommates, because if she helped one, the other roommate rushed her to get help. In an interview on 05/20/25 at 5:01 PM, the ADON stated she was not at the facility during the incident in January when Resident #3 stated Resident #1 threatened her. The ADON stated she did remember Resident #3 moved to a different room that day, but she stated she was not sure if staff moved her or if she moved herself. The ADON stated the nurse supervisor that helped LPN B during that incident currently did not work for the facility. The ADON stated the Administrator, who was the abuse coordinator was the one responsible for completing an investigation of the allegations. In a telephone interview on 05/20/25 at 5:12 PM, LPN A stated she did not feel comfortable discussing the incident over the phone, that the state did not normally make telephone calls during an investigation, and she did not feel safe to discuss the incident with Surveyor. She stated she was not able to meet in person and did not feel comfortable discussing a resident via email. In an interview on 05/20/25 at 5:32 PM, the Administrator stated Resident #3 moved herself from the room with Resident #1. He stated he spoke with Resident #3 on 01/06/25, and she did not tell him that Resident #1 threatened her. The Administrator stated Resident #3 did not tell him she did not feel safe. The Administrator stated Resident #3 was all over the place and you might not know who she was talking about. The Administrator stated he spoke with Resident #1, and she denied threatening Resident #3. The Administrator stated no one in the facility would have dreamed Resident #1 would have grabbed a sticked, walked over to Resident #2's room, and beat the crap out of Resident #2. He stated Resident #1 argued with everyone, and he believed everyone at the facility had just got conditioned to Resident #1' behavior. The Administrator stated no safe surveys were completed after Resident #3 stated Resident #1 threatened to stab her. He stated there was no investigation, because neither resident recalled the threats when he spoke to them. He stated there was no one on one care. He stated the safe surveys were not completed until two days later, on 01/07/25, after Resident #1 hit Resident #2. The Administrator stated he probably should have done more after the allegations were told to staff about Resident #1 threatening Resident #3. He stated even though there was no validity to the allegations at the time, he should have done more at the time. The Administrator stated he did not think doing more at that time would have prevented Resident #1 from physically abusing Resident #2 a couple of days later. He stated Resident #1 knew what she was doing. The Administrator stated Resident #1 was arrested after the incident with Resident #2, and she did not return to the facility. In an interview on 05/21/25 at 11:19 AM, Resident #3 stated Resident #1 was her previous roommate. She stated she was scared of Resident #1, because she was very mean. She stated Resident #1 did not hit her, but Resident #1 threatened to stab her. Resident #3 stated she did not want to cause trouble. Resident #3 stated she told a nurse about Resident #1 threatening her, then she moved herself out of the room with Resident #1 to be safe. In an interview on 05/21/25 at 1:07 PM, Resident #1's Family Member stated Resident #1 had paranoia and delusions regarding Resident #2. The Family Member stated Resident #1 was saying Resident #2 was talking to her through the television. The Family Member stated the facility moved Resident #2 out of the room, and then moved Resident #3 into the room with Resident #1. The Family Member stated Resident #1 had the same delusions and paranoia about Resident #3 like she did with Resident #2. The Family Member stated the Administrator and the DON were aware of the paranoia and delusions. The Family Member stated it was discussed in care plan meetings for Resident #1. The Family Member stated the staff told her they would look into her medications and ensured she continued psych services. Record review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 12/2024, reflected the following: The facility will identify events, occurrences, patterns and trends that may constitute: Verbal abuse- means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Protection: the facility will protect residents from harm during an investigation. The Administrator and ADON were notified of an Immediate Jeopardy (IJ) on 5/21/25 at 4:25 PM, due to the above failures and the IJ Template was provided at 4:38 PM. The facility's Plan of Removal (POR) was accepted on 5/22/25 at 1:35 PM and included: (Facility Name) F-600 Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Identification of Residents Affected or Likely to be Affected: The facility should have taken the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 5/22/25) The Administrator or designee should have immediately ensured the safety and well-being of the resident who alleged abuse by removing the threatened resident from the shared room and placing her in a private room on a different hall. The Administrator or designee should have immediately initiated abuse investigation into Resident #3's abuse allegation(s). Safe Surveys should have been completed by the Social Worker on all residents with a BIMS score of 8 or higher to identify anyone not feeling safe residing in the facility. Any concerns that are identified should have been addressed immediately. Safe Surveys were completed on all residents by the Social Worker on 5/21/25 . 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/22/25) All Federal and State protocols will be followed in investigating and reporting any abuse allegation(s). Residents with BIMS scores of 8 or higher will be interviewed/assessed to identify if they feel safe and if they have ever experienced abuse while living at the facility. Concerns were/were not identified. (Provide details if concerns were identified from the interviews). Abuse policies were reviewed by the Administrator, all department managers, and all care staff. Abuse investigation procedure and documentation process were reviewed. The Administrator implemented a new abuse investigation checklist to ensure investigations were initiated and completed thoroughly. All staff were educated on changes. All staff received education on facility abuse policies by the ADON. All staff received education on abuse prevention and reporting by the ADON. Facility abuse policies and procedures will be reviewed with any agency staff prior to their shift, if agency staff are employed. Staff members are not permitted to work a shift until education had been completed. The Administrator, DON, and Social Services Director received education from the SR. VP of Clinicals on timely and thorough abuse investigations and reporting. The regional/corporate staff member will visit the facility weekly for eight (8) weeks to provide oversight, audits, and additional training as needed. The Activities Director held a Resident Council meeting in which the residents were educated on the facility's abuse policies and procedures. The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference. The Administrator or designee will continue to interview residents with BIMS scores of 8 or higher monthly to ensure they have not experienced abuse. The findings of these interviews will be presented to the QAPI Committee as a PIP project. On 5/22/25 at 1:35 PM, the investigator began monitoring to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy with the following: In an interview on 05/22/25 at 1:39 PM, RN D stated she received in-services today, that covered abuse and neglect, resident rights, reporting of abuse and neglect, care plans, suicidal ideations, and reporting of suicidal ideations. She stated the in-service reviewed reporting of abuse, who the abuse coordinator was, the Administrator, and also received an in-service on resident-to-resident aggression. She stated three types of abuse were physical, mental, and emotional. In an interview on 05/22/25 at 1:55 PM, the ADON stated she and the Administrator facilitated the in-services with the staff, on abuse and neglect, resident rights, resident-to-resident aggression, and care planning. She stated she and the Administrator received in-services on those subjects and it was facilitated by the VP from their corporate office. She stated there was an additional in-services on psych services and suicidal ideations facilitated by the behavioral health doctor on site today. In an observation on 05/22/25 at 1:58 PM, an in-service on behavioral health, suicidal ideations, and suicide was observed with over 20 staff members present in the in-service, which was conducted by the Behavioral Health Physician, in the dining hall. In an interview on 05/22/25 at 2:02 PM, RN E stated she received in-services that started yesterday and covered abuse, neglect, resident rights, reporting of abuse and neglect, care plans, suicidal ideations, and reporting when a resident had suicidal ideations. She stated the abuse coordinator was the Administrator. She stated three types of abuse were emotional, sexual, and physical. In an interview on 05/22/25 at 2:18 PM, LVN F stated he received in-services today that covered, abuse and neglect, resident rights, reporting of abuse, neglect and suicidal ideations. He stated it also covered to report any allegations immediately. He stated he also received in-services on care planning, updates to care plans, and resident-to-resident issues and incidents. LVN F stated three types of abuse were verbal, physical, and mental. In an interview on 05/22/25 at 3:09 PM, Nurse Aide G stated she was in the behavioral health in-service today, and she also received an in-service on abuse and neglect, resident rights, care plans, updates with residents, reporting incidents and behaviors of residents to the nursing staff, suicidal ideations heard from residents, suicide attempts, and residents fighting with each other. She stated three types of abuse were physical, psychological, and sexual abuse. She stated if she witnessed any abuse or neglect, she would report it immediately to the Administrator. In an interview on 05/22/25 at 4:01 PM, Nurse Aide H stated she was trained, today, on abuse and neglect, reporting of abuse and neglect, and reporting of suicidal ideations. She stated she would report any of that to the Administrator, who was the abuse coordinator. She stated she was also aware that she could report abuse to HHS. She stated she was also trained on resident rights, resident altercations, care plans, changes in residents, and reporting those changes in residents. She stated three types of abuse were financial, mental, and physical abuse. In an interview on 05/22/25 at 4:22 PM, with Spanish Interpreter 2633, the Housekeeper stated she received in-services today on abuse and neglect, resident rights, changes with residents, reporting any issues like behavior or abuse to the nurses or the Administrator. She stated the was in the behavioral health in-service. She stated her in-services are usually given to her in Spanish, so she can understand everything. She stated her supervisor interprets it for her. The Housekeeper stated there was always someone present to interpret the trainings for her. She stated three types of abuse were physical, mental, and sexual. She stated she would report any of that to the Administrator or her supervisor. In an interview on 05/22/25 at 4:41 PM, the Dietary Manager stated she was trained this week on abuse, neglect, resident rights, resident-to-resident altercations, suicide, suicidal ideations, behavioral issues and concerns with residents, resident changes, and reporting of allegations. She stated if she witnessed anything she would immediately tell the Administrator. She stated she in-serviced her staff on all of those subjects this week, and she stated all of her staff attended the in-service on behavioral health today. She stated three types of abuse were neglect, verbal, and sexual abuse. In an interview on 05/2/25 at 4:47 PM, the Receptionist stated she received in-services that started yesterday, and covered, abuse and neglect, resident rights, altercations with residents, changes in residents and reporting suicidal ideations. She stated she attended the in-service on behavioral health. The Receptionist stated three types of abuse were physical, neglect, and sexual. She stated she would report any concerns to the Administrator, who was the abuse coordinator. In an interview on 05/22/25 at 5:02 PM, the ADON stated the DON was still on vacation, but she would be in-serviced by the VP of Clinical Services prior to her working again. She stated all other staff had received in-services on abuse, neglect, resident rights, behavioral health, care plans, suicide prevention, and medication administration. She stated she, the DON, and the Administrator would continue to do routine in-services and audits to ensure there were no more concerns with abuse and neglect in the facility. In an interview on 05/22/25 at 5:10 PM, the VP of Clinical Services stated she in-serviced the Administrator and the ADON on abuse and neglect, resident rights, care planning, resident to resident altercations, medication administration, and managing residents. She stated she would in-service the DON prior to her returning to work from leave. She stated they started audits and will continue to routinely do audits to ensure the staff are following through with all the trainings, as well as the Administrator, ADON, and DON following through with continued training and auditing. In an interview on 05/22/25 at 5:18 PM, the Social Worker stated she attended the behavioral health in-service today. She stated she was also in-serviced on care plans, resident rights, resident altercations, suicidal ideations, reporting abuse and neglect, and investigation of abuse and neglect. She stated she was helping the MDS Nurse audit the care plans today and on-going. She stated she was responsible for completing audits on suicidal ideations and anxiety. The Social Worker stated the residents with behaviors would be checked on twice a week for the next 6-8 weeks, then quarterly afterward. In an interview on 05/22/25 at 5:23 PM, the MDS Nurse stated she received an in-service on behavioral health, resident rights, abuse and neglect, care planning, resident altercations, and suicidal ideations. She stated he also received an in-services on reporting abuse, neglect, suicidal ideations. She stated she started auditing all resident MDS assessments to ensure all behaviors were addressed on the MDS, and she would do that for all in-coming residents as well. In an interview on 05/22/25 at 5:58 PM, the Administrator stated he completed in-services this week on abuse and neglect, resident rights, behavioral health, resident altercations, care planning, medication administration, and reporting of anything concerning. He stated they have all started completing the audits and the audits would continue for a while according to the plan. Record review of the following: In-services on abuse and neglect, resident rights, behavioral health, care plans, medication administration, resident-to-resident altercations, reporting of abuse and neglect dated 05/21/25 and 05/22/25. Audit of all resident care plans dated 05/22/25 May Activity Report dated 05/22/25 MDS Nurse Audit of the MDS assessments of residents Audit report of incidents reported, grievances reported, and any allegations of abuse or neglect Resident Council Meeting minutes Abuse Investigation Checklist An Immediate Jeopardy (IJ) was identified on 5/21/25 at 4:25 PM and an IJ Template was provided to the Administrator at 4:38 PM. While the IJ was removed on 5/22/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #1 and Resident #2) of 6 residents, reviewed for care plans. 