Every finding on record at Colonial Pines Healthcare Center

Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 4 of 4 residents (Residents #5, #6, #17, and #35) reviewed for medical records. The facility failed to ensure Resident #5, Resident #6, Resident #17 and Resident #35's medical records were accurate when staff did not document meal intake for evening meal for dates of January 1, 2026 thru January 20, 2026. This deficient practice could place residents at risk of improper care and monitoring due to inaccurate medical records.Findings included: 1.Record review of Resident #5's admission record, dated 1/21/2026, indicated an [AGE] year old female admitted on [DATE] with diagnoses that included hypertension (high blood pressure), anxiety (fear characterized by behavioral disturbances), and schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking). Record review of Resident #5's annual MDS, dated [DATE], indicated severe impairment with thinking with a BIMS score of 04. She required supervision with meals. Record review of Resident #5's care plan, dated 12/04/2025, indicated cognitive loss and risk for dehydration and malnutrition. Interventions included to monitor oral intake of food and fluids. Record review of Resident #5 weekly weight record, dated 01/21/26, indicated a stable weight of 112.4 pounds for six weeks. During observations on 01/19/26 Resident # 5 was observed eating lunch consuming greater than 75% of meal. Observation on 01/20/26 Resident #5 was observed eating breakfast and consuming greater than 75% of meal. Unable to interview Resident #5 due to cognitive impairment, Resident #5 oriented to person only. Record review of Resident #5's nurse aide flow sheet, dated January 2026, indicated evening meal intake percentages were not documented for 01/01/2026 through 01/20/2026. 2.Record review of Resident #6's admission record, dated 1/21/2026, indicated an [AGE] year old female, admitted [DATE], with diagnosis that included: Alzheimer's Disease (a neurodegenerative disease that usually starts slowly and progressively worsens), hypertension (high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #6's annual MDS, dated [DATE], ndicated severe impairment with thinking with a BIMS score of 03. She was independent with meals. Record review of Resident #6's care plan, dated 12/26/2025, indicated she had Alzheimer's Disease and required assistance with ADLs. Record review of Resident #6 weight record, dated 01/21/26, indicated stable weight with no weight loss for one month. Weight was 145 pounds. During observations on 01/19/26 Resident # 6 was observed eating lunch consuming greater than 75% of meal. Observation on 01/20/26 Resident #6 was observed eating breakfast and consuming greater than 75% of meal. Unable to interview Resident #6 due to cognitive impairment, Resident #6 oriented to person only. Record review of Resident #6's nurse aide flow sheet, dated January 2026, indicated evening meal intake percentages were not documented for 01/01/2026[KA20] through 01/20/2026[KA21] [KA22] . 3.Record review of Resident #17's admission record, dated 1/21/2026, indicated a [AGE] year old female, admitted [DATE], with diagnosis that included Alzheimer's Disease (a neurodegenerative disease that usually starts slowly and progressively worsens), and hypertension (high blood pressure). Record review of Resident #17's annual MDS, dated [DATE], indicated severe impairment with thinking with a BIMS score of 01. She required moderate assistance with meals. Record review of Resident #17's care plan, dated 1/09/2026, indicated she had Alzheimer's Disease and required assistance with ADLs. Record review of resident #17 weight record, dated 01/21/26, indicated stable weight of 87 pounds with no weight loss for one month. During observations on 01/19/26 Resident # 17 was observed eating lunch with assistance of staff consuming greater than 75% of meal. Observation on 01/20/26 Resident #6 was observed eating breakfast with assistance of staff and consuming greater than 75% of meal. Unable to interview Resident #17 due to cognitive impairment, Record review of Resident #17's nurse aide flow sheet, dated January 2026, indicated evening meal intake percentages were not documented for 01/01/2026 through 01/20/2026. 4.Record review of Resident #35's admission record, dated 1/21/2026, indicated an [AGE] year old female, admitted [DATE], with diagnosis that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic obstructive pulmonary disease (a condition that limits airflow into and out of the lungs ) and history of cerebrovascular accident (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #35's annual MDS, dated [DATE], indicated moderate impairment with thinking with a BIMS score of 05. She was independent with meals. Record review of Resident #35's care plan, dated 1/14/2026, indicated she had cognitive loss and required assistance with ADLs. Record review of resident # 35 weight record, dated 01/21/26, indicated stable weight of 118 pounds with no weight loss for one month. During observations on 01/19/26 Resident # 35 was observed eating lunch consuming greater than 75% of meal. Observation on 01/20/26 Resident #35 was observed eating breakfast and consuming greater than 75% of meal. Unable to interview Resident #35 due to cognitive impairment, Resident #5 oriented to person only. Record review of Resident #35's nurse aide flow sheet, dated January 2026, indicated evening meal intake percentages were not documented for 01/01/2026 through 01/20/2026. During an interview on 01/21/2026 at 11:00 a.m.,CNA C stated she worked the day shift on the secured unit. She stated the CNA's were responsible for documenting meal intakes after each meal. She stated day shift CNAs documented all three meals because all meal services occurred during the day shift. She stated she documented all meals each shift she worked, including the evening meal. She said she documented the percentage of meals eaten by each resident on the CNA flow sheet using the computer on the secured unit. She stated she did not understand why resident evening meal intakes were not available to view on the monthly report. She stated she documented meal percentages for the evening meals for all residents on the secured unit when she worked. She stated meal intake monitoring was important for monitoring residents' nutritional intake and possibly any changes in the residents' condition. During an interview on 01/21/2026 at 11:20 am LVN D stated she worked the day shift. She stated the CNA's were responsible for recording residents' meal intakes after meals. She stated the resident's electronic medical record did not alert for meal intake percentages not recorded. She stated the nurse would have to check every residents' flow sheet to ensure that meal intake percentages were documented. She stated she did not check resident flow sheets, but the CNAs reported if a resident had poor intake to the charge nurse. She stated the risk of not tracking resident meal intakes was malnutrition, weight changes and change in condition. During an interview on 01/21/2026 at 11:30 a.m., the DON stated the CNAs were responsible for charting resident meal intake percentages in the computer system. She stated the day shift CNAs charted intakes for all three meals throughout the facility. She said the current charting system did not alert if meal intakes were not entered. She stated the charge nurses were responsible for monitoring that CNA flow sheets were completed at the end of each shift. She said she was currently working with her corporate information technology department on a solution to the evening meal intakes not available to view. She stated there was possibly an error in the system and the information was not being displayed. She said the risk of not monitoring resident intakes could include not recognizing changes in resident conditions and nutritional concerns. She stated her expectations, moving forward, were CNAs accurately record all residents' meal intake percentages after each meal and the charge nurses monitored CNA flow sheets were completed daily at the end of the shift. During an interview on 01/21/2026 at 11:50 a.m., the administrator stated the CNAs and nurses were responsible for ensuring resident meal intakes were charted. He stated the risk of not monitoring resident meal intakes could include weight loss and weight gains as well as impact on overall nutrition. He stated he expected meal intakes were recorded in the medical record and that providers have access to the information when needed. Record review of a facility policy titled Meal Intake Documentation, dated revised 01/12/2020, . 7. The nursing assistant may use the tray ticket as a worksheet to document intake at the end of the meal and then from this, documents on the Meal Intake Record either in percents or points.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 dining room reviewed for pest control. The facility failed to ensure the dining room remained free from roaches on 01/19/2026, during the lunch meal, when observed crawling on the floor. This failure could place residents at risk for reduced quality of life and poor sanitary environment. Findings included: During an observation and interview on 01/19/2026 at 11:45 a.m., a live roach was seen crawling on the floor underneath a dining table while residents were eating the lunch meal. The Medical Records Director walked over and stepped on the roach and killed it. The Medical Records Director said that roaches were a problem in the dining area and on hallway A. During an interview on 01/21/2026 at 8:45 a.m., the Floor Tech said they had a problem with a resident hoarding food in their room on the A hallway, but the facility cleaned everything out of the room and treated the area. The Floor Tech said that the contracted pest service treated the facility about every two weeks. He said roaches were unsanitary and needed to be eliminated. During an interview on 01/21/2026 at 8:55 a.m., the Maintenance Director- Housekeeping Supervisor said the roaches were an ongoing problem in the facility. He said the contracted pest control services treated the facility last Saturday (1/17/2026) . He said roaches were unsanitary. During an interview on 01/21/2026 at11:45 a.m., the Administrator said he knew about the roach problem in the dining area. He said the contracted pest control company treated the area every two weeks to address the roach problem. He said he was aware there were still roaches in the dining area and he contacted the contract service on 01/20/2026 to return , after he was made aware of the roaches in the dining room on 1/19/2026. The Administrator said the pest control service would provide a new chemical product to exterminate the roaches. He said the roaches were an infection control issue.Record review of contracted pest control company invoice, dated 11/15/2025, indicated treated all hallways, treated kitchen area, nurse's stations, dining room, lobby, treated exterior building, and put granules out for ants and other crawling insects.Record review of contracted pest control company invoice, dated 11/26/2025, indicated treated interior building, kitchen area, washroom area, preparation area. dining room, nurses station, all hallways, treated exterior building, and put granules out for ants and other crawling insects. Record review of contracted pest control company invoice, dated 12/10/2025, indicatedtreated interior, treated all hallways, nurses station, activity rooms, dining room, kitchen, treated exterior building, and put granules out for ants and other crawling insects. Record review of contracted pest control company invoice, dated 12/22/2025, indicated Treated interior. All hallways. Cafeteria. Dining room. Nurse station. Treated exterior building. Put granules out for ants and other crawling insects. Record review of contracted pest control company invoice dated 01/17/2026 indicated Treated interior. All hallways. Nurses station. Kitchen. Dining room. Lobby. Treated exterior building. Put granules out for ants and other crawling insects. Record review of an undated facility policy for Pest Control indicated: Policy: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation1.This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.2.Pest control services are provided by Contracted Pest Control 3.Windows are screened at all times.4.Only approved Federal Drug Administration and Environmental Protection Agency insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas.5.Garbage and trash are not permitted to accumulate and are removed from the facility daily.6.Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and homelike environment for 1 of 8 (Resident #41 residents reviewed for resident rights.The facility failed to ensure Resident #41 had a wheelchair that was not soiled with old food particles on 01/19/2026 and 01/20/2026. This failure could place residents at risk infections and dignity issues.Findings included:Record review of Resident #41's facility face sheet, dated 1/20/2026, indicated Resident #41 was an [AGE] year-old female, admitted [DATE], with diagnos es of cerebral infarction (stroke) and dysphagia (difficulty swallowing).Record review of Resident #41's quarterly MDS assessment, dated 12/18/2025, indicated Resident #41 had a BIMS of 00 indicating severely impaired cognition, was dependent on staff for assistance with all ADLs , required a mechanically altered diet, received hospice care, used a wheelchair, and had functional limitation of range of motion to both upper and lower extremities.Record review of Resident #41's comprehensive care plan, dated 12/19/2025, indicated Resident #41 had CVA late effects with potential for further decline related to late effects of CVA as evidenced by decreasedmobility and required adaptive equipment wheelchair. During an observation and interview on 01/19/2026 at 9:24 a.m., Resident #41 was in a wheelchair at the nurses' station that was soiled with old food particles and residue that was thick and white. She was nonverbal and unable to answer any questions. During an observation on 01/19/2026 at 11:43 a.m., Resident #41 was in her wheelchair near the dining room and the wheelchair was soiled with old food particles and residue that was white and thick. During an observation on 01/20/2026 at 9:01 a.m., Resident #41 was up in the activity room. Her wheelchair continued to be soiled with food particles and residue that was thick and white. During an interview 01/20/2026 11:21 a.m., LVN E said the night CNAs had a schedule for cleaning resident wheelchairs and the night nurse should make sure they were cleaned. He said if he noticed a dirty wheelchair he would see that it was cleaned but had not noticed Resident #41's wheelchair being dirty. He said having a dirty wheelchair could make the residents feel bad. During an interview on 01/20/2026 at 6:09 p.m., CNA F said she was assigned to Resident #41's hall, and she was not sure about the cleaning schedule for resident equipment, such as wheelchairs. She said this was her first night back from leave. She said the night aides were responsible for cleaning the resident's wheelchairs at least weekly and as needed. She said residents that were in soiled wheelchairs could be embarrassed or get sick. During an interview on 01/20/2026 at 6:22 p.m., CNA G said she worked the night shift and each resident's equipment was to be cleaned no less than weekly. She said there was a schedule for cleaning posted at one time but was not sure where that schedule was now. She said there was nowhere she knew to document that the equipment was cleaned. She said that dirty resident equipment could be embarrassing and cause infections. During an interview on 01/21/2026 at 10:40 a.m., the DON said all resident equipment should be cleaned weekly by the night CNAs and there was a cleaning schedule located at the nurses' station. She said the charge nurse on night shift should be overseeing that the CNAs were cleaning the equipment. She said there was not a place to document that the equipment was cleaned. She said that resident's using dirty equipment could cause them to be upset or get sick.During an interview on 01/21/2026 at 11:35 a.m., the Administrator said all resident equipment was to be cleaned by the night nurse aides. He said there was a cleaning schedule posted on each hall by the shower rooms. He said the administration staff should be monitoring the residents' equipment, like wheelchairs, to ensure the schedule was being followed. He said using soiled equipment could affect the residents' dignity and expected the staff to keep every resident's care equipment clean and sanitary. Record review of an undated document titled Wheelchair Cleaning Schedule revealed Resident #41's wheelchair was to be cleaned on Wednesday night. Record review of a facility policy titled Resident General Equipment Cleaning', dated 2/20/2023, indicated, .Resident's general equipment will be cleaned on a routine basis in accordance with manufacturer's specifications and guidelines. Guidelines: Facility will check equipment weekly or as needed General equipment may include, but it not limited to: Enteral Feeding Equipment, Respiratory Equipment, Oxygen Equipment, Wheelchairs, Beds, Scaled, Miscellaneous .

Based on interview and record review, the facility failed to assess each resident quarterly, once every three months, using the quarterly review instrument specified by the state and approved by CMS for 1 of 12 residents (Resident # 41) reviewed for quarterly assessments. The facility failed to ensure Residents # 41 had a quarterly MDS assessment completed within three months from the previous assessment.This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.Findings included:Record review of Resident #41's facility face sheet, dated 1/20/2026, indicated Resident #41 was an [AGE] year-old female, admitted [DATE], with diagnos es of cerebral infarction (stroke) and dysphagia (difficulty swallowing).Record review on (date record review conducted) of Resident #41's medical record revealed a quarterly MDS was completed on 09/19/2025 and subsequent quarterly MDS dated [DATE] was not completed until 01/06/2026, 17 days overdue.During an attempted interview on 01/20/2026 at 5:50 p.m., a voicemail message was left for the MDS nurse at the contact number provided by the facility with no return call received. During an interview on 01/21/2026 at 8:23 a.m., the Corporate Reimbursement Nurse said she was responsible for oversight of the MDS assessments at the facility. She said a quarterly review assessment should be completed at least every 92 days. She said with Resident #41 the facility was having internet issues, and she was unable to sign her 12/18/2025 Quarterly MDS assessment until 1/06/2026. She said there was a report she could run to ensure all assessments were completed and transmitted but she only reviewed that report monthly. She said resident assessments that were not completed by the guidelines could cause an inaccurate depiction of the resident and delay generation of the resident's care plan. During an interview on 01/21/2026 at 10:40 a.m., the DON said the MDS nurse was responsible for the timely completion of each MDS assessment. She said she did not provide oversight of the MDS assessments and that was done at the corporate level. She said that completing MDS assessments late could result in care plan inaccuracy and negative outcomes to the residents.During an interview on 01/21/2026 at 11:35 a.m., the Administrator said the MDS nurse was trained on MDS assessments, and the Corporate Reimbursement Nurse assisted her with the completion of assessments per the guidelines. He said he expected all MDS assessments to be completed by the regulations to prevent reimbursement and care plan issues. Record review of facility policy titled, Resident Assessment, dated 1/12/2020, indicated, . It is the Standard of Care at this facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual.Review of the RAI manual, dated October 2019, indicated, quarterly assessments are completed by calculating from the ARD (assessment reference date) of the previous assessment plus 92 calendar days.

