Every finding on record at Crestview Healthcare Residence

These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 1 resident (Resident #1) reviewed for quality of care.Resident #1 had an appointment on or around 4/28/2025, for an MRI (a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in your body) for his prostate, and the facility failed to schedule the appointment and failed to place the necessary preop instructions needed for the procedure in PCC; subsequently Resident #1 missed his appointment twice. There were no adverse reactions from him not attending his appointment. These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Record review of Resident #1's admission record, dated 8/14/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included major depressive disorder, recurrent severe without psychotic feature (s characterized by multiple episodes of major depressive disorder that are severe in nature but do not include psychotic symptoms), chronic embolism and thrombosis of unspecified vein (a blood clot in a deep vein that has lasted for at least a month. It can be difficult to treat and can lead to scarring and vein damage), overactive bladder (causes sudden urges to urinate that may be hard to control), and benign prostatic hyperplasia with lower urinary tract symptoms (is a noncancerous enlargement of the prostate gland that can lead to lower urinary tract symptoms, affecting urination and overall quality of life). Record review of Resident #1's quarterly MDS, dated [DATE] reflected a BIMs of 10, which indicated mild cognitive impairment. Record review of Resident #1's physicians order dated 10/31/2024 reflected Resident #1 had a referral to see the urologist upon admission. Original orders from the hospital dated 3/31/2025 revealed the resident had a cystoscopy on 3/26/2024 which identified large bladder capacity. The resident has an overflow incontinence. TRUS not performed. It was recommended a Urolift but the patient canceled. 12/3/24: the resident wen in there of complaints included severe urge incontinence. Overall, he is frustrated with his status. Patient report delayed ejaculation. During an interview on 8/14/2025 at 1:50 PM with Resident #1 revealed he had an MRI that was scheduled that he did not attend. Resident #1 stated he waited a month to get the appointment scheduled, he was advised the facility never received he prep instructions. He stated he gave the instructions to the ADON. He stated he has waited 3 months for the appointment, and it is finally scheduled for 8/15/2025. He stated the DON apologized and assured him it was rescheduled, and he will be prepped the night before and he will be transported to his appointment. He stated he was upset that once he saw the ADON, she did not apologize to hm for the mistake she made. During an interview on 8/14/2025 at 4:20 PM with ADM revealed there was a transportation driver that brings the residents to their appointments if she was informed. He stated if residents had appointments scheduled at the same time, they utilized a ride share company. He stated there was a mix up with the appointment with Resident #1. He stated it was missed once and it was rescheduled. He stated it was an MRI appointment for urology. He stated it was not an appointment that was life threatening. During an interview on 8/14/2025 at 5:08 PM with ADON revealed Resident #1 came from another town hospital and he scheduled his own MRI and set up his own transportation where he attended his appointment in the other town. She stated he came back with no follow-up paperwork. She stated she received a call from the surgical confirming his appointment on or about 3/30/2025. She advised the surgical representative that there will not have anyone medically equipped on the van to handle Resident #1 after the procedure. The next day they called from the same surgical center and stated he cannot get on the van after the procedure. The ADON stated that was why the first appointment was cancelled. She stated Resident #1 then received a referral from the doctor to a local urologist. The ADON stated the appointment was scheduled but never questioned anything regarding preop instructions because she figured he did not need anything for the MRI. Once he arrived at the appointment, he could not be seen because he had not been prepped. The ADON stated they received the orders from the doctors' office, but the orders were not put into PCC so Resident #1 missed that appointment. The ADON stated the orders was now placed into the system and Resident #1 appointment was scheduled and he has started his preop for the procedure that will take place on tomorrow. The ADON stated the was not a life-threatening procedural appointment he missed. During an interview on 8/14/2025 at 5:38 PM with DON revealed it was the ADON or the charge nurse job to make sure appointments and orders are placed in PCC but ultimately it was her responsibility. The DON stated the first time, the surgical center in [NAME] did not communicate the instruction. The second time, it was not entered into PCC. When she learned about it, she scheduled it. She stated the ADON went on vacation, and she did not see the instruction. It was revealed, the instructions were not placed in PCC. She found the instructions and she went over them with Resident #1. She advised him it was scheduled for 8/15/2025 and he was alright with that. A record review of the facility's Abuse Prohibition undated policy revealed, each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. It may include failure to assist in personal hygiene, or in provision of food, clothing, shelter; failure to provide medical care for physical and mental health needs or failure to protect from health and safety hazards.

Based on interview and record review, the facility failed to protect and promote the resident's right to a dignified existence and self-determination for 1 of 6 residents (Resident #1) reviewed for resident rights, in that: The facility failed to allow Resident #1 to maintain her smoking privileges. This failure could place residents at risk of feelings of poor self-esteem, anxiety, decreased quality of life and loss of dignity.The findings were: Review of resident #1's face sheet dated 7/24/2025 revealed she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Schizoaffective disorder, Bipolar type (mental health conditions involving mood disorders), Epilepsy (seizure disorder) Ulna Fracture (broken bone in forearm), Intellectual Disabilities (limitations in both intellectual functioning and adaptive behavior), Type 2 Diabetes (blood sugar disorder). Dementia with other behavioral disturbance (loss of memory) and Major Depressive Disorder. Face sheet further revealed that a family member was resident #1's Power of Attorney. The face sheet did not identify a responsible party. Review of resident #1's quarterly MDS dated [DATE], revealed a BIMs of 9, suggesting moderate cognitive impairment. In the behavior symptom section, resident #1 was noted to have verbal behaviors directed towards others occurring in 1 to 3 days in the last 7-day lookback period. There was no section in the MDS that addresses smoking. Review of resident #1's progress notes from 6/27/2025 to 7/23/2025 reflected no notes concerning removal of resident #1's smoking privileges. Review of resident #1's smoking assessment dated [DATE] reflected she was safe to smoke but needed supervision. This was the only smoking assessment found in resident #1's EMR Review of resident #1's Smoking Agreement dated 5/29/2025, reflected it was signed by resident #1 on 5/29/2025. In the agreement Resident #1 agreed to abide by the smoking rules which were centered around safe smoking habits. Specifically, #11 stated Failure to adhere to safe smoking practices may result in denial of smoking rights at [the facility]. Family and resident will be kept informed of issues that arise. Review of resident #1's untitled contract dated 6/27/2025 reflected I [resident] entering into this contract with [nursing facility] in the agreement. I will only smoke 3 cigarettes per day at 8:30 am, 1:30 pm and 6:30 pm. I understand if I break this agreement, I may have my smoking privileges taken away. Contract was signed by resident using her first name on 6/27/2025. Review of resident #1's care plan dated 7/24/2025 reflected [resident #1] is a smoker with goal of resident will smoke safely through next review and interventions: complete smoking assessment, if it is determined that resident is safe to smoke, staff will review and explain facility smoking policy and smoking agreement. During an interview on 7/24/2025 at 12:09 pm, the ADON stated on 7/23/2025 herself, the activities person and the ADM were having a meeting in her office and resident #1 came in and talked to the ADM about smoking. She stated resident #1 asked ADM if he would give her one more chance to smoke and ADM stated he didn't think it was a goo idea. She stated resident #1 started crying at that point which was not unusual for her - she would cry a lot when she didn't get her way. She stated the ADM had decided about 3 weeks ago for resident #1 to stop smoking. She stated she did not remember a meeting with resident, family member or IDT to discuss taking away resident #1's smoking privileges. During an interview on 7/24/2025 at 12:53 pm facility SW stated the facility cut out smoking for resident #1 because behaviors would happen around smoking times because resident #1 would get impatient. SW stated resident #1 has not verbalized any desire to smoke since the smoking privileges were taken away. He stated he did not recall their being an IDT meeting with the resident, a family member or the PASSAR case manager to discuss removing resident #1's smoking privileges. He stated resident #1's smoking privileges were taken away about a month ago. SW states smoking is a privilege, not a right. During an interview on 7/24/2025 at 1:30 pm ADM stated smoking at the facility was a resident privilege not a resident right. He stated resident #1's smoking privileges were taken away somewhere around 7/3/2025 because issues with smoking would lead to an escalation of behaviors with resident #1 with verbal and physical aggression incidents directed towards staff and other residents. ADM stated resident #1 did not have another smoking assessment completed when her smoking privileges were revoked because it was not a safe smoking issue, it was a behavior issue. ADM provided the facility policy on smoking, resident #1's smoking agreement and resident #1's cigarette contract for investigator review. During an interview on 7/24/2025 at 2:40 pm, PASARR Case Manger stated she was not aware of resident #1 having smoking restrictions or that her privileges had been revoked. She stated she attended resident #1's initial PASARR meeting on 7/3/2025 and resident #1 was still smoking at that time. She stated at that time no behavioral concerns around smoking were discussed in the meeting. She stated they did discuss resident #1's desire to continue smoking and what the expectations of resident #1 were - being patient, waiting for staff, only smoking when allowed - and resident #1 was in agreement with those expectations at that time. She stated she was not aware until yesterday 7/23/2025, that resident #1 was not allowed to smoke at the facility. When she asked staff why resident #1 was no longer allowed to smoke, she was informed it was because of increased behaviors around the time she was able to smoke, having access to cigarettes and refusing to come back in after smoke break. She could not remember which facility staff had informed her of these behaviors. During an interview on 7/24/2025 at 2:50 pm, resident #1 stated they took my cigarettes away and they wouldn't give them back She stated she didn't think it was right that other residents go out to smoke, and she isn't allowed to go out with them to smoke. She stated she wanted her cigarettes back and she wanted to go out and smoke. During an interview with the ADM on 7/24/2025 at 3:12 pm he stated he had a meeting with the resident regarding her smoking - he thought it had been on 6/30/2025 but it could have been the first or second of July. He staed he knows they had a conversation with her to tell her they were taking away her smoking privileges dur to her behaviors. He stated he could not find where it was documented anywhere in the EMR. He stated, we didn't document anything - how is that possible. During an interview on 7/24/2025 at 3:42 pm, the Medical Director stated he was not aware of resident #1's smoking privileges being revoked. He stated he doesn't necessarily get involved in day-to-day behavior issues and he is okay with not knowing about this issue. He stated resident #1 was being followed by psyche services and the last note on 6/29/2025 did not mention any behavior issues with smoking. MD was informed that resident #1's care plan had not been updated to reflect her smoking privileges being revoked and there being no progress notes or IDT meeting about the revocation. He stated the care plan should have been updated and documentation completed in the EMR. During an interview on 7/24/2025 at 4:12 pm, ADM stated it was his responsibility to follow up and ensure progress notes were completed when they had the conversation with resident #1 about revoking her smoking privileges. He stated he knew they had the conversation; it just wasn't documented. He stated the care plan should have been updated by the MDS coordinator but the MDS coordinator would not have known about the conversation [with resident #1 about revoking smoking privileges] and he [ADM] didn't remember sharing details with the MDS coordinator. ADM was asked who is responsible for doing smoking assessments when there are changes and he stated a re-assessment was not applicable [with resident #1] because resident was able to smoke safely, she just had behaviors around not being able to smoke, when she didn't get her way. Review of undated facility policy Smoking Policy - Residents reflected the following: This facility has established and maintains safe resident smoking policies.8. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive0 and as determined by staff. 9. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen and 3 (nourishment room [ROOM NUMBER], 2, and 3) of 3 nourishment rooms reviewed for food safety and sanitation. 1. The facility failed to conduct temperature checks and/or complete the temperature check logs for refrigerators and freezers in the facility's kitchen and nourishment rooms. 2. The facility failed to conduct temperature checks and/or complete the temperature check log form for the 3-compartment sink in the facility's kitchen. 3. The facility failed to ensure the refrigerators and freezers in the facility's nourishment rooms were cleaned, sanitized, and in proper working condition. 4. The facility failed to ensure food items stored in the nourishment room refrigerators/freezers were labeled and dated. 5. The facility failed to ensure items stored in the nourishment room refrigerators/freezers were restricted to residents' items only. These failures could place residents at risk for foodborne illnesses. Findings include: Observation of the facility's kitchen on 6/17/2025 at 8:37 AM revealed written directives posted on the door of the refrigerator that stated in part: PUT A DATE ON ALL ITEMS IN THE FRIDGE PERSONAL ITEMS ARE NOT ALLOWED IN THE FRIDGE, THERE'S A FRIDGE IN THE BREAKROOM. Observation of the facility's kitchen on 6/17/2025 at 8:48 AM revealed the REFRIGERATOR/FREEZER TEMPERATURE LOG for the month of June 2025 in which staff failed to conduct and/or log temperature checks for the kitchen refrigerators and freezers as follows: 6/13/2025-No morning temperature check logged for refrigerator #2. 6/14/2025-No morning temperature check logged for refrigerator #2. 6/14/2025-No morning temperature check logged for freezer #1. 6/15/2025-No evening temperature check logged for refrigerator #1. 6/15/2025-No evening temperature check logged for refrigerator #2. 6/15/2025-No evening temperature check logged for freezer #1. 6/16/2025-No evening temperature check logged for refrigerator #1. 6/16/2025-No evening temperature check logged for refrigerator #2. 6/16/2025-No evening temperature check logged for freezer #1. Observation of the facility's kitchen on 6/17/2025 at 8:48 AM revealed the 3 Compartment Sink Log for the month of June 2025 in which staff failed to conduct and/or log the water temperature checks and sanitation solution concentration levels following dinner service on 6/15/2025 and 6/16/2025. Observation of the facility's kitchen on 6/17/2025 at 8:49 AM revealed the DAILY/AFTER EACH USE CLEANING SCHEDULE FORM for each week in the month of June 2025. Each form listed all items and areas that required at least daily cleaning and the staff members responsible for completing each task. The items and areas listed included refrigerators, freezers, microwave, food carts, and the janitor's closet, but did not include items or areas with the facility's nourishment rooms. Observation of nourishment room [ROOM NUMBER] (center station) on 6/17/2025 at 8:52 AM, revealed a refrigerator/freezer combination unit operable and in use. Adhered to the front of the unit was a temperature log form for June 2025. The Refrigerator Temperature Log included instructions that stated the following: Monitor Temperatures Closely Record Temps twice each day. Initial after you record the temp. Take action if temp is out of range - above 46'F or below 36'F. The temperature log was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month, and no evening temperature checks conducted or logged on 6/11/2025 and 6/12/2025. Also adhered to the front of the unit were typed signs with directives which read as follows: EMPLOYEE FOOD ITEMS THERE IS A NEW REFRIGERATOR IN THE BREAK ROOM FOR EMPLOYEE FOOD ITEMS. BEGINNING MARCH 16TH, ALL EMPLOYEE FOOD ITEMS THAT ARE STORED IN THE NURSES STATION REFRIGERATORS WILL BE DISPOSED OF EACH DAY. YOU ARE NOT ALLOWED TO COMMINGLE RESIDENT AND STAFF FOOD ITEMS INCLUDING WATER AND SODAS. PLEASE HELP US MEET THE STATE REQUIREMENTS FOR THESE REFRIGERATORS; and Resident Refrigerator Personal Snacks and Supplements No Employee Items Allowed!! Observation of the interior of nourishment room [ROOM NUMBER]'s freezer on 6/17/2025 at 8:52 AM revealed an opened and partially consumed bottle of water, a pint of ice cream wrapped and tied in a plastic grocery bag, evidence of spillage of a red liquid which pooled, dripped and dried within the bottom and sides of the freezer. Stored within the shelves of the freezer door was a large frozen bottle of water, instant ice packs, and various plastic ice packs. None of the items stored within the freezer were labeled with a name or date the products were obtained or stored. The items stored in the freezer door shelves were also soiled and stained red from the evident spillage. Observation of the interior of nourishment room [ROOM NUMBER]'s refrigerator on 6/17/2025 at 8:53 AM revealed evidence of spillage of a red liquid that had dripped down and under the storage compartment drawers. The seal around the refrigerator door was contained red liquid which caused the door to be sticky and hard to open. An opened and partially empty plastic bottle containing red soda was observed within the refrigerator along with an opened can of coffee with a napkin shoved into the opening of the can and opened and unopened beverage jugs, bottles and cans. None of which were labeled with a name or date the products were obtained or stored. Observation of nourishment room [ROOM NUMBER]'s (central east station) refrigerator on 6/17/2025 at 8:54 AM revealed the absence of a temperature check log or documentation which indicated if or when temperature checks were done. Inspection of the interior of the refrigerator revealed the absence of a thermometer, and storage of food and beverage items which were inconsistent with resident type meals or snacks. These items included several plastic grocery bags full of fresh vegetables that appeared to have been brought in from someone's personal garden, partially consumed bottles of water, a can of diet Coke, a bag of chips, leftovers covered and stored in a personal looking storage container, yogurt, and a box of leftover pizza. None of the items were labeled or dated. Observation of nourishment room [ROOM NUMBER]'s (secure unit) refrigerator/freezer unit on 6/17/2025 at 8:59 AM revealed a temperature log form adhered to the front of the freezer door and a temperature log adhered to the front of the refrigerator door. Both forms were dated June 2025. The Refrigerator Temperature Log forms included instructions that stated the following: Monitor Temperatures Closely Record Temps twice each day. Initial after you record the temp. Take action if temp is out of range - above 46'F or below 36'F. The temperature log adhered to the freezer door had the word Freezer handwritten on it. The freezer temperature log was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month of June 2025, and no evening temperature check conducted or logged on 6/14/2025. The temperature log adhered to the refrigerator door was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month of June 2025, and no evening temperature checks conducted or logged on 6/13/2025 and 6/14/2025. Observation of the interior of nourishment room [ROOM NUMBER]'s (secured unit) freezer and refrigerator on 6/17/2025 at 8:59 AM revealed a thick layer of ice and frost build up around all sides of the freezer and the back of the refrigerator. The freezer and refrigerator were observed as not maintaining acceptable temperatures as evidenced by the lack of cold air coming from the unit, condensation droplets from the melting ice build-up, and observation of the refrigerator temperature reading was 60'F on the thermometer placed near the back of the unit. Contained within the freezer were frozen beverage bottles with ice buildup around each and a frozen Magic cup. None of which were labeled or dated. The refrigerator contained an opened gallon of whole milk, several opened containers of pre-thickened water, pudding cups, packets of jalapeno ranch, and a ham, cheddar, and cracker snack pack. In an interview on 6/17/2025 at 8:50 AM, DC A stated the kitchen staff were responsible for cleaning equipment, surfaces, and areas within the facility's kitchen according to the posted cleaning schedule. DC A stated kitchen staff were responsible for conducting and logging temperature checks within the kitchen according to the schedule listed on the various temperature log forms. DC A also stated kitchen staff were responsible for conducting temperature checks and sanitation solution concentration checks for the kitchen's 3-compartment sink and dishwasher and logging such on the forms provided. DC A stated there was a refrigerator/freezer unit in each of the facility's nourishment rooms, but she and the kitchen staff were not responsible for those. In an interview on 6/17/2025 at 8:52 AM, TD A stated each of the facility's nourishment rooms contained a refrigerator/freezer unit which was restricted to resident use only. In an interview on 6/17/2025 at 8:53 AM, TD A stated the nourishment room refrigerators/freezers were supposed to be used to store resident items only. TD A stated he was uncertain as to who was responsible for cleaning the nourishment room refrigerators, or who was responsible for completing and documenting temperature checks of the refrigerators/freezers in the nourishment rooms. In an interview on 6/17/2025 at 8:55 AM, TD A stated the refrigerator in nourishment room [ROOM NUMBER] likely contained staff members' personal food and beverage items because during the facility's recent remodel, that room and refrigerator were not in use for resident items because the residents on this unit were moved elsewhere while construction was going on. TD A stated the renovation was completed several months prior and staff were instructed to use the breakroom refrigerator for storage of personal items. In an interview on 6/19/2025 at 2:19 PM, the HKS stated the housekeeping staff were not typically responsible for the cleaning and upkeep of nourishment room refrigerators, but he stated housekeeping staff would assist if asked. The HKS stated these tasks were the responsibility of the nursing staff, along with conducting and logging refrigerator/freezer temperatures. In an interview on 6/19/2025 at 2:21 PM, the ADM stated the facility had no specific policy regarding refrigerator/freezer tasks, which included which staff were responsible for maintaining them. The ADM stated it was known and understood that nursing staff was responsible for cleaning nourishment room refrigerators/freezers, and logging refrigerator/freezer temperature checks. If the units or thermometers contained therein were not working or malfunctioning, nursing staff should create an electronic work order and route it to the maintenance department, or nursing staff could report the problem directly to the ADM and he would address the issue right away. In an interview on 6/19/2025 at 2:25 PM, CNA A stated she had been employed with the facility for 4 years. CNA A stated it was the responsibility of the nursing staff to log temperature checks for the nourishment room refrigerators. CNA A stated the temperature check logs should be maintained on the outside of each unit. CNA A stated facility staff should never store personal items in the nourishment room refrigerators. These were for resident items only. CNA A stated this was necessary to prevent cross contamination and to prevent the possibility of mistakenly serving a resident a product not intended for them. CNA A stated nursing staff was responsible for cleaning and maintaining the nourishment refrigerators/freezers. In an interview on 6/19/2025 at 2:38 PM, LVN A stated she was a charge nurse who typically worked the dayshift. She stated she had been employed with the facility for 5 years. LVN A stated she's not sure who was responsible for cleaning and maintaining the nourishment room refrigerators. LVN A said the night shift nurse was responsible for completing and logging temperature checks for the nourishment room refrigerators/freezers. LVN A said the ADON was responsible for making sure this got done. LVN A said she did not know who was responsible in the absence of the ADON. LVN A said the facility's policy on was unclear and she's not sure what the policy stated. LVN A said the refrigerator in nourishment room [ROOM NUMBER] (east center station) was reopened about 2 months ago after the remodel of that unit was completed. LVN A said the nourishment room [ROOM NUMBER] (east station) refrigerator had historically been used by staff to store personal items such as coffee creamer. LVN A said the center station nourishment room was used to store resident items because that was where the kitchen staff delivered resident snack items. In an interview on 6/19/2025 at 2:45 PM, the DON said nursing staff was responsible for maintaining the nourishment rooms. The DON said the unit manager was responsible for making sure temperature checks were completed and logged, and the unit was clean and in working order. In an interview on 6/19/2025 at 2:45 PM, the RNC stated the ADM received the policies request. The RNC stated the ADM provided the only policies they had regarding nourishment room temperature check logs and cleaning. Record review of the facility's policy regarding measuring unit refrigerators for safe temperatures, updated January 2023, revealed the following: Refrigerators: All facility refrigerators should have working thermometers to measure and monitor safe temperatures. Freezers should be solid frozen at all times. Leakages in freezers must be reported to the maintenance team immediately. Refrigerator temperatures shall remain at 41 degrees and below at all times. Daily logs: The temperature will be checked and recorded by designated staff. When checking temperature, the doors should have been kept closed for at least 10 minutes prior to evaluation. The reading and time of the reading will be noted, along with the signature of the person checking. Maintain logs per the retention policy and procedure. If the refrigerator/freezer was not maintaining acceptable temperatures the contents will be removed and destroyed Daily record keeping of refrigerator temperature shall be kept near or on the actual refrigerator. Any temperature issues (if below 41 degrees) should be communicated with the maintenance team. De-frosting of the freezers is recommended to be done monthly. During the de-frosting process and while cleaning the refrigerator, all stored items shall be transferred to another refrigerator/freezer and not left out in the open. Review of the U.S. Food and Drug Administration Food Code dated 2022 revealed the following: 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P 3-305.11 Food Storage. (B) (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (C) (1) In a clean, dry location; (D) (2) Where it is not exposed to splash, dust, or other contamination 3-307.11 Miscellaneous Sources of Contamination. (E) FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (D) Surfaces of UTENSILS and EQUIPMENT contacting TIME/TEMPERATURE CONTROL FOR SAFETY FOOD may be cleaned less frequently than every 4 hours if: (5) EQUIPMENT is used for storage of PACKAGED or unpackaged FOOD such as a reach-in refrigerator and the EQUIPMENT is cleaned at a frequency necessary to preclude accumulation of soil residues.