1. The facility failed to address Resident #1's verbal abuse towards others and threat toward Resident #3, on 01/05/25, on the comprehensive care plan. 2. The facility failed to address Resident #2's suicidal ideations on 09/26/24, 12/11/24, and 01/03/25 on the comprehensive care plan. An Immediate Jeopardy was identified on 05/21/2025. The IJ template was provided to the facility on [DATE] at 4:38 PM. While the immediacy was removed on 05/22/2025 at 1:35 PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's face sheet, dated 05/20/25, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had diagnoses of Bipolar Disorder (mental health condition with extreme shifts in mood, energy, and activity levels), Major Depressive Disorder (serious mental illness with low mood, loss of interest in activities, and sleep disturbance), Anxiety Disorder (persistent and excessive worry or fear), and Cognitive Communication Deficit (cognitive function issues with memory and functioning) Record review of Resident #1's Quarterly MDS Assessment, dated 10/11/24, reflected Resident #1 had a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS noted Resident #1 had no issues with mood or behavior. Record review of Resident #1's Care Plan, with an initial date of 06/24/22, reflected the following: Initiated date 02/17/24- Resident is paranoid thinking everyone is against her Resident #1's Care Plan did not address Resident #1's verbal abuse or threats toward Resident #3. Record review of the progress notes on Resident #1's electronic record reflected the following: 01/07/25 16:52 (4:52 PM) Documented by LPN A This nurse heard screams coming from hall 400. Ran to room [ROOM NUMBER] where I saw resident hitting resident who resides in room [ROOM NUMBER] 'lying' in the bed screaming 'my eye, my eye'. Resident was standing over resident in 410 hitting her repeatedly with a 'poll-like' object with a hood on the end of it. I immediately attempted to take the object from resident who would not let go. I examined the resident who resides in room and noticed her eye was red, around the eye was bruised, dorsal side of both hands were bruised. I called 911 for the police and paramedics. [sic] 01/07/25 1:07 AM Late Entry with an original date of 01/05/25 20:30 (8:30 PM) Documented by LPN B This nurse went to resident's room to talk to resident about the C/O made against her by her roommate. Resident refuted all the allegations made against her by roommate. She denied ever touching her roommate and also denied making any threat of stabbing the roommate with any weapon. My supervisor and myself went back to resident room and the only thing we found was a hand held back scratcher which my supervisor took away from the room. [sic] Record review of Resident #2's face sheet, dated 05/20/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #2 had diagnoses of Dementia (decline in memory, thinking, and reasoning), Major Depressive Disorder (serious mental illness with low mood, loss of interest in activities, and sleep disturbance), Post Traumatic Stress Disorder (mental health condition that develops after experiencing or witnessing a traumatic event, which can be triggered by violence or abuse), and Anxiety Disorder (persistent and excessive worry or fear). The face sheet reflected Resident #2 discharged from the facility on 05/17/25. Record review of Resident #2's Quarterly MDS Assessment, dated 03/26/25, reflected Resident #2 had a BIMS score of 9, which meant Resident #2's cognition was moderately impaired. Record review of Resident #2's Care Plan, with an initial date of 09/03/24, did not address suicidal ideations, and no interventions were noted regarding suicidal ideations. Record review of Resident #2's progress notes reflected the following: 09/26/24 11:45 AM Signed by ADON Resident by therapy door crying this nurse asked the resident why is she crying and resident stated I want to go heaven, I am tired of this place. This nurse called resident's (Family Member) and notified. (Family Member) said she will be come shortly. Resident cont. on Sertraline 100 mg daily, Clonazepam 0.5mg BID and Quetiapine 25mg BID. Psych Dr. called and left a voice message with call back # awaiting for call back. Resident in her room sitting in her wheel chair water provided by the CNA and resident is drinking at this time. [sic] 12/11/24 13:56 (1:56 PM) Signed by LPN A Resident was having crying outbursts. She stated- 'I want to die' and it would be better if I weren't here. She also said that her daughter committed suicide. She was crying. Resident got a new roommate and feels anxious about it. Physician gave verbal order to give 1 mg Clonazepam now and increase scheduled dose from .5 mg to 1 mg BID. Gave Stat dose. updated order, [sic] 01/03/25 22:02 (10:02 PM) Signed by LPN I Resident got up around 8:45 PM , and tried to exit the building . She wanted to talk to her Pastor but did not know his name or his phone number . Resident grabbed a lamp in the lobby and wanted to hurt herself . This nurse asked resident if she would like to talk to one of our chaplains , then this nurse called Pastor (Pastor Name) and they talked for about one hour and then resident calmed down and she was able to go to sleep . The Chaplain promised resident that he will come to visit her tomorrow afternoon . Scissors which were in her room have been removed and kept in 400 hall cart . Family member (Family Member name) called but was not able to answer the phone call. [sic] 05/17/25 9:33 AM Sign by LPN J right after breakfast about 8 am charge nurse summone this nurse stating that resident was calling the police when spoke to resident she was saying that last night they didn't give her medication she has to wait a long time to get it. try to explain that this is morning and will give her all her med personally. and did administer her am meds including clonazepam and spoke with the officer that she will be calming after a while instead after they left while trying to get a hold of her daughter resident came to nursing station with scissor on hand pointing it to her neck stating I am going to do it the other nurses took away her scissor from her hand contacted MD on call and received an order to send resident to ER for evaluation. Resident is at nursing station. [sic] 05/17/25 9:44 AM Signed by LPN J Resident locked her self in receptionist room holding a stapler saying she want to be left alone at this time EMT has been notified and able to open the door and get resident, when EMT arrived resident refuse to go with them (Name of City) police department were involved. Resident insist speaking with (Administrator name) (Administrator) and he spoke with her. Even then she refuse to go with them after police spoke with their chief since she was threatening to harm herself and disrupting the facility they lifted her to the stretcher and took her to (Hospital Name). EMT personal said they will take her to (facility name) facility but if they have to use sedation then they have to take her to (hospital name). called daughter and notified her. and told her exactly what the EMT told me. administrator, DON, ADON notified. [sic] Record review of Resident #2's hospital record, dated 01/07/25, reflected Resident #2 was diagnosed with assault, abrasion of left cornea (clear domed-shaped front of the eye), and an abrasion of the face. Record review of emails sent by the Administrator on 05/20/25, reflected the following: (Resident #2) - Both of them have psych issues and were arguing all the time. (Resident #2) was new so we moved her. (Resident #2) would throw stuff in the floor and (Resident #1) would complain about it and they would argue. (Resident #1) was hateful to (Resident #3) and complained about her all the time. It was escalating so we moved (Resident #3). (Resident #1) had a backscratcher she used and mentioned to staff she should hit (Resident #3) with it to shut her up. We moved (Resident #3) to avoid any escalation. I know (Resident #3) moved herself to (room number) on 12/15/2024. (Resident #2) moved to (room number) on 8/28/2024. It seems some of these moves were made at night by staff to de-escalate a situation, but we don't have specific information to be certain. The common denominator in all this was (Resident #1). She made it difficult for the staff and the other residents. When your census is low you are desperate for admissions and more times than not, you admit some you later regret admitting. It is never a dull moment, I can promise you that. In a received email on 05/21/25 at 10:06 AM, the Administrator stated the following: The incident this past weekend with (Resident #2) resulted in her being sent to the hospital for evaluation and treatment. It started with her being confused as to the time and was thinking staff 'hadn't given her the medications she needed. She called the police, and staff explained the time and administered her medications as scheduled. She was at the nurse's station, and they were in the process of sending her to the hospital when she wheeled herself to the receptionist area and locked the door behind her keeping staff out. She grabbed the stapler and wanted everyone to leave her alone. Staff were able to get inside the door when the receptionist returned. The EMTs were here and assisted with this. The receptionist had gone to get a resident some water and was just returning. I spoke with her by phone and was encouraging her to go with them, reminding her they were only here to help. She was still refusing to go and eventually allowed them to take her to the hospital. The staff did everything they could in this situation to protect her. They removed the scissors and were in the process of sending her to the hospital for treatment. This is the first time Resident #2 has given any indication of self-harm. She has expressed her wishes that she would die but has never done anything to facilitate this. The staff ensured she did not hurt herself and assisted the EMTs in her transportation to the hospital. No in-services or investigations were done during this time. In an interview on 05/20/25 at 4:27 PM, Nurse Aide C stated Resident #1 was always needed her privacy and always fought with people. She stated Resident #1 got aggressive with staff at times and they would have to work with her to calm her down. Nurse Aide C stated Resident #2 was the same way as Resident #1, and she stated it was hard to work with both of them when they were roommates. She stated she let the DON know whenever she had a hard time with either resident. In an interview on 05/2025 at 4:37 PM, the MDS Nurse stated the ADON and DON were responsible for changes on the care plan regarding acute issues like suicidal ideations and abuse. She stated the nursing team was responsible for adding those interventions to the care plan. She stated the DON was responsible for signing off on changes on the care plan for acute issues. The MDS Nurse stated the Social Worker might also be responsible for adding interventions for suicidal ideations. In an interview on 05/20/25 at 5:01 PM, the ADON stated the DON was on vacation. She stated the MDS nurse was responsible for ensuring the interventions were added to the care plan after a significant event. She stated the MDS Nurse was responsible for adding interventions related to suicidal ideations and verbal threats from one resident to another. The ADON stated the risk of not updating the care plan was the resident would not be monitored properly. In an interview on 05/20/25 at 5:32 PM, the Administrator stated Resident #1 argued with everyone. The Administrator stated ultimately, the MDS Nurse was responsible for ensuring the care plans were updated when it came to changes. He stated the ADON, DON, Social Worker, and the MDS Nurse all worked together to ensure the care plans were completed, but he stated they would all revisit the responsibilities to ensure everyone was aware who was responsible for what when he came to care plans. The Administrator stated it would be revisited so there was not a mishap. The Administrator stated the risk of not updating the care plan or adding interventions was that staff could not keep tabs on the residents. He stated the care staff would have a harder time, because it would not be noted exactly what the staff should look for when assisting certain residents. Record review of the facility's policy, titled, Care Plans, Comprehensive, dated 12/2024, reflected the following: 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 I. 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. 1. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 2. The IDT includes: a. The Attending Physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 3. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning process; b. Identify individuals or roles to be included; c. Request meetings; d. Request revisions to the plan of care; e. Participate in establishing the expected goals and outcomes of care; f. Participate in determining the type, amount, frequency and duration of care; g. Receive the services and/or items included in the plan of care; and h. See the care plan and sign it after significant changes are made. 4. The resident will be informed of his or her right to participate in his or her treatment. 5. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable. 6. The care planning process will: a. Facilitate resident and/or representative involvement; b. Include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing the goals of care. 7. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; d. Describe any specialized services to be provided as a result of PASARR recommendations; e. Include the resident's stated goals upon admission and desired outcomes; f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. Incorporate identified problem areas; continues on next page h. Incorporate risk factors associated with identified problems; i. Build on the resident's strengths; j. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; I. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards of practice for problem areas and conditions. 8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 9. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. a. No single discipline can manage an approach in isolation. b. The resident's physician (or primary healthcare provider) is integral to this process. 10. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident. 11. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment. 12. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 13. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. 14. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies. The Administrator and ADON were notified of an Immediate Jeopardy (IJ) on 5/21/25 at 4:25 PM, due to the above failures and the IJ Template was provided at 4:38 PM. The facility's Plan of Removal (POR) was accepted on 5/22/25 at 1:35 PM and included: (Facility Name) F-656 Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 5/22/25) Resident directly involved in this deficient practice had their care plan reviewed by the DON or designee and updated to reflect current /past verbal abuse, threatening to harm self and other residents and aggression towards others. The MDS Coordinator reviewed Section D & E of the MDS and associated CAA for all residents. Care plans were reviewed and updated to ensure they reflect audit findings. Any concerns identified will be addressed immediately. Residents at risk for verbal abuse and/or aggressive behavior were re-evaluated using a PQH-9. All nursing staff on all shifts received education by the ADON on the importance of care plan reflecting residents' accurate behavior (ex. Verbal and physical aggression etc.) Any staff on leave will receive education on their next scheduled workday. The DON will be in-serviced prior to her return to work by the SR. VP. Of Clinicals. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: (5/22/25) The Managing Residents with Aggressive Behaviors policy was reviewed by department managers and all care staff. The DON or designee will audit new admissions for aggressive behavior risk and ensure appropriate interventions are in place. The DON or designee will audit completed MDS's to ensure the care plan reflects concerns identified in the CAAs. New hires will receive education from Nurse Management on dealing with residents with aggressive behaviors, and resident safety at orientation. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAPI meeting for a minimum of three months or until the pattern of compliance is maintained. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: (5/22/25) On 5/22/25 at 1:35 PM, the investigator began monitoring to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy: In an interview on 05/22/25 at 1:39 PM, RN D stated she received in-services today on care plans and following interventions put into place for residents. In an interview on 05/22/25 at 1:55 PM, the ADON stated she and the Administrator facilitated the in-services with the staff, on abuse and neglect, resident rights, resident-to-resident aggression, and care planning. She stated she and the Administrator received in-services on those subjects and it was facilitated by the VP from their corporate office. She stated there was an additional in-service on psych services and suicidal ideations facilitated by the behavioral health doctor on site today. In an interview on 05/22/25 at 2:02 PM, RN E stated she received in-services today on care plans and following interventions put into place for residents. In an interview on 05/22/25 at 2:18 PM, LVN F stated he received in-services today on care planning, updates to care plans, and following interventions on the care plans. In an interview on 05/22/25 at 3:09 PM, Nurse Aide G stated today she in-serviced on care plans, updates with residents, reporting incidents and behaviors of residents and following interventions set for those residents. In an interview on 05/22/25 at 4:01 PM, Nurse Aide H stated she was trained, today on changes with residents, reporting those changes in residents, and following-up to see if new interventions were set by reviewing the care plans or asking the nurses. In an interview on 05/22/25 at 4:22 PM, with Spanish Interpreter 2633, the Housekeeper stated she received in-services on changes with residents, reporting any issues like behavior or abuse to the nurses or the Administrator, and following-up with the nurses on what the resident needs. In an interview on 05/22/25 at 4:41 PM, the Dietary Manager stated she was trained this week on behavioral issues and concerns with residents, resident changes, and knowing to look at resident information or get with the nurses to know what the needs of the resident are at that time. In an interview on 05/2/25 at 4:47 PM, the Receptionist stated she received in-services that started yesterday on changes in residents and reporting those changes. She stated she also received an in-service on getting updates from the nurse or in the meetings on new interventions for certain residents. In an interview on 05/22/25 at 5:02 PM, the ADON stated the DON was still on vacation, but she would be in-serviced by the VP of Clinical Services prior to her working again on care plans and interventions. She stated all care staff had received in-services on care plans and interventions. She stated she, the DON, the Social Worker, the MDS Nurse, and the Administrator would continue to do routine in-services and audits to ensure there were no more concerns with care planning in the facility. She stated they were all responsible for ensuring the care plans were updated when needed. In an interview on 05/22/25 at 5:10 PM, the VP of Clinical Services stated she in-serviced the Administrator and the ADON on abuse and neglect, resident rights, care planning, resident to resident altercations, medication administration, and managing residents. She stated she would in-service the DON prior to her returning to work from leave. She stated they started audits and will continue to routinely do audits to ensure the staff are following through with all the trainings, as well as the Administrator, ADON, and DON following through with continued training and auditing. In an interview on 05/22/25 at 5:18 PM, the Social stated she received in-services on care plans and interventions. She stated she was helping the MDS Nurse audit the care plans today and on-going. The Social Worker stated the residents with behaviors would be checked on twice a week for the next 6-8 weeks, then quarterly afterward. In an interview on 05/22/25 at 5:23 PM, the MDS Nurse stated she received an in-service on care planning, resident changes and interventions. The MDS Nurse stated she was auditing care plans to ensure all addressed the needs of all residents. She stated she would do the same for all newly admitted residents. In an interview on 05/22/25 at 5:58 PM, the Administrator stated he completed in-services care planning and updating interventions for all residents. He stated they have all started completing the audits and the audits would continue for a while according to the plan. Record review of the following: In-services on abuse and neglect, resident rights, behavioral health, care plans, medication administration, resident-to-resident altercations, reporting of abuse and neglect dated 05/21/25 and 05/22/25. Audit of all resident care plans dated 05/22/25 May Activity Report dated 05/22/25 MDS Nurse Audit of the MDS assessments of residents Audit report of incidents reported, grievances reported, and any allegations of abuse or neglect. An Immediate Jeopardy (IJ) was identified on 5/21/25 at 4:25 PM and an IJ Template was provided to the Administrator at 4:38 PM. While the IJ was removed on 5/22/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Treatment Cart #1) of one treatment cart reviewed. The facility failed to ensure Treatment Cart #1 was locked when unattended on 05/21/25. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation and interview on 05/21/25 at 9:23 AM, Treatment Cart #1 was observed unlocked and unattended, near the nurses' station, against the wall between the 500 wing and 600 wing. All drawers were unlocked, and there were bandages and prescription creams on the cart. There were residents in the immediate area and no staff at the nurses' station. The treatment cart was unlocked and unattended for at least 5 minutes. The items on the cart were scissors, gauze, iodine, honey patches, and saline. The Administrator stated the treatment cart should be locked all the times. The Administrator stated he would go find out who left the treatment cart unlocked and unattended. The Administrator did not locate a nurse, so the ADON went to the treatment cart and locked it. The ADON stated she was not sure who left the cart unlocked and unattended. The ADON stated all nurses were responsible for ensuring the treatment cart was locked. The ADON stated she would research to see who the last nurse was to use the cart. In an interview on 05/22/25 at 5:02 PM, the ADON stated she never figured out which nurse was responsible for the unlocked treatment cart. She stated all nurses were in-serviced on the importance of locked treatment carts. She stated the risk of an unlocked treatment cart was confused patients could open the cart and get items of the cart that were dangerous. In an interview on 05/22/25 at 5:58 PM, the Administrator stated the risk of the unlocked treatment cart was residents had access to scissors, medications, and fingernail clippers. He stated his nurses knew better than to leave the treatment cart unlocked. Record review of the facility's undated policy titled, Medication Administration General Guidelines, reflected the following: 1. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked. Record review of the in-service, titled, Should Not Leave Med Carts Open Tx Cart, dated 05/21/25, reflected the following: Medication carts should be kept locked and secured at all times when not in use to prevent unauthorized access and potential med errors.

Based on interview and record review, the facility failed to thoroughly investigate and report findings to the State Survey Agency within 5 working days of the incident and the corrective action taken if the alleged violation was verified for 1 (Resident #3) of 3 residents reviewed for abuse. 1. The facility failed to conduct a thorough investigation when Resident #3 told staff her roommate threatened to stab her on 01/05/25. This failure could place residents at risk of not having allegations of abuse, neglect, and neglect investigated and reported to the State Agency. Findings included: Record review of Resident #3's face sheet, dated 05/20/25, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #3 had diagnoses of Schizoaffective Disorder (combination of a brain disorder that affects thinking, feeling, and behavior along with a mood disorder), Major Depressive Disorder (serious mental illness with low mood, loss of interest in activities, and sleep disturbance), Cerebral Infarction (stroke), and Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness on one side of the body). Record review of Resident #3's Quarterly MDS Assessment, dated 03/22/25, reflected Resident #3 had a BIMS score of 03, which indicated Resident #3's cognition was severely impaired. 01/07/25 1:07 AM Late Entry with an original date of 01/05/25 20:30 (8:30 PM) Documented by LPN B This nurse went to resident's room to talk to resident about the C/O made against her by her roommate. Resident refuted all the allegations made against her by roommate. She denied ever touching her roommate and also denied making any threat of stabbing the roommate with any weapon. My supervisor and myself went back to resident room and the only thing we found was a hand held back scratcher which my supervisor took away from the room. In an interview on 05/20/25 at 5:32 PM, the Administrator stated Resident #3 moved herself from the room with Resident #1. He stated he spoke with Resident #3 on 01/06/25, and she did not tell him that Resident #1 threatened her. The Administrator stated Resident #3 did not tell him she did not feel safe. The Administrator stated Resident #3 was all over the place and you might not know who she was talking about. The Administrator stated he spoke with Resident #1, and she denied threatening Resident #3. The Administrator stated no safe surveys were completed after Resident #3 stated Resident #1 threatened to stab her. The Administrator stated he probably should have done more after the allegations were told to staff about Resident #1 threatening Resident #3. He stated even though there was no validity to the allegations at the time, he should have completed a more thorough investigation to ensure the safety of Resident #3. The Administrator stated he was the one responsible for completing an investigation of abuse. In an interview on 05/21/25 at 11:19 AM, Resident #3 stated Resident #1 was her previous roommate. She stated she was scared of Resident #1, because she was very mean. She stated Resident #1 did not hit her, but Resident #1 threatened to stab her. Resident #3 stated she did not want to cause trouble. Resident #3 stated she told a nurse about Resident #1 threatening her, then she moved herself out of the room with Resident #1 to be safe. Record review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated, 12/2024, reflected the following: Compliance Guidelines The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to ensure that the facility is doing all that is within its control to prevent occurrences. 6. Investigation: The facility will investigate all allegations and types of incidents listed above in accordance to facility procedure for reporting/response as described below. The Administrator should follow up with the government agencies, during business hours, to confirm the report was received and to report the results of the investigation when final as required by state agencies.

Based on observation, interviews, and record review the facility failed to thoroughly investigate and report findings to the State Survey Agency within 5 working days of the incident and the corrective action taken if the alleged violation was verified. The facility failed to conduct a thorough investigation when Resident #12 told staff she had wrapped her call light around her neck to kill herself on 12/10/24. This failure could place residents at risk of not having allegations of abuse, neglect, and neglect investigated and reported to the State Agency. Findings included: Review of Resident #12's Face Sheet, dated 12/14/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #12 was diagnosed with chronic respiratory failure (airway to lungs because narrow and damaged), anxiety disorder (intense feelings of fear or worry that recur for 6 months or longer), post-traumatic stress disorder (mental health condition caused by an extremely stressful or terrifying event), major depressive disorder (persistent feeling of sadness and loss of interest), and Asperger syndrome (disorder that impacts how a person perceives and socializes with others). Review of Resident #12's Quarterly MDS (tool used to assess resident's health status and needs) Assessment, dated 12/08/2024, revealed a BIMS (test to assess cognitive status) Assessment was not conducted for Resident #12. Resident #12's Quarterly MDS Assessment reflected physical therapy and occupational therapy services were provided. Medication was administered for a diagnosis of depression. Review of Resident #12's Comprehensive Care Plan, dated 10/31/2024, reflected Resident #12 received Cymbalta (medication used to treat depression and anxiety) for depression. Some interventions included Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Review of a progress note by the facility social worker, dated 12/10/24 reflected SW and ADON spoke with resident about making suicidal statements; resident stated that she wants to kill herself rather than live in a place like this; resident has a bruise on right side of neck; resident told staff that she tried to harm herself; resident stated that she would like to speak with a chaplain; SW suggested resident's pastor; resident stated that it has been two years since she has spoken with her pastor and stated that the church has been paying her rent for eight months; resident stated that she doesn't want SW to call her pastor because she only calls when she needs something; SW explained to resident that she would have to go to the ER to be assessed for inpatient psych resident began to yell, scream, and cursing at SW; resident already followed by Psych Services; SW to assist as needed. During an interview 12/14/24 at 04:10 PM, the Social Worker stated she received the information third hand and did not know who Resident #12's friend reported the incident to. The Social Worker stated she found out on Tuesday 12/10/24 Resident #12 told a friend she pulled her call light cord around her neck because she wanted to kill herself. The friend reported this to someone at the facility. The Social Worker stated this was immediately reported to Resident #12's physician and the facility psych services. The Social Worker stated she went to Resident #12's room to talk to her, but Resident #12 became upset and dismissed her from the room. She stated Resident #12 was originally scheduled to discharge home 12/09/24. She stated the facility attempted to send the resident out via 911, however the resident refused transport. She stated the facility obtained a mental health warrant, and the local police department was involved. She stated Resident #12 was sent out and was admitted to a behavioral unit on 12/11/24. The Social Worker stated she did not know if an incident report should have been filled out. She said that was nursing judgment. She stated it was important for nursing staff to know so they could provide the appropriate care and in-service staff. In an interview on 12/14/24 at 04:10 PM, the VP of Clinical Services stated if a resident tells us they are going to harm themselves, we interview them. We ask what is troubling you and do you have a plan? She stated if a resident verbalizes I want to harm myself and they have a plan, we have psychiry see them. We make sure they are taking medications as ordered. She stated she looked through the incident reports but there was no report about it. She stated staff was not required to fill out an incident report if someone stated they wanted to hurt their self. She stated an incident report was not required for one-to-one observation of a resident. She stated Resident #12 did not tell anyone at the time of the incident. She stated a visitor reported it later. She stated that arrangements were made to discharge the resident to get appropriate care. She stated staff members at the facility monitored Resident #12 vigilantly until she left the facility. She stated the incident was not investigated and was not reported to State. She stated that it should have been investigated. She stated it was important to investigate and report incidents to be sure no abuse was allowed to go on and residents were safely cared for. The facility provided monitoring sheets reflecting Resident #12 was monitored one one one by facility staff, including a member from the facility psych service, until she transferred to a behavior unit on 12/11/24. Record review 12/14/24 reflected there was no progress note stating a staff member was told by a visitor that Resident #12 tried to harm herself. Record review of progress notes reflected Resident #12 was already receiving psych services and taking medication for depression. Review of Facility Policy Investigation of Alleged Abuse, Neglect and Exploitation, revised December 2023, reflected Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation.