Based on observations, interviews, and record review , the facility failed to develop a person-centered comprehensive care plan to address medical needs for 1 of 12 residents (Resident #41) reviewed for comprehensive care plans.The facility failed to ensure Resident #41's comprehensive care plan was revised to reflect current transfer status of requiring a mechanical lift, hospice services, swallowing difficulties that required an altered diet and a contracture with mobility limitations.This failure could place residents at increased risk of falls, injuries, and a decreased quality of life.Findings included:Record review of Resident #41's facility face sheet, dated 1/20/2026, indicated Resident #41 was an [AGE] year-old female, admitted [DATE], with diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing).Record review of Resident #41's quarterly MDS assessment, dated 12/18/2025, indicated Resident #41 had a BIMS of 00 indicating severely impaired cognition, was dependent on staff for assistance with all ADLs, required a mechanically altered diet, received hospice care, used a wheelchair, and had functional limitation of range of motion to both upper and lower extremities.Record review of Resident #41's comprehensive care plan, dated 12/19/2025, indicated Resident #41's care plan did not reflect the current transfer status of requiring a mechanical lift, hospice services, swallowing difficulties that required an altered diet, and a contracture with mobility limitations.Record review on (date record review conducted) of Resident #41's order summary report revealed Resident #41 had an order on 6/18/2025 for hospice services and a pureed diet. There was no order related to Resident #41's contractures or use of mechanical lift. During an attempted interview on 01/20/2026 at 5:50 p.m., a voicemail message was left for the MDS nurse at the contact number provided by the facility with no return call received. During an interview on 1/21/2026 at 8:23 a.m., the Corporate Reimbursement Nurse said the MDS assessment generated the care plan and the MDS nurse should be ensuring each care area the resident required was on the comprehensive care plan. She said with each assessment the care plan should be reviewed and revised as needed to ensure accuracy. She said she was responsible for oversight of the care plans at the facility. She said not having an accurate comprehensive care plan could potentially cause the staff to be unaware of resident needs. During an interview on 1/21/2026 at 10:40 a.m., the DON said that each resident should have a thorough and accurate care plan that covered the care areas the residents needed. She said the Corporate Reimbursement Nurse provided the oversight of the comprehensive care plans, but they were reviewed by the IDT during their standards of care meetings. She said somehow Resident #41 's care plan was not accurate after changing to their new charting system. She said if the comprehensive care was not reviewed and revised to depict the full picture of the resident, residents could affect receiving services. During an interview on 1/21/2026 at 11:35 a.m., the Administrator said the MDS nurse was responsible for completing the comprehensive care plan thoroughly and accurately. He said he expected each residents' care plan should be reviewed and revised per the regulations to prevent any possible care issues. Record review of a facility policy titled Care Plan - Process dated 3/27/2023 indicated, .4. Interdisciplinary Team meets & reviews the care plan as follows: Seven (7) days after the closure on the date of the admission MDS Quarterly and annually Within fourteen (14) days after a significant change MDS With any change of condition .

Based on observations, interviews, and record review , the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for 1 of 4 (Resident #41) residents reviewed for mobility services.The facility failed to implement interventions to prevent further decline of Resident #41's contracture to her left hand and lower extremities on 01/19/2026 and 01/20/2026.This could affect residents with contractures and mobility limitations and could result in a decrease in mobility.Findings included:Record review of Resident #41's facility face sheet, dated 1/20/2026, indicated Resident #41 was an [AGE] year-old female, admitted [DATE], with diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing).Record review of Resident #41's quarterly MDS assessment, dated 12/18/2025, indicated Resident #41 had a BIMS of 00 indicating severely impaired cognition, was dependent on staff for assistance with all ADLs, required a mechanically altered diet, received hospice care, used a wheelchair, and had functional limitation of range of motion to both upper and lower extremities.Record review of Resident #41's comprehensive care plan, dated 12/19/2025, indicated Resident #41's care plan did not reflect the resident had a contracture with mobility limitations.Record review of Resident #41's physician order summary report dated 1/20/2026 revealed Resident #41 did not have an order related to contractures or use of any device. During an observation on 1/19/2026 at 9:27 a.m., Resident #41 was in a wheelchair at the nurse's station and both feet and legs were dangling. There was no footrest on her wheelchair. She had a contracture to her left hand, and no contracture device was present. She was unable to answer questions. During an observation on 1/19/2026 at 11:34 a.m., Resident #41 was in a wheelchair in the dining room and both feet and legs were dangling, and no footrest was on her wheelchair. Resident #41 did not have any contracture device present in her left hand. During an observation on 1/20/2026 at 9:01 a.m., Resident #41 was up in a wheelchair in the activity room with legs and feet dangling and no footrest. She had a hand device in her left hand that looked like a carrot. During an interview on 1/20/2026 at 11:54 a.m., CNA B said she was assigned to Resident #41 and was not sure why Resident #41 did not have footrest on her wheelchair. She said she had them in the past. She said Resident #41's legs should be supported to prevent discomfort. She said Resident #41 required the carrot device in her hand during the day but could not recall if she placed the device in the resident's hand yesterday or not. She said the device helped prevent further worsening of her contracture. During an interview on 1/20/2026 at 11:58 a.m., LVN E said the nurse should monitor each resident's position and ensure each resident had the devices they needed for proper positioning. He said not properly supporting a resident's feet and legs could cause circulation changes and pain. He said residents with hand contractures were to have a hand device to prevent the worsening of the contracture and the nurse should monitor that they were in place. He said he could not recall if Resident #41 had hers yesterday or not. During an interview on 1/21/2026 at 10:40 a.m., the DON said dependent residents should have their body supported and positioned and should not have their legs and feet dangling from their wheelchair. She said that non-positioned and supported legs could cause circulation changes and increase in contractures of the feet. She said she was not sure why Resident #41 did not have leg supports on her wheelchair and all staff should monitor residents for proper support. She said that Resident #41 had hand contractures and should have a device in place to prevent the worsening of the contracture. She said the nurses and aides should be ensuring those services were in place. She said the facility did not have a policy for contracture management or position management. During an interview on 1/21/2026 at 11:35 a.m., the Administrator said dependent residents should have proper support of their lower body when up in a wheelchair and some kind of device to prevent worsening of contractures. He said if a resident's legs were dangling without support it could affect circulation, the skin and muscles. He said contractures could worsen without the use of devices to help prevent them and expected all staff to monitor every resident for the care they needed and provide it to prevent further decline.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 4 residents reviewed for quality of care. (Resident #41)The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #41.This failure could result in a loss of quality of life due to injuries.Findings included:Record review of Resident #41's facility face sheet, dated 1/20/2026, indicated Resident #41 was an [AGE] year-old female, admitted [DATE], with diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing).Record review of Resident #41's quarterly MDS assessment, dated 12/18/2025, indicated Resident #41 had a BIMS of 00 indicating severely impaired cognition, was dependent on staff for assistance with all ADLs, required a mechanically altered diet, received hospice care, used a wheelchair, and had functional limitation of range of motion to both upper and lower extremities.Record review of Resident #41's comprehensive care plan, dated 12/19/2025, indicated Resident #41's care plan did not reflect current transfer status of requiring a mechanical lift.Record review of resident #41's physicians order summary report dated 1/20/2026 revealed Resident #41 did not have an order related to use of a mechanical lift.During an observation on 1/19/2026 at 9:47 a.m., Resident #41 was up in the common area in her wheelchair with a lift sling pad under her. The lift sling's loops were faded in color. She was unable to answer questions. During an observation on 1/20/2026 at 9:01 a.m., Resident #41 was up in her wheelchair in the activity room and the lift sling's loops were faded in color. During an interview on 1/20.2026 at 12:00 p.m., CNA B said that before a resident was transferred by a lift the sling should be inspected for fading and breakdown of the materials. She said she had gotten Resident #41 up yesterday and today and her sling looked good to her, and the faded loops were just from every day washing. She said the laundry only washed them and hung them to dry. She said she could see how the fading could be from use of bleach but was not sure. She said using slings that were faded could break and cause resident injuries. During an interview on 1/20/2026 at 12:10 p.m., the Laundry Aide said she was new at her position, and she washed all lift slings on the same setting as the towels and bleach was automatically distributed in the wash per the settings. She said she was not aware bleach was not allowed but she was told not to dry the lift slings by the housekeeping supervisor, and they had to be hung to dry. She said lift slings that were damaged could cause a resident to get hurt. During an interview on 1/21/2026 at 10:40 a.m., the DON said before a CNA used a lift sling, they should inspect the sling for fraying, fading, and/or wear. She said the slings were sent to the laundry but should not be bleached or dried. She said the housekeeping supervisor assisted with monitoring the slings and removing them from service. She said lift slings that were not in good order could cause resident injuries during transfers. During an interview on 1/21/2026 at 11:35 a.m., the Administrator said all lift slings were to be washed without bleach and hung to dry. He said all slings should be inspected by the housekeeping director before placing them on the floor and again by the CNAs before using them. He said if a sling was frayed, faded, or worn it should not be used to prevent resident injury. He said he expected the staff responsible to properly wash, dry, inspect and use all lift slings per the manufacturer's guidelines. During an interview on 1/21/2026 at 1:07 p.m., the Housekeeping Director said he was now assigned to monitor the lift slings for wear and fading. He said he had a book he kept track of them by and as he removed them from service he replaced them with new ones. He said he was not aware that the new laundry aide was using bleach on the slings until today and would reeducate his staff on proper care of the slings. He said slings that were damaged could result in resident injuries. Record review of a facility policy titled Mechanical Lifts, dated 5/12/2023, indicated, .1. Mechanical Lift Pre-Operations Check e. Check to ensure the sling is in good working condition with no torn or ripped areas, etc .

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 infections for 1 of 4 residents (Resident #26) and 2 of 5 staff (CNA A and CNA B) reviewed for infection control. The facility failed to ensure CNA A and CNA B followed EBP for Resident #26 when providing care on 1/19/2026. This failure could place residents at risk of exposure to infectious diseases.Findings included: Record review of Resident #26's admission Record, dated 1/20/2026, indicated a [AGE] year-old male, admitted [DATE], with diagnoses of type 2 diabetes, morbid obesity (extremely overweight), and dementia. Record review of Resident #26's active physician orders, dated 1/20/2026, indicated he had an order for EBP every shift that started on 12/23/2025. Record review of Resident #26's care plan, dated 11/12/25, indicated he had a diabetic wound on his left fifth toe. Interventions included EBP that were effective 1/19/2026. Record review of Resident #26's Quarterly MDS Assessment, dated 10/14/2025, indicated moderate impairment in thinking with a BIMS score of 7. He was totally dependent on all ADLs and always incontinent of urine/bowel. During an observation on 1/19/2026 at 3:01 p.m., CNA A and CNA B were in the room to provide incontinent care to Resident #26. Both staff washed their hands. There was PPE hanging on the bathroom door that included gowns and gloves. CNA B placed water in a basin with soap and placed it on Resident #26's over bed table with washcloths. Both CNAs applied gloves to their hands but did not don (put on) a gown. Resident #26's brief was opened and pulled down between his thighs. CNA B took a washcloth, dipped it in the water, wiped his inner thighs, and placed the washcloth in a plastic bag. CNA B took another washcloth, dipped it in the water, and wiped his penis in a circular motion and pushed his foreskin back and cleaned and then she placed the foreskin back and cleaned the shaft of his penis. CNA A rolled Resident #26 onto his right side. CNA B took a washcloth, placed it in the water, and handed it to CNA A. CNA A wiped Resident #26's rectal area and removed the brief and placed it in the trash. CNA B removed her gloves and placed them in the trash and washed her hands and applied clean gloves. CNA A removed her gloves and placed them in the trash, washed her hands, and put on clean gloves. CNA A placed a clean brief underneath his buttocks, and he was rolled onto his back and then to his left side and the brief was secured. Resident #26 was repositioned in bed. Both CNA A and CNA B removed their gloves and placed them in the trash and washed their hands.During an interview on 1/19/2026 at 3:14 p.m., CNA B said she was employed at the facility for 37 years. She said residents on EBP had blue signs on the door in the hallway by their names to indicate they were on EBP. She said PPE would be hanging on the bathroom doors in those rooms. She said Resident #26 did not require EBP. She said the charge nurses in the facility notified the staff of a resident that required more PPE than just gloves. She said if the appropriate PPE was not worn during care, then the staff could transfer things to different residents in the facility. She said there were not any residents on Resident #26's hall on EBP. During an interview on 1/19/2026 at 3:28 p.m., CNA A said she was employed at the facility for four years. She said residents who were on EBP required a gown and gloves when care was provided and EBP was for residents with open wounds. She said she thought there were two residents on A hall that required EBP. CNA A said she was not sure if Resident #26 required EBP. She said if the appropriate PPE were not worn, residents could be at risk for infections. She said the residents would have a blue tag by their name plates outside their doors if they required EBP. During a follow up interview on 1/19/2026 at 3:45 p.m., CNA A said during the care provided to Resident #26, they should have worn a gown and gloves because he had a blue tag by his name. During an interview on 1/21/2026 at 10:26 a.m., the ADON said she was the IP for the facility and she along with the DON were both responsible for training staff on infection control and the staff had training monthly. She said Resident #26 was on EBP for a wound to his toe. She said EBP required staff to wear a gown and gloves when direct patient care was provided and that included any resident with an indwelling device or wounds. She said staff were made aware of residents who required EBP by her and the residents would have a blue tag with their name plate along with PPE hanging on their bathroom doors. She said both staff CNA A and CNA B both had training on EBP in October 2025 during a skills checkoff. She said residents were at risk for infections if staff did not follow EBP. During an interview on 1/21/2026 at 11:00 a.m., the DON said the ADON was over infection control but they both trained staff on infection control. She said staff were trained all the time and as needed and EBP was required for anyone with a wound, g-tube, catheter, or PICC lines. She said Resident #26 was on EBP because he had a diabetic wound to his fifth left toe. She said staff should wear gowns and gloves when care was provided. She said on the door were blue tags by their name plates and the Kardex (electronic medical record) for the nurse aides indicated if a resident required EBP. She said if EBP were followed, it would help to prevent organisms from transferring from the staff to residents and if it were not followed it could cause infections. During an interview on 1/21/2026 at 11:32 a.m., the Administrator said the administrative nursing staff that included the DON and ADON were responsible for training staff on infection control on hire and as needed. He said EBP was for any resident with open wounds or indwelling devices. He said the residents had a blue name tag on the door for staff to recognize who required EBP and PPE was on the bathroom doors. He said staff should wear gowns and gloves for residents on EBP and if they did not follow infection control then residents could be at risk for infections.Record review of a facility policy titled Enhanced Barrier Precautions, dated revised March 2025, indicated, .Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resistance organisms. Enhanced barrier precautions: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact care activities that provide opportunities for transfer of MDROs to staff hands and clothing. 3. High contact resident care activities: f. Changing briefs .