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 2 of 4 residents (Resident #19 and Resident #88) reviewed for infection control. 1. The facility failed to ensure hand hygiene was implemented appropriately when CNA-A provided perineal and catheter care for Resident #19. 2. The facility failed to ensure hand hygiene was implemented appropriately when LVN-B provided wound care to Resident #88. These deficient practices could place residents at-risk of the spread of infection. Findings include: Record review of Resident #19's face sheet, dated 01/06/2025, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #19's primary diagnosis included Spinal Stenosis, Cervical Region (a condition where the spinal column narrows, putting pressure on the spinal cord or nerves in the neck area). Record review of Resident #19's Care Plan, last updated 01/16/2025, revealed a Problem which included Resident # 19 requires a foley catheter secondary to Neurogenic Bladder,. This problem area included the following interventions: - Change foley catheter monthly with 18 .F, 10 .CC. - foley catheter care Q shift - Monitor for evidence of blockage, flush catheter per MD order, change catheter as indicated. Record review of Resident #19's Quarterly MDS assessment, dated 06/05/2025, revealed a BIMS score of 15, which indicated intact cognition. Resident #19 was assessed as having an indwelling catheter. Record review of Resident #19's Active Orders, dated 06/18/2025, revealed orders which included: - Foley catheter care every shift start date 06/02/2024. Observation on 06/18/2025 at 01:06 PM revealed there was a sign which indicated Enhanced Barrier Precautions outside the door to Resident #19's room, and there was a supply of PPE available outside the door/room. CNA-B sanitized her hands and donned gloves and gown prior to performing perineal care and foley care for Resident #19. During the care, CNA-B failed to sanitize her hands two of five times she changed from dirty gloves to clean gloves. During these instances, she removed soiled gloves and donned clean gloves after removing a soiled brief and she removed soiled gloves and donned clean gloves after wiping the perineal area of stool. During an interview with CNA-B on 06/18/2025 at 1:30PM, she stated it was an expectation that hand sanitization be performed each time dirty gloves were removed. She stated she may have failed to sanitize her hands in between glove changes as she was nervous. 2. Record review of Resident #88's face sheet, dated 09/17/2024, revealed a [AGE] year-old male with a diagnosis which included Cerebral Infarction (a condition where brain tissue dies due to a lack of blood supply). Record review of Resident #88's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #88's Care Plan and Orders, of 06/18/2025, revealed Resident #88 was assessed as having a skin tear wound to the left anterior superior leg. The orders stated Cleanse with NS, pat dry, apply Alginate Calcium with silver daily. Observation on 06/18/2025 at 12:52 AM of wound care treatment to Resident #88 by LVN B revealed LVN B changed gloves multiple times while care was provided which included after moving from dirty to clean areas and after touching the outside environmental object but did not sanitize her hands in between one glove change after LVN B removed the soiled dressing and donned clean gloves to cleanse the wound. During an interview with LVN B on 06/18/2025 at 1:10 PM, LVN B stated she did not sanitize her hands after each glove change while providing wound care to Resident #88 because she was nervous, but also stated she should have. During an interview with the DON on 06/19/2025 at 8:57 AM, she stated it was the policy to perform hand sanitization before donning gloves and when there was a change from dirty to clean gloves, and then when the procedure was completed. The DON stated staff were trained on hand hygiene expectations during their three-day orientation period and frequently thereafter. The DON reported the Infection Control Practitioner and herself performed random rounds and observations to ensure compliance with hand hygiene. The DON stated failure to perform hand hygiene could result in the spread of bacteria. During an interview with the Infection Control Practitioner on 06/19/2025 at 9:34 AM, she stated staff were expected to perform hand hygiene anytime there was a transition from dirty to clean. She stated staff were educated during their three-day orientation period and periodically during the year on the hand hygiene policy. The Infection Control Practitioner stated she performed monitoring of six instances of hand hygiene every two weeks. During an interview with the Administrator on 06/18/2025 at 10:10 AM, he stated it was his expectation that hand hygiene be performed each time soiled gloves were discarded and before clean gloves were donned. The Administrator stated a possible outcome of the failure to perform hand hygiene could result in the spread of infection. During a record review of the hand hygiene policy revealed the following: Purpose: Hand washing with either soap and water or hand sanitizer is one of the best ways to stop the spread of infection. Handling soiled or used linens, dressing, bedpans, catheters, and urinals. Removing gloves or aprons.

Based on interview and record review, the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 2 medication carts reviewed for pharmaceutical services. The facility failed to ensure all controlled medications were accurately reconciled at the start and end of each shift. This failure could place residents at risk of drug diversion and could result in diminished health and well-being. Findings include: Record review of the Change of Shift Narcotic Count Sheets for Cart #1 revealed missing documentation for 06/01/2025, 6:00 AM on-coming and 6:00 PM off -going shifts and the 06/04/2025 6:00 PM on-coming and 6:00 AM off-going shifts. Record Review for Cart #2 revealed missing documentation for 06/02/2025 6:00 PM off-going shift, 06/03/2025 6:00 AM on-coming shift, 6:00 PM on-coming, and 6:00 AM off-going shifts, 06/06/2025 6:00 PM on-coming and 6:00 AM off-going, and 06/11/2025 6:00 PM off-going shifts. During an interview with CMA A on 06/18/2025 at 11:37 AM, she stated it was required for the off going and oncoming staff to count narcotic medications and sign the Narcotic Count Sheet. During an interview with LVN A on 06/18/2025 at 11:40 AM, she stated it is required for the off going and oncoming staff to count narcotic med's and signed the Narcotic Count Sheet. During an interview with ADON A on 06/19/2025 at 9:35 AM, she stated it was the expectation the off-going and on-coming shifts count narcotics and signed the Narcotic Count sheet at each shift change. ADON A reported she made rounds every morning and audited the Narcotic Count Sheets. If a deficiency was found, a narcotic count was immediately performed, and the responsible staff were educated. ADON A stated new staff were educated about the change of shift narcotic count expectation during their three-day orientation period. During an interview with the Administrator on 06/19/2025 at 10:10 PM, he stated it was the expectation that the off-going nurse and the on-coming nurse counted the narcotics together at the change of shift. He stated a negative outcome of not consistently following the narcotic count expectations was there was a possibility of drug diversion. Record review of the facility's, undated policy stated Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observations, interviews, and record review the facility failed to protect the residents' right to be free from neglect for 1 (Resident #3) of 6 residents reviewed for neglect. The facility failed to ensure Resident #3's safety and well-being when RN D and CNA E left her in the Shower Room in soiled undergarments unattended for approximately 30 minutes. This failure could result in residents receiving injuries and possible skin breakdown. Noncompliance existed from 02/13/2025 to 02/18/2025, but the facility corrected the noncompliance through inservicing, one on one inservicing and the QAPI process. Therefore, the findings are of past noncompliance. Findings included: Record review of Resident #3's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of Generalized Atherosclerosis (a widespread buildup of plaque in the arteries throughout the body, which can lead to narrowing and blockage of blood vessels), Unspecified Dementia (a decline in cognitive function that cannot be attributed to a specific underlying cause), and Unspecified Abnormalities of Gait and Mobility (difficulty walking or moving without a specific cause). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 3, indicating she had a significant level of cognitive impairment. Her Functional Status reflected she required partial/moderate assistance with mobility, Supervision or touching assistance with toileting hygiene, and Substantial/maximal assistance with showering. Record review of Resident #3's care plan, initiated on 06/27/2019 and most recently update 02/04/2025, reflected she had an ADL Self Care Performance Deficit related to diagnosis of Dementia/schizoaffective Disorder, and Major Depressive Disorder. Care Planned Interventions include the following: Resident requires staff x 1 for participation with bathing. Resident requires staff x 1 to use toilet. Resident participates in toileting process. Resident requires assist of staff x 1 for transfers. Resident participates in transfer process. Resident requires staff x 1 to choose simple comfortable clothing and for ability to dress self. Resident requires staff xx1 for a sponge bath when a full bath or shower cannot be tolerated. Resident requires staff x 1 for reminding, prompting, cueing, for assistance with eating. Resident requires setup help with meals but can feed self independently. Resident requires staff x 1 to set up or assist with oral care. Check nail length and trim and clean on bath day. Report any changes to the nurse. Praise all efforts at self-care. Record review of the facility's investigation report on 02/26/2025 at 12:21 PM reflected the facility was notified of this event by the outside representative on 02/13/2025 at 11:00 AM. According to the Facility's Investigation Report, RN D walked thru the Dining Room on 02/07/2025 after lunch and the outside representative notified him that Resident #3 needed to be changed as she had urinated on the floor. RN D notified CNA E that the resident needed to be changed. RN D placed Resident #3 in the Shower Room per CNA E's request. CNA E reported to RN D she would finish her round and attend to Resident #3. The outside representative later called Social Worker to report Resident #3 was alone in the shower for approximately 30 minutes unattended. Record review of the Facility follow up included the following: 02/13/2025 RND and CNA E are suspended pending further investigation. 02/13/2025 Ad Hoc QAPI 02/13/2025 and 02/14/2025 Notification of Medical Director 02/13/2025-02/14/2025 All staff inservicing to include Abuse and Neglect, Resident rights/Dignity-Bowel and Bladder, Communication-Clarification of Task Assignment, and Shower Room Monitoring. 02/14/2025 Attempted notification of responsible party. 02/17/2025 Education sent to outside providers regarding reporting of Abuse and Neglect. 02/18/2025 One on One communications with RN D and CNA E to include Communication and Clarification and Shower supervision. Record review of Resident #3's medical record on 02/26/2025 at 11:00 AM ,reflected the Social Worker completed an assessment for injury on 02/13/2026 at 4:45 PM. According to the note, Resident #3 did not demonstrate any signs of a negative outcome from this event. Skin Assessment completed on 02/14/2025 at 1:09 PM is negative for any physical injury. Interview with Resident #3 was conducted on 02/26/2025 at 11:33 AM. Resident #3 stated the staff are good to her and always help her. She has no recollection of being left in the Shower Room unattended. Interview with DON on 02/26/2025 was conducted at 10:26 AM. The DON stated it was her expectation that residents are not to be left alone in the Shower Room even if they can shower themselves. The DON stated the following interventions were implemented. RN D and CNA E were suspended on 02/12/2025 pending investigation. One on one communication with RN D and CNA E for training on staff-to-staff communication was completed on 02/18/2025. One on one training on Shower Supervision was completed with RN D and CNA E on 02/18/2025. The following in-service training was also implemented with direct care staff on 2/13/25 and 2/14/2025: Abuse and Neglect Resident Rights/Dignity related to Bowel and Bladder needs. Communication-Clarification of Task Assignment Shower Room Monitoring Interview conducted with CNA F was conducted on 02/26/2025 at 2:23 PM. She confirmed receiving training as listed above and described that a resident is never to left alone in the shower room. She also stated staff should always communicate clearly with coworkers and nurse to make sure everyone understands what is going on. Interview conducted with Activity Therapy staff G on 2/26/2025 at 2:35 PM. AT staff G confirms having received training as list above. She stated the main theme of the training was regarding monitoring residents in the shower and residents should never be left alone in the shower. Confirms receiving training on clear communication with coworker. Also reported having received training on reporting abuse and/or neglect the facility Administrator. Interview conducted with CNA H on 02/26/2025. CNA H confirms receipt of training as listed above. CNA stated she was trained on the types of abuse and neglect and to whom to report. CNA H verbalized receipt of training on rights and dignity. CNA H stated staff are to be in the shower room with any resident regardless of their mobility status. Interview with LVN I was conducted on 02/26/2025 at 2:51 PM. LVN, I confirmed receipt of training on abuse/neglect/exploitation and Resident Rights. LVN I stated residents are never to left unattended in the shower room for any reason. Interview with the Social Worker on 02/26/2025 at 1:27 PM revealed, he had received information about this event from the outside representative on 02/13/2025 at 11:00 AM. The outside representative reported she thought Resident #3 was in the shower room unattended for approximately 30 minutes. Interview with the outside representative by phone on 02/26/2025 at 2:07 PM was conducted. The outside representative stated she heard CNA E tell RN D to take Resident #3 to the shower and CNA E would be there in a little bit. The outside representative stated she did not know exactly how long Resident #3 was in the Shower Room, but she guessed it was about 30 minutes. The outside representative stated she did not realize Resident #3 was in the Shower Room alone until she heard her yell out. Interview with RN D on 02/26/2025 at 1:55 PM stated Resident #3 was taken to the Shower Room to await CNA E. He stated, I should have just done the hygiene care myself. RN D also reported he will change his practice by not ever leaving anyone in the Shower Room but, rather outside in the hallway. RN D also stated he should have communicated better with CNA E. Interview with CNA E was conducted at 02/26/2025 at 2:01 PM. CNA E stated she and RN D did not communicate regarding how long it was going to take CNA E to get to Resident #3. CNA E stated she should have let RN D know how long it was going to take her to get to Resident #3. Interview with the Administrator was conducted 02/26/2025 at 4:54 PM. The Administrator stated every resident must be supervised while in the Shower Room. If the resident can shower independently, the CNA was to stand outside the door, knock and check on the resident frequently. Additionally, the Administrator was asked about the existence of documentation of notification of the physician and the resident representative regarding the event. The Administrator responded the physician was not notified because there was no injury, and the Resident Representative was not notified because Resident #3 was legally her own representative. A telephone interview was conducted with Resident #3's family member at 5:42 PM. He stated he was pleased with the care and treatment Resident #3 received from the facility and was thankful for the assistance. He stated: they're doing a great job and I'm thankful for that. Review of the facility's Abuse Prohibition policy, dated 12/2019, reflected: Each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriate of property.

Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #13) reviewed for accidents hazards and supervision, in that: On 01/23/2025 Resident #13 was transferred by CNA C using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #13 pivoted into the chair, her leg did not pivot well, and the knee twisted and popped which later caused swelling and pain to the left knee. This failure could lead to injury or death to residents. Findings include: Record review of Resident #13's face sheet dated 02/11/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis (a chronic, autoimmune disease that affects the central nervous system-brain and spinal cord, Muscle Weakness (a lack of muscle strength or the inability to control voluntary muscle force), and Unspecified Abnormalities of Gait and Mobility. Record review of Resident #13's Quarterly MDS assessment, dated 01/30/2025, reflected a BIMS of 15 which suggested the resident's cognition was intact. Section G revealed Resident #13 required extensive assistance with 2 persons for transfers. The prior Quarterly MDS assessment, dated 12/28/2024, in effect at the time of the event, revealed the resident was classified as requiring substantial/maximal assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. There was no designation for 2 person assist with a mechanical lift. Record review of Resident #1's Care Plan dated 03/27/2015 and revised on 02/03/2025, revealed Resident #13 required a mechanical lift X 2 staff assist for all transfers. The previous Care Plan dated 12/6/24 did not specifically address the resident's transfer needs. Record review of the Provider Investigation Report, dated 02/05/2025, related to the facility's self-report of Resident #13's injury on 01/23/2025, revealed on 01/23/2025 at 5:15 PM, [CNA C] performed a one person standing assist, as the resident pivoted into the chair the leg did not pivot well and the knee twisted and popped. At the time the resident denied any pain. X-ray results received on 01/24/2025 were negative with no acute fractures. On 01/24/2025 the resident did not communicate any pain. On 01/25/2025 the knee was found to be visibly swollen. The resident declined pain medications. An order for prednisone for inflammation was given and referral for an Orthopedic Physician appointment was given. The Orthopedic appointment is scheduled for 2/11/2025. Upon medical record review it was discovered that there was no order for transfer with a lift. At that time an order was placed for two-person mechanical lift device for transfer. The Administrator was informed of the event by Resident #13 on 01/29/2025 and the event was reported to HHSC on 01/29/2025 at 5:44 PM. Record review of the statement from the Director of Therapy reflected he stated he verbally communicated a transfer status change sometime during the dates of 1/20/2025 to 1/24/2025 from one person assist to two person Hoyer lift to another CNA but had not appropriately communicated the transfer status change to clinical leadership. As a result, an appropriate order was not received to officially change the status to a 2 person assist with a mechanical lift. This failure to communicate the resident's transfer status created confusion amongst the front-line staff and led to the injury. On 01/23/2025 when CNA C performed the transfer, Resident #13's order still reflected the need for a one person standing assist. Further record review revealed in-services on Safe Lifting and Movement of Resident and Use of Mechanical Device, Transfer List Communication, and Accessing Kardex were implemented with the staff. Interview with the Administrator was conducted on 02/11/2025 at 3:00 PM. The Administrator described the facts as disclosed in the Facility Investigation Report. The administrator stated after the investigation was completed, an Ad Hoc QAPI Committee was convened, a Root Cause Analysis was completed, and the Director of Therapy received a corrective action for his failure to communicate. A Performance Improvement Plan was initiated. The Administrator described the current process of monitoring of resident transfer needs. The Administrator stated the transfer needs of each resident is discussed in the facility's morning meeting. On 02/11/2025 Record Review of the Interview with CNA C was conducted. CNA C stated she was not aware Resident #13's transfer status had changed prior to the implementation of the transfer. Record Review of the facility policy titled, Safe Lifting & Movement of Residents policy statement reads, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and moved residents.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 29 of 29 ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) residents by 5 ( DON,ADON,LVN C, CNA D and CNA E) of 5 staff passing lunch trays that were reviewed for infection control and transmission-based precautions policies and practice, in that: The facility failed to ensure DON, ADON, LVN C, CNA D and CNA E did not grab resident's cups by the rim with bare hands, contaminating the tops of the rims, during the lunch meal serving process. This failure could place residents at risk for infection through cross contaminations of pathogens. Findings include: During the lunch observation on 4/29/2024 at 12:15pm DON, ADON, LVN C, CNA D and CNA E were observed touching the rims of the Resident's cups ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) covered with plastic lids that did not fit properly with bare hands during the meal service. Hand hygeine was preformed between residents, however the lids of the cups were touch once to place on the tray , the tray deliver to the resident then removed from the tray to place in front of the resident. Interview with CNA D on 4/29/2024 at 1:00 pm he stated he did not even realize he was grabbing the cups by the rims and will start grabbing by the sides. He was not sure what harm could come to the resident, but he would not want to drink from a cup someone had grabbed from the rim. Interview with CNA E on 4/29/2024 at 1:05 pm she stated that she was not aware she was supposed to grab the cup from the side, and the way they have them on a tray it is hard to always grab from the side when you are trying to get the residents served their meals. Interview with ADON on 4/29/2024 at 1:15 pm she stated that the cups should be grabbed by the side, but lunch was a little late today and they were in a hurry to get the residents their meal. She stated that grabbing the cups by the rim could potentially cause cross contamination. She also stated employees are encouraged to use hand sanitizer between delivery of resident trays and there is some available in the dining room. Interview with LVN C on 4/29/2024 at 1:25 pm she stated that it is hard to grab the cups by the side for the first several residents as the drinks are pre poured and are on a tray . She stated that after she thought about it, grabbing by the side makes sense to help with cross contamination. Interview with DON on 4/29/2024 at 1:30 pm she stated that she did not realize the lids did not cover the entire drinking area of the cup. She stated that cups should be grabbed by the side of the cups to prevent cross contamination. Interview with ADM on 4/29/2024 at 2:00 pm he stated that his expectation is that the infection control and hand hygiene policies be followed. He stated anytime it is not followed it puts the resident at risk for infection from cross contamination. Record review of the facility's infection prevention and control program policy, undated, stated: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of transmission of communicable disease and infection as per accepted national standards and guidelines. Record review of the facility's Hand Hygiene policy, undated, stated: Hand washing with either soap and water or hand sanitizer is the best way to stop the spread of infection, Before and after Assisting a resident with meals.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage and sanitation, in that: 1) The facility failed to ensure the kitchen prep area was free of personal items. 2) The facility failed to ensure food and beverages in refrigerator #1 and #2, and the freezer, were covered, labeled, and dated. These deficient practices could cause cross contamination and place residents at risk of foodborne illness. Findings include: 1.) Observation of the kitchen food prep table #1 on 04/29/2024 at 8:28am revealed a pink travel cup. Observation of the kitchen food prep table #2 on 04/29/2024 at 8:28am revealed car keys on a Miami Beach key chain and a white cell phone charger sitting next to a box of sandwich bags. Observation of kitchen Refrigerator #1 on 04/29/2024 at 8:31am revealed a Styrofoam drink container with a red straw and what appeared to be a red liquid inside the container. The drink container was on the bottom shelf of Refrigerator #1, next to a gallon of milk. Interview with DA #1 on 5/1/2024 at 2:05pm, she stated personal items should be kept in the DM's office. She said it was not okay to have personal drinks in the kitchen refrigerator. Interview with DA #2 on 05/01/2024 at 2:10pm, she stated personal items should be kept in the DM's office and it was not okay for a drink to have been in the refrigerator. Interview with DM on 05/01/2024 at 2:25pm, she stated all personal items should be kept in her office and personal drinks should be kept in the staff refrigerator in her office. Surveyor requested policy for storing personal items and the facility does not have one. 2.) Observation of the kitchen Refrigerator #1 on 04/29/2024 at 8:31am revealed an unsealed and unlabeled storage bag with contents that resembled sliced cheese (yellow/orange squares). Observation of the kitchen Refrigerator #1 on 04/29/2024 at 8:31am revealed an unlabeled storage bag containing an opened, bag of Whipped Topping. Observation of the kitchen Refrigerator #2 on 04/29/2024 at 8:34am revealed with a rolling cart and two gray tubs with small drinking glasses containing a white liquid that resembled milk. The white plastic lids were ajar and not placed securely on the drinking glasses. Observation of the kitchen Refrigerator #1 on 04/29/2024 at 8:35am revealed a white box labeled Peeled and Cooked Eggs. Inside the box were multiple sealed bags of eggs. The box was not labeled with an opened on and use by date. Observation of the kitchen Freezer on 04/29/2024 at 8:37am revealed a blue storage bag tied in a knot. The bag contained what resembled frozen kernels of corn. The bag was not labeled with an opened on and use by date. Interview with DA #1 on 5/1/2024 at 2:05pm, she said all items in the refrigerator and freezer should have been placed in a plastic bag with a label and date. She said this task is the responsibility of all kitchen staff. Interview with ADM On 5/1/2024 at 2:00 Surveyor requested policy for storing personal items and the facility does not have one. Interview with DA #2 on 05/01/2024 at 2:10pm, she stated food in the refrigerator should be labeled and in storage bags. She said the kitchen staff were responsible for the labels and dates and the DM came behind them to ensure it was completed. Interview with DM on 05/01/2024 at 2:25pm, she stated her expectation was for items to be wrapped or placed in a storage bag, labeled with the contents and the date. She said this task was everyone's responsibility and she completes rounds to ensure it was done correctly. Review of facility policy titled Food Receiving and Storage, MED-PASS, Inc. Revised November 2022 states the following: Policy Statement Foods shall be received and stored in a manner that complies with safe food and handling practices. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 7. Refrigerated foods are labeled, dated and monitored so they are labeled by their use by date, frozen or discarded. Record review of Federal Drug Administration Food Code 2022 indicated [(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 Code of Regulation 101 FOOD Labeling, 9 Code of Regulation 317 Labeling, Marking Devices, and Containers, and 9 Code of Regulation 381 Subpart N Labeling and Containers, and as specified under S 3-202.18.

Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 1 (medication room [ROOM NUMBER]) of 2 medication storage rooms and 1 (medication cart #1) of 4 medication carts reviewed for medication storage that. Medication cart # 1 was left unattended and unlocked. An undated, opened and accessed, vial was stored in the medication room [ROOM NUMBER] refrigerator. The medication room [ROOM NUMBER] refrigerator temperature was not monitored daily. This failure could allow residents unsupervised access to prescription and over the counter medication and can result in the resident receiving ineffective medication due to lack of temperature management or proper labeling. Findings included: Observation on 4/29/2024 at 11:53 am revealed Medication cart # 1 was unlocked and unattended at the nurse's station not visible from the nurses sitting at the desk. Inspections of the contents revealed insulin pens and needles, prescription and over-the-counter medications. No nurses approached during the inspection. After approximately 4 minutes LVN A, who was sitting at the nurse's station, was asked about the cart. LVN A came around the desk and locked the cart. An observation on 05/01/24 at 8:12 AM revealed a multi-dose vial of Influenza Vaccine in the medication room [ROOM NUMBER] refrigerator. The vial which had been opened and accessed, was not labeled with the date the vial was opened. An observation on 05/01/24 at 8:15 AM revealed the medication refrigerator temperature log taped to the front of the refrigerator. The log was dated April 2024. The log did not have any entries for 4/2/24, 4/5/24, 4/6/24, 4/7/24, 4/15/24, 4/16/24, 4/19/24, 4/20/24, and 4/30/24. Interview of LVN A on 4/29/2024 at 12:00 pm stated that she was unaware the cart was unlocked and that it may have been unlocked for about 5 minutes. She stated she did see the surveyor going through the drawers and did not see an issue with it. She stated that if a resident had been opening the drawers she would have intervened. She stated that most of the resident would not be at risk for the cart being unlocked because they were oriented and did not go thru things. Interview with DON on 4/29/2024 at 12:30 pm she stated her expectation was the medication carts be locked when not attended. She stated that residents and visitors could have access to prescription and over-the counter medications and that could put them at risk for possible overdose and medication side effects. During an interview on 05/01/24 at 8:16 AM, the DON stated, anything opened, including multi-dose vials, were dated when opened. She stated the nurse who opened the vial or bottle was responsible for dating the medication. She stated vials were good for 30 days once opened. She stated expired medications may not have been effective and then residents may not receive the desired effect. She stated the medication room refrigerator temperature was supposed to be monitored daily. She stated some medications were stored in the refrigerator to maintain their effectiveness. She stated it did not meet her expectations that 9 of 30 days were not monitored. Record Review of the policy titled Storage of Medications, undated, states 6. Compartments (including, but not limited to, drawers, Cabinets, rooms, refrigerator, carts, and boxes) containing drugs and biological are locked when not in use. Unlocked medications are not left unattended. and 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication is stored separately from food and are labeled accordingly. Record Review of the policy titled Medication, vaccine refrigerator temperature monitoring, updated January 2024, states Daily logs: The temperature will be checked and recorded by designated staff.