Based on observations, interviews, and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 (Resident #12) of 1 resident reviewed for reporting. 1. The facility failed to follow their policy to report to the State Agency when Resident #12 told staff she had pulled the call light cord around her neck to kill herself on 12/10/24. 2. The facility failed to ensure the Administrator or person(s) delegated followed their policy to report to the State Agency and initiate an investigation after Resident #12 told staff she pulled the call light around her neck to kill herself on 12/10/24. This failure could place residents at the facility at risk of continued abuse and neglect. Findings included: Review of Resident #12's Face Sheet, dated 12/14/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #12 was diagnosed with chronic respiratory failure (airway to lungs because narrow and damaged), anxiety disorder (intense feelings of fear or worry that recur for 6 months or longer), post-traumatic stress disorder (mental health condition caused by an extremely stressful or terrifying event), major depressive disorder (persistent feeling of sadness and loss of interest), and Asperger syndrome (disorder that impacts how a person perceives and socializes with others). Review of Resident #12's Quarterly MDS (tool used to assess resident's health status and needs) Assessment, dated 12/08/2024, revealed a BIMS (test to assess cognitive status) Assessment was not conducted for Resident #12. Resident #12's Quarterly MDS Assessment reflected physical therapy and occupational therapy services were provided. Medication was administered for a diagnosis of depression. Review of Resident #12's Comprehensive Care Plan, dated 10/31/2024, reflected Resident #12 received Cymbalta (medication used to treat depression and anxiety) for depression. Some interventions included Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. In an interview 12/14/24 at 04:00 PM, the Social Worker stated the incident should have been reported to State because Resident #12 could have followed through with it. She stated Resident #12's physician, and the facility psych services following the resident, were immediately notified. The Social Worker stated the facility attempted to send Resident #12 out via 911, but the resident refused transport. The Social Worker stated she obtained a mental health warrant and the local police department was involved. She stated the resident was sent out and admitted to a behavioral unit on 12/11/24. The Social Worker stated the administrator or whoever was acting in that role should have investigated and reported the incident as soon as possible or within 2 hours. In an interview 12/14/24 at 04:10 PM, the VP of Clinical Services stated the administrator, social worker, or herself should have reported the incident to State within 24 hours. She stated she was filling the role of Director of Nursing until the new DON started January 1st. She stated the new administrator's first day would be Monday. She stated the abuse coordinator was social services at that time but normally the administrator filled the role of abuse coordinator. She stated Resident #12's physician and the facility psych service was immediatley notified. She stated Resident #12 was immediately placed on one-on-one monitoring with facility staff, including a staff member from the facility psych service, until Resident #12 was sent out on 12/11/24. She stated the incident was not investigated and was not reported to State. She stated that it should have been investigated and reported to State. She stated it was important to report incidents to be sure no abuse was allowed to go on and residents were safely cared for. The facility provided monitoring sheets reflecting Resident #12 was monitored one one one by facility staff, including a staff member of the facility psych sevice, until she transferred to a behavioral unit on 12/11/24. Record review 12/14/24 reflected there was no progress note stating a staff member was told by a visitor that Resident #12 tried to harm herself. Record review of Resident #12's progress notes, dated 12/11/24, reflected the resident was already under care of facility psych services and received medication for depression. Review of facility policy Abuse, Neglect, and Exploitation: Reporting/Response, revised December 2023, reflected The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to discard expired foods according to guidelines. The facility failed to discard dented cans according to guideline. The facility failed to ensure all damaged eggs were removed from the other eggs stored in its original container. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on [DATE] from 09:05 AM to 09:15 AM in the facility's only kitchen reflected: Two-pound container of Strawberry Yogurt had a prep date of [DATE] and the container had a best used by date of [DATE], expired, was observed in the refrigerator. Five-pound container of coleslaw dressing dated [DATE] and had an opened date of [DATE]. There was no visible expiration date. Five-pound container of cottage cheese with a prep date of [DATE] and the container had a best used by date of [DATE], expired, was observed in the refrigerator. One broken egg in a tray with other eggs located in the walk refrigerator. A zipped lock bag containing sliced meat was dated [DATE] (expired) was stored in the refrigerator. One 6.5 pound can of diced pears, located in the pantry area, was dented. One 6.5 pound can of peas located in the pantry area, was dented. Two raw pork chops in a zipped lock bag was unlabeled and undated. One 10-pound bag of frozen meat was unlabeled and undated. There was no visible expiration date. An interview on [DATE] at 01:05 PM with the Dietary Manager and Dietician, they were shown the concerns observed in the kitchen. The DM stated she had all kitchen staff assigned to storing the food and removing any expired foods. The DM and Dietician stated they would in-service the team on the food storage requirements and will remove the concerns observed. They both stated the risk of the concerns not being addressed could result in food contamination. An interview on [DATE] at 10:31 AM with the Administrator, she was made aware of the findings in the kitchen. She stated that she expects the kitchen to meet all required expectations. She stated the kitchen area had made some improvements since she had been at the facility. She stated she would follow up with the DM. She stated the risk of the concerns not being addressed could result in food contamination. Record Review of the Facility's policy on Food Storage dated ,d+[DATE], revealed Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under Ssection ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based on observation, interviews and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for three (Resident #35, Resident #40, and Resident #46) of six residents reviewed for accuracy of assessments. The facility failed to ensure Resident #35's Quarterly MDS Assessment, dated 06/14/2024, accurately reflected that Resident #35 had impairments to both upper extremities. The facility failed to ensure Resident #40's Quarterly MDS Assessment, dated 04/26/2024, accurately reflected that Resident #40 had impairments to both upper extremities. The facility failed to ensure Resident #46's Quarterly MDS Assessment, dated 04/04/2024, accurately reflected that Resident #46 had impairment to right upper extremity. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #35 Review of Resident #35's Face Sheet, dated 06/25/2024, revealed that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included contracture (tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of right hand's muscle and contracture of left hand's muscle. Review of Resident #35's Quarterly MDS Assessment, dated 06/14/2024, revealed the resident had a severe impairment in cognition with a BIMS score of 02. Resident #35's Minimum Data Set, Section GG - Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion specified Resident #35 had no impairment to upper extremity. Review of Resident #35's Comprehensive Care Plan, dated 06/06/2024, reflected the resident did not want to wear bilateral hand splints. Review of resident #35's Physician Order, dated 04/26/2024, reflected Pt to wear [NAME] guards/hand splints at bedtime only every night. At bedtime for Hand and finger contractures BUE's Observation and interview on 06/25/2024 at 10:50 AM revealed Resident #35 was in his bed resting. It was noted that the resident's both hands were contracted. According to Resident #35, he had been in that condition since he was in an accident. He said he needed assistance with everything because he cannot fully use his hands. Observation and interview with LVN C on 06/26/2024 at 10:25 AM, LVN C stated Resident #35's had some sort of impairment on both upper extremities but said she was not sure to what extent. LVN C logged on to her computer and searched the resident's profile. She said Resident #35 had a diagnosis of contractures to both right and left hands. Resident #40 Review of Resident #40's Face Sheet, dated 06/25/2024, revealed that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified injury of head and sprain of ligament of cervical (pertaining to the neck) spine. Review of Resident #40's Quarterly MDS Assessment, dated 04/26/2024, revealed the resident had a severe impairment in cognition with a BIMS score of 00. Resident #40's Minimum Data Set, Section GG - Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion specified Resident #40 had no impairment to upper extremity. Review of Resident #40's Comprehensive Care Plan, dated 05/10/2024, reflected the resident had an alteration in musculoskeletal (pertaining to both musculature and skeleton) status related to contracture and wore an elbow extensor splint on left elbow and hand carrot splint (cone-shaped orthosis [device used for badly formed part of the body] used for contracted hands) in left hand. Review of Resident #40's Physician Order, dated 04/26/2024, reflected Pt to wear elbow extensor splint on left elbow to extend hand away from shoulder for 4 hours daily or as tolerated. Every day shift for elbow flexion contracture 4 hours only daily. Review of Resident #40's Physician Order, dated 04/26/2024, reflected Pt to wear hand carrot and or rolled washrag in left hand daily at all times, every shift for hand contracture. Observation on 06/25/2024 at 10:26 AM revealed Resident #40 was on her bed, sleeping. It was noted that resident's left hand was contracted. Resident #40 was not able answer the questions asked due to a cognitive communication deficit. In an interview with RN A on 06/25/2024 at 11:00 AM, RN A stated Resident #40 had a contracture on her left hand. She said the order for the resident's contracture was to put an elbow extensor and a splint with a shape of a carrot. Shae said the resident was dependent on all ADLs because of her impairment. Resident # 46 Review of Resident #46's Face Sheet, dated 06/27/2024, revealed that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting right dominant side. Review of Resident #46's Quarterly MDS Assessment, dated 04/04/2024, revealed the resident was cognitively intact with a BIMS score of 15. Resident #46's Minimum Data Set, Section GG - Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion specified Resident #46 had no impairment to upper extremity. Review of Resident #46's Comprehensive Care Plan, dated 05/10/2024, reflected the resident had an ADL Self Care Performance Deficit r/t impaired mobility. Observation and interview on 06/25/2024 at 10:35 AM revealed Resident #46 was on his bed, resting. It was noted that resident's right arm was limp. Resident #46 stated he could not raise his right hand. It was noted that the resident tried to move his right arm but was not able to do so. In an interview with CNA D on 06/25/2024 at 10:53 AM, CNA D stated Resident #46 was unable to move his right arm. He said the resident was dependent on the staff for transfer, bed mobility, and personal hygiene because of his inability to move his hand. In an interview and observation with MDS Coordinator on 06/26/2024 at 9:45 AM, the MDS Coordinator stated if a resident had an impairment, it should be reflected on the MDS assessment or on the resident's profile. She said the medical diagnosis, physician order, MDS, and the care plan should be all in-line and should match to provide a clear overview of the resident's current condition. She said, by doing so, accurate goals and interventions would be provided. The MDS Coordinator logged on to her computer, searched for Resident #35, #40, and #46's profile, and put the appropriate code for the residents' functional limitation in range of motion. She said the nurses were doing the assessment but said she should have double-checked to see if the assessment was accurate. She said if the resident had impairments, it should be communicated to the MDS Coordinator. She said an accurate MDS assessment was important because it would be the basis of the care needed by the resident. If the assessment was not accurate, the current status of the resident would not be correct resulting in a possible confusion on the residents' care. She said inaccurate assessment could also result in the resident not getting the appropriate care needed. She said she would do an in-service about accurate assessment and for the staff to document if the resident has contracture or other form of impairments. In an interview with PT E on 06/26/2024 at 11:48 AM, PT E stated the objective of an assessment was to know the current status or identify the level of function of the resident. She said a detailed assessment is necessary to be able to facilitate a comprehensive problem list so the goals and interventions could be properly constructed. She said it was also important to know the resident's functional deficits, weakness, or strengths that could help in planning. She said if there was no accurate assessment, the condition of the resident could worsen. She also said that any assessment should be reflected on the resident's profile so all the staff would know the appropriate care. In an interview with the ADON on 06/27/2024 at 07:24 AM, the ADON stated she was not familiar with the MDS but said if a resident had an impairment, it should be reflected on the system to make sure all the needed care was given to the residents. She said accuracy in assessment would help the staff make a correct care plan for the resident. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. In an interview with the DON on 06/27/2024 at 07:37 AM, the DON stated if a resident had impairments, it should be indicated on the resident's profile. She said it should be reflected on the medical diagnosis, physician orders, MDS, and care plan. She said the resident should be accurately assessed to provide the needed interventions. If the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was the residents were properly assessed not only during admission but every day to see if there was a change in condition, any refusal of care, or resident acting different than usual. She said she would collaborate with the MDS Coordinator and the ADON to audit MDS assessments and make appropriate changes. In an interview with the Administrator on 06/27/2024 at 08:06 AM, the Administrator stated that if a resident had an impairment, it should be on the MDS to reflect the current condition of the resident. She said, by doing so, the needs of the residents would be addressed. She said she would coordinate with the clinical managers to evaluate the situation, discuss it during quality assurance and do in-services. Record review of facility policy, Conducting an Accurate Assessment revised 12/2023 revealed, Policy: The purpose . assure that all residents receive an accurate assessments, reflective of the resident's status . Policy Explanation and Compliance Guidelines: . 2. Qualified staff . will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline . 3 . will correctly document the resident's medical, functional abilities and psychological status.