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 2 of 4 hallways, (hallway 200 and 400), 2 resident rooms (Resident #33 and Resident #15 rooms) and two of two dining areas (main and locked unit dining areas) reviewed for pest control. The facility failed to ensure hallways, resident rooms and dining rooms were free of flies. This failure could place residents at risk of a diminished quality of life due to an unsanitary environment. Findings include: Record review of a face sheet dated 10/28/2024 for Resident #33 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of chronic obstructive pulmonary disease (inability to maintain adequate oxygen exchange in the blood), vitamin deficiency, lack of coordination, and anxiety disorder (excessive worry about everyday issues and situation). Record review of a Quarterly MDS Assessment for Resident #33 dated 9/30/2024 indicated she had severe impairment in thinking with a BIMS score of 4. During an observation and interview on 10/27/24 at 10:30 AM revealed Resident #33 had several flies in her room crawling on her bed and table. Resident #33 said the flies come and go; she really doesn't pay them any attention because they were always here. Record review of a face sheet dated 10/28/2024 for Resident #15 indicated she admitted to the facility on [DATE] and was an [AGE] year-old female with diagnoses of hypertension and chronic pain. Record review of a Quarterly MDS Assessment for Resident #15 dated 10/02/2024 indicated she was cognitively intact with a BIMS score of 13. During an observation and interview on 10/27/24 at 10:45 AM revealed 2-3 flies were flying inside Resident #15's room, and a fly swatter was on the bedside table. Resident #15 said that flies were a problem at the facility because of a pasture behind the facility just had chicken litter applied and that created lots of them. During an observation on 10/27/24 at 11:08 AM revealed flies down hallway 200 crawling on doorways and on a Hoyer lift sitting out in the hallway. There were no operating blowers at doorways at the facility entrance or at the exits on 200 and 400 hallways. During an observation on 10/27/24 at 11:50 AM revealed Resident #15 arrived at the dining room with a fly swatter on her rolling walker. During an observation on 10/27/24 at 12:10 PM of the lunch meal in the dining room, revealed 1-2 flies crawling on 4 of 7 tables. Flies were crawling on the front right table onto Resident #15's plate and over the vegetables. Resident #15 swatted a fly away with her hand then continued to eat. During an interview on 10/27/24 at 2:15 PM Resident #15 said the flies were a nuisance and she kept a swatter with her during meals and at her bedside. During an observation and interview on 10/28/24 at 4:11 PM revealed a blower on the kitchen door was turned off. The DM said the blower worked but she wasn't sure how to turn it on and went to ask the Maintenance Director . The DM returned to the kitchen and turned the blower on, and the blower started working. The DM said typically the blower was on and they did not have any problem with flies in the kitchen. During an observation on 10/28/24 at 12:11 PM flies in the Locked Unit Dining room revealed flies crawling on the table and down the hallway crawling on doorways During an observation on 10/28/24 at 12:11 PM revealed there were flies present in the 400-hall dining room and the 400- hall hallway. The flies were on resident food. During an interview on 10/28/24 at 12:15 PM CNA A said the flies were better than they were but still present in the facility. She said they swatted them daily, but they kept coming back. She said the flies in the facility could affect sanitation. During an interview on 11/29/24 at 10:30 AM the Maintenance Director said the pest control company came monthly to treat for pests in general. He said the facility had issues with flies since the summer. He said they were bad in July 2024 but were better. He said the pasture behind the facility had chicken litter spread (raw fertilizer) recently and that increased the number. He stated he did not know the risk of having flies other than it being unsanitary. The Maintenance Director said he did not know why the blower located at the kitchen doorway was turned off. He said the blower being turned off could cause flies to enter the facility. The Maintenance Director said no one had logged a request for interventions for the flies and no one had told him that flies were an increased problem in the facility. He said if he knew it was a problem, he could have asked for additional interventions from pest control service to control the flies. During an interview on 11/29/24 at 11:00 AM the Administrator said pest control comes to the facility bi-monthly. The Administrator said they had provided residents fly swats to help with fly control. The Administrator said that keeping the blower on at the kitchen door would help keep flies out of the facility. He said the risk to the residents was unsanitary conditions when flies were in the building, risk of flies carrying infection and not a homelike environment. Record review of pest control bi- monthly visit summary reports dated from July 2024 to September 2024 indicated the facility had no specific treatment for flies at bi- monthly visits. Record review of a facility policy undated titled Pest Control indicated, Our facility shall maintain an effective pest control program . this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents . Maintenance services assist, when appropriate and necessary, in providing pest control services .

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication storage refrigerators reviewed for temperature controls and storage. The facility failed to log and monitor medication refrigerator temperatures for AM and PM as required per facility policy (24-hour periods of time) on 10/02/24 and 10/03/24 for medication storage. The facility failed to log and monitor temperatures twice daily, as required per facility policy, for the month of October 2024 (10/08/24, 10/21/24 and 10/22/24 were the only days logged for the required notations of twice daily medication refrigerator temperature checks for vaccine storage). This failure could place residents at risk of harm by not maintaining proper controlled temperatures for medications, vaccines, and biologicals. Findings included: During an observation and interview on 10/28/24 at 10:28 AM revealed a log was posted on the medication refrigerator that contained vials of flu vaccine, 2 vials of tuberculin skin testing (TST) and 20 unopened insulin pens. The log was not filled out twice daily and had omissions for 24-hour periods of time. The ADON said not monitoring the vaccine and medication refrigerator could result in ineffective medication and vaccine efficiency. The ADON said an in-service would start immediately for correct procedure for recording temperatures for the medication refrigerator and recording per policy. Record review of a temperature log for the month of October 2024 for the only medication refrigerator for the facility indicated: No temperature logged for AM or PM on 10/02/24 and 10/03/24. 10/08/24, 10/21/24 and 10/22/24 were the only days logged for the required notations of twice daily medication refrigerator temperature checks for vaccine storage. During an interview 10/29/24 10:08 AM the DON said not monitoring the medication refrigerator could cause the medication refrigerator to be out of range resulting in loss of vaccine efficiency. The DON said in-services for nursing staff would start immediately and the log would be monitored for compliance. During an interview 10/29/24 10:09 AM the Administrator said not monitoring the medication refrigerator could cause the medication refrigerator to be out of range resulting in loss of vaccine efficiency. The Administrator said that the DON and ADON were responsible for ensuring the medication storage was monitored for compliance. Record review of a facility policy: dated 01/2024 Medication- Storage of Medication POLICY: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURES: . 10. Medications requiring storage at room temperature are kept at temperatures ranging from 15 Celcius (59 F) to 25 Celcius (77 Fahrenheit). Controlled room temperature is defined as 20 Celcius (68 F) to 25 C (77 Fahrenheit). Excursions between 15 Celcius (59 F) to 30 Celcius (86 F) are allowed, with transient spikes to 40 Celcius (104 F) as long as they don't exceed 24 hours. 11. Medications requiring refrigeration or temperatures between 2 Celcius (36 Fahrenheit) and 8 Celcius (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label as cool temperatures are those between 8 Celcius (46 F) and 15 Celcius (59 Farenheit). A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. If using a temperature monitoring device (TMD; digital data logger recommended) that records min/ max temps (I.e., the highest and lowest temps recorded in a specific time period), document current and min/max once each workday preferably in the morning. If using TMD that does not record min/max temps, document current temps twice, at beginning and end of each workday. If no vaccines are stored in the refrigerator, document temperature checks at least once daily.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 3 (Residents #4, Resident #13, and Resident #22) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #4, Resident #13 and Resident #22. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings included: Record review of face sheet dated 10/29/24 for Resident #4 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of cerebral infarction (disrupted blood flow to the brain), dementia unspecified (decline in cognitive abilities), dysphagia (difficulty swallowing). Record review of quarterly MDS dated [DATE] indicated Resident #4 had severe cognitive impairment with a BIMS of 7. Section GG indicated supervision or touching assistance with eating. Record review of a physician's order summary for Resident #4 indicated an order for pureed diet level 4 and thin liquids dated 10/14/24. Record Review of face sheet dated 10/29/24 for Resident #13 indicated she admitted to the facility on [DATE] and was [AGE] year-old female with diagnoses of dysphagia (difficulty swallowing), metabolic encephalopathy (problem in the brain). Record review of a quarterly MDS dated [DATE] indicated Resident #13 was not assessed for cognition. Section GG indicated Resident #13 required supervision or touching assistance for eating. Record review of a physician's order summary dated 10/29/24 indicated an order for pureed diet level 4 and thin liquids dated 7/11/24. Record review of face sheet dated 10/29/24 for Resident #22 indicated she admitted to the facility on [DATE] and was [AGE] year-old female with diagnoses of vascular dementia (blood flow to the brain is interrupted, damaging brain cells and impairing thinking, memory, and behavior), and vitamin D deficiency. Record review of a quarterly MDS dated [DATE] indicated Resident #13 was not assessed for cognition. Section GG indicated Resident #22 required substantial/maximal assistance for eating. Record review of a physician's order summary dated 10/29/24 indicated an order for pureed diet level 4 and thin liquids dated 6/23/23. During an observation on 10/28/24 10:30 AM revealed [NAME] E began to prepare the puree foods. The cook was not able to get the puree meatloaf to a smooth texture in the food processor. [NAME] E was observed adding slices of white bread and hot water from a drink pitcher to thin the puree. [NAME] E said it was as smooth as he was going to be able to get it. The puree meatloaf was a chili like texture and not smooth. When pureeing the English peas [NAME] E was not able to get a smooth consistency. The cook was observed adding sliced white bread to the peas and hot water from a drink pitcher to thin the puree peas. [NAME] E said that it was the same texture that he normally served. The Dietary Manager went and got the Administrator to observe the surveyor's concern and the Administrator directed the cook not to serve the puree meatloaf or peas at that time. The Administrator said he was going to consult with the Dietician and come up with backup plan to serve the purees for lunch. [NAME] E said he was told by a dietician to add bread and hot water to all puree foods because it enhanced the flavor of the food. During an observation on 10/28/24 at 11:30 AM the Dietary Manager was observed pureeing boneless pork ribs in the food processor, she was using milk to thin the mixture. She said she had spoken with the Dietician and said she was instructed wrong about adding bread and hot water to the puree mixtures. SLP J and SLP K were present for the making of the puree boneless pork ribs and green beans and agreed the mixture was safe for resident consumption. During an interview on 10/29/24 at 10:30 a.m. [NAME] E said the Dietician before the current Dietician told him to add bread to the puree foods because it added flavor and texture to the foods, and that a chef had taught her that. He said he always used hot water to thin out the purees because the Dietician saw him thinning the mixture with milk and told them they did not have to use milk, they could use water. He said it was the same dietician that told them to use bread. During an interview on 10/29/24 09:42 AM the Dietary Manager said she had worked at the facility for about 1 1/2 years. She said the previous Dietician told her the correct way to puree foods was to add white bread and hot water; she said before that she was using milk or broth and was not adding bread. She said on 10/28/24 when she told her current Dietician they were adding bread and hot water to the puree foods she was told that was not the correct way. She said the residents could choke if the texture was not correct. The Dietary Manager said she had worked at other facilities and did not think the texture was as smooth as purees she had made at other facilities. During an interview on 10/29/24 at 9:58 a.m. the Dietician said she had been the dietician since April of 2024. She said she came to the facility every 2 weeks. The Dietician said she had not watched the pureeing process but had checked the food consistency and it was appropriate. She said she had always found pureed foods to be adequate during her visits. The Dietician said she was not aware they were using bread and hot water to mix puree foods. She said per the recipes they indicated to use broth or milk, gravy, sauces, or butter to mix puree foods. She said the Dietary Manager had been told by the previous Dietician to use bread and hot water and that was not correct, and she had not watched the puree process, so she had missed that. The Dietician said by not following the proper way to puree foods it could cause the resident to aspirate (accidental breathing in food into the lungs). She said by adding water to the puree food it was not adding any flavor or calories and by adding bread it would skew portion sizes. She said the residents would receive insufficient protein, vitamins and minerals and could possibly cause weight loss but was more concerned with missing the micronutrients. During an interview on 10/29/24 at 10:40 a.m. the Administrator said pureed foods should be nutritional and palatable and a smooth consistency. He said water should never be used to thin puree foods. He said if the pureed foods were not prepared correctly the resident would not get the full nutritional value of the food. Record review of the undated recipe for Seasoned Peas indicated: Dysphagia/Puree: place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, add 3 TBSP thickener and 1/4 C hot liquid (cooking liquid, water, or broth); process until smooth. With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds. Press the pureed vegetables through a cone shaped sieve (a chinois Strainer) with a pestal or a spoon to remove any hulls. Reheat to 165*F and serve with a #12 scoop. Record review of the undated recipe for Meatloaf/Ketchup Sauce indicated: Dysphagia/Puree: place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 1 TBSP thickener and 1/2 cup hot liquid; mix well with a wire whip. Add 1/2 of the slurry to the meat; process for 1 minute. If too dry, add more slurry until meat is pudding consistency. With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds. Reheat to 165*F and serve with a #8 scoop. Record review of the undated recipe for [NAME] Beans indicated: 1. Remove portions needed from regular prepared recipe; drain and reserve liquid. 2. Place drained portions into a food processor; process to a fine texture. 3. Add thickener and liquid. Process until smooth. With a rubber spatula scrape down the sides of the bowl; reprocess 30 seconds. 4. Reheat to 165*F and serve. Record review of the undated recipe for BBQ Pork Rib indicated: place portions needed into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 4 TBSP thickener and 3/4 cup hot water; mix well with a wire whip. Add 1/2 of the slurry to the meat. process for 1 minute. If too dry, add more slurry until pudding consistency is achieved. Reheat to 165*F and serve with a #8 scoop. Record review of the facility's policy titled Use of Recipes dated August 1, 2018, indicated: 3. Nutrition Services employees are expected to use and follow the recipes provided.

46436 Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 dining rooms (400 hall Dining Room), 1 of 4 halls (400 hall) and 1 of 6 (Resident #33) residents reviewed for environment. The facility failed to ensure that the 400-hall dining room and floors and walls were clean and maintained in good repair on 10/27/24. The facility failed to ensure the 400 hall walls and floors were maintained in good repair on 10/27/24. The facility failed to ensure Resident #33's box fan was free of dust and debris on 10/27/24. These failures could affect residents and the staff by placing them at risk for diminished quality of life and injury due to lack of a sanitary and well-kept environment. Findings: 1.During an observation on 10/27/24 at 9:09 am revealed the dining room floors located on hall 400 were dirty with a sticky substance and dark colored grime. There was a dark, black, thick buildup around the edges of all the walls. The base boards located in the dining room were torn, black and brown stained , and pulled away from the wall. There were chips in the paint throughout the dining room and the edges of the wall s throughout the dining room were torn exposing the sheetrock. There were dried discolored substances on the walls near the sink areas as well as under the sinks. During an observation on 10/27/24 at 9:12 am revealed there was black tape material on the floor at the exit door on hall 400 that was torn and raised from the floor. The wall going into the shower room hallway had breaks in the sheetrock. During an interview on 10/27/24 at 9:49 am the Floor Tech said he and the housekeeping staff were responsible for the floors in the facility. He said he had not had a chance to deep clean the dining room in several months but tried to do it monthly and as needed. He said as far as the tape at the exit door on 400 hall the Maintenance Director was responsible for changing it, but he cleaned around it the best he could. He said the residents could fall on the torn tape at the door and the floors not being clean could cause infections. During an interview on 10/28/24 at 9:43 am the Housekeeper B said she had been in housekeeping for a year, and she swept and mopped the dining room on 400 hall every day. She said she was not sure who did the deep cleaning to remove the buildup on the floors and walls, but it probably should be housekeeping. She said the floors in the halls were the responsibility of the Floor Tech and the damaged items were to be fixed by maintenance. She said if the area was not kept clean and in good repair it could cause resident injury or sickness. During an interview on 10/28/24 at 12:13 pm the Maintenance Director said he had been at the facility 6 years and was responsible for all maintenance in the facility. He said he was aware of the damaged areas on 400 hall and was in the process of starting repairs. He said the tape at the exit door had been there for many years and he had not noticed how worn and torn it was. He said damaged areas could cause resident injury. During an interview on 10/29/24 at 10:29 am the Administrator said that the housekeeping staff and Floor Tech were responsible for ensuring the floors and walls were clean and the Maintenance Director was responsible for all repairs in the facility. He said he was aware of the damaged areas on 400 hall and was in the process of getting to the repairs but was not aware of the uncleanliness of the dining room. He said if the environment was not maintained it could affect the residents safety and psychosocial wellbeing. He said he expected the facility to have a safe and clean environment for all residents. 2. Record review of a face sheet dated 10/28/2024 for Resident #33 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of chronic obstructive pulmonary disease (inability to maintain adequate oxygen exchange in the blood), vitamin deficiency, lack of coordination, and anxiety disorder (excessive worry about everyday issues and situation). Record review of a Quarterly MDS Assessment for Resident #33 dated 9/30/2024 indicated she had severe impairment in thinking with a BIMS score of 4. She required oxygen 7 days per week continuously and respiratory therapy 7 times per week for at least 15 minutes. Record review of a care plan dated 9/25/2024 for Resident #33 indicated she had an altered breathing pattern problem related to COPD and interventions included to provide oxygen per nasal cannula continuously. During an observation and interview on 10/28/24 at 10:10 am revealed a box fan was running and sitting on the floor blowing toward Resident #33. The protective grill (fan cage) had dark brown dust and lint build up, area 15 inches by 20 inches with lint and brown matter dangling in the air current. Resident #33 said that she had the fan on to help her breathe since she had difficulty and used oxygen constantly. Resident #33 said the fan heled her feel better when she had increased symptoms from her COPD. Resident #33 said she had not noticed the fan was so dirty and had never observed anyone cleaning it. During an interview on 10/28/24 at 2:23 am Housekeeper B said she did not know who was responsible for cleaning fans in resident rooms. She said she had cleaned one before but not the one in Resident #33's room. She said she did not know who the housekeeping supervisor was or who her direct report was. She said not keeping equipment clean for resident use could cause the resident harm by spreading germs, dust and give them a feeling of not being in a clean place to live. During an interview on 10/28/24 at 2:31 am the DON said that it was housekeeping's responsibility to clean any equipment used for the residents. She said that she would get the fan cleaned right away. She said she would notify the Administrator since there was no housekeeping supervisor and start an in-service with the housekeeping staff. She said the risk to the resident could be blowing particles of lint and dust and cause exacerbation of symptoms of COPD for Resident #33. During an interview on 10/29/24 at 08:45 am the Maintenance Director said the housekeeping department would be responsible for cleaning of the fans and other equipment used for the residents. He said not cleaning the fan was unsanitary and could cause the resident risk of breathing lint and particles. During an interview on 10/29/24 at 11:13 am the Administrator said the housekeeping department would be responsible for cleaning of the fans and other equipment used for the residents. He said not cleaning the fan was unsanitary. Record review of an undated facility policy titled Maintenance Services indicated, .I. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance, but are not limited to: b. Maintaining the building in good repair and free from hazards .