Based on observations, interviews, and record reviews, the facility failed to provide a Safe/Clean/Comfortable/Homelike Environment for three of six residents (Resident #57, Resident #23, and Resident #66). The facility failed to ensure a safe/clean/comfortable/ homelike environment for Resident #57, Resident #23 and Resident #66. This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and placing residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings Include: 1) Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female readmitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Hypothyroidism (a condition that causes decreased thyroid hormones), Parkinson's Disease (a movement disorder that causes tremors or stiffness), Other Idiopathic Peripheral Autonomic Neuropathy (a condition that causes numbness, pain, and balance issues) and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior). During observation and interview on 04/29/2024 at 10:05AM with Resident #57, the room appeared cluttered with items stacked haphazardly against the wall. Multiple items on the floor which could have been dropped. The residents room appeared messy; bed disheveled and trash can was full. Resident stated housekeeping does not sweep and mop like they should. 2) Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected he was dependent on staff for personal hygiene, bathing, and toileting. Section I (Active Diagnoses) reflects medically complex conditions, Other Hereditary and Idiopathic Neuropathies (a condition that causes gradual muscle weakness), Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Unspecified Lack of Coordination (a condition that affects balance), Schizophreniform Disorder (a mental health condition that causes hallucinations, delusions and disorganized speech), Spinal Stenosis Spinal Region (where the space inside the backbone is too small placing pressure on the spinal cord), Low Back Pain, Kissing Spine (a condition that causes pain, inflammation and nerve damage), Generalized Muscle Weakness, Abnormalities of Gait and Mobility (problems with walking or standing) and Aphasia (a condition that affects how you communicate with speech). During observation on 04/29/2024 at 10:12AM with Resident #23, the room appeared cluttered with multiple items stacked high on counters and bedside table. There were personal items and debris on the floor. The bathroom had a walker lying on the shower floor with soiled underwear and socks. 3) Review of Resident #66's MDS assessment dated [DATE] reflected a [AGE] year-old female originally admitted to the facility 09/23/22 with a readmission on 11/19/23. Her diagnoses included septicemia (infection in the blood), diabetes mellitus (a condition that affects the way the body processes blood sugar) and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs). Her BIMS score was fifteen, indicating intact cognition. During observation on 04/30/2024 at 8:50AM with Resident #66, her room appeared cluttered with multiple boxes stacked and a piece of wood furniture sitting directly in front of the sink. The boxes in front of the sink protruded outward approximately 3-4 feet. There were dirty containers that appeared to have had food in them. On the privacy curtain near the resident's bed, there were different colored marks on the curtain, which appeared to have been drawn with a marker, by the resident. During an interview on 05/01/2024 at 1:52PM with HS , he stated the housekeepers swept and mopped the residents' rooms daily. He said that it was everyone's responsibility to pick up items off the floor when they observed it. He said resident rooms have clutter and that the facility had a deep cleaning scheduled soon. He said the clutter presented challenges for the housekeeping staff, making it difficult to sweep and mop around the items. During an interview on 05/01/2024 at 2:45PM with DON, she stated her expectation was that the resident rooms were swept and mopped daily, by housekeeping. She said excess personal items and boxes piled up in residents' rooms create clutter, a potential fire hazard, and issues with cleanliness. During an interview on 05/01/2024 at 3:00PM with ADM, he stated that he was aware of clutter is resident rooms. He said he had called some of the resident's family members in the past, to come pick up the extra items. He said the clutter caused issues with bugs, mildew, and mold when the boxes became wet, tripping hazards, and a fire hazard. He said the facility had another deep clean/declutter on the upcoming schedule. He acknowledged clutter was an ongoing issue within the resident's rooms. The surveyor requested a policy regarding personal items for residents and the facility did not have one.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received services within the facility with reasonable accommodation of the residents' needs and preferences for 4 of 12 residents (Resident #23, Resident # 57, Resident #83, and Resident #45) reviewed, in that: The facility failed to: 1) Ensure a call light was within reach for Resident #23 2) Ensure a call light was within reach for Resident #57 3) Ensure a call light was within reach for Resident #83 4) Ensure a call light was within reach for Resident #45 This deficient practice placed residents at risk for delayed care and a decreased quality of life. Findings Include: 1) Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected he was dependent on staff for personal hygiene, bathing and toileting. Section I (Active Diagnoses) reflects medically complex conditions, Other Hereditary and Idiopathic Neuropathies (a condition that causes gradual muscle weakness), Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Unspecified Lack of Coordination (a condition that affects balance), Schizophreniform Disorder (a mental health condition that causes hallucinations, delusions and disorganized speech), Spinal Stenosis Spinal Region (where the space inside the backbone is too small placing pressure on the spinal cord), Low Back Pain, Kissing Spine (a condition that causes pain, inflammation and nerve damage), Generalized Muscle Weakness, Abnormalities of Gait and Mobility (problems with walking or standing) and Aphasia (a condition that affects how you communicate with speech). Review of Resident #23's care plan initiated 11/11/22 reflected a focus, Resident is bed bound due to his own decision and refuses to be transferred with a mechanical lift and is unable to move and sit in a wheelchair /geriatric chair. Interventions include, keep call light within reach of resident and keep resident belongings accessible and within reach. An observation and interview on 04/29/2024 at 01:15pm with Resident # 23, resident stated he can't reach call light and will usually ask his roommate for help to call for staff. Resident call light was not visible to surveyor nor to the resident. 2) Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female readmitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section I (Active Diagnoses) Hypothyroidism (a condition that causes decreased thyroid hormones), Parkinson's Disease (a movement disorder that causes tremors or stiffness), Other Idiopathic Peripheral Autonomic Neuropathy (a condition that causes numbness, pain, and balance issues) and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior). Review of Resident #57's care plan initiated 11/11/22 reflected a focus, Potential for falls related to Decreased mobility and noncompliance with using walker for ambulation. Resident has had falls due to not using walker. Interventions include, encourage resident to keep belongings within reach, provide a safe environment with floors free from spills, assist with removing room clutter, glare free lighting, reachable call bell etc. An observation and interview on 04/29/2024 at 10:05am with Resident #57, residents call light was not within reach. The call light was between the wall and the bed near the floor. 3) Review of Resident # 83's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE] 3. Section C (Cognitive Patterns) Reflected a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) reflected resident is independent with activities of daily living. Section I (Active Diagnoses) reflected, Hyperlipidemia (a condition that causes high lipids or fat in the blood), Major Depressive Disorder (a condition that affects mood), Insomnia (a condition that causes trouble falling or staying asleep), Constipation (a condition that causes bowel movements less than three times per week), Hypothyroidism (a condition that causes decreased thyroid hormones), Bipolar II Disorder (also known as manic depression), Schizoaffective Disorder Bipolar Type (a condition causing hallucinations, delusions, confused thoughts and behavior) , Diabetes Mellitus without Complications (a condition that affects the way the body processes blood sugar), Disorder of Muscle and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior). Review of Resident #83's care plan initiated 12/05/2023 reflected a focus, The resident has an ADL Self Care Performance Deficit. Interventions include, Encourage Resident to use bell to call for assistance before attempting any ADL's that resident cannot do independently. An observation and interview on 04/29/2024 at 10:12am with Resident # 83, the resident stated he can't reach his call light and asks his roommate to press the button for him. Resident call light was not visible to surveyor. When the surveyor asked resident to locate the call light, he could not see nor find the light. 4) Review of Resident #45's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 03/06/20. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she was dependent on staff for personal hygiene, bathing and toileting. She required substantial/maximal assistance with upper body dressing. She was dependent on staff and a mechanical lift for transfers to and from bed. Section I (Active Diagnoses) reflected, hemiplegia following cerebral infarct affecting left dominant side (paralysis of the left side of the body due to a stroke), diabetes mellitus (a condition that affects the way the body processes blood sugar), generalized muscle weakness, contracture of hand (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), and morbid (severe) obesity. Review of Resident #45's care plan initiated 11/11/22 reflected a focus, Alteration in musculoskeletal status related to contractures to left hand. Interventions included, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. A focus initiated on 03/06/20 reflected, Resident has the potential for falls related to CVA . An intervention reflected, Place the resident's call light within reach and encourage the resident to use it for assistance as needed. An observation on 04/29/24 at 2:14 PM revealed Resident #45 sitting up in a bariatric wheelchair next to her bed. Her left side, with hemiparesis (a condition that causes weakness or the inability to move on one side of the body) and a hand contracture was closest to the bed. The string for the resident's call light was hanging down from the ceiling. A stuffed animal was tied to the end of the string. The Stuffed animal was hanging several inches above the bed. During an interview on 04/29/24 at 2:15 PM with Resident #45, she stated she wanted to get into bed, but she could not reach her call light, so she had to wait for staff. She stated she sometimes got her roommate to push her call light to get staff to the room. During an interview on 05/01/24 at 2:00 PM, LVN L stated call lights should be in reach, accessible to the residents. She stated if the call light was not within reach, the residents may not be able to get medications, toileted, or have any other needs met. She stated she was not working with Resident #45 today but she would check the call light placement. During an interview on 05/01/2024 at 2:15PM CNA F stated she checks on residents every thirty minutes during her shift, and she thought everyone had a call light string. She said there should not have been anyone that didn't have a string attached to their call light. She said she would notify her charge nurse if a resident didn't have a call light string, or she would go find a longer string herself. During an interview on 05/01/2024 at 2:45PM with DON, she stated nursing staff checked each resident every 2 hours and should have ensured they could reach the call light with a string attached. She said it was unacceptable for any resident to not have independent access to the call light. During an interview on 05/01/2024 at 3:00PM with ADM, he stated that all residents should have a working call light and the CNAs are responsible to ensure the resident can access the call light. He said residents should not have had to ask their roommates for assistance. Review of facilities undated policy titled Answering Call Light, which states: Purpose The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 4. Be sure the call light is plugged in and functioning at all times. 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, the shower and bathing facility and from the floor. 6. Report all defective call lights to the nurse supervisor promptly.

Based on record review and interview, the facility failed to inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #300 and Resident #301), reviewed for changes made to charges or other items and services. The facility failed to ensure that Resident #300 and Resident #301 were provided a SNF ABN (SNF ABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services not covered by Medicare and their financial responsibilities. Findings included: Review of Resident #300's admission MDS assessment dated [DATE], Section A (Identification Information) revealed an [AGE] year-old female admitted to the facility 09/06/23. Section C (Cognitive Patterns) revealed a BIMS score of 8 indicating moderately impaired cognition. Section I (Active Diagnoses) reflected diagnoses including coronary artery disease (disease of the blood vessels of the heart), septicemia (infection in the blood), and cerebrovascular accident (stroke). Review of Resident #300's electronic medical record revealed no SNF ABN form. Review of Resident #301's admission MDS assessment dated [DATE], Section A (Identification Information) revealed a [AGE] year-old female admitted to the facility 11/10/23. Section C (Cognitive Patterns) revealed a BIMS score of 14 indicating intact cognition. Section I (Active Diagnoses) reflected diagnoses including cerebrovascular accident (stroke), encephalopathy unspecified (damage or disease that affects the brain), and urinary tract infection. Review of Resident #301's electronic medical record revealed no SNF ABN form. Review of the Medicare discharge list reflected Resident #300's Medicare benefit days started on 09/06/23 and ended on 11/16/23. Resident #301's Medicare benefit days started on 11/10/23 and ended on 11/25/23. During an interview on 04/30/24 at 2:56 PM, the ADM stated neither Resident #300 nor Resident #301 were provided with an ABN document. The ADM stated they did not have a policy regarding ABN notifications. He stated the facility had recently found the notices were not being provided and the staff were not sure of the process or who was responsible for providing the form to residents. He stated they recently started reviewing and monitoring Medicare days and potential changes in service during their daily meetings. The ADM stated he would be contacting the corporate office regarding a policy. Review of the Medicare Claims Processing Manual accessed at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf, Chapter 30, section 70 reflected in part, If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in S70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events.

Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of one residents (Resident #1) reviewed for pain. 1. The facility failed to assess, reassess, and/or take steps to manage Resident #1's pain when she informed them of the pain to her left stump. 2. The facility failed to administer Resident #1's PRN Tylenol #4 to adequately control her pain. This failure caused the resident to experience avoidable pain that was severe, and more than transient lasting for weeks and put all could place residents at the facility at risk of suffering pain which could prevent them from achieving their highest practicable physical, mental, and psychosocial outcome. Findings include: Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, lung disease, and cerebrovascular disease (brain). Record review of Resident #1's 03/03/23 MDS dated [DATE] revealed a BIMSs of 15, which indicated the resident was cognitively intact. Record review of Resident #1's undated care plan revealed she will be free from pain related to amputations of both legs above the knee and peripheral vascular disease and stated she was also on Pain medication therapy because of Chronic Pain, peripheral vascular disease (poor blood flow in arms and legs), Gout, and migraines with the following initiation date: 03/03/15. The interventions were: Review (FREQ) for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. The care plan Later stated she has, Hemiplegia/Hemiparesis (paralysis) from Stroke; interventions were: Give medications as ordered. Monitor/document for side effects and effectiveness and the Date Initiated: 03/03/15. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 03/03/2015. And another section stated she has chronic/acute pain because of chronic physical disability, fracture, depression and disease process. Interventions listed were: Monitor/record pain characteristics PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors and the date Initiated: 03/03/15. Monitor/record/report to Nurse any signs of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) and the date Initiated: 03/03/15. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Therapeutic regimen followed, but pain control not adequate, changes required. Record review of Resident #1's physician active orders printed 05/18/23 revealed the following orders for pain: Cyclobenzaprine HCl Tablet 5 MG, Give 2 tablet by mouth every 12 hours as needed for muscle spasms 2 tabs = 10mg with a start date of 12/15/22. Tylenol with Codeine #4 Tablet 300-60 MG (Acetaminophen-Codeine) Give 2 tablet by mouth every 6 hours as needed for Pain related to OTHER CHRONIC PAIN and a Start Date of 08/30/22. In an interview and observation on 05/17/23 at 2:12 pm Resident #1 she did not get her night medicine on 05/12/23, which included medicine for sleep and for pain. She stated that her pain on 05/12/23 was a 10 out of 10 and she couldn't sleep either. She said her pain was relieved sometime after 7:00 am on 05/13/23 when the morning shift arrived. Resident #1 cringed multiple times and grabbed her left leg stump while she spoke. She also grimaced 3 times and then gasped while grabbing her left leg. She became tearful and stated that she has told all of the nurses she was in pain, and it has been for a few weeks; she said she has not been re-evaluated by a doctor after she informed the nurses she was in pain. Resident #1 did not feel the Tylenol #4 PRN was helping. She stated her current pain level was a 10 out of 10. In an interview on 05/17/23 at 2:24 pm with the DON, this Surveyor informed her of Resident #1 complaining of 10 out of 10 pain. Record review on 05/17/23 revealed that Resident #1's May 2023 MAR was blank on 05/11/23 and 05/12/23 for her 8:00 pm medications which were Melatonin 10 mg, Glucophage 500 mg, Tizanidine 4 mg, gabapentin 800 mg, Aggrenox 25-200, dilantin 200 mg, coreg 50 mg, Cymbalta 60 mg, and trazadone 250 mg. In addition, her 4:00 pm ziprasidone 40 mg was not administered on either date. Interview on 05/17/23 at 2:30 pm with LVN O stated Resident #1 likes meds and got people fired; sShe had never seen the resident grimace. She stated she had a med at 6:45 am and she goes to pain management in Waco and [NAME]. Resident #1 was a drug addict. In an interview on 05/17/23 at 2:35 pm with ADON 2 she said Resident #1 goes to [NAME] for pain management because they have a lift and she gets injections in Waco. In an interview and observation on 05/17/23 at 4:40 pm with ADON 2 and DON, DON walked to medication cart and pulled out medication baggies that had a resident name at the top and a date and time for administration. She stated if the medications were not administered they would be in the cart and no medications were in the cart. In an interview on 05/17/23 at 4:48 pm, while observing a med cart with the DON, unprompted CMA A stated that on 05/11/23 before she left for the evening she noted that a few residents, including Resident #1, did not have baggies for their night medications. She stated the new pharmacy company had a rep on site and the rep was informed that residents were missing meds and the rep stated she would send an email but it could take a day to get it straightened out . She stated that 05/10/23 was the first day of the new pharmaceutical system using the medications and baggies, so the rep was present. In an observation on 05/17/23 at 4:52 pm with the DON she came out of a room carrying 2 baggies of medications with Resident #1's name and 05/12/23 8:00 pm on the top. In an interview on 05/17/23 at 5:19 pm with the DON she stated she spoke to CMA B on phone and CMA B stated that Resident #1 refused her medications on 05/12/23. The DON asked if she should enter a progress note at this time reflecting the resident refused her medications. The DON stated that the expectation was that CMA B should have informed the nurse working that night of the refusal, the nurse should have spoken to the resident and offered the medications again. She said medications not being administered was a risk to the resident and the expectation was that medications be administered or reason be documented in the MAR . In an interview on 05/17/23 at 5:19 pm with the ADON she stated Resident #1 can't be in pain, she was outside smoking and smiling just before she claimed to be in pain. In an interview on 05/18/23 at 8:23 am with PHAR P she stated the rep would not call me back, she is her supervisor. She stated the deliveries arriving around midnight tonight would be for the day after tomorrow. The medication carts should have today's medications to be distributed and tomorrow's. She said it was not possible that the medications were not present in the building and that there was a central computer called a cubex that had the common medications so they could be pulled if needed. In an interview on 05/18/23 at 9:55 am with MD, stated he took over for other medical director 3 days ago (05/15/23), and that he has not seen all of the residents yet. He stated his expectation was that he be notified if a resident was in pain and the medication was not resolving the pain, if the resident complained of uncontrolled pain. He stated he would then evaluate the resident to determine the best course of action. In an interview on 05/18/23 at 1:27 pm with CMA A she stated she was pretty sure Resident #1, Resident #38 and Resident #50 were all missing night medications on 05/11/23 and she informed the pharmacy rep of these items being missing. She stated that she did not inform the DON because she told the pharmacy rep. In an interview and observation on 05/18/23 at 4:50 pm with Resident #1 she said she saw the pain doctor today but doesn't think the medications are working. She said she did not get any medications last Thursday (05/11/23) or Friday (05/12/23) which included medications for pain and sleep. She said she did not get sleep on Thursday or Friday, she was in pain and couldn't calm down and she was crying on and off through the night. She stated that hell no I did not refuse my medications, and said she refused a patch that did not help her but other than that she did not refuse her medications ever. She said her left stump pain started around an 8 of 10 and went up to a 10 of 10 on both nights. She told ADON 2 on Tuesday 05/16/23 that she was in pain and she said they would try to fix it, but she told her a few times over the last few weeks and nothing was done about her pain. She was clearly uncomfortable, shifting multiple times, grabbing her left leg stump, and cringing and gasping a few times. In addition, she got emotional several times as we spoke. She said that it was a horrible anxiety and pain that got worse and worse through the night on Thursday and Friday when she did not get her medicine and her roommate was snoring and added to her frustration; she said it was overwhelming to deal with the pain and lack of sleep. In an interview on 05/18/23 at 5:05 pm with the DON and ADON 2, ADON 2 she said the resident was a drug addict , and she had failed the screening for a pain pump. The DON and ADON 2 said Resident #1 should have hit her call light and she could have called or texted them to get her medicine . In an interview on 05/18/23 at 7:15 pm with LVN C she stated that if the CMA had told her a resident refused medications she would have spoken to the resident, if the resident still refused she would document it in the MAR. She said CMA B left at 10:00 pm and the medication delivery came around midnight. She said there were a handful of medication in the corner of the drawer when CMA B left if she recalled correctly. She said she had not seen the pharmacy system that was used, and so she was going slowly to be thorough and not make mistakes. She did not recall the fate of the medications left in the drawer and nor did she recall any names on the baggies. In an interview on 05/19/23 at 10:13 am the DON stated that the expectation was that the CMA notify the nurse if a medication was refused and the nurse would offer or document. She said without the correct documentation that residents could end up not getting the correct amount of medicine which would harm them. She said she and ADON 1 and ADON 2 run a report to look for blanks in the MAR and address these blanks. She stated the report was supposed to be run daily, but she had not run it this week. She said she did not know why it did not get done. In an interview on 05/19/23 at 11:00 am with Resident #1 she stated she was in about a 3 of 10 pain level and that was comfortable for her. In an interview on 05/19/23 at 11:52 am with CMA B she stated she couldn't find Resident #1 on 05/12/23 to give her the medicine she was supposed to administer and when she finally saw the resident around 9:30 pm the resident refused her medication. She said she did not inform anyone working that night. She stated she had the phone number for the DON but did not inform her of the refusal either. She confirmed she should have informed the nurse but forgot and forgot to chart the refusal. Record review of Resident #1's pain assessment printed 05/17/23 revealed on 05/14/23 a pain assessment was done at 8:13 am, but no pain assessment was done on the following shift. On 05/05/23 at 2:14 am her pain was assessed, but it was not assessed again until 05/06/23 at 6:32 pm. On 05/02/23 no pain assessment was done on the morning shift, the only assessment was 8:10 pm and 9:15 pm. On 05/01/23 a pain assessment was done at 1:35 am, but no other pain assessment was done on 05/01/23. Record review of Resident #1's progress notes printed 05/17/23 revealed her pain medication was marked as ineffective on 05/11/23 at 11:26 am with a follow-up pain of 8. Record review of the progress notes for Resident #1 printed on 05/22/23 r evealed the following dates and mentions of pain and medications: 5/17 6:45 am c/o muscle discomfort; c/o gen discomfort, 5/16 7:27 am requested; 7:24 am pain in stump, 5/15 10:16 PM pending rx delivery for 10 medications, 5/15 7:50 pm Tylenol 4, 5/15 8:01 am requested for muscle spasms; pain in stump, 5/13 7:30 am requested prn pain medicine for pain in stump & requested PRN pain medication for level 9 pain in stump, 5/13 1:04 am pain 10/10, 5/12 7:55 am per resident request; c/o generalized pain; 5/11 11:26 am PRN administration was effective and a separate note 5/11 11:26 am PRN administration was ineffective with a follow up pain scale was 8; 5/11 7:24 am requested for pain; 5/10 9:26 am back; 5/9 9:28 am requested, back; 5/8 7:08 pm requested for stump pain noted; 5/8 8:39 am AD voiced her stump hurt; 5/8 7:44 am requested; back; 5/7 7:42 pm requested for stump pain noted; 5/7 2:33 am requested for back/stump pain noted 5/10; 5/6 6:32 pm stump/back pain noted; 5/4 6:42 pm requested for back pain noted; 5/4 7:45 am requested (effective documented at 2:18 pm); 5/3 6:47 pm requested for stump pain noted (effective documented at 11:35 pm); 5/3 7:31 am requested; back pain; 5/2 8:10 pm , assume administered just copied order but f/u 9:15 pm marked effective.

Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for four (Resident #46, #63, #28, and #33) of 4 residents reviewed for ADLs. The facility failed to ensure residents were provided with ADL care when needed for Resident #46, #63, #28 and #33. These failures could place residents at risk of worsening health conditions due to not having their personal hygiene needs addressed. Findings include: In a confidential staff interview, staff member stated that they were understaffed and residents did not always get checked every 2 hours, which led to the smells. In an interview with a confidential visitor to the facility, the visitor stated several residents the visitor noted dirty and soiled clothing. Record Review of Resident #46's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including dementia, depression, anxiety. Record review of Resident #46's 03/17/23 MDS revealed her BIMS was left blank. It further revealed she required extensive assistance for bed mobility, transfer, walking in room, dressing, toilet use, and personal hygiene. In an observation on 05/21/23 at 10:50 am Resident #46 was laying on the left side and observed wearing grey jogging pants that were wet from the top of the pants on down. A brief was be seen at the top. The room smelled of urine. In an interview with a confidential visitor to the facility, the visitor stated several residents the visitor noted dirty and soiled clothing. Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction (stroke). Record review of Resident #33's 02/10/23 MDS revealed a BIMS of 13, which indicated cognitively intact answers. It further revealed he required extensive assistance with bed mobility, transfers and assistance with toileting and hygiene. In an interview on 05/19/23 at 1:00 pm Resident #33 stated that the normal time it takes for his call light to be answered is 30 minutes, but it can be a lot longer. He stated he often had his urinal left for hours without being emptied. He stated that he was uncomfortable with his full urinal being left unemptied and it was embarassing. Record Review of Resident #63's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including spinal stenosis, pulmonary disease, schizophreniform disorder. Record review of Resident #63's 03/08/23 MDS revealed his BIMS was left blank; it further revealed he was an extensive assist for hygiene, eating, and dressing and for toilet use it was marked as activity did not occur. A record review of a photo dated 04/10/23 at 6:32 pm revealed Resident #63 in a soiled brief with a soiled pad underneath him. Record Review of Resident #28's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including intracerebral hemorrhage (stroke), and schizoaffective disorder (distorted reality). Record review of Resident #28's 04/14/23 MDS revealed a BIMS of 10, which indicated he had moderately impaired cognition. It further revealed that he was an extensive assist with toileting, personal hygiene, and dressing. A record review of a photo dated 04/24/23 at 10:18 am revealed Resident #28 with 2 soiled briefs on and 2 pads under him and all were soaked with urine . Record Review of Resident #35's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction, schizoaffective disorder (distorted reality), and anxiety. Record review of Resident #35's 04/15/23 MDS revealed a BIMS of 08, which indicated moderatley impaired cognition. Further review revealed he required extensive assistance with toileting, hygiene, dressing, bed mobility, and transfers. A record review of a photo dated 04/24/23 at 4:46 pm revealed Resident #35 in his wheelchair with no socks on, just slip-on shoes and his trousers are covered in yellow stains on both legs, starting in the hip and pelvic area and continuing down his gray sweat pant legs [lunch was served at 12:00 pm]. A record review of the undated facility dining times revealed that breakfast was at 8:00 am, lunch was at 12:00 pm, and dinner was at 5:00 pm. In an interview on 05/19/23 at 10:15 am the DON stated that CNAs are expected to check on residents every 2 hours and as needed and that she had not noticed strong odors. She said residents left soiled could cause infections and skin breakdown. She denied any complaints about urine odors to the best of her knowledge. Record review of an undated facility policy on Resident Rights stated that residents have a right to safe, decent and clean conditions. Record review of the abuse prohibition policy, revised [DATE], revealed each resident has a right to be free from neglect; it further defined neglect as .failure to assist in personal hygiene . failure to provide medical care for physical and mental health needs.

Based on interview and record review the facility failed to ensure that residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days for 2 (Resident #68 and #8) of 4 residents reviewed for psychotropic medication errors. The facility failed to ensure psychotropic medications were prescribed for appropriate medical diagnoses for Resident #68 and Resident #8. This failure put all residents at risk of decreased quality of life due to improper use of psychotropic medications. Finding included: Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, bipolar disorder, and depression. Record review of Resident #68's May MAR revealed an order for aripiprazole 10 mg, give 1 tablet 1 time per day for behavior. Further record review revealed no diagnosis associated with the medication order. Record Review of Resident #8's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including kidney disease, dementia, depression, anxiety, and adjustment disorder with mixed anxiety and depression. Record review of Resident #8's 04/13/23 MDS revealed her BIMSs was blank. Record review of the progress notes for Resident #8 printed on 05/22/23 at 4:11 pm revealed a progress note dated 05/16/23 at 4:21 pm written by ADON that stated stated spoke with family (RP) about AM and afternoon trazadone being discontinued and he was upset to why that would be the case; notified NP E and resident was placed back on trazadone 100 once in am and in afternoon and 150 mg 2 tab at night before bedtime. RP happy with change. Record review of Progress note dated 05/15/23 at 3:16 pm stated Resident #8 was yelling down the hall and was entered by AD; 5/12/23 at 3:22 pm yells at other residents per LVN N, 5/12/23 3:08 pm combative today hitting other residents and cursing able to redirect by AD . Record review of the progress notes for May, printed 05/22/23 at 4:11 pm revealed 05/05/23 at 12:02 pm physician progress note mdd stable but does cry at times per staff; Cymbalta 30 mg hs and trazadone 100 mg po hs vit d3 25 mcg po daily signed by NP E. Record review of Resident #8's May MAR revealed from 05/01/23 - 05/08/23 8:00 pm 100 mg Trazadone, and 12:00 pm 100 mg trazadone; from 05/08/23 - 05/16/23 150 mg trazadone at 8:00 pm; then starting 05/17/23 100 mg trazadone at 8:00 am, 100 mg trazadone at 12:00 pm, and 300 mg trazadone at 8:00 pm. Record review revealed no existing order for trazadone scheduled at 8:00 am prior to 05/17/23. Record review of the manufacturer prescribing information for trazadone, in section 2.1 dosage selection, the dose may be increased by 50 mg/day every 3 to 4 days . The maximum dose for outpatients usually should not exceed 400 mg/day in divided doses. Inpatients (i.e., more severely depressed patients) may be given up to but not in excess of 600 mg/day in divided doses. In an interview on 05/23/23 at 1:28 pm with DON she stated she would review all psychotropic medications and limit PRN orders to 14 days and add diagnoses for medications that were lacking an associated diagnosis. She stated that the consultant pharmacist had recommended a 30 day maximum on PRN psychotropic medications. She stated she was not aware that hospice was required to follow the 14 day PRN guidelines.

Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #67, #33, #1) 3 residents reviewed for rights. 1. The facility failed to prevent CNA K from calling Resident #67 a feeder on 2 occasions. 2. The facility failed to empty Resident #33's urinal in a timely manner. 3 The facility failed to respect Resident #1's personal property and care wishes. The findings include: Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. Record review of Resident #1's 03/03/23 MDS revealed a BIMs of 15 which indicated that she was cognitively intact. Record Review of Resident #67's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy, rheumatoid arthritis, and reflux. Record review of Resident #67's 04/13/23 MDS revealed a blank for the section that provided a BIMs score. Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction Record review of Resident #33's 02/10/23 MDS revealed a BIMS of 13, which indicated he was cognitively intact. In an observation on 05/17/23 at 2:12 pm CNA K entered the room and called Resident #67 a feeder while speaking to a new staff member. In an interview on 05/17/23 at 2:12 pm with Resident #1 she stated she has heard staff use the term feeder often when referring to her roommate because her roommate, Resident #67 requires assistance with her meals. In an interview and observation on 05/17/23 at 2:13 pm with Resident #67 she was lying in the bed with her eyes closed and she was not interviewable, and not able to verbalize her feelings or thoughts In an observation on 05/17/23 at 2:23 pm in the hall next to the nurses station CNA K was speaking to a new staff member and again used the term feeder while going through a list of residents with the new staff member. In an interview and observation on 05/17/23 at 2:24 pm with CNA K she did not realize the term feeder was disrespectful and should not be used; she was going over required tasks for each resident with a new staff member. In an observation on 05/20/23 at 4:00 pm with Resident #33 in his room the urinal with urine in it was sitting on the table in full view. In an observation on 05/22/23 at 10:20 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table. In an observation on 05/22/23 at 11:00 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table. In an interview with Resident #1 on 05/17/23 at 2:12 pm she stated that CNA M had worked for the facility before and Resident #1 had problems with her because she was rude and not polite. CNA M has returned to the facility and and she came into the room and Resident #1 asked her not to use Resident #1's red hairbrush on her roommate (who has a blue brush) and CNA M told her Don't you think I know that, which upset Resident #1. Then CNA M proceeded to use Resident #1's hairbrush on her roommate (Resident #67). The resident ws upset that this staff member was alloweed back at the facility and felt she was disrespectful by using her brush on her roommmate and ignored becuase she had just asked her not to do that. Record review of the undated facility policy titles Statement of Resident Rights revealed .1. All care necessary for you to have the highest possible level of health . 2. Safe, descent and clean conditions . 4. Be treated with courtesy, consideration, and respect