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 rooms (room [ROOM NUMBER], #507, #509, #511, #510, and #610) of 10 rooms observed for environment. The facility failed to ensure that Resident room [ROOM NUMBER], #507, #509, #511, #510, and #610 were cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 06/25/24 at 10:59 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. The base of the faucet handles had thick calcium build up. The handrails in the bathroom had black specks of dirt and reddish dots. An observation on 06/25/24 at 11:01 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An observation on 06/25/24 at 11:04 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. The base of the faucet handles had calcium building up and was cracked. An observation on 06/25/24 at 11:08 AM of Resident room [ROOM NUMBER] reflected the base of the faucet handles had calcium building up. The handrails in the bathroom had black specks of dirt and reddish dots. An observation on 06/25/24 at 11:14 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An observation on 06/25/24 at 11:26 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An interview on 06/27/24 at 09:31 AM with the Director of Environmental Services, she stated she had been at the facility for [AGE] years. She stated she pairs the new housekeeping aides with the seasoned housekeepers, and they are showed how to clean the entire room, including the floor, bathrooms, and air conditioning. She stated maintenance cleans the air filters. She stated her staff understands English but when they get nervous, they need an interpreter. She stated the maintenance director was out on leave, but she would make sure that the air conditioning units in all the rooms were checked and cleaned. She was shown pictures of the concerns observed in Rooms #505, #507, #509, #511, #510, and #604 and she stated she would have her team address the issues. She stated the risk of the areas mentioned not being clean could result in respiratory problems for the resident. An interview on 06/27/24 at 10:31 AM with the Administrator, she was made aware of the findings in Rooms #505, #507, #509, #511, #510, and #610. She stated that she was surprised to hear that there were concerns observed with the cleanliness of the facility. She stated that they took pride on how clean they keep the facility and she stated she would meet with the maintenance director upon his return to address the air conditioning filters being cleaned more regularly and she would also meet with the Director of Environment to ensure that in the future these items are being thoroughly cleaned. She stated the risk of not having these areas clean could result in respiratory problems for the residents. Review of the facility's policy on Safe/Comfortable/Homelike Environment (Revised 2022) reflected Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #2, Resident #21, Resident #51, and Resident #54) of sixteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #2, Resident #21, Resident #51, and Resident #54's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #2 Review of Resident #2's Face Sheet, dated 06/25/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included lack of coordination and unsteadiness of feet. Review of Resident #2's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #2 had a moderate impairment in cognition with a BIMS score of 10. Resident #2 required assistance for toileting and shower. Review of Resident #2's Comprehensive Care Plan, dated 06/11/2024, reflected Resident #2 was at risk for falls and one of the interventions was to be sure the call light was within reach. Observation and interview with Resident #2 on 06/25/2024 at 10:07 AM revealed she was on her bed awake. Resident #2's call light was noted on the floor, between the bed and the side table. Resident #2 tried to search for her call light but was not able to find it. Resident #2 shrugged her shoulder and said she would just wait for somebody to come in. Resident #21 Review of Resident #21's Face Sheet, dated 06/25/2024, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting left non- dominant side, lack of coordination, and unsteadiness of feet. Review of Resident #21's Quarterly MDS Assessment, dated 03/27/2024, reflected Resident #21 had a severe cognitive impairment with a BIMS score of 06. Resident #21 required assistance for bed mobility, transfer, and toilet use. Review of Resident #21's Comprehensive Care Plan, dated 05/06/2024, reflected Resident #21 was at risk for falls r/t unsteady gait and balance and one of the interventions was to be sure her call light is within reach. Observation and interview with Resident #21 on 06/14/2024 at 9:14 AM revealed resident was lying in bed. Resident #21's call light was noted on the floor, between the wall and the head of the bed. The resident said she used the call light to call the staff. The resident searched for the call light but was not able to find it. She said the call light should be clipped to her pillow so it will not fall on the floor. Resident #51 Review of Resident #51's Face Sheet, dated 06/26/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #51's diagnosis was anoxic brain damage (lack of oxygen to the brain). Review of Resident #51's Quarterly MDS Assessment, dated 05/15/2024, reflected Resident #51 was cognitively intact with a BIMS score of 14. Resident #51 required moderate assistance for shower, dressing, and personal hygiene. Review of Resident #51's Comprehensive Care Plan, dated 06/15/2024, reflected Resident #51 was at risk of falls r/t gait/balance problems and one of the interventions was to keep the call light within reach at all times. Observation and interview with Resident #51 on 06/25/2024 at 10:17 AM revealed resident was in his wheelchair inside his room. He said his call light was behind the head of the bed. He said he would put it always on the side but when the staff would make his bed, the staff would misplace it. He said it was challenging for him to get the call light because there was a chair in front of the bed's side table. He said it was hard for him to get the call light and clip it on his pillow because his hands were unstable. It was observed that the resident transferred to his bed but had a hard time pulling the call light. Resident #51 said he hope the staff would clip the call light to his bed before leaving the room. Resident #54 Review of Resident #54's Face Sheet, dated 06/25/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting (loss of muscle mass due to the muscles weakening and shrinking) and unsteadiness of feet. Review of Resident #54's Quarterly MDS Assessment, dated 05/10/2024, reflected Resident #54 had a moderate impairment in cognition with a BIMS score of 11. Resident #54 required moderate assistance for toilet use, dressing, and personal hygiene. Review of Resident #54's Comprehensive Care Plan, dated 05/06/2024, reflected Resident #54 was at risk for falls related to immobility and one of the interventions was to keep the call light within reach at all times. Observation and interview with Resident #54 on 06/25/2024 at 10:40 AM revealed resident was lying in bed. Resident #54's call light was noted wrapped on the drawer's handle of the side table. The resident said she used the call light every time she needed assistance. She said the call light was so far that she cannot reach it. Observation and interview with CNA D on 06/25/2024 at 10:53 AM, CNA E stated he did incontinent care for Resident #21 but did not notice that the call light was on the floor. CNA D said he did not make sure the call light was with the resident when he left Resident #21's room. CNA D went to Resident #21's room, picked up the call light from the floor, cleaned it, and clipped it on the pillow. He said he would also check the call lights in Resident #2, #54, and #51's room. He said the call light must always be within the reach of the residents because they use the call lights to call the staff in case they need something or they were not feeling well. CNA D added that if the call lights were not with the residents, the residents might fall, or the staff would not know the residents were having an emergency. He said he was responsible for ensuring the call lights were within reach for his assigned residents. In an interview with LVN B on 06/26/2024 at 9:53 AM, LVN B stated the call light should be within the reach of the residents at all times. LVN B said for some residents, the call light was their sense of protection. She added the residents use the call lights when they needed something, were having an emergency, or were in pain. LVN B said the residents might fall trying to get up to get the call light or may be frustrated because they cannot call anybody to help them. LVN B said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. LVN B said she should have checked the call lights during her initial round. In an interview with the ADON on 06/27/2024 at 07:24 AM, the ADON stated the call light was important for the residents. She said the residents use the call lights if they needed help or assistance. She said if the call light was not with the resident, they might try to get up or try to go to the bathroom by themselves. She said it could result in fall, injury, and compromised skin integrity. She added that if the call lights were far from the residents, their needs will not be addressed. She said she would do an in-service about call lights. She said the expectation was all staff that would enter the room would leave the call light with the resident before coming out of the resident's room. In an interview with the DON on 06/27/2024 at 07:37 AM, the DON stated the call lights were important for the residents because this would alert the staff that the resident needed something, was having pain, was experiencing shortness of breath, or if there was a change in condition. She added if resident was non-ambulatory, the resident might try to get out of the bed, wheelchair, or recliner and fall. She said call lights were the responsibility of everybody. She said expectation was for the staff to make an effort to make sure the call light was with the residents when they leave the room. She said she will do an in-service about call light being with the residents at all times. She concluded she would follow-up and would ask why the call light was not given to the resident before leaving the room. In an interview with the Administrator on 06/27/2024 at 08:06 AM, the Administrator stated the call light is the residents' voice to let the staff know that they needed something. She said the residents use the call lights if they were in danger or in pain. She said if the call lights were not within the reach of the residents, it could result in injury, sickness, death, or the residents not being happy. She said the expectation was for the staff would make sure the call lights were within reach. She said any staff that would see that the call lights were on the floor or not within reach, they should pick it up and clip it somewhere the resident could access it. She said the call lights were everybody's responsibility, even housekeeping, management, or therapy. She concluded they would in-service all the staff in the facility and would monitor them if they were making sure the call lights were with the residents. Record review of facility's policy Answering the Call Light reviewed December 2023 revealed, Purpose: The purpose of this procedure is to respond to the resident's requests and needs . General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based 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 two (Resident #21 and Resident #46) of eight residents observed for infection control. The facility failed to ensure that CNA D performed hand hygiene and changed his gloves while providing incontinence care to Resident #21. The facility failed to ensure that CNA D performed hand hygiene and changed his gloves while providing incontinence care to Resident #46. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: Resident #21 Review of Resident #21's Face Sheet, dated 06/25/2024, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting left non- dominant side. Review of Resident #21's Quarterly MDS Assessment, dated 03/27/2024, reflected Resident #21 had a severe cognitive impairment with a BIMS score of 06. Resident #21 required assistance for bed mobility, transfer, and toilet use. Review of Resident #21's Comprehensive Care Plan, dated 05/06/2024, reflected Resident #21 had an ADL Self Care Performance Deficit r/t impaired mobility. Review of Resident #21's Bowel and Bladder Assessment, dated 05/17/2024, revealed resident had incontinence for bowel and bladder. Observation and interview on 06/25/2024 at 9:14 AM revealed CNA D was walking on the hallway holding a plastic bag with linens and a brief. CNA D said he was about to change Resident #21. CNA D went inside the room and told the resident that he would clean her up. The resident nodded her head. CNA D proceeded to put on a pair of gloves. He did not wash his hands before putting on the gloves. Before doing incontinent care, CNA D pulled the trash can and placed it beside him. CNA D then pulled the blanket to the foot part of the bed. He then took the new brief from inside the plastic bag, opened it, and placed it on the side of the resident's leg. He unfastened the brief and pushed the front part in between the resident's legs. He pulled some wipes and placed the wipes on top of the plastic container for the wipes. CNA D cleaned the front part of the resident from front to back, rolled the resident towards the wall, and cleaned the bottom of the resident. While CNA D was cleaning the resident's bottom, the resident had a bowel movement. CNA D continued to clean the resident's bottom. After he was done cleaning the resident's bottom, CNA D pulled the soiled brief, threw it in the trash can, pulled the new brief from the side of the resident, and put it on the resident's bottom. He rolled back the resident, fixed the brief, took a thin blanket from the plastic bag, and put it on top of the resident. He took off his gloves and threw them in the trash can. CNA D said he was done cleaning Resident #21 and would go to another resident to do another incontinent care. He went out of the room. He did not change his gloves all throughout incontinent care nor wash his hands before leaving the room. Resident #46 Review of Resident #46's Face Sheet, dated 06/27/2024, revealed that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting right dominant side. Review of Resident #46's Quarterly MDS Assessment, dated 04/04/2024, revealed the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated Resident #46 was always incontinent for bowel and bladder. Review of Resident #46's Comprehensive Care Plan, dated 05/03/2024, reflected the resident had bowel and bladder incontinence r/t impaired mobility and one of the interventions was to change every two hours and PRN. Observation on 06/25/2024 at 10:35 AM revealed CNA D was about to provide incontinent care for Resident #46. CNA D prepared the things needed. CNA D washed his hands and put on a pair of gloves. CNA C then unfastened the tape on both sides of the brief, rolled the front half of the brief, and pushed it between the resident's thighs. CNA D cleaned the front part of Resident #46. CNA D instructed and assisted the resident to roll to the right. CNA D changed his gloves but did not sanitize his hands before putting on the new pair of gloves. CNA D then proceeded to clean the bottom of the resident. After wiping down the resident, CNA D rolled the rest of the brief, pulled it, and threw it in the trash can. CNA D took off the soiled gloves and proceeded to change his gloves. He did not do hand hygiene in between gloves changes. CNA D then proceeded to get the new brief, opened it, and placed it at the bottom of the resident. The resident was instructed to roll back. CNA D took off his gloves, fixed the brief, and fastened the tape on both sides. He did not have any gloves on when he fixed and fastened the brief. CNA D then put on a pair of gloves and pulled the blanket up. CNA D did not sanitize his hands before putting on the gloves. CNA D took off his gloves, threw them in the trash can, and washed his hands. Interview with CNA D on 06/25/2024 at 10:53 AM, CNA D stated it is important to wash the hands before and after doing any care for the resident. He then acknowledged that he did not wash his hands when he did the first incontinent care. He said he also did not change his gloves after cleaning the residents' bottom and did not sanitize his hands in between changing of gloves. He said hand washing was important to prevent cross contamination and infection. He said it was also important to change gloves when touching clean items and to sanitize hands when changing the gloves to make sure the hands were clean when touching the residents. He also said he should have changed his gloves when he touched the trash can and put it on his side. He said he had in-services about infection control and hand hygiene. In an interview with LVN B on 06/26/2024 at 9:53 AM, LVN B stated the right procedure was to wash the hands before and after incontinent care. She said it was also important to change the gloves and to sanitize the hands during the duration of incontinent care especially if soiled items were touched. LVN B added that any soiled items should not touch the clean items to prevent cross contamination and possible infection. She said, for the same reason, the gloves should have been changed after touching the trash can. In an interview with the ADON on 06/27/2024 at 07:24 AM, the ADON stated hands should be washed before and after any care done for the residents. The ADON said gloves should be changed and hands should be sanitized after touching soiled items such as the soiled brief and the trash can. The ADON added that not washing the hands, not changing the gloves after touching a soiled brief, and not sanitizing the hands when changing the gloves could result in cross contamination. She continued that cross contamination could lead to infection such as urinary tract infection. The ADON said the expectation was for the staff to wash their hands and change their gloves during incontinent care. She said she would start an in-service to address the infection control issue. In an interview with the DON on 06/27/2024 at 07:37 AM, the DON stated she was made aware, by the CNA, about the issue during incontinent care. She said she already talked to the staff and did a one-on-one in-service with him. She said she would also do an in-service about infection control, hand hygiene, and incontinent care for all the staff responsible for the residents' direct care. She said not washing their hands before and after any care, not changing their gloves after touching soiled items, and not sanitizing the hands in between changing of gloves could eventually introduce microorganisms to the clean items. She said not doing proper hand hygiene could result in any kind of infection. She said the DON and the ADON were responsible in making sure the staff were adhering to the infection control practices. The DON said the expectation was for the staff to carry out care without the possibility of cross contamination and introduction of infection. She also would do a check off with CNA D about peri-care. She concluded that she would continually remind the staff to be attentive to the procedures for infection control. In an interview with the Administrator on 06/27/2024 at 08:06 AM, the Administrator stated not washing hands and not changing gloves could cause cross contamination and possible infection. She said clean and dirty items should not be touching each other to prevent infection. She said the expectation was for the staff to be mindful and do the right and proper way of care to protect the residents. The Administrator said she would collaborate with the clinicals to address the issue. Record review of facility's procedure, Hand-Washing/Hand Hygiene reviewed December 2023, revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 2. All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents . After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #50) of 6 residents reviewed for care plans. The facility failed to ensure Resident #50 was care planned for his diagnosis of Parkinson's disease (nerve disorder). This failure could place the resident at risk of needs not being met. Findings included: Record review of Resident #50's face sheet dated 06/27/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's disease. Record review of Resident #50's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 (cognitively intact). The assessment also indicated the resident had an active diagnosis for Parkinson's disease. Record review of Resident #50's Comprehensive care plan dated 06/18/24 revealed no care planning for the Resident's diagnosis of Parkinson's disease. An interview on 06/26/24 at 12:30 PM with the DON, ADON, and MDS Nurse, they verified that Resident #50 had Parkinson's disease and stated that it should be care planned. The MDS Nurse verified that Resident #50 did not have the diagnosis care planned. They all stated that if the resident's care plan does not have his Parkinson's disease, he may not receive all the required care he needs. Record review of facility's policy, Comprehensive Person-Centered Care Planning, Policy & Procedure, Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident . Procedure: . 3. The facility team will provide a written summary . initial goals . any services and treatments to be administered.

Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #1, #2, #3, #4, and #5's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #1 Review of Resident #1's Face Sheet dated 01/04/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Parkinson's disease (movement disorder that causes tremor, stiffness, or slowing of movement) without dyskinesia (uncontrolled, involuntary movements of the face, arms, or legs) and major depressive disorder. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 07. Resident #1 required extensive assistance for toilet use and limited assistance for bed mobility and transfer. Review of Resident #1's Comprehensive Care Plan dated 11/13/2023 reflected resident was at risk for falls related to unsteady gait and balance and one of the interventions was to ensure the call light was within reach and encourage the resident to use it for assistance. Observation and interview with Resident #1 on 01/03/2024 starting at 09:09 AM revealed resident was sitting on his recliner beside his bed, watching tv. Resident #1's call light was noted hanging behind the bed's headboard. Resident #1 was unable to point out where his call light was. Observation and interview with CNA M on 01/03/2024 starting at 9:13 AM, CNA M stated the call lights were especially important for the residents. CNA M said the residents used their call lights to call the staff if they needed something or they needed assistance. The residents used the call lights if they needed to be changed, if they needed refill for their pitcher of water, if they cannot reach the tv remote, or if they needed the nurse for a pain pill. CNA M added if the residents did not have their call lights, the residents might fall trying to reach for the call light or even try to get the remote by themselves. Without the call lights, the needs of the residents would not be addressed. CNA M went inside Resident #1's room, went to the left side of the bed, pulled the call light from behind the headboard, and placed on top of the bed. CNA M acknowledged he missed putting the call light near the resident after attending to his needs. Interview with LVN S on 01/03/2024 at 9:18 AM, LVN S stated all the residents must have their call lights within reach. LVN S said the residents used their call lights to let the staff know they needed an assistance. LVN S said without the call lights, the staff would not know if the residents needed something, wanted to go to the bathroom, or was having any pain. LVN S added the residents might fall trying to get the call light or trying to get somebody to help them. LVN S added she had been educating the CNAs to make sure the call lights were with the resident before they leave the room. Resident #2 Review of Resident #2's Face Sheet dated 01/04/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included contracture (tightening of the muscles) of right hand, contracture of left hand, and muscle wasting (Loss of muscle leading to its shrinking and weakening). Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 03. Resident #2 required extensive assistance for bed mobility and limited assistance for transfer and eating. Review of Resident #2's Comprehensive Care Plan dated 10/14/2023 reflected resident was at risk for falls related to gait/balance problems and one of the interventions was to have a safe environment by having a working and reachable call light. Observation on 01/04/2023 at 8:17 AM revealed Resident #2's was laying on his bed sleeping. Resident #2's call light was noted hanging behind the side table located on the right side of the bed. Resident #3 Review of Resident #3's Face Sheet dated 01/04/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included muscle wasting, lack of coordination, and generalized muscle weakness. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected resident was not able to complete the interview to determine the BIMS score. Resident #3 required extensive assistance for bed mobility, eating, and toilet use. Review of Resident #3's Comprehensive Care Plan dated 11/18/2023 reflected resident was at risk for falls related to gait/balance problems and one of the interventions was to ensure the call light was within reach and encourage the resident to use it for assistance. Observation and interview with Resident #3 on 01/04/2024 starting at 8:17 AM revealed Resident #3 was sitting on his wheelchair on the left side of his bed. Resident #3's call light was noted hanging behind the side table located on the left side of the bed. When asked where his call light was, the resident looked towards his bed and then shrugged his shoulders and shook his head. Resident #4 Review of Resident #4's Face Sheet dated 01/04/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, lack of coordination, and repeated falls. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 00. Resident #4 required extensive assistance for bed mobility, transfer, eating, and toilet use. Review of Resident #4's Comprehensive Care Plan dated 10/22/2023 reflected resident was at risk for falls related to muscle weakness and one of the interventions was to be sure the call light was within reach and encourage the resident to use it for assistance. The Comprehensive Care Plan also indicated had actual falls on 01/15/2023, 05/11/2023, 05/31/2023, and 07/29/2023. Observation and interview with Resident #4 on 01/04/2024 starting at 8:16 AM revealed Resident #4 was laying on her bed. She said she was waiting for her breakfast. Resident #4's call light was noted hanging behind the side table located on the right side of the bed. When asked where her call light was, Resident #4 stated her call light was hanging by the wall since last night. Resident #5 Review of Resident #5's Face Sheet dated 01/04/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included monoplegia (paralysis restricted to one limb or region of the body) of upper limb following unspecified cerebrovascular disease (a group of conditions affecting the blood flow in the brain) affecting right dominant side and speech and language deficits following cerebral infarction (stroke). Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 03. Resident #3 was dependent for transfer and toilet use and required extensive assistance for bed mobility. Review of Resident #5's Comprehensive Care Plan dated 12/14/2023 reflected resident was at risk for falls related to weakness, unsteady gait, history of Parkinson's disease and CVA (stroke) and one of the interventions was to ensure the call light was within reach and encourage the resident to use it for assistance. Observation on 01/04/2024 at 8:19 AM revealed Resident #5 was laying on her bed, awake. Resident #5's call light was noted hanging by wall where the resident could not reach it. Resident #5 was not interviewable due to language and speech deficit following cerebral infarction. Observation and interview with LVN E on 01/04/2024 starting at 8:32 AM, LVN E stated she was not aware Resident #2, 3, 4, and 5's call lights were not within their reach. She said she must had missed it when she made her morning round. LVN E said the call lights should always be within the reach of the residents at all times. LVN E said the call lights were used by the residents to call the attention of the staff if they needed something or if they needed help. LVN E added the call lights should be placed somewhere secured so that the call lights will not fall. She added if the call lights fell , the staff should place it back within reach of the residents. LVN E said without the call lights, the staff would not know if the residents needed something, wanted to go to the bathroom, or was having any pain. LVN E added the residents might fall trying to get the call light or trying to get somebody to help them. LVN E went inside Resident #2 and Resident #3's room and placed the call lights where the residents could reach it. LVN E then went to Resident #4's room and pulled the call light from behind the side table and secured it by Resident #4's pillow. LVN E then went to Resident #5 room and pulled the call light from behind the side table. LVN E said she would do her round to check on the call lights of the other residents. She added she would educate the staff to make sure the call lights were clipped near the resident. Interview with CNA A on 01/04/2024 at 9:01 AM, CNA A stated the call lights were important for the residents. The residents used their call lights to call the staff if they needed some assistance or if they needed the nurse because they were not feeling well. CNA A added if the residents did not have their call lights, the residents might be frustrated or mad because their needs were not met. CNA A further said the residents could fall in the process of getting the call light or getting the things they needed. CNA A said he would do round to check the call lights. Interview with the DON on 01/04/2024 at 9:59 AM, the DON stated the call lights must be always within the reach of the residents. The DON said the residents used the call lights if they needed help or to alert the staff they were not feeling well. The DON added a lot of things could happen if the call lights were not with the residents. She continued the residents might try to get up on their own and fall on the process. She added the staff will not be able to deal with the resident's needs during emergencies. The DON said the expectation was for the staff to make sure the call lights were within the reach of the residents. The DON said all the staff were responsible in placing the call lights within reach. The DON said she would make an audit of the call lights to make sure they were working and within the reach of the residents. She added she would do a scheduled rounds for two weeks and then randomly check if the staff were following the policy for call lights. Interview with the Administrator on 01/04/2024 at 12:31 PM, the Administrator stated the call lights should always be always within the reach of the residents. The Administrator said the call lights were part of the residents' voice. They used the call lights to say what they need or there was a medical emergency. The Administrator said a lot of things could happen if the call lights were far from the resident. She continued if the call lights were not within reach, the resident could fall, be injured, be unhappy, be frustrated, and the needs will not be met. She said the expectation was call lights be with the residents at all times. She said the staff, from top down should be educated on the importance of the call light for the residents. The Administrator said she would collaborate with the DON to make sure the call lights were being monitored. Record review of facility's policy Call Lights: Accessibility and Timely Response, rev. 12/01/2023 revealed Policy: . to assure the facility is adequately equipped with a call light at each resident's bedside . 1 . ensuring resident access to the call light.