Based on interviews, and record reviews, the facility failed provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 out of 8 dietary staff. The facility did not ensure Dietary Aide H had a current food handler permit. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings included : During an observation of the kitchen on 10/27/24 at 9:30 a.m. revealed Dietary Aide H was working in the kitchen as a dietary aide. Review of the food handler's certificates of completion provided by the facility on 10/28/2024, revealed Dietary Aide H did not have a food handler's certificate. An attempted telephone interview on 10/28/2024 at 2:25 p.m. with Dietary Aide H was unsuccessful. During an interview on 10/29/2024 at 9:42 a.m., the Dietary Manager said she was responsible for ensuring staff completed their food handler certification training upon hire and every 2 years. The Dietary Manager said she was unsure why Dietary Aide H had not completed her food handler certification training. The Dietary Manager said Dietary Aide H had been working at the facility for 2-3 months without her food handler's certification, but Dietary Aide H was no longer working at the facility and 10/27/24 was her last day of work. The Dietary Manager said she had not asked Dietary Aide H to get her food handlers certification. The Dietary Manager stated the failure could potentially put residents at risk for food borne illness and cross contamination. During an in interview on 10/29/24 at 9:58 a.m. the Dietician said she had worked for the facility since April of 2024. She said she usually came to the facility every 2 weeks. She said when she came to the facility, she would review all the kitchen systems which included checking for the staffs food handler's certificates. She said she last checked for the food handler's certifications about 2 months ago and Dietary Aide H was working at the facility at that time so she must has missed it that Dietary Aide H did not have her food handler's certification. She said Dietary Aide H had already given notice that she would no longer be working at the facility but said the facility was short on staff on 10/27/24 so the Dietary Manager had asked Dietary Aide H to come in to work. She said by Dietary Aide H working without having her food handler's certification she could possibly handle food inappropriately which could cause residents to become sick by food borne illness. During an interview on 10/29/2024 at 10:40 a.m., the Administrator said he expected the Dietary Manager to ensure the dietary staff had their food handler certificates within 30 days of hire. The Administrator said the importance of obtaining the food handler certificate training was to teach staff to follow proper procedures and prevent infection control issues. The Administrator said the facility did not have a specific policy for obtaining food handler's certification and they followed the Texas Administrative Code. Record review of the Texas Administrative Code chapter 228 subchapter (b) (d) indicated: All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerator were not kept past their expiration dates. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the cooler/refrigerator on [DATE] at 9:30am, the following items were observed: (2) 32-ounce containers of vanilla Greek yogurt with the expiration date on [DATE]. During an interview on [DATE] at 9:05 a.m. [NAME] E said it was everyone's responsibility to check for expired foods in the fridge. He said they threw away expired foods. He said the Dietary Manager check ed for expired foods in the separate storage area. He said he had checked the refrigerator Thursday [DATE] for expired food and did not see the expired food. He said he did not have time to look at every expiration date on every product because he basically had 6 meals a day to cook. He said the residents could get sick from consuming expired foods such as diarrhea or upset stomach. During an interview on [DATE] at 9:21 a.m. Dietary Aide G said she had worked at the facility since [DATE]th 2024. She said it was everyone's responsibility to check for expired foods in the refrigerator. She said she did it to help out, but she is not sure whose job it was to check for the expired foods. She said residents could get sick by consuming expired foods. During an interview on [DATE] at 9:42 a.m. the Dietary Manager said she had worked at the facility for about 1 ,d+[DATE] years. She said it was everyone's responsibility to check for expired foods. She said on Fridays she checked for expired foods when she gets her food truck. She said if the residents consumed expired foods, they could get sick. During an interview on [DATE] at 9:58 a.m. the Dietician said she had been coming to the facility since April of 2024. She said staff should be checking for expired foods daily. She said the Dietary Manager was supposed to do a daily checklist and checking for expired foods was on the list to be done daily. She said food borne illness was a potential risk to the resident for consuming expired foods. During an interview on [DATE] at 10:40 a.m. the Administrator said all foods should be used or disposed of by the use by date. He said food borne illness was a potential risk to the resident for consuming expired foods. Record review of undated Daily Quick check of Kitchen/Foodservice Operations checklist indicated: .Refrigerators . No expired foods . Record review of facility policy titled Food Storage dated [DATE], indicated: Sufficient storage facilities are provided to keep foods safe. Wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 2. Refrigerator: .All foods are covered, labeled and dated.

Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. One of six gas stove burners (right back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings include: During an observation on 10/27/24 at 9:30 a.m., revealed the gas stove had six burners and one burner located in the right back had excess carbon buildup. The right back burner would not light automatically. During an interview on 10/27/24 09:30 a.m. [NAME] F said that the burner would not light last week. She said the Maintenance Director fixed the oven about 1-2 months ago and the burner had been working up until last week. During an interview on 10/29/24 at 8:25 a.m., the Maintenance Director said he had worked at the facility for 6-7 years. He said no one had notified him that the burner on the stove was not working until Sunday 10/27/24. He said he cleaned the burner on Sunday 10/27/24 and the burner started lighting. He said sometimes when the kitchen staff were cooking, they dropped grease on the burners, and they would get clogged up and not light. He said sometimes he had to use a drill bit and clean the burner holes due to the buildup of grease. He said if the stove burner was not lighting appropriately the kitchen could fill up with gas. During an interview on 10/29/24 at 9:05 a.m. [NAME] E said he had worked at the facility for about 10 months. He said he worked on Friday 10/25/24 and did not use the right back burner. He said sometimes the burners wouldn't light and he would use a lighter to light the burners. He said the last time he used the right back burner was sometime last week and it was working. He said he clean ed the stove grates every day at the end of his shift. He said the Maintenance Director cleaned the actual burner and said it was last month when that was done during mock survey. He said the burners had buildup on them then. During an interview on 10/29/24 at 9:42 a.m. the Dietary Manager said she had worked at the facility for about 1 1/2 years. Said she was not aware of the back stove burner not lighting until Sunday 10/27/24 upon surveyor entry. She said she would report any stove issues to the Maintenance Director. She said on Sunday 10/27/24 the Maintenance Director came to look at the stove after she reported to him the right back burner was not working. She said the stove burners had never had any issues not working prior to Sunday 10/27/24. She said if the stove was not working properly, they could smell gas and it could make employees and residents sick. During an interview on 10/29/24 at 9:58 a.m. the Dietician said she had been coming to the facility since April of 2024. Said she comes into the facility every 2 weeks. She said she reviewed all the systems, equipment, pantry's, food prep areas looking for broken equipment, and cleanliness. She said she was at the facility last week and checked the stove because the stove was an issue during mock survey. She said she observed the Maintenance Director cleaning the stove due to excessive build up on the burners. She said she did observe the burners at that time and they all lit. During an interview on 10/29/24 at 10:40 a.m. the Administrator said all equipment should be maintained by the Maintenance Director. He said the potential hazard for the stove not working properly was it could lead to fire. Record review of facility policy titled Maintenance Schedules undated indicated: Preventive maintenance schedules shall be developed and implemented to assure that the building and equipment are maintained in a safe and operable manner. 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for the 1 of 1 facility . The facility failed to ensure the staff were smoking in the designated smoking area and disposing of smoking materials properly on 10/27/24. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings: During an observation on 10/27/24 at 9:40 AM revealed cigarette butts were observed in a plastic cup on the ground outside the exit door located on 400 hall and there were four cigarette butts sitting on the outside keypad next to the door. During an interview on 10/27/24 at 9:42 AM LVN C said there were no residents that smoked on the 400 hall and the cigarette butts belonged to the staff. She said there was a smoking area out back and the area outside the exit door was not a designated area to smoke. She said if smoking occurred in undesignated areas there could be risk of fires. During an interview on 10/27/24 at 9:44 AM CNA D said she worked on 400 hall and the cigarette butts were hers. She said the designated area was out back, but she could not leave and thought it was ok for her to smoke in that area. She said she would pick up her cigarette butts and throw them away at the end of her shift. She said by not smoking in the designated area and properly disposing of her cigarette butts it could cause a fire. During an interview on 10/28/24 at 8:42 AM the Administrator said the only designated smoking area was located outside the main dining room and he was not aware staff were smoking outside 400 hall. He said the smoking policy was directed to the residents smoking but he expected all staff to following the smoking rules and only smoke in the designated area per the staff handbook. He said that smoking in undesignated areas could be a fire risk. Record review of an undated facility floor plan indicated designated smoking area outside the main dining room. Record review of a facility team member handbook titled Smoking indicated, .Team members may smoke on their rest breaks and meal periods in designated smoking areas outside the facility. Team members must discard smoking materials in appropriate receptacles and not on the ground .

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 2 Residents (Resident # 3) observed for care in that: The facility failed to ensure Resident #3's urinary drainage bag had a privacy cover on 10/22/2024. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect. Findings included: Record review of a Face Sheet for Resident #3 dated 10/22/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of intellectual disabilities (a condition that limits intelligence and disrupts the ability to live independently), anemia (low red blood cells that affect oxygen delivery to the body), and retention of urine (bladder not able to empty urine). Record review of a care plan for Resident #3 dated 9/18/2024 indicated he was at risk for problems with elimination related to retention of urine. He had a urinary catheter with interventions for care/changing of urinary catheter as ordered. Record review of an Annual MDS assessment for Resident #3 dated 9/3/2024 indicated his speech was unclear and he was usually able to understand others. He required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene. He had an indwelling catheter. Record review of active physician orders for Resident #3 indicated an order dated 6/28/2024 for foley catheter 16 Fr to continuous gravity drainage and catheter care, privacy bag checked, and placement of leg strap verified q shift. During an observation on 10/22/2024 at 9:36 AM, Resident #3 was in his room in bed, snoring, with a sheet pulled over his head. His bed was in a low position. His urinary catheter drainage bag was noted in the bed with a small amount of pink, tinged urine, resting by his feet without a privacy cover. During an observation on 10/22/2024 at 10:50 AM, Resident #3 was propelling himself in a wheelchair using his feet down the hallway toward the nurse station. Foley catheter drainage bag noted hanging underneath his wheelchair without a privacy cover. During an observation on 10/22/2024 at 11:47 AM, Resident #3 was propelling himself in a wheelchair by the nurse station with his Best Friend walking behind him headed to the activity room. The urine drainage bag was noted hanging underneath his wheelchair without a privacy cover. The ADON was standing up by the nurse station and instructed staff to take Resident #3 to his room so they could put a leg bag on him. During an interview on 10/22/2024 at 2:31 PM, LVN A said she had been employed at the facility since April 2024 and was assigned to the hall where Resident #3 resided. She said he was nonverbal and had a foley catheter. She said the nurses were responsible for ensuring the foley catheters were positioned properly. She said she was not aware the drainage bag was on the bed earlier that morning. She said he had gone to the ER that morning because he had ripped out his catheter and had to get it replaced. She said when he arrived back to the facility, she assisted EMS put him back to bed and did not see where they had positioned the drainage bag. She said she did not notice the drainage bag did not have a privacy cover until after he had been out and about in the facility. She said when the residents leave out of their rooms, they should have a cover on the bag. She said not having a cover over the drainage bag, could make them feel bad and be a dignity issue. During a joint interview on 10/22/2024 at 3:25 PM, the ADON said she had been employed at the facility for 2 years. The DON said she had been employed at the facility for [AGE] years but in her current position since 7/25/2024. Both said nursing staff were responsible for the privacy covers on the foley drainage bags when the residents were out of their rooms and the bags should be positioned below the bladder. Both said staff noticed Resident #3 did not have a privacy cover when he was out and about in the facility but did place a leg bag on him. Both said residents could be at risk for UTI's and it could be a dignity issue. During an interview on 10/23/2024 at 9:24 AM, the Administrator said foley catheters were the responsibility of the charge nurses. He said the facility had drainage bags with covers built in but when he came back from the ER that morning with a new foley catheter from the ER, the charge nurse did not ensure the bag had a cover. He said the drainage bags should not be placed in the bed; they should be positioned below the bladder. He said they started an in-service with staff to make sure they positioned the drainage bags properly. He said there could be a risk for urine to back into the bladder, infections, and urinary retention. Record review of a urinary catheter infection prevention policy revised August 2018 indicated, .Indwelling or intermitted urinary catheterization will be used for those residents whose medical condition requires intervention for urinary elimination. III. Catheter Maintenance and Care: K. Gravity Drainage Bag: 8. Gravity drainage bags are positioned below the level of the patient's bladder .

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 Resident's (Resident #3) reviewed for catheter and incontinence care. 1. The facility failed to ensure LVN A maintained the urine catheter drainage bag below Resident #3's bladder on 10/22/2024. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: Record review of a Face Sheet for Resident #3 dated 10/22/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of intellectual disabilities (a condition that limits intelligence and disrupts the ability to live independently), anemia (low red blood cells that affect oxygen delivery to the body), and retention of urine (bladder not able to empty urine). Record review of a care plan for Resident #3 dated 9/18/2024 indicated he was at risk for problems with elimination related to retention of urine. He had a urinary catheter with interventions for care/changing of urinary catheter as ordered. Record review of an Annual MDS assessment for Resident #3 dated 9/3/2024 indicated his speech was unclear and he was usually able to understand others. He required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene. He had an indwelling catheter. Record review of active physician orders for Resident #3 indicated an order dated 6/28/2024 for foley catheter 16 Fr to continuous gravity drainage and catheter care, privacy bag checked, and placement of leg strap verified q shift. During an observation on 10/22/2024 at 9:36 AM, Resident #3 was in his room in bed, snoring, with a sheet pulled over his head. His bed was in a low position. His urinary catheter drainage bag was noted in the bed with a small amount of pink, tinged urine, resting by his feet without a privacy cover. During an observation on 10/22/2024 at 10:50 AM, Resident #3 was propelling himself in a wheelchair using his feet down the hallway toward the nurse station. Foley catheter drainage bag noted hanging underneath his wheelchair without a privacy cover. During an observation on 10/22/2024 at 11:47 AM, Resident #3 was propelling himself in a wheelchair by the nurse station with his Best Friend walking behind him headed to the activity room. The urine drainage bag was noted hanging underneath his wheelchair without a privacy cover. The ADON was standing up by the nurse station and instructed staff to take Resident #3 to his room so they could put a leg bag on him. During an interview on 10/22/2024 at 2:31 PM, LVN A said she had been employed at the facility since April 2024 and was assigned to the hall where Resident #3 resided. She said he was nonverbal and had a foley catheter. She said the nurses were responsible for ensuring the foley catheters were positioned properly. She said she was not aware the drainage bag was on the bed earlier that morning. She said he had gone to the ER that morning because he had ripped out his catheter and had to get it replaced. She said when he arrived back to the facility, she assisted EMS put him back to bed and did not see where they had positioned the drainage bag. She said she did not notice the drainage bag did not have a privacy cover until after he had been out and about in the facility. She said when the residents leave out of their rooms, they should have a cover on the bag. She said not having a cover over the drainage bag, could make them feel bad and be a dignity issue. During a joint interview on 10/22/2024 at 3:25 PM, the ADON said she had been employed at the facility for 2 years. The DON said she had been employed at the facility for [AGE] years but in her current position since 7/25/2024. Both said nursing staff were responsible for the privacy covers on the foley drainage bags when the residents were out of their rooms and the bags should be positioned below the bladder. Both said staff noticed Resident #3 did not have a privacy cover when he was out and about in the facility but did place a leg bag on him. Both said residents could be at risk for UTI's and it could be a dignity issue. During an interview on 10/23/2024 at 9:24 AM, the Administrator said foley catheters were the responsibility of the charge nurses. He said the facility had drainage bags with covers built in but when he came back from the ER that morning with a new foley catheter from the ER, the charge nurse did not ensure the bag had a cover. He said the drainage bags should not be placed in the bed; they should be positioned below the bladder. He said they started an in-service with staff to make sure they positioned the drainage bags properly. He said there could be a risk for urine to back into the bladder, infections, and urinary retention. Record review of a urinary catheter infection prevention policy revised August 2018 indicated, .Indwelling or intermitted urinary catheterization will be used for those residents whose medical condition requires intervention for urinary elimination. III. Catheter Maintenance and Care: K. Gravity Drainage Bag: 8. Gravity drainage bags are positioned below the level of the patient's bladder .