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 25 (Resident #2, #11, #14, #18, #19, #22, #23, #31, #33, #34, #36, #38, #39, #40, #41, #1, #47, #51, #61, #63, #64, #66, #67, #68, and #70) of 72 residents reviewed for missing medication doses, and for 2 of 2 (Center cart log and Center cart #1 log) medication cart logs that were reviewed for pharmacy services. #1 The facility failed to ensure medications were available as ordered by a practitioner for Resident #2, #11, #14, #18, #19, #22, #23, #31, #33, #34, #36, #38, #39, #40, #41, #1, #47, #51, #61, #63, #64, #66, #67, #68, and #70. #2 The facility failed to ensure accurate documentation in narcotic count sheets for 2 of 2 (Center cart log and Center cart #1 log) medication cart logs that were reviewed for pharmacy services: The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications on the medication cart logs that were reviewed for pharmacy services. The facility failed to ensure medications were available as ordered by a practioner. These failures could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not being reconcile every shift and at risk for worsening of medical condition due to not having prescribed medications available. The findings included: #1 The facility failed to ensure medications were available as ordered by a practitioner In an interview on 05/17/23 at 4:40 pm with ADON 2 she stated the facility had a new system that started 05/10/23 for pharmacy services that involved a nightly delivery that contained medications for the following day. Record Review of Resident #2's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, heart disease, bipolar disorder, hypertension, and schizoaffective disorder. Record review of the progress notes for Resident #2 printed on 05/22/23 at 4:11 pm revealed a progress note dated 05/06/23 at 5:28 am revealed none on cart, med unavail. Didn't come out of passport Facility failed to provide Resident #2's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #11's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including crohn's disease, bipolar disorder, depression, anxiety, mood disorder, dementia, and schizoaffective disorder. Record review of Resident #11's May 23 MAR revealed on 05/03/23 at 8:00 pm, for administration of Ingrezza 60 mg, give 1 capsule by mouth at bedtime for tardive diskenesia (uncontrollable movements) related to drug induced subacute dyskinesia , the number 9 was entered which indicated to see the progress notes. Record review of the progress notes for Resident #11 printed on 05/22/23 at 4:11 pm revealed a progress note dated 5/3/23 at 6:44 pm medication on order . Record Review of Resident #14's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including dementia, bipolar disorder, depression, schizoaffective disorder, subdural hemorrage, and anxiety. Record review of Resident #14's progress notes, printed on 05/22/23 revealed a progress note on 5/9/23 at 00:51 am re-ordered oxcarbazepine 75 mg via pcc. Pending RX delivery. 00:51 am med not available. Pending Rx delivery. Record Review of Resident #18's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including syncope & collapse, hypothroidism, and cirrhosis. Record review of Resident #18's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/22/23 8:20 am not available, awaiting delivery; another progress not 5/21/23 3:30 pm not available; 10:20 am medication pending to delivery 5/20/23 4:36 pm medication pending to delivery; 09:52 am 5/19/23 3:53 pm awaiting delivery; 10:40 am awaiting delivery; 5/14/23 5:26 am drug unavailable 5/7/23 4:06 am med unavail. None on cart 5/5/23 4:50 am none on cart, med. Unavail. 5/4/23 4:01 am none on cart, med. Unavail. 5/1/23 4:04 am med. Unavail. Facility failed to provide Resident #18's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #19's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, paraplegia, and spinal stenosis. Record review of Resident #19's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 05/12/23 11:51 pm med not available on cart, need to be ordered Record review of Resident #19's May 23 MAR revealed on 05/13/23 at 12:00 am he did not get his Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth every 8 hours for pain. Record Review of Resident #22's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including heart disease, dementia, and schizoaffective disorder. Record review of Resident #22's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/20/23 5:11 pm drug unavailable Record review of Resident #22's May 23 MAR revealed 05/20/23 at 5:00 pm she did not get Cyclobenzaprine HCl Tablet 5 MG Give 1 tablet by mouth three times a day for muscle pain. Record Review of Resident #23's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, epilepsy, and hyperlipidemia. Record review of Resident #23's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 05/05/23 4:07 am med unavail none on cart/passport 05/04/23 8:10 am on order; 5:32 am med unavail; none on cart/passport 05/03/23 5:11 pm medication not here; 9:57 am medication not here 05/01/23 4:01 am med unavail Record review of Resident #23's May 23 MAR revealed she did not get the following: 05/05/23 5:00 am Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth in the morning for low thyroid hormone 05/04/23 5:00 am Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth in the morning for low thyroid hormone 05/03/23 4:00 pm Colchicine Oral Tablet 0.6 MG (Colchicine) Give 2 tablet by mouth two times a day for edema to leg for 4 Days 05/01/23 5:00 am Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth in the morning for low thyroid hormone Record Review of Resident #31's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, respiratory failure, and cardiovascular syphilis. Record review of Resident #31's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/18 10:22 pm pending delivery; 5:57 pm benztropine blister pack was empty 5/1/23 7:52 pm medication on hold, pending delivery from pharmacy Facility failed to provide Resident #31's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction. Record review of Resident #33's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/12/23 11:50 pm med not available on cart, need to be ordered Facility failed to provide Resident #33's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #34's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including sepsis, lymphedema, and seizures. Record review of Resident #34's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/21/23 4:38 pm not available; 9:00 am not available 5/5/23 8:38 am phenobarbital waiting on pharmacy to deliver 5/4/23 6:39 pm on order Record review of Resident #34's May 23 MAR revealed he did not receive his 05/04/23 4:00 pm PHENobarbital Oral Tablet 97.2 MG (Phenobarbital) Give 1 tablet by mouth two times a day related to OTHER SEIZURES; his 05/05/23 8:00 am PHENobarbital Oral Tablet 97.2 MG (Phenobarbital) Give 1 tablet by mouth two times a day related to OTHER SEIZURES; and on 05/21/23 at 8:00 am Metamucil Oral Powder 28.3 % (Psyllium) Give 1 tsp by mouth two times a day for Constipation. Record Review of Resident #36's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, heart failure, depression, and anxiety. Record review of Resident #36's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 05/21/23 11:14 pm pending RX delivery Facility failed to provide Resident #36's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #38's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease, bipolar disorder, and pulmonary disease. Record review of Resident #38's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/14/23 11:06 am medication is not available, nurse ordered medication at this time awaiting for pharmacy to send Record review of Resident #38's May 23 MAR revealed on 05/14/23 at 8:00 am she did not receive ZyPREXA Tablet 10 MG (OLANZapine) Give 1 tablet by mouth two times a day for Agitation related to SCHIZOPHRENIA. Record Review of Resident #39's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including hypertension, and reflux disease. Record review of Resident #39's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/16/23 1:51 am pending rx delivery Record review of Resident #39's May 23 MAR revealed he did not get: 05/15/23 4:30 pm Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Atrial Fibrillation Not Caused by a Heart Valve Problem 05/16/23 12:00 am Tylenol with Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet orally every 8 hours for pain 05/16/23 8:00 am Tylenol with Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet orally every 8 hours for pain 05/16/23 8:00 am Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for diuretic 05/16/23 8:00 am Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 tablet by mouth one time a day for supplement 05/16/23 8:00 am Levothyroxine Sodium Oral Capsule 75 MCG (Levothyroxine Sodium) Give 1 capsule by mouth one time a day for elevation is TSH. Record Review of Resident #40's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including Huntington's disease, hypertension, reflux, and psychotic disorder. Record review of Resident #40's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/5/23 4:49 am none on cart, med unavail 5/4/23 4:03 am none on cart, med unavail 5/1/23 4:03 am med unavail Recod review of Resident #40's May 23 MAR revealed she did not get: 05/05/23 5:00 am Levothyroxine Sodium Tablet 88 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/04/23 5:00 am Levothyroxine Sodium Tablet 88 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/01/23 5:00 am Levothyroxine Sodium Tablet 88 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM Record Review of Resident #41's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including pulmonary disease, dementia, and Parkinson's disease. Record review of Resident #41's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/13/23 5:00 am med not available on cart need to be ordered 5/5/23 4:48 am med unavail. None on cart/passport 5/4/23 4:03 am med unavail, none on cart 5/1/23 4:02 am med unavail Record review of Resident #41's May 23 MAR revealed she did not get: 05/13/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/05/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/04/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/01/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM Record Review of Resident #47's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including atherosclerosis, schizoaffective, depression, and anxiety. Record review of Resident #47's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/22 11:33 am not in stock, pharm will re-order - ingrezza Resident #1 Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. Record review of the progress notes for Resident #1 printed 05/22/23 revealed a note dated 05/21/23 at 1:35 pm revealed Resident stated that she did not receive her 12:00 am Tizanidine and Gabapentin and she did not receive her 0500 Levothyroxine. Contracted Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated. As for the 12:00 am Tizanidine and gabapentin, both of those needed to be pulled from the Cubex machine because the times were updated and there was no med packs for those. Contracted pharmacist was contacted and it was confirmed that at 12:00 am both of those medications were pulled from the Cubex machine by LVN D and in the MAR both medications were signed off by LVN D as they were administered. Record review of the progress notes for Resident #1 printed on 05/22/23 revealed the following date when medication was not available: 5/15 at 10:16 PM pending rx delivery for 10 medications. Record Review of Resident #51's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, pulmonary disease, heart disease, and hypertension. Record review of Resident #51's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/12/23 7:10 pm pending del Record review of Resident #51's May 23 MAR revealed on 05/12/23 at 4:00 pm her Haloperidol Tablet 1 MG Give 4 tablet by mouth two times a day related to SCHIZOAFFECTIVE DISORDER was not administered. Record Review of Resident #61's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, cerebral infarction, and dementia. Record review of Resident #61's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/6 9:18 pm Aricept unavailable; 9:04 pm trazadone unavailable; 9:01 pm abilify unavailable; 4;11 am simvastatin, unavailable; 4:11 am trazadone med not available; 4:10 am Remeron - blank note; 4:10 am melatonin blank note; 4:09 aricept med not available; 4:07 am ability not available Record Review of Resident #63's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including spinal stenosis, pulmonary disease, and schizophreniform disorder. Record review of Resident #63's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/12/23 6:23 pm pending del Record review of Resident #63's May 23 MAR revealed on 05/12/23 at 4:00 pm the following medication was not administered: Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol (Ophth)) Instill 1 drop in both eyes two times a day related to DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS. Record Review of Resident #64's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including dementia, respiratory failure, and schizophrenia. Record review of Resident #64's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/09/23 3:31 am re-ordered trazadone via pcc, pending rx delivery 05/06/23 8:50 pm trazadone 25 mg med unavailable Record Review of Resident #66's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's, hypertension, reflux, and kidney failure. Record review of Resident #66's MDS dated [DATE] revealed a BIMS of 0 which indicated severely impaired cognition. Record review of Resident #66's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/08/23 2:11 pm ADON 2 Review of Seroquel by NP, at this time no change in dose, not recommended for GDR due to behaviors could worsen. Record Review of Resident #67's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy, rheumatoid arthritis, and reflux. Record review of Resident #67's MDS dated [DATE] revealed her BIMS section was blank. Record review of Resident #67's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/20/23 10:07 am Spoke with pharmacy regarding antibiotics the packaging is dated for 5/21/2023 no packages were received for 05/20/2023 tech she will add more packages on the run tonight for tomorrows medication pass 05/19/23 Order entered 1:46 pm for pneumonia, first does dose due at 4:00 pm, not in facility Record review of Resident #67's May 23 MAR revealed an order for Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for pneumonia for 7 Days give 100 mg PO BID for X7 days; which was not administered until 05/20/23 at 8:00 am despite being scheduled for 05/19/23 at 4:00 pm. Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, hypothyroidism, bipolar disorder, and depression. Record review of Resident #68's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/19/23 5:21 pm on order 05/17/23 00:22 pending RX delivery; 00:21 pending RX delivery 05/16/23 7:23 pm - all meds NH with 9, no information in progress note, just copied order 05/16/23 5:03 pm on order Record review of Resident #68's May 23 MAR revealed that on 05/16/23 at 4:00 pm he was supposed to have a 10 cc saline flush before and after each dose of ertapenem, but this was on order. On 05/16/23 an order for Ertapenem 1 gram every 8 hours for infection in foot bone was entered with a start date of 05/16/23 4:00 pm, and was discontinued 05/16/23 at 3:25 pm. On 05/16/23 at 7:00 pm his Mirtazapine Oral Tablet 15 MG was not given, his 4:00 pm Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole- Trimethoprim) Give 1 tablet by mouth two times a day for bone infection was not given, his 5:00 pm Gabapentin Capsule 400 MG Give 1 capsule by mouth three times a day for pain was not given because they were not available. On 05/17/23, 12:00 am his Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Use 1 gram intravenously every 8 hours for foot infection for 36 Administrations was not given pending delivery, his 05/17/23 12:00 am 10 cc saline flush before and after each dose of ertapenem was pending delivery, and on 05/19/23 at 4:00 pm his Hydrocortisone External Cream 1 % (Hydrocortisone (Topical)) Apply to left ankle /calf topically two times a day for itching for 7 Days was not given because it was on order. Record Review of Resident #70's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, kidney disease, hepatitis c, and dementia. Record review of Resident #70's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/14/23 11:03 am Medication was not available nurse ordered medication at this time Record review of Resident #70's May 23 MAR revealed on 05/14/23 at 8:00 am she did not get amLODIPine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR less than 60 or SBP less than 100. Record Review of Resident #34's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including sepsis, lymphedema, and seizures. Record review of Resident #34's May 23 MAR revealed he did not receive his 05/04/23 4:00 pm phenobarbital 97.2 mg tab for seizures, nor did he receive his 05/05/23 8:00 am dose. Record review of the progress notes for Resident #34 printed 05/22/23 at 4:11 pm revealed a progress note dated 5/4/23 at 6:39 pm on order; a progress note dated 5/5/23 8:38 am waiting on pharmacy to deliver. Record Review of Resident #51's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, pulmonary disease, heart disease, and hypertension. Record review of Resident #51's MDS dated [DATE] revealed a BIMS of 11 which indicated moderately impaired cognition. Record review of Resident #51's May 23 MAR revealed she did not receive her 05/12/23 4:00 pm dose of haloperidol 4 mg dose. Record review of the progress notes for Resident #51 printed 05/22/23 at 4:11 pm revealed a progress note dated 05/12/23 7:10 pm stating pending del [halodperidol 4 mg]. Record Review of Resident #23's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, epilepsy, and hyperlipidemia. Record review of Resident #23's MDS dated [DATE] revealed a BIMS of 14, which indicated the resident was cognitively intact. Record review of Resident #23's May 23 MAR revealed she did not receive colchicine 1.2 mg on 05/03/23 8:00 am, 05/03/23 4:00 pm, and 05/04/23 at 8:00 am. Record review of the progress notes for Resident #23 printed 05/22/23 at 4:11 pm revealed a progress note dated 05/03/23 9:57 am medication not here; 05/03/23 5:11 pm medication not here; 05/04/23 8:10 am on order. Record review of Resident #23's orders revealed an order for Colchicine Oral Tablet 0.6 MG (Colchicine) Give 2 tablet by mouth two times a day for edema to leg for 4 Days with a start date of 04/30/23 4:00 pm. Record review of the undated facility policy title Administering Oral Medications revealed Steps in the procedure 9. prepare the correct dose for the resident . 10. Confirm the identity of the resident 11. Explain the procedure to the resident 12. Place medications on the bedside tray or table . 14 assist the resident to a sitting position . 15 offer water to assist .21. Remain with the resident until all medications have been taken. Record review of the undated facility policy title Documentation of Medication Administration revealed . 2. Administration of medication must be documented immediately after (never before) it is given . 3. Must include d.date and time administered; e reason(s) why a medication was withheld, not administered, or refused (as applicable) . #2 The facility failed to ensure accurate documentation in narcotic count sheets for 2 of 2 (Center cart log and Center cart #1 log) medication cart logs that were reviewed for pharmacy services: During an observation on 05/17/23 at 2:08 pm an inspection of the medication cart log on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 05/01/23, 05/02/23, 05/12/23, 05/13/23, 05/14/23, and 05/15/23. In addition, there was already a signature by CMA A in the spot for the 05/17/23 11 pm to 7 am shift in the nurse off signature block. During an observation on 05/17/23 at 2:25 pm an inspection of the medication cart #1 log on Center Hall revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 05/01/23, 05/02/23, 05/10/23, 05/14/23, 05/15/23 and 05/16/23. During an observation on 05/18/23 at 1:32 pm an inspection of of the medication cart log on Center Hall revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), revealed a signature by CMA A already present in the spot for the 05/18/23 11 pm to 7 am shift in the nurse off signature block. In an interview on 05/18/23 at 1:40 pm with CMA A she stated that she signed the logs the way she was supposed to, but she had noticed that there were missing signatures . Record review of the CMS form 2567 with an exit date of 03/02/23 revealed the facility was cited for the same deficiency. In the plan of correction the facility stated the DON would monitor the logs for accuracy for 3 months. Record review of the facility's policy titled, Controlled Substances, no date, revealed, .12. At the end of Each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.

Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 2 hallways (Secure Hall, and 200 Hall) of 4 hallways observed for environment 1. The facility failed to ensure the rooms and halls were free from offensive odors on the Secure Hall and the 200 Hall. 2. The facility failed to ensure the walls, ledges and windows were free from stains on the Secure Hall and the 200 Hall. These failures placed all residents at risk of living in an unclean, uncomfortable, un-homelike environment. Findings include: In an observation on 05/17/23 at 2:10 pm a strong odor of urine was detected outside of rooms [ROOM NUMBERS]. In an observation on 05/17/23 beginning at 3:52 pm on the secure unit revealed in the end of the hall on the wall to the left of the exit door stains were observed on the blinds; stains on the wall and ledge; and on the wall to the left of the window a drop of red substance and smear of brown substance. In a confidential staff interview, staff member stated that they were understaffed and residents did not always get checked every 2 hours, which led to the smells. In an observation on 05/22/23 at 10:20 am on the secure unit the same issues observed on 05/17/23 at 3:52 pm were still present; the secure unit the wall in the hall by the exit door stains were observed on the blinds; stains on the wall and ledge; and on the wall to the left of the window a drop of blood and smear of dirt. In an observation on 05/21/23 at 10:38 am a strong smell of urine was detected down the 200 Hall off the common area where the residents were gathered sitting in wheelchairs. In an interview with a confidential visitor to the facility, the visitor stated the facility floors were sticky and on several residents the visitor noted dirty and soiled clothing. Record review of an undated facility policy on Resident Rights stated that residents have a right to safe, decent, and clean conditions.