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #16) of five residents reviewed for quality of care. The facility failed to ensure Resident #16, who was immunocompromised, received treatment and care for his Central Venous Catheter (CVC), including routinely monitoring and assessing the site for infections or complications, and changing the dressing. The facility failed to notify the provider of a new central line, obtain orders, and care plan Resident #16's central line since his return from the hospital on 02/05/22. The facility failed to change the central line dressing when the dressing became open on 02/16/22 and even after they were notified by HHSC Surveyor on 02/16/22 at 10AM. An Immediate Jeopardy (IJ) situation was identified on 02/16/22 at 6:28 PM. While the IJ was removed on 2/18/22 at 4:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of potential harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for developing a systemic infection, complications with blockage or restrictive access, dislodgement, collapsed lung, [CONDITION(S)], and death. Findings Included: Review of Resident #16's MDS assessment, dated 12/09/21, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His BIMS score was 15 and indicated Resident #16 was cognitively intact. Review of Resident #16's hospital records, dated 02/05/22, reflected he was discharged from the hospital on 02/05/22. The discharge instructions included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected Resident #16's Mediport (a small medical appliance that was surgically installed beneath the skin; A plastic tube (catheter) connects the port to a vein), had been removed and central venous catheter had been placed on 02/01/22 for administration of Resident #16's [CONDITION(S)] and antibiotics. Review of Resident #16's order report dated 02/16/22 reflected an order initiated on 02/06/22 for [MEDICATION(S)] Solution Reconstituted [antibiotic] Use 700 milligram intravenously one time a day for WOUND INFECTION until 02/25/2022 . There were no orders for flushing, dressing changes, nor assessments of the central line. Review of Resident #16's MAR for February 2022 reflected an order initiated on 02/06/22 for [MEDICATION(S)] Solution Reconstituted [antibiotic] Use 700 milligram intravenously one time a day for WOUND INFECTION until 02/25/2022 . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's care plan dated with admitted [DATE], reflected was not a care plan for the care and management of Resident #16's central venous catheter. The care plan indicated Resident #16 still had a Mediport to his right chest. An observation on 02/15/22 at 10:29 AM, revealed Resident #16 was lying in bed. He stated he had lived at the facility for about 5 years. There was a CVC to Resident #16's left chest. There were black illegible markings on the dressing and the upper left edge of the dressing was loose. Resident #16 stated the CVC was placed at the hospital one and a half weeks ago, because the Mediport to his right chest had become infected with staph (type of bacteria commonly found on skin). Resident #16 stated since his return from the hospital on 02/05/22, the dressing to his CVC dressing had not been changed. An observation and interview on 02/16/22 at 9:30 AM revealed Resident #16's dressing to the CVC on his left upper chest was not intact and open to air. The left upper edge of the transparent dressing was loose and had folded into itself. Resident #16 stated he believed the dressing became open during his shower that morning of 02/16/22. In an interview on 02/16/22 at 9:40 AM, LVN A stated she was aware and had observed Resident #16's CVC dressing was open, and she thought it had come open when he received his shower that morning of 02/16/22. LVN A stated she did not address the open dressing because she needed to get with the VPOCO to see what she needed to do. In an interview on 02/16/22 at 10AM, LVN A stated after she was interviewed by HHSC Surveyor at 9:40 AM, she told the VPOCO about Resident #16's central line dressing being open, and she was told to re-enforce the dressing. LVN A stated the facility needed to get an RN in the building and in the meantime, we can just re-enforce [the central line dressing]. LVN A stated she had been IV certified in a previous job but had not received any trainings on IVs or central lines since she was employed at the facility for one year. LVN A stated she believed Resident #16 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the orders to care for the central line should have been put in as an IV standing order by the admitting nurse. LVN A stated if a central line dressing became loose or open, she would be concerned about infection because the line went straight into the blood stream and the resident could get [CONDITION(S)] (body's extreme response to an infection. It was a life-threatening medical emergency). LVN A stated Resident #16 had a PICC line (peripherally inserted central line), and the former DON did the dressing changes. LVN A also stated in the past, there had always been an RN in the building. LVN A stated the only RNs at the facility were the DON, who had been out sick a week, and the weekend RN supervisor. An interview with the VPOCO on 02/16/22 at 11:53 AM revealed the DON was out sick and she was standing in for her as an RN. HHSC Surveyor informed the VPOCO of Resident #16's CVC dressing being open, and she stated she instructed LVN A to re-enforce the dressing. The VPOCO stated she would need an RN to change the central line dressing for Resident #16. The VPOCO stated she was not aware when there would be an RN in the building and would need to look at the schedule. The VPOCO said central lines were an RN responsibility, but if an LVN was IV certified, they could change the dressing. The VPOCO stated the risk of a resident having an intact dressing could be a severe infection because the catheter went directly into the bloodstream and heart. In an observation on 02/16/22 at 2:45 PM, Resident #16 was lying in bed with his eyes closed. The dressing to his left upper chest central line had not been replaced and the left upper edge was still open to air. In a telephone interview on 02/17/22 at 2:29 PM, LVN G stated he did not remember if he was the admitting nurse for Resident #16 on 02/05/22. LVN G stated he called the doctor about Resident #16's re-admission from the hospital and said the only medication change was for the antibiotic, [MEDICATION(S)]. LVN G stated he did not think he told the doctor about Resident #16's central line and said he should have notified the doctor about the central line because that was where the antibiotic was given. LVN G stated when a resident was admitted or readmitted , the admitting nurse was to complete a head-to-toe assessment to see whether the resident had any injuries and to identify their COVID-19 vaccination status. He stated the admitting nurse also reviewed the hospital records, called the doctor to verify the medication list, and updated the resident's care plan or implemented a baseline care plan. In an interview on 02/16/22 at 1:18 PM, MD F stated she was the primary care provider for Resident #16. MD F stated she was not notified Resident #16's right chest Mediport was removed, and a new left chest central line was placed when he was in the hospital. MD F stated she expected the admitting nurse to notify her of a new line so she could give orders for dressing changes and flushes. MD F said Resident #16 had cancer, his immunity was low, and he was anemic (low red blood cell count). In an interview on 02/18/22 at 10:15 AM, the Medical Director said he was notified of the IJ was about not having adequate documentation that there was a central line, and a protocol about changing the dressing. The Medical Director stated he was not notified Resident #16's central line dressing was open and said he would be concerned about infection and whether the central line was in the right place. He also stated there could be a risk of infiltration (fluid leaking out of the vein into surrounding soft tissue), but there was a high risk for infection. The Medical Director stated if a nurse observed a central line dressing not intact, he expected the nurse report it to the physician and report it to the ADON and the DON. He stated the nurse should receive instructions on cleaning the site, secure it, and repeat a chest x-ray to look at the placement of the central line. He said the nurse should also assess the central line site for signs of infection such as redness. He stated since the resident received [CONDITION(S)], the nurse should also call the infusion center and let them know as well. According to the Center for Disease Control (CDC) a central venous catheter accessed from https://www.cdc.gov/hai/bsi/catheter_faqs.html on 02/25/22 indicated is a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly. These long, flexible catheters empty out in or near the heart, allowing the catheter to give the needed treatment within seconds. According to the American Nurse Today (journal of the American Nurses Association) article, Providing optimal care for patients with central catheters, dated 05/11/14, accessed from https://www.americannursetoday.com/providing-optimal-care-for-patients-with-central-catheters/ on 02/25/22 indicated care and maintenance of central venous catheters requires vigilance and attention to detail to prevent complications and maintain patency. The article revealed more than 80% of bloodstream infections are linked to vascular access devices and 50% of these infections are preventable. The article indicated dressings at the insertion site help protect the catheter and transparent dressings should be changed every 7 days and gauze dressings every 48 hours. The article also revealed the catheter must be flushed to maintain patency, and failure to maintain patency could lead to occlusion, malfunction, and infection. The article indicated all central catheters should be flushed with normal saline solution before and after medication administration and additional flushing should be based on the facility's guidelines. According to the article competent, confident central-catheter care and maintenance can help prevent dangerous complications that imperil a patient's life. According to the Center for Disease Control and Prevention's Guidelines for the Prevention of Intravascular Catheter-Related Infections, updated 02/2017, catheter sites should be monitored visually when the dressing is changed and by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. The guidelines indicated needleless components should be changed based on the facility's determination or according to the manufactures' recommendations. The guidelines also reflected a facility should: educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters . Central venous catheters-Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, [MEDICATION(S)] artery puncture, [MEDICATION(S)] vein laceration, [MEDICATION(S)] vein stenosis, hemothorax, [CONDITION(S)], air embolism, and catheter misplacement) . Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site . Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled . Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter. (accessed from https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html on 02/25/22) An Immediate Jeopardy (IJ) situation was identified on 02/16/22 at 6:28 PM and the Administrator was notified. While the IJ was removed on 2/18/22 at 4:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of potential harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility's Plan of Removal was accepted on 02/17/22 at 3:45 PM and included: Individual Approach Please accept this as a Plan of Removal to lift the alleged Quality of Care Immediate Jeopardy initiated at 6:30pm on 2/ 16/ 2022. The following corrective items have been taken for Resident #16 o Resident assessed by RN with no adverse outcome. o Attending physician was notified on 2/16/2022 and a new order for central line care was given o Resident's central line dressing was changed by RN. o Nursing staff are being in-serviced beginning 2/16/2022 on the following: o Applying and maintaining sterile dressing on the IV access devices with emphasis placed on the dressing needing to stay clean, dry and intact educating the resident also that the dressing should not get wet. o Change dressings if any suspicion of contamination is suspected. o Catheter site care shall allow for observation and evaluation of the catheter skin junction and surrounding tissue. o Central line dressing will be changed at least every 5-7 days and as needed when dressing becomes wet, soiled or not intact o Removal of old dressing using aseptic technique (a non-sterile technique) o Catheter insertion site will be covered/protected during patient bath days to prevent site from becoming wet. Systemic Approach 1. a. Charge Nurses check central line each shift to ensure that dressing is clean, dry and intact. And that are no signs/symptoms of infection and documented in the resident's MAR. DON/Designee will audit documentation for any issues daily. The administrator will perform random audits weekly for 4 weeks. Findings will be monitored via QAPI. b. If there is an issue with the dressing's integrity, the nurse will ensure that the central line is secured and the dressing will be immediately changed. The nurses will have been in-serviced and will be checked off for competency on completing a central line dressing change prior to actually changing any dressings. c. DON/designee. will check resident's chart within 24hrs. of admission against their admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator will do random audits weekly for 4 weeks to ensure compliance. d. DON/designee will audit and check all new and readmission charts to verify that orders were transcribed correctly and that the care plans have been updated to reflect residents current condition weekly x4 weeks then monthly x2. This will be documented using an audit tool. DON will provide copies of audit tool to Administrator to monitor for compliance. e. Results of audits will be review monthly in QAPI x 3 months until substantial compliance achieved . 2. In-Services a. RNs & LVNs will be in-serviced by RN/designees beginning 2/16/2022 on the following and will continue and be ongoing to be completed by 2/17/2022. Licensed staff who do not receive training by 2/17/2022 will be unable to work until training is completed. In-service training on the below and comprehension test will be added to licensed staff new hire orientation and will be completed prior to working on the floor. i. Charge Nurses will be educated to the general guidelines for central venous catheter care dressing changes. ii. The equipment and supplies necessary to remove an old or soiled dressing as well as what's necessary to place a sterile dressing and the steps in the procedure for both removing old dressing and applying a new sterile dressing, what information should be documented in the resident's medical record. iii. Importance of observing the insertion site and surrounding area for any complications and the dressing's integrity 3. Quality Assurance a. All audits of resident IV sites will be referred to the QAPI Committee for analysis and recommendation with input from the Medical Director going forward. b. Resident's IV site dressing will be monitored daily by the Nurse Manager and/or Director of Nursing to ensure in place and being changed timely. c. Ongoing training classes with comprehension test will be completed quarterly by the Director of Nursing and/or designee. POR Monitoring Included: An observation on 02/17/22 at 10:00 AM revealed Resident #16's dressing to left upper chest CVC was intact and dated 02/16/22. In an interview on 02/17/22 at 3:35 PM, LVN H stated he worked the 6AM to 2PM shift. He stated if a CVC dressing was loose, it needed to be changed the dressing immediately because it could become dislodged or it would be easy for bacteria to enter and the resident could get an infection. LVN H said CVC dressing were to be changed every 5-7 days if or as needed. In an interview on 02/18/22 at 11:10 AM LVN B stated she worked the 6AM to 2PM shift as a charge nurse. She stated she received an in-service that day regarding central lines, and every CVC dressing had to be changed weekly and an order needed to be entered. She said the dressing also needed to be changed as needed if it was soiled or loose. LVN B said if a resident had a new CVC, she would need to notify the doctor and note any orders. LVN B said if the doctor was not notified of a new CVC, it jeopardized the care of the resident. In an interview on 02/18/22 at 12:43 PM, LVN G stated he worked weekends. He said he received training on central lines and how to address the dressing, there had to be an order, and it had to be changed every 7 days and as needed if it was soiled or wet because it would cause an infection. LVN G said the admitting nurse was responsible for notifying the doctor if a resident was admitted with any IV lines. In an interview on 02/18/22 at 1:58 PM, LVN I said he worked at the facility since 2012 and he worked the 10PM to 6AM shift. He said he received an in-service on 02/17/22 regarding central line management and dressing changes. He said CVC dressing should be changes as needed if noted soiled or every 5 to 7 days. LVN I said when a resident arrived, the nurse should call and verify the orders with the doctor and there should never be any instances when the physician is not made to know that their resident has a central line. In an interview on 02/18/22 2:39 PM, the ADM stated the DON will have an