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from verbal abuse for one of twelve residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent verbal abuse for Resident #1 witnessed by CNA A and CNA B to have been told to shut up and you are the one who shit on yourself by CNA C on 03/26/2024 at approximately 1:00 p.m. during incontinence care. The noncompliance was identified as PNC that began on 03/26/2024 and ended on 04/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse. Findings included: Review of a face sheet for Resident #1, dated 04/24/2024, revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: type 2 diabetes mellitus with hyperglycemia (high blood pressure), non-ketotic hyperglycinemia (metabolic accumulation of large amounts of glycine in blood, urine, and cerebrospinal fluid, acute kidney failure, Chronic kidney disease, stage 3, seizures, Essential (primary) hypertension high blood pressure), Personal history of transient ischemic attack (stroke), and cerebral infarction without residual deficits, Chronic obstructive pulmonary disease (lung disease). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms or decrease in mood or social isolation, had impairment to both upper and lower extremities, and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 04/01/2024, revealed he had an anti-anxiety and antidepressant goal in place for resident to be free of any discomfort or adverse side effects within the next 90 days initiated on 3/26/2024 to include the following interventions: monitor behaviors every shift, offer non-pharmacological interventions, and administer medication as ordered, Monitor closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any changes in dosage, and monitor for interaction/adverse side effects of anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Review of incident statement, dated 03/26/2024, signed by Administrator, revealed the following: Reported to me that resident was placed in the bed for incontinent care. When resident was turned by aide [CNA C], the resident hollered out, ouch you hurt me. The aide [CNA C] was overheard by [CNA A] and [CNA B] to say, shut up. You're the one that shit yourself. [CNA A] left the room and reported the incident initially to [LVN D]. [LVN D] brought [CNA C] into my office to discuss allegations. [CNA B] was in turn brought into my office and questioned about the allegations. The incident was in turn reported to the administrator. [CNA C] was questioned regarding the allegations. Review of witness statement, dated 03/26/2024, signed by CNA A, revealed the following: I walked into [Resident #1's] room looking for the other aides. They were in the middle of a bed change, and they were pulling him up in the bed and he said ouch you're hurting me and [CNA C] said shut up you're the one that shit all over yourself. Review of witness statement, dated 03/26/2024, signed by CNA B, revealed the following: I was changing [Resident #1] and he had a huge blowout [bowel movement]. I turned him to pull the brief and noticed he had bowel going up his back and needed new sheets so [CNA C] went [and] got some sheets. She came back and when we were turning him to change sheet and briefs [CNA C] turned [Resident #1] and he said ow because his hip hurt and [CNA C] told him 'Shut up, I don't know why you are complaining you are the one that shit all over his self.' Review of witness statement, dated 03/26/2024, signed by CNA C, revealed the following: CNA walked into room to help other CNA with resident put back into the bed due to needing to be changed. When changing patient, noticed he had poop all the way up his back when lifting [patient] up to change him to get the poop off his back and to take his shirt off. He was complaining of him hurting this CNA said hush we are trying to not get poop on your face and continued to get the poop off resident. Review of witness statement, dated 03/26/2024, signed by LVN D and ADON, revealed the following: [Resident #1]. While I was in resident's room for incontinent care, I asked resident if a CNA talked ugly to him earlier in the day. Resident stated 'yes, she did but I didn't tell the other lady because I didn't want to get her in trouble. People need their jobs.' I told resident no one is allowed to curse at them or talk rudely to them. Resident's roommate stated 'Miss [LVN D] come here.' I approached roommate's bed and he stated, 'I heard it, but I didn't tell because he didn't [Resident #1], and we [Resident #1 and Resident #2] don't want to get anyone in trouble.' Review of notice of warning, dated 03/26/2024, signed by CNA C and ADM revealed CNA C received warning for allegation of verbal abuse of a resident. Review of interview statement by CNA A, dated 03/27/2024, signed by the ADON, revealed the following: I walked into [Resident #1's] room looking for the other aides. They were in the middle of a bed change and they [CNA B and CNA C] we're pulling him up in bed. [Resident #1] stated 'Ouch, you're hurting me. At this time, [CNA C] said 'shut up, you're the one that shit all over yourself.' [Resident #1] said 'I know I did and it stinks'. At this time I stated I'm leaving on that note. I went directly to [LVN D] and reported what was said. [LVN D] then sent me to the ADON/DON office where I reported what I had heard. Review of interview statement by CNA B, dated 03/27/2024, signed by the ADON, revealed the following: I was changing [Resident #1] brief. One that involved a large BM (bowel movement). I turned him to pull the brief and noticed he had feces going up his back and needed new sheets. So [CNA C] went and grabbed sheets. During care of changing his sheeets and brief, [CNA C] turned [Resident #1] at this time he said 'ow' because his hip hurt. [CNA C] told him to 'shut up, I don't know why you are complaining, you are the one that shit all over yourself.' At this time, the peri care was completed. I proceeded to peri care on another resident. When this task was completed, [LVN D] approached me and asked me to speak with [DON]. I give my statement to what I had heard [CNA C] say to [Resident #1] at this time. Review of provider investigation report, a resident interview titled Safe Survey, dated 03/27/2024 and signed by the Social Worker, revealed Resident #1 and his roomate had no concerns or complaints and felt comfortable talking to staff about them if he had them. Additional safe surveys on neighboring residents revealed no concerns. Review of social note, dated 03/28/2024 at 10:40 a.m., signed by the Social Worker, revealed the following: There were witness statements saying an aide, that was helping them change a resident, had made a {vulgar} comment towards the resident. Resident was hollering/moaning due to pain, of being moved around, and the aide told the resident to 'shut up, you are the one who shit yourself.' When I asked the resident did he hear her say that, he said he heard her say something, but could not make it out to what she had said. Resident had also admitted to another nurse, that he in fact did hear her, he just did not want to get her in trouble. Review of witness statement, dated 03/29/2024, signed by LVN D, revealed the following: I entered [Resident #1]'s room to clarify if he heard exactly what [CNA C] said to him on 3/26/2024. Resident stated 'Is she in trouble? I don't want to get anyone in trouble.' I told resident we need to know if he heard what she said since he previously told me she was ugly to him. Resident stated 'she said shut the fuck up.' I thanked resident for speaking with me and left room. Review of grievance summary, dated 03/29/2024, signed by the Social Worker, revealed the following concern and conclusion: .Resident was hollering while getting changed, when an aide was helping assist him said 'Shut up, you are the one who shit yourself' .Resident was said he did hear her say something, but does not know exactly what she said. He has not had any mood or behavioral changes. A safe survey (resident interview regarding safety) was conducted and it was found, he was comfortable and safe here. He didn't feel like any harm in his way. The end result of the matter was that, the aide was terminated. RP, [family] was notified about the abuse allegations. Review of personnel record for CNA C, revealed a hire date of 03/05/2024 and received training on abuse with completed post test on 03/05/2024. Review of provider investigation report, dated 04/02/2024, signed by the ADM, revealed the incident ocurred 03/26/2024 at 1:00 p.m. and included the following: Investigation Summary . On 3/26/24 [CNA C] was providing incontinent care to [Resident #1], a resident. Two other staff members were present in the room: [CNA B and CNA A]. While assisting the resident he verbally complained of pain. At that time [CNA C] allegedly stated 'shut up, you are the one who shit all over yourself. This statement was heard by the two staff members that were in the room with [CNA C]. Administrator, DON, Physician, Responsible Party, Corporate Office, and HHSC notified. Alleged perpetrator suspended pending investigation. Staff inserviced regarding abuse/neglect, resident rights, safe transfers. Other residents interviewed in an attempt to discover if similar incidents had ocurred and not been reported. No other incidents or allegations were identified. Resident was interviewed/couseled by the social worker. Resident initially denied hearing what [CNA C] said to him. Administrator spoke to resident and made the same statement, that he had not heard what [CNA C] had said. Resident also told the administrator that he did not wish to get any staff members in trouble. Resident was later interviewed by [LVN D]. During that conversation the resident stated that he had heard [CNA C] tell him to 'shut the fuck up,' but he had not been honest about it because he did not wish to get anyone in trouble. Based on the evidence provided this investigator confirms the incident. Evidence suggests [CNA C] made the statements alleged. Investigation Findings: Confirmed Provider Action Taken Post-Investigation: [Facility] continues to make the safety and well being of its residents top priority. [CNA C]'s employment at [facility] has been terminated and she is not eligible for rehire. [Resident #1] continues to display no lasting effects as a result of the incident and no further incidents have been reported as o the writing of this report. Review of Resident Mood Interview for Resident #1, dated 04/09/02024 at 12:08 p.m., signed by the Social Worker, revealed no symptoms present. Review of in-services between March 2024 through April 2024 and employee roster, revealed training was provided to staff on abuse for the following dates: 03/21/2024, 03/26/2024, 03/27/2024, and 04/23/2024. During an interview with the ADM and DON on 04/24/2024 at 11:00 a.m., the ADM said that he was the abuse coordinator and was aware of the self reported incident of verbal abuse related to Resident #1. The ADM said there were multiple staff members in the room providing incontinent care and one of those aides was CNA C. The ADM said during that time, they were turning Resident #1 and he voiced that CNA C was hurting him and she told him to shut up, you are the one who shit yourself and that statement was corroborated by other staff in the room. The ADM said we immediately suspended her pending the investigation and terminated her with no eligibility for rehire. The ADM said the other aides in the room were CNA B and CNA A. The ADM said CNA A and CNA B were not at the facility that day due to CNA A no longer employed by the facility and CNA B works the night shift. The ADM said Resident #1 was doing good and has had no psychosocial harm apparent from the incident. The ADM and DON said they were ensuring residents were free from abuse by reporting, conducting safe surveys, increased monitoring, and in-services with staff. The ADM and DON said it was important to protect residents from verbal abuse to prevent psychocial harm. During an observation and interview on 04/24/2024 at 11:42 a.m., CNA E was walking with a resident down the hall and interaction appeared pleasant. CNA E said that she had worked at the facility for [AGE] years and had received training on abuse recently from in-services and that verbal abuse would be anything from talking down to a resident or cussing. She said she did not suspect any current abuse but was aware of CNA C being let go because of a verbal abuse incident. CNA E said she has had no additional concerns since CNA C was terminated and that she was not working when the incident occurred. CNA E said if she ever witnessed staff cursing at a resident she would immediately report to the ADM, the abuse coordinator. CNA E said it was important to prevent verbal abuse of residents because it could cause psychosocial harm. CNA E said she had never had to report abuse and that she felt residents were safe at the facility. During an interview on 04/24/2024 at 12:09 a.m., the ADON said she had been employed at the facility for 16 months. She said she had received and provided training on abuse and was aware of an abuse allegation and had recently reported alleged abuse on herself from a resident on the secure unit that said she had scratched her during her assessment on 4/23/2024 at around 8:15 a.m The ADON said she reported herself immediately to the ADM, the abuse coordinator, and was suspended until 12:30 p.m. the same day. The ADON said she was out that day when Resident #1 had his incident with the aides and that she has a good relationship with Resident #1 and he will ask for her personally over any issues. The ADON said she asked Resident #1 about the incident with CNA C and he was reluctant to provide any information, but informed him on his safety. The ADON said Resident #1 never told her what CNA C said to him and the DON called her that day with him on the phone so he would feel comortable talking to the ADON since they have a good relationship. The ADON said Resident #2 was his roommate and she asked if he had heard anything and he said no. The ADON said Resident #1 was doing good and has exhibited no signs of psychosocial harm from the incident. The ADON said staff had received training on abuse via in-services and that they did a skills fair recently addressing abuse in March 2024 consisting of a two day event with hands on scenarios and they get the residents involved. The ADON said she felt the incident with CNA C was isolated and that the facility handled the situation appropriately with her termination and felt residents were safe at the facility. The ADON said it was important for residents to remain free from verbal abuse to prevent psychosocial harm. During an interview on 04/24/2024 at 2:08 p.m., LVN F said she had no concerns with staff talking to residents inappropriately and if she did she would report to the ADM. LVN F said she had not worked with CNA C and that if she witnessed staff being verbally abusive to residents she would intervene and make sure both parties are safe before reporting to the ADM. LVN F said she did not suspect any verbal abuse that would consist of talking inappropriately to resident like cursing and that she aware of the incident with CNA C and Resident #1 but did not witness the incident. LVN F said she felt the facility handled that situation appropriately and CNA C was terminated. LVN F said it was important to prevent and protect residents from verbal abuse because it could cause them to become more depressed, socially withdrawn, and could cause psychosocial harm. During an interview on 04/24/2024 at 2:36 p.m. by phone, CNA G said she was PRN. CNA G said she had received training on abuse and verbal abuse would be yelling at a patient, being irate and disrespectful. CNA G said it was important to prevent verbal abuse of residents because it could cause psychosocial harm, that she did not suspect abuse at this facility, and that if she did she would report it to the ADM immediately. During an interview on 04/24/24 at 2:48 PM via phone, CNA C said she and CNA B went to get Resident #1 cleaned up. CNA C said they got him in the bed with the hoyer and he freaks out sometimes because he has arthirits in his back. CNA C said CNA A was coming in the room and when CNA B rolled him over she said it [feces] is up your back we are going to have to take your shirt off and when we sat him up. CNA C said she told Resident #1 to hush, stop, look at me, when we pull it over the top of your head, if you jerk back like that you are going to get poop on your face. CNA C said Resident #1 undesrstood what we were doing and they got him cleaned up and that was it. CNA C said she did not tell him to shut up because she does not talk like that. CNA C said she told him to hush and to look at me. CNA C said she probably did say shit but never told him to shut the fuck up and that the charge nurse said CNA A told her six different stories. CNA C said one story was she said shut up and then it was shut the fuck up and I wanted to ask them questions because if it that was serious why didn't the other aides stop me at the time because the resident's safety was first and they just stood there. CNA C said the facility did not provide training on abuse, but they had in-services on paper at the front and told you to sign them. CNA C said she honestly did not have time to read them when she had 22 residents to take care and was not going to remember what that paper said. CNA C said verbal abuse would be considered belittling and cursing at residents and that it could affect resdidents mentally if they have depression and make them withdrawal. CNA C said she did not curse near any other residents and could not remember if his roommate was in the room at the time of the incident. During an interview on 04/24/2024 at 3:23 p.m., the ADM said verbal abuse was confirmed with Resident #1 and that the resident was truthfully reluctant to provide information that he had overheard what the aide said because he did not wish to get anyone in trouble. The ADM said that Resident #1 was doing fine and has had no negative psychosocial outcomes and that it was important to protect residents from verbal abuse to prevent resident from becoming with more withdrawn and the resident experieincing verbal abuse could experience psychosocial harm. The ADM said to ensure residents are safe from abuse he has provided training, reported to HHSC, and appropriate entities listed in policy, safe surveys were conducted, the incident was QAPI'd (Quality Assurance and Performance Improvement), and alleged perpetrator was terminated. The ADM said there was no concern with her background or licensure check. The ADM said that he did feel this incident caused reason for referral of CNA C. The ADM said that the Social Worker was at the facility and had assessed Reisdent #1's mood and behavior following the incident. During an interview on 04/24/2024 at 3:29 p.m., the Social Worker said she had been employed since October of 2023 and did not suspect abuse. The Social Worker said she had safe surveys to ensure residents are safe and that it was important for residents to be free from verbal abuse to prevent psychocial harm. The Social Worker said Resident #1 was doing good and has not had any complaints with him as far as his care provided. The Social Worker siad there was an incident with CNA C changing him and he never admitted it to me that he heard her say something and could not make out what she said. The Social Worker said Resident #1 has had no mood changes and has been more active in activities. During an observation on 04/24/2024 at 3:45 p.m., Resident #1 was lying in bed with his head covered. He did not respond to greeting or questions and exhibited no signs of distress. There was no other resident in his room. During an interview on 04/25/2024 at 11:17 a.m., Resident #1's RP said they were notified of the verbal abuse incident on 3/26/2024 and that the resident had socially improved since the incident and was attending more activities than previously. RP said they had no concerns and that they felt the CNA that told the resident to 'shut up' should not have been fired because the resident can be very difficult and rude to nursing staff and that they believe she should be rehired. RP said they had no concerns with the care and services provided by the facility or staff related to abuse. RP said it has been over a month since she had visited the resident because she was diagnosed with cancer and also because of his rude behavior when RP did visit. Review of facility policy, titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property, effective June 23, 2017, revealed the following: Purpose The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property . Policy 1.Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2 Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms . 5. Training. The facility will conduct staff member training regarding abuse, neglect, and exploitation and the misappropnat1on of resident property, to include prevention, intervention, detection, reporting and employee rights. During each new staff member's orientation and annually thereafter, the facility at a minimum provide training on the following topics: a. Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property b. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property c. Dementia management and resident abuse prevention. Additional training may be provided in new employee orientation and thereafter in on-going training sessions on the following topics: a. Activities and behaviors that constitute abuse, neglect, and exploitation . d. Working with residents with dementia or cognitive impairment. e. Techniques for management of difficult residents. f. Identification of factors that contribute to, or escalate, hostile behavior. g. Assessment of staff responses to aggressive or hostile behavior h. Identification of employee and resident coping behaviors, and how to reinforce positive and adaptive behaviors. i. How to report any incidence of suspected abuse, who the abuse coordinator is, and how investigations are conducted at the facility. j. How to file a complaint with the state survey agency against any facility that retaliates against an employee who makes a report. k. Appropriate interventions that are implemented to deal with aggressive and/or catastrophic reactions of residents. l. How to recognize signs of burnout, frustration and stress that may lead to abuse. m. Behavioral interventions that can be used for inappropriate resident behaviors . To provide protection to the resident during an investigation, the Facility should apply the following procedures: a. protect residents by removing immediate threats and potential harm; b. if the alleged perpetrator is a staff member, the staff member will be suspended from employment and not allowed in the facility, pending the outcome of the investigation, and the Regional Human Resources Consultant will be notified of the suspension; c. the Abuse Coordinator or designee will be assigned throughout the investigation to follow-up with the person and/or persons involved with the concern, incident, or grievance. If allegations of abuse, neglect, exploitation, or misappropriation involve the Administrator's conduct, then the Regional Director of Operations will be assigned to coordinate the investigation; d. the Abuse Coordinator or designee will conduct relevant interviews to determine if any form of retaliation has occurred . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. (42 CFR S488.301). This also includes the deprivation by an individual (including a caretaker), of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish . Abuse Coordinator: Licensed Facility Administrator. Adverse event: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury. Verbal abuse: 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, inability to comprehend, or disability. Examples of verbal abuse include, but are not limited to threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again . The surveyor confirmed PNC had been implemented sufficiently to remove the deficiency by: - Facility implementation of monitoring resident for psychosocial harm. - Facility notification of abuse incident to responsible parties, MD, police, Ombudsman, and HHSC. - Completion of mood assessment on resident/victim. - Completion of in-services on abuse. - Completion of safe surveys on residents. - Suspension of involved staff pending outcome. - Completion of warning notices for involved staff. - Termination of confirmed perpetrator. The noncompliance was identified as PNC. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident to ensure residents were free from verbal abuse for one of twelve residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent verbal abuse for Resident #1 witnessed by CNA A and CNA B to have been told to shut up and you are the one who shit on yourself by CNA C on 03/26/2024 at approximately 1:00 p.m. during incontinence care. The noncompliance was identified as PNC that began on 03/26/2024 and ended on 04/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse. Findings included: Review of a face sheet for Resident #1, dated 04/24/2024, revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: type 2 diabetes mellitus with hyperglycemia (high blood pressure), non-ketotic hyperglycinemia (metabolic accumulation of large amounts of glycine in blood, urine, and cerebrospinal fluid, acute kidney failure, Chronic kidney disease, stage 3, seizures, Essential (primary) hypertension high blood pressure), Personal history of transient ischemic attack (stroke), and cerebral infarction without residual deficits, Chronic obstructive pulmonary disease (lung disease). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms or decrease in mood or social isolation, had impairment to both upper and lower extremities, and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 04/01/2024, revealed he had an anti-anxiety and antidepressant goal in place for resident to be free of any discomfort or adverse side effects within the next 90 days initiated on 3/26/2024 to include the following interventions: monitor behaviors every shift, offer non-pharmacological interventions, and administer medication as ordered, Monitor closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any changes in dosage, and monitor for interaction/adverse side effects of anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Review of incident statement, dated 03/26/2024, signed by Administrator, revealed the following: Reported to me that resident was placed in the bed for incontinent care. When resident was turned by aide [CNA C], the resident hollered out, ouch you hurt me. The aide [CNA C] was overheard by [CNA A] and [CNA B] to say, shut up. You're the one that shit yourself. [CNA A] left the room and reported the incident initially to [LVN D]. [LVN D] brought [CNA C] into my office to discuss allegations. [CNA B] was in turn brought into my office and questioned about the allegations. The incident was in turn reported to the administrator. [CNA C] was questioned regarding the allegations. Review of witness statement, dated 03/26/2024, signed by CNA A, revealed the following: I walked into [Resident #1's] room looking for the other aides. They were in the middle of a bed change, and they were pulling him up in the bed and he said ouch you're hurting me and [CNA C] said shut up you're the one that shit all over yourself. Review of witness statement, dated 03/26/2024, signed by CNA B, revealed the following: I was changing [Resident #1] and he had a huge blowout [bowel movement]. I turned him to pull the brief and noticed he had bowel going up his back and needed new sheets so [CNA C] went [and] got some sheets. She came back and when we were turning him to change sheet and briefs [CNA C] turned [Resident #1] and he said ow because his hip hurt and [CNA C] told him 'Shut up, I don't know why you are complaining you are the one that shit all over his self.' Review of witness statement, dated 03/26/2024, signed by CNA C, revealed the following: CNA walked into room to help other CNA with resident put back into the bed due to needing to be changed. When changing patient, noticed he had poop all the way up his back when lifting [patient] up to change him to get the poop off his back and to take his shirt off. He was complaining of him hurting this CNA said hush we are trying to not get poop on your face and continued to get the poop off resident. Review of witness statement, dated 03/26/2024, signed by LVN D and ADON, revealed the following: [Resident #1]. While I was in resident's room for incontinent care, I asked resident if a CNA talked ugly to him earlier in the day. Resident stated 'yes, she did but I didn't tell the other lady because I didn't want to get her in trouble. People need their jobs.' I told resident no one is allowed to curse at them or talk rudely to them. Resident's roommate stated 'Miss [LVN D] come here.' I approached roommate's bed and he stated, 'I heard it, but I didn't tell because he didn't [Resident #1], and we [Resident #1 and Resident #2] don't want to get anyone in trouble.' Review of notice of warning, dated 03/26/2024, signed by CNA C and ADM revealed CNA C received warning for allegation of verbal abuse of a resident. Review of interview statement by CNA A, dated 03/27/2024, signed by the ADON, revealed the following: I walked into [Resident #1's] room looking for the other aides. They were in the middle of a bed change and they [CNA B and CNA C] we're pulling him up in bed. [Resident #1] stated 'Ouch, you're hurting me. At this time, [CNA C] said 'shut up, you're the one that shit all over yourself.' [Resident #1] said 'I know I did and it stinks'. At this time I stated I'm leaving on that note. I went directly to [LVN D] and reported what was said. [LVN D] then sent me to the ADON/DON office where I reported what I had heard. Review of interview statement by CNA B, dated 03/27/2024, signed by the ADON, revealed the following: I was changing [Resident #1] brief. One that involved a large BM (bowel movement). I turned him to pull the brief and noticed he had feces going up his back and needed new sheets. So [CNA C] went and grabbed sheets. During care of changing his sheeets and brief, [CNA C] turned [Resident #1] at this time he said 'ow' because his hip hurt. [CNA C] told him to 'shut up, I don't know why you are complaining, you are the one that shit all over yourself.' At this time, the peri care was completed. I proceeded to peri care on another resident. When this task was completed, [LVN D] approached me and asked me to speak with [DON]. I give my statement to what I had heard [CNA C] say to [Resident #1] at this time. Review of provider investigation report, a resident inerview titled Safe Survey, dated 03/27/2024 and signed by the Social Worker, revealed Resident #1 and his roomate had no concerns or complaints and felt comfortable talking to staff about them if he had them. Additional safe surveys on neighboring residents revealed no concerns. Review of social note, dated 03/28/2024 at 10:40 a.m., signed by the Social Worker, revealed the following: There were witness statements saying an aide, that was helping them change a resident, had made a {vulgar} comment towards the resident. Resident was hollering/moaning due to pain, of being moved around, and the aide told the resident to 'shut up, you are the one who shit yourself.' When I asked the resident did he hear her say that, he said he heard her say something, but could not make it out to what she had said. Resident had also admitted to another nurse, that he in fact did hear her, he just did not want to get her in trouble. Review of witness statement, dated 03/29/2024, signed by LVN D, revealed the following: I entered [Resident #1]'s room to clarify if he heard exactly what [CNA C] said to him on 3/26/2024. Resident stated 'Is she in trouble? I don't want to get anyone in trouble.' I told resident we need to know if he heard what she said since he previously told me she was ugly to him. Resident stated 'she said shut the fuck up.' I thanked resident for speaking with me and left room. Review of grievance summary, dated 03/29/2024, signed by the Social Worker, revealed the following concern and conclusion: .Resident was hollering while getting changed, when an aide was helping assist him said 'Shut up, you are the one who shit yourself' .Resident was said he did hear her say something, but does not know exactly what she said. He has not had any mood or behavioral changes. A safe survey (resident interview regarding safety) was conducted and it was found, he was comfortable and safe here. He didn't feel like any harm in his way. The end result of the matter was that, the aide was terminated. RP, [family] was notified about the abuse allegations. Review of personnel record for CNA C, revealed a hire date of 03/05/2024 and received training on abuse with completed post test on 03/05/2024. Review of provider investigation report, dated 04/02/2024, signed by the ADM, revealed the incident ocurred 03/26/2024 at 1:00 p.m. and included the following: Investigation Summary . On 3/26/24 [CNA C] was providing incontinent care to [Resident #1], a resident. Two other staff members were present in the room: [CNA B and CNA A]. While assisting the resident he verbally complained of pain. At that time [CNA C] allegedly stated 'shut up, you are the one who shit all over yourself. This statement was heard by the two staff members that were in the room with [CNA C]. Administrator, DON, Physician, Responsible Party, Corporate Office, and HHSC notified. Alleged perpetrator suspended pending investigation. Staff inserviced regarding abuse/neglect, resident rights, safe transfers. Other residents interviewed in an attempt to discover if similar incidents had ocurred and not been reported. No other incidents or allegations were identified. Resident was interviewed/couseled by the social worker. Resident initially denied hearing what [CNA C] said to him. Administrator spoke to resident and made the same statement, that he had not heard what [CNA C] had said. Resident also told the administrator that he did not wish to get any staff members in trouble. Resident was later interviewed by [LVN D]. During that conversation the resident stated that he had heard [CNA C] tell him to 'shut the fuck up,' but he had not been honest about it because he did not wish to get anyone in trouble. Based on the evidence provided this investigator confirms the incident. Evidence suggests [CNA C] made the statements alleged. Investigation Findings: Confirmed Provider Action Taken Post-Investigation: [Facility] continues to make the safety and well being of its residents top priority. [CNA C]'s employment at [facility] has been terminated and she is not eligible for rehire. [Resident #1] continues to display no lasting effects as a result of the incident and no further incidents have been reported as o the writing of this report. Review of Resident Mood Interview for Resident #1, dated 04/09/02024 at 12:08 p.m., signed by the Social Worker, revealed no symptoms present. Review of in-services between March 2024 through April 2024 and employee roster, revealed training was provided to staff on abuse for the following dates: 03/21/2024, 03/26/2024, 03/27/2024, and 04/23/2024. During an interview with the ADM and DON on 04/24/2024 at 11:00 a.m., the ADM said that he was the abuse coordinator and was aware of the self reported incident of verbal abuse related to Resident #1. The ADM said there were multiple staff members in the room providing incontinent care and one of those aides was CNA C. The ADM said during that time, they were turning Resident #1 and he voiced that CNA C was hurting him and she told him to shut up, you are the one who shit yourself and that statement was corroborated by other staff in the room. The ADM said we immediately suspended her pending the investigation and terminated her with no eligibility for rehire. The ADM said the other aides in the room were CNA B and CNA A. The ADM said CNA A and CNA B were not at the facility that day due to CNA A no longer employed by the facility and CNA B works the night shift. The ADM said Resident #1 was doing good and has had no psychocial harm apparent from the incident. The ADM and DON said they were ensuring residents were free from abuse by reporting, conducting safe surveys, increased monitoring, and in-services with staff. The ADM and DON said it was important to protect residents from verbal abuse to prevent psychosocial harm. During an observation and interview on 04/24/2024 at 11:42 a.m., CNA E was walking with a resident down the hall and interaction appeared pleasant. CNA E said that she had worked at the facility for [AGE] years and had received training on abuse recently from in-services and that verbal abuse would be anything from talking down to a resident or cussing. She said she did not suspect any current abuse but was aware of CNA C being let go because of a verbal abuse incident. CNA E said she has had no additional concerns since CNA C was terminated and that she was not working when the incident occurred. CNA E said if she ever witnessed staff cursing at a resident she would immediately report to the ADM, the abuse coordinator. CNA E said it was important to prevent verbal abuse of residents because it could cause psychosocial harm. CNA E said she had never had to report abuse and that she felt residents were safe at the facility. During an interview on 04/24/2024 at 12:09 a.m., the ADON said she had been employed at the facility for 16 months. She said she had received and provided training on abuse and was aware of an abuse allegation and had recently reported alleged abuse on herself from a resident on the secure unit that said she had scratched her during her assessment on 4/23/2024 at around 8:15 a.m The ADON said she reported herself immediately to the ADM, the abuse coordinator, and was suspended until 12:30 p.m. the same day. The ADON said she was out that day when Resident #1 had his incident with the aides and that she has a good relationship with Resident #1 and he will ask for her personally over any issues. The ADON said she asked Resident #1 about the incident with CNA C and he was reluctant to provide any information, but informed him on his safety. The ADON said Resident #1 never told her what CNA C said to him and the DON called her that day with him on the phone so he would feel comortable talking to the ADON since they have a good relationship. The ADON said Resident #2 was his roommate and she asked if he had heard anything and he said no. The ADON said Resident #1 was doing good and has exhibited no signs of psychosocial harm from the incident. The ADON said staff had received training on abuse via in-services and that they did a skills fair recently addressing abuse in March 2024 consisting of a two day event with hands on scenarios and they get the residents involved. The ADON said she felt the incident with CNA C was isolated and that the facility handled the situation appropriately with her termination and felt residents were safe at the facility. The ADON said it was important for residents to remain free from verbal abuse to prevent psychosocial harm. During an interview on 04/24/2024 at 2:08 p.m., LVN F said she had no concerns with staff talking to residents inappropriately and if she did she would report to the ADM. LVN F said she had not worked with CNA C and that if she witnessed staff being verbally abusive to residents she would intervene and make sure both parties are safe before reporting to the ADM. LVN F said