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 26 (Resident #1, #7, #9, #12, #14, #15, #20, #22, #23, #25, #28, #30, #31, #33, #38, #45, #46, #47, #50, #54, #56, #62, #64, #65, #68, and #70) of 72 residents reviewed for medication errors. 1. The facility failed to administer medications prescribed by provider(s) for Resident #1, #7, #14, #20, #22, #23, #25, #28, #31, #33, #38, #46, #47, #62, #64, #65, and #70. 2. The facility failed to adhere to the parameters of medication administration as written by the provider(s) for Resident #1, #15, #12, #9 #25, #56, #47, #54, and #45. 3. The facility failed to administer medications in a timely manner, within an hour of the scheduled administration time, and before meals as prescribed for Resident #33. 4. The facility failed to ensure the administration of levothyroxine on 05/21/23 at 5:00 am for 3 of 3 (Resident #1, Resident #50, and Resident #68) residents reviewed for missing levothyroxine complaints on 05/21/23. 5. The facility failed to ensure the administration of medications that have a narrow therapeutic index for Resident #1, #25, and #30. These failures could place resident at the facility and placed each resident at risk of continued serious medication errors that were likely to cause injury, harm, impairment or death, in addition to impairing psychosocial wellbeing. Findings included: #1 The facility failed to administer medications prescribed by provider(s). Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. In an interview and observation on 05/17/23 at 2:12 pm Resident #1 she did not get her night medicine on 05/12/23, which included medicine for sleep and for pain. She stated that her pain on 05/12/23 was a 10 out of 10 and she couldn't sleep either. She said her pain was relieved sometime after 7:00 am on 05/13/23 when the morning shift arrived. Resident #1 cringed multiple times and grabbed her left leg stump while she spoke. She also grimaced 3 times and then gasped while grabbing her left leg. She became tearful and stated that she has told all of the nurses she was in pain, and it has been for a few weeks; she said she has not been re-evaluated by a doctor after she informed the nurses she was in pain. Resident #1 did not feel the Tylenol #4 PRN was helping. She stated her current pain level was a 10 out of 10. In an interview on 05/17/23 at 2:24 pm with DON this Surveyor informed her of Resident #1 complaining of 10 out of 10 pain. Record review on 05/17/23 revealed that Resident #1's May 2023 MAR was blank on 05/11/23 and 05/12/23 for her 8:00 pm medications which were Melatonin 10 mg, Glucophage 500 mg, Tizanidine 4 mg, gabapentin 800 mg, Aggrenox 25-200, dilantin 200 mg, coreg 50 mg, Cymbalta 60 mg, and trazadone 250 mg. In addition, her 4:00 pm ziprasidone 40 mg was not administered on either date. Interview on 05/17/23 at 2:30 pm with LVN O stated Resident #1 likes meds [enjoys narcotics] and got people fired [complained often about care]; she had never seen the resident grimace. She stated she had a med at 6:45 am and she goes to pain management in Waco and [NAME]. Resident #1 was a drug addict, she knew from back in the day [before the resident admitted to the facility in 2015]. In an interview and observation on 05/17/23 at 4:40 pm with ADON 2 and DON, the DON walked to the medication cart and pulled out medication baggies that had a resident name at the top and a date and time for administration. She stated if the medications were not administered they would be in the cart and no medications were in the cart . In an interview on 05/17/23 at 4:48 pm, while observing a med cart with DON, unprompted CMA A stated that on 05/11/23 before she left for the evening she noted that a few residents, including Resident #1, did not have baggies for their night medications. She stated the new pharmacy company had a rep on site and the rep was informed that residents were missing meds and rep stated she would send an email but it could take a day to get it straightened out. She stated that 05/10/23 was the first day of the new pharmaceutical system using the medications and baggies, so the rep was present. In an observation on 05/17/23 at 4:52 pm with DON she came out of a room behind the nurses station carrying 2 baggies of medications with Resident #1's name and 05/12/23 8:00 pm on the top [the medications that should have been administered to Resident #1 on Friday 05/12/23 at 8:00 pm]. In an interview on 05/17/23 at 5:19 pm with DON she stated she spoke to CMA B on the phone and CMA B stated that Resident #1 refused her medications on 05/12/23. The DON asked if she should enter a progress note at this time reflecting the resident refused her medications. The DON stated that the expectation was that CMA B should have informed the nurse working that night of the refusal, the nurse should have spoken to the resident and offered the medications again. She said medications not being administered was a risk to the resident and the expectation was that medications be administered or the reason be documented in the MAR . In an interview on 05/17/23 at 5:19 pm with the ADON she stated Resident #1 can't be in pain she was outside smoking and smiling just before she claimed to be in pain. In an interview on 05/18/23 at 8:23 am with PHAR P she stated the rep would not call me back, she is her supervisor. She stated the deliveries arriving around midnight tonight would be for the day after tomorrow. The medication carts should have today's medications to be distributed and tomorrow's. She said it was not possible that the medications were not present in the building and that there was a central computer called a cubex that had the common medications so they could be pulled if needed. In an interview on 05/18/23 at 1:27 pm with CMA A she stated she was pretty sure Resident #1, Resident #38 and Resident #50 were was all missing night medications on 05/11/23 and she informed the pharmacy rep of this In an interview and observation on 05/18/23 at 4:50 pm with Resident # 1 she said she saw the pain doctor today, but doesn't think the medications are working. She said she did not get any medications last Thursday (05/11/23) or Friday (05/12/23) which included medications for pain and sleep. She said she did not get sleep on Thursday or Friday, she was in pain and couldn't calm down and she was crying on and off through the night. She stated that hell no I did not refuse my medications, and said she refused a patch that did not help her but other than that she did not refuse her medications ever. She said her left stump pain started around an 8 of 10 and went up to a 10 of 10 on both nights. She told ADON 2 on Tuesday 05/16/23 that she was in pain and she said they would try to fix it, but she told her a few times over the last few weeks and nothing was done about her pain. She was clearly uncomfortable, shifting multiple times, grabbing her left leg stump, and cringing and gasping a few times. In addition, she got emotional several times as we spoke. She said that it was a horrible anxiety and pain that got worse and worse through the night on Thursday and Friday when she did not get her medicine and her roommate was snoring and added to her frustration; she said it was overwhelming to deal with the pain and lack of sleep. In an interview on 05/18/23 at 5:05 pm with DON and ADON 2, ADON 2 she said Resident #1 was a drug addict, and she had failed the screening for a pain pump. The DON and ADON 2 said Resident #1 should have hit her call light and Resident #1 could have called or texted them to get her medicine. In an interview on 05/18/23 at 7:15 pm with LVN C she stated that if the CMA had told her a resident refused medications she would have spoken to the resident, if the resident still refused she would document it in the MAR. She said on 05/12/23 CMA B left at 10:00 pm and the medication delivery came around midnight. She said there were a handful of medication in the corner of the drawer when CMA B left if she recalled correctly . She did not now if the left over meds belonged to Resident #1 and they were in the cart when she signed off the cart in the morning. In an interview on 05/19/23 at 10:13 am the DON stated that the expectation was that the CMA notify the nurse if a medication was refused and the nurse would offer or document. She said without the correct documentation that residents could end up not getting the correct amount of medicine which would harm them. She said she and ADON 1 and ADON 2 run a report to look for blanks in the MAR and address these blanks. She stated the report was supposed to be run daily, but she had not run it this week. She said she did not know why it did not get done. She stated missing medication could harm residents. She was not sure how these were missed and she was not sure why parameters were missing from several orders for blood pressure. She said she would get back to me and left the room. In an interview on 05/19/23 at 11:00 am with Resident #1 she stated she was in about a 3 of 10 pain level and that was comfortable for her [her pain was under control]. In an interview on 05/19/23 at 11:52 am with CMA B she stated she couldn't find Resident #1 on 05/12/23 to give her the medicine she was supposed to administer and when she finally saw the resident around 9:30 pm the resident refused her medication. She said she did not inform anyone working that night;. sShe stated she had the phone number for the DON but did not inform her of the refusal either. She confirmed she should have informed the nurse but forgot and forgot to chart the refusal. Record review of the Medication Admin Audit Report run on 05/17/23 at 4:52 pm for residents who had a blank for medication administration between 05/11/23 - 05/13/23 revealed the following medications were missed in addition to Resident #1 listed above: Resident #7, Center 3 unit, 05/11/23 8:00 pm, melatonin 5 mg Resident #14, Secure unit, 05/13/23 1:00 pm, Depakote sprinkles 125 mg Resident #20, Secure unit, 05/13/23 8:00 am, metoprolol 12.5 mg Resident #22, Center 3 unit, 05/11/23 8:00 pm, Aricept 10 mg, melatonin 5 mg, Xanax .5 mg, trazadone 50 mg, dicyclomine 10 mg Resident #23, Center 3 unit, 05/11/23 8:00 pm, Humalog sliding scale (no blood sugar done) Resident #25, Center 3 unit, 05/11/23 8:00 pm, Novalog sliding scale (no blood sugar done), lantus 30 units 05/12/23 8:00 pm, Novalog sliding scale (no blood sugar done), lantus 30 units Resident #28, Center 3 unit, 05/11/23 8:00 pm, melatonin 5 mg, risperidone 1 mg Resident #29, Center 1 unit, 05/12/23 4:00 pm, combigan ophthalmic solution 1 drop in both eyes, methocarbamol 500 mg 05/12/23 8:00 pm, senna 8.6 mg, latanoprost ophthalmic solution 1 drop in both eyes Resident #31, Center 1 unit, 05/12/23 6:30 am, pantoprazole 40 mg 05/12/23 8:00 am, benztropine .5 mg, baclofen 10 mg, coreg 25 mg, sertraline 100 mg, amlodipine 10 mg, Depakote Sprinkles 500 mg, Vistaril 25 mg 05/12/23 1:00 pm, Vistaril 25 mg Resident #33, Center 1 unit, 05/11/23 8:00 pm, atorvastatin 80 mg, hydromorphone 2 mg, Flomax .4 mg, trazadone 150 mg, novolog sliding scale, Gabapentin 600 mg, lantus 15 units, docusate 100 mg Resident #38, Center 3 unit, 05/13/23 8:00 am, Zyprexa 10 mg Resident #46, Secure unit, 05/13/23 1:00 pm, Depakote sprinkles 125 mg, med pass 2.0 Resident #47, Secure unit, 05/13/23 1:00 pm, lorazepam 1 mg, sodium chloride 1 g Resident #62, Center 1 unit, 05/12/23 7:00 pm, metaxalone 400 mg 05/12/23 8:00 pm, trazadone 50 mg, Aricept 5 mg Resident #64, Center 1 unit, 05/12/23 5:00 am, levothyroxine 05/11/23 4:00 pm, gabapentin 100 mg, risperidone 1 mg, benztropine .5 mg Resident #65, Center 3 unit, 05/11/23 8:00 pm, Advair diskus 1 puff Resident #70, Center 3 unit, 05/11/23 8:00 pm, lantus 15 units, Humalog sliding scale 05/13/23 8:00 am, amlodipine 5 mg Record review of all active orders printed 05/22/23 at 3:58 pm revealed the following orders: Resident #7 had an order Melatonin Tablet 5 MG Give 1 tablet by mouth at bedtime related to INSOMNIA Resident #14 had an order for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule by mouth three times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE Resident #20 had an order for Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 0.5 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR <60 or bp <120/60. Resident #22 had the following orders: Aricept Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for DEMENTIA; Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth at bedtime for anxiety; Melatonin Oral Tablet 5 MG (Melatonin) Give 5 mg by mouth at bedtime for insomnia; traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER; and Dicyclomine HCl Capsule 10 MG Give 1 capsule by mouth at bedtime for IBS; Resident #23 had an order for tor HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals and at bedtime related to TYPE 2 DIABETES Resident #25 had an order for NovoLOG Injection Solution (Insulin Aspart) Inject as per sliding scale, subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS; and an order for Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS Resident #28 had an order for Melatonin Tablet 5 MG Give 1 tablet by mouth at bedtime for insomnia; and RisperiDONE Tablet 1 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER Resident #29 had an order for Combigan Ophthalmic Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol Maleate) Instill 1 drop in both eyes two times a day related to UNSPECIFIED GLAUCOMA; Methocarbamol Oral Tablet 500 MG (Methocarbamol) Give 1 tablet by mouth two times a day related to UNSPECIFIED OSTEOARTHRITIS; Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth at bedtime for constipation; and Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime for GLACOMA. Resident #31 had an order for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 40 mg by mouth in the morning related to GASTROESOPHAGEAL REFLUX DISEASE; Benztropine Mesylate Oral Tablet 1 MG (Benztropine Mesylate) Give 0.5 tablet by mouth two times a day for EPS; Baclofen Oral Tablet 10 MG (Baclofen) Give 10 mg by mouth two times a day for muscle spasms; Coreg Oral Tablet 25 MG (Carvedilol) Give 25 mg by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for BP under 100/60 or HR under 60; Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 100 mg by mouth one time a day for Depression; amLODIPine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 10 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for BP less than 100/60, HR less than 60; Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule by mouth two times a day related to GENERALIZED ANXIETY DISORDER; and Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth three times a day related to GENERALIZED ANXIETY DISORDER. Resident #33 had an order for Atorvastatin Calcium Tablet 80 MG Give 1 tablet by mouth at bedtime for HLD; HYDROmorphone HCl Tablet 2 MG Give 1 tablet by mouth every 4 hours related to ACQUIRED ABSENCE OF RIGHT LEG BELOW KNEE; Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia; traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED (G47.00) administer with 100mg tablet = 150mg; traZODone HCl Tablet 100 MG Give 1 tablet by mouth at bedtime for Insomnia related to INSOMNIA, UNSPECIFIED (G47.00) administer with 50mg tablet = 150mg; NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale, subcutaneously before meals and at bedtime related to TYPE 1 DIABETES; Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 capsule by mouth every 4 hours for diabetic nerve pain; Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously at bedtime for diabetes; and Docusate Sodium Capsule 100 MG Give 1 capsule by mouth at bedtime for constipation Resident #38 had an order for ZyPREXA Tablet 10 MG (OLANZapine) Give 1 tablet by mouth two times a day for Agitation related to SCHIZOPHRENIA Resident #46 had an order for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule by mouth three times a day related to ANXIETY DISORDER; and Med Pass 2.0 three times a day for 80cc offer snacks with med pass Resident #47 had an order for LORazepam Tablet 1 MG Give 1 mg by mouth three times a day for ANXIETY DISORDER; and Sodium Chloride Tablet 1 GM Give 1 tablet by mouth three times a day for HYPONATREMIA. Resident #62 had an order for Metaxalone Tablet 400 MG Give 1 tablet by mouth at bedtime for muscle spasm; TraZODone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime for Inability to Sleep related to INSOMNIA; and Aricept Tablet 5 MG (Donepezil HCl) Give 1 tablet by mouth at bedtime for dementia. Resident #64 had an order for Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth in the morning for low thyroid hormone related to HYPOTHYROIDISM, UNSPECIFIED (E03.9) pt requests med be given at 0730; Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for pain; RisperDAL Oral Tablet 2 MG (Risperidone) Give 1 tablet by mouth two times a day related to PARANOID SCHIZOPHRENIA; and Benztropine Mesylate Oral Tablet 0.5 MG (Benztropine Mesylate) Give 1 tablet by mouth two times a day for . Resident #65 had an order for Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone-Salmeterol) 1 puff inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Resident #70 had an order for Lantus 100 UNIT/ML Solution Inject 15 unit subcutaneously at bedtime related to DIABETES; HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale, subcutaneously before meals and at bedtime related to DIABETES MELLITUS, and amLODIPine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR less than 60 or SBP less than 100. Record review of the MAR for the month of April 2023 revealed every resident in the facility had medications that were not administered, with a total of 1239 omissions on the secured unit (Residents #8, #44, #27, #54, #4, #72, #42, #47, #45, #16, #60, #14, #61, #59, #46, and #30) and 255 omissions (Residents #56, #37, #12, #15, #25, #22, #70, #41, #50, #1, #22, #11, and #6) for the center unit. These counts reflected only medication administrations and did not include other orders that were not completed. Record review of the MAR for the month of May (05/01/23 - 05/19/23) revealed 55 omitted medication administrations on the secure unit and 419 omitted medication administration on the center unit. #2 The facility failed to adhere to the parameters of medication administration as written by the provider(s). Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease (lung disease), and cerebrovascular (blood flow in brain) disease. Record review of Resident #1's 03/03/23 MDS dated revealed a BIMSs of 15, which indicated the resident was cognitively intact. Record review of Resident #1's May 23 MAR revealed on 05/04/23 8:00 pm her Coreg 50 mg (hold for BP less than 100/60 or heart rate less than 60) was held when her blood pressure was 124/60 and heart rate was 76. On 05/03/23 7:00 am her blood pressure was 177/77 and her Cozar 100 mg (hold if blood pressure is under 100 and call MD if over 170) but there was no documentation that the physician was not notified of her 177 systolic blood pressure. In an interview on 05/18/23 at 5:08 pm with ADON 2 she stated that if a physician was notified of anything there should be a progress note on the date and time the notification was made. In addition, she said it should be on the 24-hour report. She denied any notifications of blood pressure out of range being on the 24-hour report in May. Record Review of Resident #15's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, depression, anxiety, and schizoaffective disorder. Record review of Resident #15's 05/08/23 MDS revealed a BIMSs of 13, which indicated the resident was cognitively intact. Record review of Resident #15's May 23 MAR revealed on 05/07/23 at 8:00 am her BP was 174/96 and her metoprolol 50 mg ER (hold for BP under 100 and notify MD if over 170) was administered and MD was not notified;. oOn 05/17/23 at 8:00 am her BP was 175/89 and her metoprolol was administered, and the MD was not notified. Record Review of Resident #12's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, lung disease, and low thyroid. Record review of Resident #12's 03/24/23 MDS revealed a BIMSs of 15, which indicated the resident was cognitively intact. Record review of Resident #12's May 23 MAR revealed on 05/01/23 at 8:00 am her BP was 107/42 and heart rate was 79, and her metoprolol 50 mg was administered. On 05/02/23 at 8:00 am her BP was 110/53 and heart rate was 80 and her metoprolol was administered. The medication required measuring BP and heart rate but had no hold parameters. On 05/02/23 at 8:00 am her BP was 110/53 and HR was 80 and her lisinopril 20 mg (hold if BP less than 100/60) was administered by CMA B. Record Review of Resident #9's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, cerebral infarction (stroke), and hyperlipidemia (high cholesterol). Record review of Resident #9's 03/15/23 MDS revealed a BIMSs of 6, which indicated severely impaired cognition. Record review of Resident #9's May 23 MAR revealed on 05/05/23 at 8:00 am his BP was 106/68 and his lisinopril 20 mg (hold if BP is less than 100/60) was marked as held by CMA B per parameters but the parameters were safe to administer his medication. Record Review of Resident #25's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, pulmonary disease, Alzheimer's, and bipolar disorder. Record review of Resident #25's 05/08/23 MDS revealed a BIMSs of 2, which indicated a severely impaired cognitive function. Record review of Resident #25's May 23 MAR revealed the following orders: Humalog sliding scale before meals and bedtime Humalog inject 8 units before meals (no parameters) Lantus inject 32 units one time per day (7:00 am, no parameters) Lantus inject 30 units at bedtime (no parameters) On 05/13/23 at 8:00 pm her Lantus 30 units at bedtime was held with a note BS=199 by LVN J. On 05/03/23 at 7:00 am her lantus 32 units was held with a note glucose 111 held by LVN G. On 05/03/23 at 7:00 am her Humalog 8 units was held with a note 111 by LVN G. On 05/04/23 at 7:00 am her Lantus 32 units was held with a note 107 by LVN G. On 05/04/23 at 7:00 am her Humalog 8 units was held with a note 107 by LVN G . Record Review of Resident #56's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy (mental confusion), and hypertension (high BP) . Record review of Resident #56's 05/10/23 MDS revealed a BIMSs of 0, indicating the resident was not able to complete the test. Resident review of Resident #56's May 23 MAR revealed an order for metoprolol 25 mg give 1 tablet via PEG-tube two times a day related to essential (primary) hypertension, hold if SBP under 100, DBP under 60 or HR under 55; there are no blood pressures or heartrates associated with administration and no boxes to enter the information. Record Review of Resident #47's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including atherosclerosis (blocked vessels), depression, and anxiety. Record review of Resident #47's 03/01/23 MDS dated [DATE] revealed it had a blank for the BIMSs score. Record review of Resident #47's May 23 MAR revealed an order for lisinopril 5 mg (hold if BP less than 100/60), and on 05/04/23 at 8:00 am her BP was 96/50 and her lisinopril was administered by LVN N. Record Review of Resident #54's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, Alzheimer's disease, and hypertension. Record review of Resident #54's 04/21/23 MDS dated revealed a blank for the BIMSs score. Record review of Resident #54's May 23 MAR revealed an order for a Lidoderm 5% patch, apply to neck topically; apply for 12 hours in a 24 hour period; the record showed the patch was applied at 8:00 am daily and removed the following day at 7:59 am, then a new patch was applied at 8:00 am . The patch was documented as applied on the following dates: 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18 and 5/19 at 8:00 am. The patch was documented as removed at 7:59 am on the following dates: 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18 and 5/19. In an interview on 05/23/23 at 1:30 pm with DON and NP E, NP E stated that the order said the patch should be applied for 12 hours out of 24 hours. DON stated that is not what was being done, the patch was applied in the morning and left in place until the next morning. She stated the instructions for the removal of the patch would be updated. Record Review of Resident #45's face sheet dated 05/22/23 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, depression, and anxiety. Record review of Resident #45's 05/03/23 MDS dated revealed a BIMSs of 15, which indicated the resident was cognitively intact. Record review of Resident #45's May 23 MAR revealed an order for amlodipine 5 mg with no parameters, on 05/09/23 at 8:00 am her BP was 116/59 and it was marked as held per parameters; on 05/10/23 at 8:00 am her BP was 116/59 and her medicine was administered. In an interview on 05/18/23 at 9:55 am with the Medical Director, he stated that administering BP medications when the resident's blood pressure is below the threshold could cause serious injuries such as heart attack and stroke and could also lead to death. #3 The facility failed to administer medications in a timely manner, within an hour of the scheduled administration time, and before meals as prescribed Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction. In an observation on 05/18/23 at 1:27 pm CMA A administered the following to Resident #33 creon, pancrealipase, 1 capsule, scheduled at 1:00 pm; hydromorphone, 2 mg, pulled from secure drawer, documented in log, scheduled at 12:00 pm, so administered an hour and a half late, and gabapentin, 600 mg, it was in a baggie, then a blister pack by itself, it was scheduled for 12:00 pm, so it was an hour and a half late, and the order was written as administer every 4 hours. Record review of the Medication Admin Audit Report run on 05/17/23 for Resident #33 revealed on 05/13/23 his novolog sliding scale insulin (ordered before meals and bedtime) scheduled at 7:30 am was administered at 8:39 am; his 11:30 am dose pre-lunch dose on the same day was administered at 2:50 pm. On 05/14/23 his 7:30 am pre-breakfast does was administered at 8:40 am. On 05/01/23 his 8:00 am medications (Plavix 75 mg, pancrelipase 6000 units, rivaroxaban 20 mg) were all administered at 1:10 pm . His 05/02/23 4:30 pm pre-dinner dose was scheduled at 4:30 pm and administered at 5:43 pm; his bedtime dose on 05/07/23 was scheduled for 8:00 pm and was administered at 11:02 pm and the next night (05/08/23) it was administered at 11:06 pm. A record review of the undated facility dining times revealed that breakfast was at 8:00 am, lunch was at 12:00 pm, and dinner was at 5:00 pm. Record review of Resident #33's hospital records obtained 05/22/23 revealed he was admitted to the emergency room [DATE] at 6:53 am. It further revealed that paramedics administered glucose prior to his arrival at the hospital because his blood sugar was 36. #4 The facility failed to ensure the administration of levothyroxine on 05/21/23 at 5:00 am for 3 of 3 (Resident #1, Resident #50, and Resident #68) Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. Record review of the progress notes for Resident #1 printed 05/22/23 written by ADON 1 revealed a note dated 05/21/23 at 1:35 pm indicated Resident stated she did not receive her 0500 Levothyroxine. Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, hypothyroidism, bipolar disorder, and depression. Record review of Resident #68's progress notes, printed on 05/22/23 revealed a note dated 05/21/23 1:44 pm by ADON 1 indicated the Resident stated that he did not receive his Levothyroxine this AM at 0500. Remedi Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated by LVN D. Record Review of Resident #50's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, renal disease, and pulmonary disease. Record review of Resident #50's MDS dated [DATE] revealed a BIMS of 14 which indicated she was cognitively intact. Record review of the progress notes printed on 05/22/23 for Resident #50 revealed a note dated 05/21/23 at 4:59 pm by ADON 2 indicated the Resident reported that she did not get her am synthroid this morning., She was informed her that a an investigation would be made and cameras pulled to verify if medication was administered. About 10 minutes later resident returned with synthroid in her hand and stated, LVN D never misses my medication she must have given it to me and I was still asleep. Provided resident with water and resident took synthroid at this time. Record review of the progress notes printed on 05/22/23 for Resident # 50 revealed a progress note dated 05/21/23 at 1:43 pm by ADON 1 indicated Resident