audit sheet of her own and I will review those. I attend the morning clinical meeting as well and we'll keep reporting [CVC] through QAPI as well. The ADM stated the VPOCP would be the DON designee while the DON was out sick. In an interview on 02/18/22 at 3:33 PM, the VPOCO stated LVNs could care with for residents with IVs or CVC if they have participated in some type of IV certification training. She stated she completed the training with the nurses regarding CVC, dressings, and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The VPOCO stated she would execute all the monitoring of new admits and readmits, and would ensure the orders from the hospital match whatever has been entered into the resident's orders. The VPOCP stated she would be auditing the resident's records to ensure the care plan is updated, and the CVC site was being checked for signs and symptoms of infection. The VPOCO stated the infusion center for Resident #16 was notified of the new CVC and of the open dressing and they had no further recommendations. An Immediate Jeopardy (IJ) was identified on 02/16/22 at 6:28 PM. While the IJ was removed on 2/18/22 at 4:45 PM, the facility remained out of compliance at a scope of isolated and at the severity level of potential harm that is not immediate jeopardy 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 provide adequate supervision to prevent accidents for 1 (Resident #17) of 14 residents reviewed for accidents and supervision. The facility failed to ensure Resident #17 a resident with goal-directed wandering was provided with adequate staff supervision, assessment, and monitoring to prevent avoidable accidents. Resident #17 suffered serious injury when he was allowed to leave the facility unsupervised on 06/12/19. Bystanders saw him fall and called for an ambulance to take him to the hospital. He suffered fractures to the skull and facial bones on his right side. Resident #17 suffered minor injury and was at risk for serious injury when he was allowed to leave the facility unsupervised on 08/08/19. He was found lying in the street by another resident's family member. He sustained abrasions to his right elbow and upper back. This failure resulted in an identification of an immediate jeopardy on 09/12/19. While the IJ was removed on 09/14/19, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated. This failure placed residents at risk of leaving the facility unsupervised and sustaining serious injury or death. Findings included: Resident #17's MDS assessment, dated 06/26/19 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #17's MDS assessment revealed he was severely cognitively impaired with a BIMS (brief interview for mental status) score of 7 (a score of 0-7 indicates severe cognitive impairment). The MDS assessment also reflected the resident had delusions and wandered daily. Resident #17's most recent Wandering Risk assessment dated [DATE] revealed a score of 12, which indicated an overall high risk for wandering. The assessment reflected he was disoriented, forgetful, had impaired safety awareness, and had a history of [REDACTED]. Resident #17's Care Plans reflected: Date initiated: 06/27/17 Focus: Resident needs supervision to go outside for walks due to disorientation and confusion. Goal: Resident will accept staff supervision for walks outside to prevent elopement. Date iniated: 07/02/19 Focus: Resident is at risk for falls related to [DIAGNOSES REDACTED]. Resident insists on walking outside in the heat and walking down the street. Fall History: 5/14/19, 6/12/19 Skull fracture, 8/8/19 Goal: Resident will be free of falls. Review of Resident #17's Hospital Records, dated 06/12/19, reflected he had a witnessed fall, hit his head, and passed out. The resident suffered a skull fracture. Bystanders present at the incident called EMS. Review of Progress Notes for Resident #17 reflected: On 05/29/19 at 1:30 PM, the Social Worker documented: Resident #17 insisted on going outside in the heat and walking down the street even though he appeared weak. The Social Worker spoke to Resident #17's Responsible Party again and the Responsible Party said he had tried to talk to the resident, but it did not do any good. The Social Worker documented they told the Responsible Party the resident could pass out while walking outside and there would be no way for staff to know. On 05/31/19 at 9:27 PM, RN P documented: At approximately 10:10 PM on 05/31/19 facility staff received a call from the convenience store stating Resident #17 was standing outside the store and appeared to be confused. RN P and another staff member went to check on the resident. The resident was outside the store standing talking to a woman. The resident was confused, had labored breathing, and an unsteady gait. On 06/05/19 at 3:00 AM, LPN O documented: Resident noted coming out of room with just brief on. Difficult to redirect. Increased agitation. Continues to walk out front door same way, staff follows with a gown. Pees at the front entrance despite effort to redirect to the bathroom. Back in room and dressed and wanted to go outside again. 'I want to take a walk outside.' Staff advised Resident that it's unsafe for him to go out at that time. Back inside and walking hallways. On 06/24/19 at 11:52 PM, RN P documented: Resident #17 sitting across the street near the convenience store. The resident refused to come inside out of the heat even after several nurses explained to him the risk of being out there and their concern for his safety for more than 30 minutes. Resident stated, the policemen told him not to talk to the nurses. Administrator notified and went to talk to the resident. The resident refused to go back to the facility. The CNA assigned to work with the resident requested to monitor him. After several minutes the resident returned back to the building and was given water with ice to drink. On 08/08/19 at 12:18 PM, the DON documented: A family member of a different resident called the facility and reported Resident #17 was lying in the middle of the street. The charge nurse went and brought the resident back to the facility. The resident reported he hit his head on the ground and a right elbow and upper back abrasion were noted. On 08/08/19 at 1:41 PM, the DON documented: Resident #17 was outside and refused to return to the facility. The resident started walking down the street and staff encouraged him to carry water, but he refused. On 08/08/19 at 11:55 PM, RN P documented: Resident #17 was walking up and down the hall in the facility wearing only his underwear. The resident refused to put on pants. Further review of Resident #17's record revealed the facility was equipped with a Wanderguard system, but the facility did not use Wanderguard for Resident #17. An attempted interview with Resident #17 on 09/12/19 at 3:23 PM was unsuccessful. The resident shouted, I'm going outside! An interview with RN N on 09/13/19 at 12:12 PM revealed Resident #17 was cognitively impaired and not aware of the dangers outside of the facility. She said he did not know the date or month and he was very difficult to redirect. She said in Morning Staff Meetings, Resident #17's condition was discussed daily, and the Administrator would provide direction on whether or not it was ok for the resident to go outside. She said Resident #17 should not have been out of the facility at that time of night on 06/12/19 and when she confronted the Administrator about this issue the Administrator responded that the resident was responsible for his own care. An interview with the Receptionist at 1:43 PM on 09/12/19 revealed she worked 9:30 AM - 6:30 PM daily and the facility did not have a receptionist after 6:30 PM. She stated Resident #17 had an informal schedule for leaving the building while she was at work, but she did not know about his night time schedule. The Receptionist said she would ask the resident to sign out and then he would leave the facility. She said he normally walked for about 30 minutes and then came back to sit under the brick patio. She said the resident would only return to the facility to take a bathroom break, drink water, eat lunch, and eat dinner. An interview with the DON at 1:56 PM on 09/12/19 revealed she had been working at the facility for approximately two months and staff told her about Resident #17's (MONTH) incident and she was aware of his (MONTH) incident. She stated the facility had implemented interventions such as changing the front door code and conferencing/care planning with the Resident's Responsible Party about the high risks involved with the resident's continued wandering. The DON said she did not think the resident was exhibiting a high degree of cognitive ability because he was always staying outside in the high temperatures. She said the staff could not follow him all the time. The DON said the Resident's Responsible Party understood that the resident could be killed if he wandered into the nearby busy cross street. Interviews with RN P at 3:27 PM and 4:48 PM on 09/12/19 revealed she had worked at the facility for about two years and had taken care of Resident #17 all that time. She said on date unknown, a CNA reported to her that at 7:00 PM they could not find the resident. RN P had staff search the building, sent a staff to the convenience store across the street, called the Administrator, and called the police. The resident was found at the hospital. RN P said Resident #17 was cognitively impaired but liked to walk around the neighborhood and would go outside because he knew the door code. RN P said after his 06/12/19 incident, the staff changed the door code and he had to have the door opened for him. Review of the facility's Wandering, Resident policy, dated (MONTH) (YEAR), revealed, 1. The staff will identify residents who are at risk of harm because of unsafe wandering (including elopement.) 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. An Immediate Jeopardy (IJ) was identified on 09/12/19 and the Administrator was notified at that time and a Plan of Removal was requested. The Facility's Plan of Removal reflected: On 9/12/19, resident was immediately placed on 1:1 monitoring to assure that he was safe when going outside. Staff were in-serviced that residents were not to leave the facility without an escort. On 9/12/19, the facility completed an audit of the BIMS Score on the other 5 residents residing in the facility who signed themselves out on pass and had the potential to be affected. There was one other resident who was identified to have a BIMS of 6 identifying her as having Severe Impairment. The physician and family were immediately notified that secondary to her BIMS Score, the resident would be evaluated further using the Outdoor Safety Awareness Assessment Tool to help determine if the resident was safe to go outside based on her awareness of the potential risks of her environment. On 09/13/19, this tool was conducted by a Speech Therapist and the resident answered 50% of the questions appropriately. The IDT discussed these results and determined that she was not safe to leave the facility unattended. The facility recognizes that elopement prevention is an interdisciplinary process that must include all resident/patient and their family. The facility will implement individualized interventions and strive to prevent elopement. Upon admission, quarterly and with any significant change in resident's condition, the facility will: Complete Admission/Readmission Assessment including, but not limited to, the following: Admission Data Collection & Initial Plan of Care Social Service Assessment/Discharge Evaluation Psychosocial History and Assessment (Activities) Review and evaluate risk factor data. Determine if the resident/patient is at risk for elopement. (History of) Include resident/patient and family in development of the Plan of Care. Review Sign out Guidelines with Resident/Resident Representative Be present at the next scheduled Interdisciplinary Plan of Care and Standards of Care meeting. Develop individualized interventions which may include, but are not limited to, the following: Electronic monitoring/alarm systems Environmental modifications Protected list of names and photographs of those at risk for elopement. Psychosocial interventions Regular rounds Resident/patient and family education Staff interventions Structured group activities Communicate risk and interventions with the resident/patient, staff and family and provide education as needed. Discuss interdisciplinary interventions with the resident/patient and family and provide education as needed. Provide staff training as needed. Review and revise Plan of Care as needed. The facility team will assess the environment to identify potential risks associated with elopement. Facility interventions will be developed and implemented to reduce the risk of elopement and/or hazards associated with elopement. Facility will maintain a current list of names and photographs of resident/patients identifies at risk for elopement. Assure picture contains the following information: o Name o Description o Height o Weight o Age o Pertinent medical information o Lot # of Electronic Bracelet if applicable o Expiration date of Electronic Bracelet if applicable Within 72 hours of an admission/re-admission or change in resident's condition: The Speech Therapist (ST) and/or the Social Services Director (SSD) will complete a BIMS to assess resident's cognitive ability and document findings on the BIMS Assessment Verification Audit Tool (see attachment). During this audit/assessment, if the ST/SSD identifies that there is a resident who has a BIMS Score of 7 or less (indicative of Severe Impairment), it is the expectation that the ST/SSD will immediately notify the charge nurse. The Occupational Therapist (OT) and/or the Physical Therapist (PT) will also be notified for those residents wanting to go outside unattended. The OT/PT, utilizing the Outdoor Safety Awareness Assessment Tool, will determine if the resident is safe to go outside based on his/her awareness of the potential risks of his/her environment and is able to ambulate/mobilize safely outside including the ability to safely cross streets. The resident's ability to safely ambulate/mobilize outdoors will be based on the above Safety Awareness Tool, how alert/oriented the resident is, and family's assessment and/or desire for resident to go outside. The IDT will utilize this information to make a final decision about the ability of the resident to go outside by himself/herself. The resident's physician, charge nurse and family will be notified of the decision of the IDT. The Charge Nurse will notify the DON and the physician and obtain an order that resident can or cannot leave facility without an escort, and then notify the family/resident representative and document appropriately. The Administrator will check the audit tool daily x 2 weeks then weekly x 2 weeks then monthly x2, then quarterly thereafter to assure that any issues identified during completion of the audit were followed up on immediately and that the physician and family were notified and the information was documented in PCC appropriately. On admission and with any significant change in status, each resident is screened by Therapy Services. This screening/evaluation process is inclusive of assessing a resident's ability to safely ambulate/mobilize. In-Services All Staff beginning 9/12/19 and will be completed by 9/13/19 on the following: Abuse/Neglect Accidents/Incidents and Resident Safety With post test administered to assess competency of subject matter. Any staff who does not receive training by 9/13/19 will be unable to work until training and competency test is completed. The Administrator will provide secondary verification and final approval for staff completion of in-service and competency test. In-service training and competency test will be added to CNA and licensed staff new hire orientation. The Administrator, DON, and ADON will monitor/evaluate competency with random, on¿ the-spot interviews with staff members regarding training. Will be started on 9/13/19 and be completed on 9/13/19. Quality Assurance: Concerns regarding BIMS Scores, residents identified as an elopement risk, resident accidents and safety investigation process, will be referred to the QAPI Committee for analysis and recommendation with input from the Medical Director, Batool Imtiaz going forward. Ongoing training classes on competency test will be completed quarterly by the Director of Nursing and/or designee. On 09/13/19, Resident #17 was transferred to a facility with a secure unit. On 09/14/19, interviews with CNA E, CNA F, CNA G, RN H, CNA I, RN J, CNA K, CNA L, and LVN M were conducted which revealed they had recently received in-services on wandering and neglect. They were able to articulate the differences between wandering, neglect and elopement. They were able to articulate that facility residents could not go outside the facility without staff present and required assessments for elopement. They understood where the Elopement/Wandering book was placed and what the contents contained. They verbalized what a Wander Guard was and what it was used for. They were able to identify which residents were allowed to sign themselves out. On 09/14/19 three residents were checked for their Wander Guard placement and verified that they were in working order. Review of clinical records for three non-wandering residents had their medical records reviewed to verify wandering assessment had been completed. While the Immediate Jeopardy was removed on 09/14/19 the facility remained out of compliance at a level of actual harm that is not immediate jeopardy and a scope of isolated.