she did not suspect any verbal abuse that would consist of talking inappropriately to resident like cursing and that she aware of the incident with CNA C and Resident #1 but did not witness the incident. LVN F said she felt the facility handled that situation appropriately and CNA C was terminated. LVN F said it was important to prevent and protect residents from verbal abuse because it could cause them to become more depressed, socially withdrawn, and could cause psychosocial harm. During an interview on 04/24/2024 at 2:36 p.m. by phone, CNA G said she was PRN. CNA G said she had received training on abuse and verbal abuse would be yelling at a patient, being irate and disrespectful. CNA G said it was important to prevent verbal abuse of residents because it could cause psychosocial harm, that she did not suspect abuse at this facility, and that if she did she would report it to the ADM immediately. During an interview on 04/24/24 at 2:48 PM via phone, CNA C said she and CNA B went to get Resident #1 cleaned up. CNA C said they got him in the bed with the hoyer and he freaks out sometimes because he has arthirits in his back. CNA C said CNA A was coming in the room and when CNA B rolled him over she said it [feces] is up your back we are going to have to take your shirt off and when we sat him up. CNA C said she told Resident #1 to hush, stop, look at me, when we pull it over the top of your head, if you jerk back like that you are going to get poop on your face. CNA C said Resident #1 undesrstood what we were doing and they got him cleaned up and that was it. CNA C said she did not tell him to shut up because she does not talk like that. CNA C said she told him to hush and to look at me. CNA C said she probably did say shit but never told him to shut the fuck up and that the charge nurse said CNA A told her six different stories. CNA C said one story was she said shut up and then it was shut the fuck up and I wanted to ask them questions because if it that was serious why didn't the other aides stop me at the time because the resident's safety was first and they just stood there. CNA C said the facility did not provide training on abuse, but they had in-services on paper at the front and told you to sign them. CNA C said she honestly did not have time to read them when she had 22 residents to take care and was not going to remember what that paper said. CNA C said verbal abuse would be considered belittling and cursing at residents and that it could affect resdidents mentally if they have depression and make them withdrawal. CNA C said she did not curse near any other residents and could not remember if his roommate was in the room at the time of the incident. During an interview on 04/24/2024 at 3:23 p.m., the ADM said verbal abuse was confirmed with Resident #1 and that the resident was truthfully reluctant to provide information that he had overheard what the aide said because he did not wish to get anyone in trouble. The ADM said that Resident #1 was doing fine and has had no negative psychosocial outcomes and that it was important to protect residents from verbal abuse to prevent resident from becoming with more withdrawn and the resident experieincing verbal abuse could experience psychosocial harm. The ADM said to ensure residents are safe from abuse he has provided training, reported to HHSC, and appropriate entities listed in policy, safe surveys were conducted, the incident was QAPI'd (Quality Assurance and Performance Improvement), and alleged perpetrator was terminated. The ADM said there was no concern with her background or licensure check. The ADM said that he did feel this incident caused reason for referral of CNA C. The ADM said that the Social Worker was at the facility and had assessed Reisdent #1's mood and behavior following the incident. During an interview on 04/24/2024 at 3:29 p.m., the Social Worker said she had been employed since October of 2023 and did not suspect abuse. The Social Worker said she had safe surveys to ensure residents are safe and that it was important for residents to be free from verbal abuse to prevent psychocial harm. The Social Worker said Resident #1 was doing good and has not had any complaints with him as far as his care provided. The Social Worker siad there was an incident with CNA C changing him and he never admitted it to me that he heard her say something and could not make out what she said. The Social Worker said Resident #1 has had no mood changes and has been more active in activities. During an observation on 04/24/2024 at 3:45 p.m., Resident #1 was lying in bed with his head covered. He did not respond to greeting or questions and exhibited no signs of distress. There was no other resident in his room. During an interview on 04/25/2024 at 11:17 a.m., Resident #1's RP said they were notified of the verbal abuse incident on 3/26/2024 and that the resident had socially improved since the incident and was attending more activities than previously. RP said they had no concerns and that they felt the CNA that told the resident to 'shut up' should not have been fired because the resident can be very difficult and rude to nursing staff and that they believe she should be rehired. RP said they had no concerns with the care and services provided by the facility or staff related to abuse. RP said it has been over a month since she had visited the resident because she was diagnosed with cancer and also because of his rude behavior when RP did visit. Review of facility policy, titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property, effective June 23, 2017, revealed the following: Purpose The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property . Policy 1.Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2 Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms . 5. Training. The facility will conduct staff member training regarding abuse, neglect, and exploitation and the misappropnat1on of resident property, to include prevention, intervention, detection, reporting and employee rights. During each new staff member's orientation and annually thereafter, the facility at a minimum provide training on the following topics: a. Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property b. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property c. Dementia management and resident abuse prevention. Additional training may be provided in new employee orientation and thereafter in on-going training sessions on the following topics: a. Activities and behaviors that constitute abuse, neglect, and exploitation . d. Working with residents with dementia or cognitive impairment. e. Techniques for management of difficult residents. f. Identification of factors that contribute to, or escalate, hostile behavior. g. Assessment of staff responses to aggressive or hostile behavior h. Identification of employee and resident coping behaviors, and how to reinforce positive and adaptive behaviors. i. How to report any incidence of suspected abuse, who the abuse coordinator is, and how investigations are conducted at the facility. j. How to file a complaint with the state survey agency against any facility that retaliates against an employee who makes a report. k. Appropriate interventions that are implemented to deal with aggressive and/or catastrophic reactions of residents. l. How to recognize signs of burnout, frustration and stress that may lead to abuse. m. Behavioral interventions that can be used for inappropriate resident behaviors . To provide protection to the resident during an investigation, the Facility should apply the following procedures: a. protect residents by removing immediate threats and potential harm; b. if the alleged perpetrator is a staff member, the staff member will be suspended from employment and not allowed in the facility, pending the outcome of the investigation, and the Regional Human Resources Consultant will be notified of the suspension; c. the Abuse Coordinator or designee will be assigned throughout the investigation to follow-up with the person and/or persons involved with the concern, incident, or grievance. If allegations of abuse, neglect, exploitation, or misappropriation involve the Administrator's conduct, then the Regional Director of Operations will be assigned to coordinate the investigation; d. the Abuse Coordinator or designee will conduct relevant interviews to determine if any form of retaliation has occurred . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. (42 CFR S488.301). This also includes the deprivation by an individual (including a caretaker), of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish . Abuse Coordinator: Licensed Facility Administrator. Adverse event: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury. Verbal abuse: 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, inability to comprehend, or disability. Examples of verbal abuse include, but are not limited to threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again . The surveyor confirmed PNC had been implemented sufficiently to remove the deficiency by: - Facility implementation of monitoring resident for psychosocial harm. - Facility notification of abuse incident to responsible parties, MD, police, Ombudsman, and HHSC. - Completion of mood assessment on resident/victim. - Completion of in-services on abuse. - Completion of safe surveys on residents. - Suspension of involved staff pending outcome. - Completion of warning notices for involved staff. - Termination of confirmed perpetrator. The noncompliance was identified as PNC. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed to ensure the residents environment remained free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for accidents, hazards, and supervision. 1.The facility failed to adequately supervise Resident #1 when being transferred. Resident #1 sustained a fracture of the distal femur (broken bone above the knee) when the Hoyer Lift Sling broke while being transferred with a Hoyer lift device on 1/31/2023. 2. The facility failed to adequately supervise Resident #2 while in a shower chair on 2/28/23. Resident #2 sustained a fracture of the distal third tibial and fibular shaft fracture with comminution and slight displacement. An Immediate Jeopardy was identified on 06/02/23 at 4:03 p.m. While the Immediate Jeopardy was removed on 06/03/23 at 2:00 p.m., the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need evaluate and monitor the effectiveness of corrective systems. These failures could place residents at risk of falls, fractures, and other accidents . Findings include: 1.Record review of Resident #1's face sheet, dated 5/15/2023, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: Unspecified fracture (broken bone) of the lower end of right femur, subsequent encounter for closed fracture with routine healing, tachycardia (rapid heart rate), pain right knee, chronic kidney disease stage 4, acute kidney failure (kidneys fail to filter), and osteoarthritis (bone degenerating). Record review of Resident #1's Admission MDS, dated [DATE], revealed a Brief Interview for Mental Status of 3, which indicated severe cognitive impairment. The MDS further revealed the resident's functional status was a 4 for transfers which indicated total dependence and a 3 for support in transfers which indicated she required two or more person assist. Record review of Resident #1's Nurses Notes, by LVN D, dated 01/31/23, read, 8:00 a.m. called to room by [LVN C] nurse observes resident on floor, leaning back against recliner, nurse observes Hoyer lift in room, staff state CNAs x 2 were transporting resident from shower chair to recliner with nurse in room, one strap on Hoyer pad broke, resident slide out of lift pad, resident's right leg bumped Hoyer lift and head fell on recliner. Orders per Medical Doctor (MD) for Mobile X ray of lower extremities and pelvis.1:30 p.m. - x-ray findings - Right Lower Extremity - fracture to distal femur, notified MD, states to send resident to hospital, Emergency Medical Service (EMS) contacted. 1:55 p.m. EMS arrives at facility, resident transported out of facility via stretcher to emergency room (ER). 4:30 p.m. - received report from ER, states XRAY confirmed fracture to right femur. ER MD recommends resident follow up with orthopedist. Resident is discharged from hospital at this time, returning to nursing facility. Record review of Resident #1's Nurses Notes, by LVN E, dated 01/31/2023, read, 12:45 p.m. EMS arrived at facility, resident transferred to stretcher for transport to Hospital for surgical consult of fracture right distal femur. Record review of a witness statement, dated 1/31/2023 and signed by CNA A, reflected, Me, another CNA and nurse used proper procedure to lift resident from bed to chair and the lift pad strap snapped. Got more help after. Record review of a witness statement, dated 1/31/2023 and signed by CNA B, reflected, Upon transferring [Resident #1] from her bed to her recliner, the color-coded hooks tore apart. Resident began slipping out of the lift pad. My co-worker [CNA A] caught her upper body to keep resident from hitting her head on the recliner. I continued to lower the lift pad to the floor. The treatment nurse was in the room and witnessed the entire ordeal. We immediately called for help and [Resident #1] was assessed by the charge nurse. Record review of a witness statement, dated 1/31/2023 and signed by LVN C, reflected, I was in the room to provide wound care to resident. After I completed care [CNA A] and [CNA B] hooked the lift pad to the lift. They began lifting the resident to move her from the bed to the recliner. I began walking away and was about to leave the room when the leg strap on the lift pad broke. The resident's legs slide down onto the floor and the resident slide down onto the floor as the CNA's tried to catch her. I immediately called for assistance and began an assessment of the resident. The resident denied pain during the entire process, we notified the ADON and the DON immediately. Record review of Resident #1's Nurses Notes by Charge Nurse E, dated 02/06/2023, reflected, Returned to facility via EMS, post open reduction with internal fixation of right distal femur (surgery to repair broken bone above knee). Record review of Resident #1's care plan, with revision date 2/23/23, revealed Impaired physical mobility with an intervention/approach .resident unable to be transferred with Hoyer lift due to location of fracture, surgical repair of right femur fracture 2/3/23 During an observation and interview on 5/15/23 at 10:30 a.m., the Administrator provided the Hoyer lift pad used to transfer Resident #1 on 1/31/23. The blue lift pad was faded, the green straps were faded to a turquoise color, the red straps were faded to a pink color. The lower right strap that was originally black in color was cream colored with the last loop and second loop broken into with frays. The Administrator said it was the pad used during the transfer of Resident #1 and it was defective , most likely due to contact with bleach. During an interview on 05/15/2023 at 11:59 a.m. with CNA A, she stated she had been working at the facility since February 2022. CNA A said she received training on Hoyer lift safety and was checked off on the procedure on 2/01/2023. She stated it was policy to use 2 people for the Hoyer lift, to check Hoyer pad straps for signs of wear before use, but she forgot them on 1/31/23 before lifting Resident #1 . She said she observed Resident #1 bumping her knee against the Hoyer lift leg as she slid onto the floor. During an interview on 05/16/2023 at 2:35 p.m., CNA B stated she had been employed at the facility for [AGE] years. She said she received training on Hoyer lift safety and was checked off on the procedure on 2/01/2023. CNA B said using a Hoyer was always a 2 person assist, the straps were to be inspected before they were connected to the lift for signs of wear, but she forgot check the Hoyer pad straps for signs of wear before lifting Resident #1 on 1/31/2023 . She said she observed the resident bumping her knee against the Hoyer lift leg as she slid to the floor. During an interview on 05/18/2023 at 2:37 p.m., LVN C stated she had been employed at this facility a little over 4 years. LVN C said she received training on Hoyer lift safety and was checked off on the procedure on 2/01/2023. She said using a Hoyer lift would always be at least a 2 person assist, the Hoyer pad straps should always be inspected before use. She said she was not actively participating in the transfer when the incident occurred but observed the resident sliding to the floor and the resident bumping her right leg on the Hoyer lift leg. During an interview on 05/16/2023 at 12:03 p.m., CNA F stated she had been working at the facility for 2 years. She stated she would always use 2 people when making transfers with a Hoyer lift and inspect the straps on the Hoyer sling before use as that was the facility policy , and safer. She said she received training on 1/31/2023 after the incident with Resident #1. During an interview on 05/16/2023 at 12:30 p.m., CNA G said she worked at the facility for 9 years. She stated it was the facility's policy to always inspect the Hoyer sling before attaching it to the lift. CNA G stated she would not transfer anyone without help and would make sure the sling straps were not worn or discolored .CNA G said she received training after the incident on 1/31/23 and would remove any sling from service if it had signs of wear. During an interview on 05/16/2023 at 2:30 p.m., CNA K stated she worked at the facility for over [AGE] years. She stated a Hoyer transfer was always a 2 person assist, staff should always check the sling straps for discoloration, signs of wear including seams and stitching. CNA K said all staff were checked off on Hoyer lift safety including signs of wear to the slings and straps after the incident with Resident #1 and she received training after the incident on 1/31/23. CNA K said the Hoyer sling used to transfer resident #1 had been damaged since it was cream colored. During an interview on 05/17/2023 at 9:30 a.m., the ADON said she worked at the facility for 6 months. The ADON said she went to the room to assist CNA A, CNA B and LVN C immediately after the incident. The ADON said there was one on one training with CNA A and CNA B on 1/31/2023. She said all nurses and aides were in-serviced on 1/31/2023 and 2/1/2023 on Hoyer lift transfers and inspection of sling straps for signs of deterioration. The ADON stated the facility policy was to use 2 people when using the Hoyer lift to transfer residents and to inspect the straps prior to placement on the hooks of the lift. The ADON said a Quality Assurance meeting was held the day of the incident and a plan was immediately put in action. During an interview on 05/16/2023 at 1:00 p.m., the Administrator stated regarding the incident with Resident #1, he remembered it was reported to him as he arrived at the facility that morning. The Administrator said the MD and family were notified, and orders were obtained. The Medical Director was informed, and a Quality Assurance Performance Improvement meeting was conducted on 1/31/23. A Quality Assurance Action Plan was developed, all slings were examined, new slings were ordered and labeled. Slings were monitored weekly for four weeks then monthly. The Administrator stated proficiencies were done with all aides due to this incident. The Administrator stated CNA A and CNA B were given a one-on-one in-service. He said there were risks of harm to residents by using a Hoyer sling that had any signs of deterioration, such as falls, lacerations, and a second person was needed to assist with movements of resident. The Administrator said all nursing staff were trained on proper use of the Hoyer lift including inspection of the slings before each use. The Administrator stated all laundry staff were retrained on the proper policy and procedures regarding laundry care (washing and air drying) of the Hoyer lift slings . Record review of the facility's in-service log reflected in-services were conducted on 1/31/2023 to 2/05/23 with competency checkoff for all nursing staff regarding proper use of the Hoyer lift and inspecting equipment prior to use. Record review of the Quality Assurance and Performance Improvement meeting minutes on 2/14/2023 and supporting documentation revealed that individual checkoffs for RN's, LVN's and CNAs were completed in January and February of 2023 for using the Hoyer lift and inspecting the sling straps prior to use. New Hoyer slings were labeled and put into use. Monthly checklist inspection of Hoyer slings had been logged each month by the ADON. Laundry staff received in-service on proper methods of washing and air-drying of Hoyer slings and when to take slings out of rotation (When slings show signs of wear, such color fading of fabric or stitch fading). During interviews and observations with 5 CNAs (CNA A, CNA B, CNA F, CNA G, CNA K and 3 LVNs ( LVN C, LVN D and LVN E) on the morning and evening shift on 5/16/23, all employees indicated they would always use at least 2 persons when transferring a resident using the Hoyer lift and inspect the Sling straps before use. Demonstration of correct transfer using Hoyer lift with sling check observed on 5/16/23 during a shower with Resident #2 and two CNAs . During interviews with Laundry Supervisor and Laundry Staff on 5/16/23, both employees indicated they would wash the slings according to manufacturer's suggestions (using no bleach and air dry) and had received inservice on signs of wear, signs of improper laundering and when to remove slings from service. A record review of the facility's policy Mechanical Lift, revised January 2020, reflected, .Residents will be assisted with their activities of daily living, utilizing lifts according to manufacturer's guidelines A record review of Full Body Slings- Medline, Instructions for use www.medline.com 2022 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use 2. Record review of Resident #2's face sheet, dated 5/17/23, reflected a [AGE] year-old female who was admitted to the facility on ,d+[DATE]/. Resident #2 had diagnoses which included: brain cancer, lung cancer, unspecified dementia (confusion), history of falling, osteopenia (brittle bones), chronic pain (pain non acute), distal third tibial and fibular shaft fracture (broken lower leg bone) with comminution and slight displacement (bone no longer joined together). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a Brief Interview for Mental Status of 6, which indicated severe cognitive impairment. The MDS further indicated the resident's functional status for bathing was a 4 which indicated total dependence and a 2 for support in bathing which indicated she was one person assist. Record review of Resident #2's care plan, dated 4/02/23, indicated the resident was high risk for falls Limited joint mobility caused resident to have a higher risk of falling, with an intervention/approach .Hoyer with 2 persons assist She had a self-care deficit need for assistance with personal care with interventions with extensive total assistance and provide assistance with self-care as needed. Record review of Resident #2's emergency room records indicated she visited the emergency roiagnom on [DATE] with a diagnosis of fracture of the distal third tibial and fibular shaft fracture with comminution and slight displacement. Record review of Resident #2's nurse note dated 02/28/23 at 5:17 p.m., LVN E wrote, 02/28/2023 called to room by CNA, Resident #2 fell while in shower chair in shower. Resident lying on right side with no complaints at this time, examined resident and large knot on front of head and indention in forehead on left side. Resident complained of head pain, Medical Doctor notified of incident and new order received to send to emergency room for evaluation. [3:10 p.m.] Emergency medical services called to facility [3:13 ] Responsible party notified called and requested [hospital name] hospital. [3:20 ]: Emergency Medical Services arrived at facility and resident transferred via stretcher. Record review of Resident's #2's nurse note dated 02/28/2023 at 7:00 p.m., and signed by LVN H, she wrote, received call from [hospital name] Hospital that resident is ready to return to facility. Ortho consult with [Doctor's name] to be follow up in the morning. Diagnosis: Left distal third tibial and fibular shaft fracture with comminution and slight displacement. Splint brace to Left leg. Record review of a witness statement, dated 02/28/23 and signed by ADON, reflected, CNA A said while showering resident, CNA reached to grab a towel to dry off the resident. At this time the resident grabbed the assist bars in the shower and tried to pull herself up and resident fell out of the shower chair. CNA A notified charge nurse immediately .This nurse notified by [LVN H], nurse on A Hall, and when entered room nurse [LVN E], was in resident's room. Observed resident laying on her right side, noted to have a knot on her left forehead. MD notified and ordered to send resident to emergency room . Record review of a facility in-service, dated 2/28/2023, indicated education was provided: 1. All items within reach during showers when provided resident care, ensure all items are within reach to prevent leaving resident. During an observation on 5/15/23 at 9:15 AM, Resident #2 was lying in bed awake alert to person only. Resident #2 was asked questions but would not respond. Attempted phone interview with Resident #2's family member on 5/15/2023 at 3:00 PM, left a message with no return phone call. During an interview on 05/15/23 at 2:37 p.m., CNA A said she had been employed at the facility for 1 year but had been a caregiver since 2019. She said on 02/28/23 she rolled Resident #2 into the shower in the shower chair. She said when she had completed the shower, she squatted down beside the shower chair with one hand on the arm of the chair to spread a towel on the floor to keep from slipping. CNA A said she turned away to grab a towel on the toilet, no more than two feet away from Resident #2. She said at that moment Resident #2 reached for the grab bar to pull herself up and fell out of the chair onto her knees on the floor. CNA A said she saw her falling and dove for the resident to try and keep her from hitting her head. She said she immediately called for her charge nurse to come and help. She said Resident #2 required 1 person for transfers and bathing. During an interview on 5/16/23 at 9:27 a.m., the ADON said CNA A turned away from Resident #2 to get a towel and that was when she fell . She said when the resident fell , she was grabbing the hand bar while CNA A turned to get a towel. The ADON said they in-serviced staff on keeping supplies within reach and safety of the resident. During an interview on 05/16/23 at 11:15 a.m., MA F said when she got through passing her medications, she tried to help the nurse aides on the floor. She said they had cut the aides because of their census. She said Resident #2 leaned forward a lot, and she would pull at things. She said Resident #2 really couldn't use her left side, but she could hold a cup in her right hand. MA F said she almost fell out of her wheelchair in the dining room last Friday (5/12/23). She said Resident #2 pushed herself back from the table and then she leaned forward and almost fell out of the chair. She said the lady cleaning the tables caught her . During an interview on 05/16/23 at 2:07p.m., CNA G said she worked at the facility since 2016. She said she always got another CNA to help her shower Resident #2 because she leaned. CNA G said she got another CNA because once she got wet with soap on her hands, it was hard to reposition the resident when she started leaning, to keep her from falling . CNA G said she had not reported the need for increased assistance to the MDS Coordinator but intended to do so. During an interview on 05/16/23 at 3:56 p.m., the Administrator said he thought CNA A left Resident #2 alone was the problem (stepping 2 feet away). The Administrator said CNA A was not suspended and had no prior disciplinary action besides frequently calling in. The Administrator said they did talk about falls every morning in the morning meeting, and they reviewed all falls during the monthly QAPI, meeting. The Administrator was unable to produce any Performance Improvement documentation involving the resident's fall. A record review of the facility's policy Fall Management, dated January 12, 2020, indicated, . The facility will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The community will manage falls by providing an environment that is free from potential hazards. This was determined to be an Immediate Jeopardy (IJ) on 06/02/2023 at 4:03 p.m. The Administrator was notified. The Administrator was provided with the IJ template 06/02/2023 at 4:03p.m. The following Plan of Removal was submitted by the facility was accepted on 6/03/2023 at 9:31 a.m. and included the following: On 01/31/2023 [Resident #1] was being transferred from bed to recliner with Hoyer lift by two CNA's. The strap broke on the right lower side and the resident slid to the floor hitting her knee on the leg of the lift causing a fracture. [Resident #1] required surgery on 02/3/23 for fracture of right femur and returned to the facility on [DATE]. Resident was transferred to acute care . 03/25/23 for complications related to preexisting arterial circulation of the right lower leg and did not return to facility. In-services and training provided by DON and ADON to all nursing staff. New nursing staff receive competency upon hire and annually thereafter. 1. Resident abuse and neglect on 1/31/23, 2/28/23 2. Hoyer Lift use, 1/31/23 3. Safe transfers, 1/31/23 4. Hoyer slings 1/31/23 5. Hoyer lift expectations. 1/31/23 6. Laundry- Lift Pads- Washing and drying -removing from service-1/31/23 provided by Housekeeping Supervisor to all Laundry Staff. All new laundry staff are trained upon hire and annually thereafter. 7. Hoyer Lift Skills and procedure for all nursing staff were completed 2/1/23 to 2/5/23 by administrative Nursing. All lift slings were removed from service and replaced with new slings by 2/2/23. Weekly monitoring of slings x 4 weeks then monthly completed by DON or designee. Verification of monitoring logs indicated all new slings in good condition and no old slings found in facility. The Medical Director was immediately notified and actively participated to develop improvement plan concerning Hoyer slings and training of staff. The plan was reviewed in Monthly QA Meeting with the Medical Director on 2/14/23 and monthly thereafter. On 2/28/2023 [Resident #2] leaned forward, reaching for the handrail and fell out of a shower chair when [CNA A] reached for a towel approximately 2 feet away. Resident #2 was diagnosed with a tibia and fibula fracture. Her leg was placed in a splint, and she returned to the facility. The leg was later placed in a cast. 18 nursing staff were in serviced by the ADON to ensure that all required items were in reach while showering a resident to prevent stepping away from the resident while being showered on 2/28/23. This in-service was repeated on 6/2/23 with nursing staff currently on shift. All nursing staff will be in serviced by 2 PM on 6/3/23. Any staff member that is not able to complete the in-service by this time will be removed from the schedule and not allowed to work until it is completed. [Resident #2] was care planned to require 2-person assistance on 5/16/23 by the MDS coordinator. All other residents were reassessed for level of assistance needed and care plan accuracy beginning 5/16/23 and completed by 5/18/23 by the MDS Coordinator and Regional Nurse Consultant. All nursing staff will be reeducated regarding ADL documentation accuracy and reporting changes via Point of Care (the documentation system used by the nurse aides) documentation by 6/3/23. DON or Designee will observe 2 showers per week for 4 weeks and periodically thereafter. Results will be reported to QA committee beginning 6/3/23 for 2 months. DON or Designee will observe 2 showers per week for 4 weeks and periodically thereafter. Results will be reported to QA committee beginning 6/3/23 for 2 months. Observations, Interviews, and record reviews were conducted 6/03/2023 from 12:30 p.m. through 2:00 p.m. and included (Administrator, ADON, 2 Laundry staff, 5 CNAs and 4 LVNs on the morning and evening shift) to ensure these interventions had been completed. Nursing staff were able to appropriately indicate they would always use at least 2 persons when transferring a resident using the Hoyer lift and inspect the sling straps before use. Laundry staff were able to appropriately indicate proper laundry methods for Hoyer slings and signs of deterioration. Nursing Staff were able to identify residents' care plans, the Kardex system and how to find level of resident care. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Nursing Staff were able to discuss the required level of staff assistance for ADLs, documentation accuracy and reporting changes via Point of Care. Staff were able to demonstrate the use of the Kardex system for resident care needs. A facility record audit from 5/16/2023 to 5/18/2023 by the MDS Nurse and Regional Nurse Consultant for all residents in current census indicated: each resident was reviewed for assistance to complete ADL tasks needed and the total number of staff members required. Nursing staff were in-serviced on 06/02/23 and 06/03/23 by the ADON to ensure that all required items were in reach while showering a resident to prevent stepping away from the resident while being showered. Nursing staff were in serviced by phone if not present at the facility and those who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. The care plan showed that Resident #2 was changed to a 2-person assist on 5/16/2023 by the MDS coordinator. Monitoring of the POR included the following: On 6/03/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: The facility completed an audit 5-16-23 to 5-18-23 of Care plans and Kardex's for level of assistance needed. Interviews with CNAs for all residents in current census to make updates to their POC. Each resident was reviewed for assistance required and the number of staff members required to complete ADL Tasks. CNAs Educated to continue to notify charge nurses of any changes with level of care needed with the charge nurses/MDS nurse so POCs can be updated to reflect the correct amount of assistance needed. This in-service was completed by [NAME] RN, MDS Nurse. (There was a total of 4 residents that required a two person Hoyer Lift which indicates two persons for Bathing and Mobility) The staff in- serviced included: 38 Nursing Staff members,16 licensed vocational nurses, 2 registered nurses, 20 CNA's certified Nurse Aides. The ADON, Regional Nurse Consultant, MDS Coordinator and Administrator were interviewed. LVN's and CNAs were interviewed from different shifts, on training and understanding to ensure compliance. All staff were able to verbalize understanding of in-service training regarding 1. Ensure POC is accurate with care/assistance needed. 2. Update Charge Nurse with any assistance needed outside of current plan, so the Plan of Care can be updated to provide correct documentation. 3. Shower Safety to include: a. All items are within reach during showers. b. When providing care for the resident ensure all items are within reach to prevent resident from being Observations, Interviews, and record reviews were conducted 6/03/2023 from 12:30 p.m. through 2:00 p.m. and included (Administrator, ADON, 2 Laundry staff, 5 CNAs and 4 LVNs on the morning and evening shift) to ensure these interventions had been completed. During an interview on 6/03/2023 with Laundry Supervisor and one laundry staff member were able to appropriately indicate proper laundry methods for Hoyer slings and signs of deterioration. During an interview on 6/03/2023 with LVN K, LVN L, LVN M, and ADON, Nursing Staff on day and evening shifts were able to identify residents' care plans, the Kardex system and how to find the level of resident care. Staff provided appropriate resident supervision and redirection. There were no observed concerns. During an observation and interview on 6/3/2023 with, MDS Co-Ordinator, ADON CNA N, CNA O, CNA P, CNA Q and CNA R on day and evening shifts were able to demonstrate the use of the Kardex system for resident care needs and were able to discuss the required level of staff assistance for ADLs, documentation accuracy and reporting changes via Point of Care. A record review on 6/3/2023 of a facility record audit from 5/16/2023 to 5/18/2023 and by the MDS Nurse and Regional Nurse Consultant (RNC-T), for all residents in the current census indicated: each resident was reviewed for assistance to complete ADL tasks needed and the total number of staff members required . The facility completed an audit 5-16-23 to 5-18-23 of Care plans and Kardex's for level of assistance needed. Each resident was reviewed for assistance required and the number of staff members required to complete ADL Tasks. Interviews were conducted by the MDS Nurse with 5 CNAs for all residents in current census to make updates to their POC. 2- RNs, 16 LVNs and 20 CNAs were educated to continue to notify charge nurses of any changes with level of care needed with the charge nurses/MDS nurse so POCs can be updated to reflect the correct amount of assistance needed. This in-service was completed by the MDS Co-Ordinator. (There were 4 residents that required a two person Hoyer Lift which indicates two persons for Bathing and Mobility) A record review on 6/3/2023 of in-services on 06/02/23 and 06/03/23 for 38 Nursing Staff members by the ADON to ensure all required items were in reach while showering a resident to prevent stepping away from the resident while being showered. Nursing staff were in serviced by phone if not present at the facility. A record review on 6/3/2023 of the care plan showed Resident #2 was changed to a 2-person assist on 5/16/2023 by the MDS coordinator. During an interview on 6/3/23 at 12:20 p.m. to 1:15 p.m. with Nursing staff LVN K, LVN L, LVN M, ADON CNA N, CNA O, CNA P, CNA Q and CNA R were able to verbalize understanding of in-service training regarding: 1.Ensure POC is accurate with care/assistance needed. 2.Update Charge Nurse with any assistance needed outside of current plan, so the Plan of Care can be updated to provide correct documentation. 3.Shower Safety to include: a. All items are within reach during showers. b. When providing care for the resident ensure all items are within reach to prevent resident from being regarding level and care, needed assistance during ADL's, Shower safety and Abuse/ Neglect. During an observation and interview on 6/3/23 at 1:25 p.m. CNA P and CNA Q transferred Resident #3 using two person Hoyer lift to the shower chair (Hoyer sling appeared new in condition) and showered the resident. Resident #3 had no complaints with his level of care and said he felt safe with the staff. CNA's verbalized understanding to always check Hoyer Lift slings for signs of wear which included discoloration or loose stitching. CNA P and CNA Q were able to demonstrate and verbalize the need to obtain supplies before beginning a shower and keep all items in reach during showers. Staff were able to verbalize/ demonstrate knowledge of procedure. The Administrator was informed the Immediate Jeopardy was removed on 06/03/23 at 2:00 p.m. The facility remained out of compliance at a severity level of actual harm and a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.