Based on observation, interview, and record review the facility failed to keep one (Resident #1) of six residents free from abuse. The facility failed to: - Protect Resident #1 from being abused by the Registered Nurse who willfully and deliberately placed a urine-soaked towel to Resident #1's face. On 12-20-22 at 4:29 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12-21-22 at 7:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of J identified due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of abuse, harm, and a decline in their psychosocial well-being. Findings Included: Record review of Resident #1 undated admission record reflected a [AGE] year-old male who was admitted to the facility on [DATE] and resided in room [ROOM NUMBER]-B. Resident #1 diagnoses included severe intellectual disabilities, fetal alcohol syndrome- (a condition that could lead to difficulty learning, remembering, or thinking, the condition could stunt the child's growth) dysmorphic (mental health condition in which you can't stop thinking about one or more perceived defects or [NAME] in your appearance), and major depressive disorder (a disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's care plan dated 8-13-2022, reflected impaired cognitive function and impaired thought process, communication problem, and was totally dependent on staff for ADL self-care. Record review of Resident #1's MDS evaluation dated 12-02-2022 revealed the BIMS score was blank which indicated the resident was unable to complete the interview. Record review of Resident #1's MDS evaluation dated 12-2-2022 reflected supervision (oversight, encouragement or cueing) and one person physical assist was needed for toilet use. Resident #1's functional status was marked as total dependence. Resident #1's toileting hygiene was marked as required supervision or touching assistance {needed}. Record review of Resident #1's MDS evaluation dated 12-2-2022 reflected he had unclear speech-slurred or mumbled words and sometimes understood and responded adequately to simple, direct communication only. Record review of Resident #1's MDS evaluation dated 12-2-2022 reflected he had short term and long-term memory problems and he was severely impaired (never/rarely made decisions) in cognitive skills for daily decision making. Record review of Resident #1's MDS evaluation dated 12-2-2022 reflected behaviors present included fluctuated-inattention (difficulty focusing attention, easily distracted, had difficulty keeping track of what was being said). Record review of Resident #1's MDS evaluation dated 12-2-22 reflected he had a short and long term memory problems. Record review of Resident #1 MDS evaluation dated 12-2-22 reflected his cognitive skills for daily decision-making was severely impaired. Record review of Resident #1's MDS evaluation dated 12-2-22 reflected inattention (difficulty focusing, difficulty keeping track of what is being said) marked as the behavior being present (fluctuated-comes and goes, changes in severity). Record review of Texas Department of Aging and Disability Services Form 3613-A reflected Resident #1 as being the alleged victim of abuse and the Registered Nurse as being the alleged perpetrator. Record review of Texas Department of Aging and Disability Services Form 3613-A provided by the Administrator reflected the Investigation Findings to be Inconclusive as written under Investigation Summary: According to the Nurse's statement (statement attached), she showered the resident after he soiled himself with BM. After the shower, she put him to bed. Later, during her shift, she visited his room & noted urine all over his bathroom. The Nurse, having to clean it all up herself as housekeeping was no longer at the facility, was unhappy about it. She turned on the lights in his room & bathroom (to clean the urine on the floor). Which upset him, as he likes his room & bathroom dark while he is resting. According to the Nurse, this is when they bumped into each other. She continues to state, that this is when she attempted to put him back to bed so she could finish cleaning his mess in the soiled bathroom. In her statement, the Nurse does admit that she took the soiled towels & presented them close to his face, attempting to explain to him the outcome of his refusing to ask for help/assistance & to explain to him why he should ask for assistance. The Facility cannot substantiate if the nurse pushed the resident against the wall as per the Aide's statement (statement attached) or if they bumped into each other as per the Nurse's statement. The brief available recording, on the Aide's phone, was recorded from outside the room only (no visual is available to determine if pushing or bumping occurred) which does not provide us with facts but leaves us with conflicting statements from the Nurse and the Aide about this incident, including the occurrence with the soiled towel. The resident cannot recall the incident to shed clarity & perspective. The Aide who recorded the part of the alleged incident never entered the room where the alleged incident occurred. She remained in the hallway only. No visuals are available to collaborate her allegation vs the Nurse's statement about the chain of events. No resident abuse nor any of the allegation was substantiated. The form was signed by the Administrator and dated on 12-9-2022. Record review of a facility inservice dated 12-4-22/12-5-22 along with the facility abuse prohibition policy was attached to Texas Department of Aging and Disability Services Form 3613-A. The inservice reflected staff printed names, signatures, titles and department. Also attached was the name and contact information for the Abuse Coordinator. Record review of Resident #1's progress note documented by the Former DON, dated 12-4-22/20:32 (8:32 PM) reflected: Head-to-toe assessment performed by this DON in the presence of Charge Nurse LVN. Resident resting in bed upon arrival, easily aroused. Resident sits on side of bed and agrees to assessment. Resident is smiling, pleasant. He denies any pain or discomfort at this time. No visible signs of pain or acute distress noted. No bruising or injuries noted during assessment. Resident has tiny old brown discoloration area about 1'' to sternum (a partially T-shaped vertical bone that forms the anterior portion of the chest wall) area and scab to lower portion of knee cap. Resident skin is dry, warm to the touch. Resident appears to have expressive aphasia (disorder that affects how one communicates), speech somewhat garbled and unclear most often. He does not appear to comprehend most questions or commands and was able to ask this nurse for a drink of water. At times he used sign language, other times he used words. His speech is limited. Record review of a handwritten statement signed by the Certified Nurse Aide reflected On the day of 12-4-22 I heard a lot of noise coming from Resident #1 room so I went to see what was going on the nurse Registered Nurse was in there yelling and wouldn't respect his right when he told her leave the room so he tried to leave the room which you can hear in the video she closes the door slams him (I saw it) into wall and drags him to his bed he was going so scared he pee on his-self which upset her more he tells her move which you can hear in the video and she mocks [sic} him move as she cleans the pee off the floor she yells at him these are new floor and proceeds to rub it in his face and say do you like the way it smells, do like the way it taste as I recorded the incident I waked in and tried to fix the situation as I went and texted the Former Director of Nursing the videos and reported right away. Record review of a handwritten statement signed on 12-5-22 by the Registered Nurse reflected: I have taken him under my wing to help [with] his ADL'S. He cannot wipe his bottom well he will p [pee] has a BM or he cannot hit to toilet with urine. I have been working with resident to sit down on toilet to urinate & he will come & get me for his BMS [bowel movements]. Yesterday [12-4-22] he came & got me to help him. I noticed he had BM in his pants. I asked him if he wanted to shower & he said yes. After the shower we changed his urine and he laid down to sleep. Later in the shift during rounds he was in bathroom & I noticed he had urinated on the floor, all over the floor. I went to find the housekeeper out [sic] was not able to. I got wet towel [with] soap was cleaning the floor. Resident #1 does not like the floor wet or light on in his rm. Resident #1 kept coming into bathrm and turning light off where I could not see to clean his mess. I stood up & Resident #1 was behind me & I bumped into him & we hit the hall. I walked his [sic] back to his bed to prevent him from falling down. He continued to come to bathroom & he hit me in the back. I grabbed his arms & ask him not to hit on me or slap me. I walked him back to his bed. I went back to finish cleaning in bathrm & then took the dirty towel to show him why the floor needed cleaning. I did put the towel close to his face so he could see the mess. I did ask him not to urinate on the floor, to ask for help. I told him he could not want to taste this mess, the mess on the towel. He hugged me. Record review of the facility provided Abuse Prohibition Policy revised December 2019 reflected: Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect involuntary seclusion and misappropriation of property. No one may subject residents to abuse including but no limited to facility staff. Definition: Abuse-Willful infliction of physical injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental or 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. Definition: Physical Abuse-Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Inappropriate physical contact includes but is not limited to striking, pinching, kicking, shoving, bumping, sexual molestation and corporal punishment. Definition: Verbal Abuse-Includes the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Language that can be interpreted as threatening, malicious, inappropriate language, name calling, angry, or hostile tone. Verbal abuse would be considered inappropriate and detrimental to the resident emotional health and well-being. Definition: Mental Abuse-Includes but is not limited to humiliation, harassment, and threats of punishment or deprivation. During an interview on 12-20-22 at 9:10 AM, the Administrator stated he was notified by the Director of Nursing on 12-4-22 of the incident involving Resident #1's and the Registered Nurse who was working in the memory care unit. The Administrator stated the Former Director of Nursing went to the facility and began an investigation on 12-4-22. The Administrator stated he had listened to the video recording provided by the Certified Nurse Aide and he could barely hear someone say what's it taste like; what's it smell like. The Administrator stated he instructed the Certified Nurse Aide to destroy the video of the incident and had to have the video sent to him again by the Assistant Director of Nursing B. The Administrator stated he was not sure what the Certified Nurse Aide did while she was not working and did not want the video posted to social media. The Administrator stated on 12-5-22, he and the Former Director or Nursing interviewed the Registered Nurse at which time she provided a handwritten and signed statement of the events that had occurred with Resident #1. The Administrator stated that he reviewed the Registered Nurse's written statement. The Administrator stated the Registered Nurse quit on 12-6-22 before she could be terminated. The Administrator stated he had completed the Provider Investigation report on 12-9-22 and the findings were inconclusive. The Administrator stated after interviewing the Certified Nurse Aide and the Registered Nurse it was a she-said-she-said situation therefore he and the Owner could not substantiate the incident as abuse. The Administrator stated that the video recording did not show the Registered Nurse abusing Resident #1. The Administrator stated the incident was not abuse therefore he did not contact law enforcement was not notified. The Administrator stated staff had received abuse/neglect policy training on 12-4-22/12-5-22. The inservice reflected staff printed names, signatures, titles and department. Also attached was the name and contact information for the Abuse Coordinator. During an interview on 12-20-22 at 9:27 AM, the Certified Nurse Aide stated she was working in the memory care unit with the Registered Nurse on 12-4-22. The Certified Nurse Aide stated around 5:45 PM, she observed the Registered Nurse walk Resident #1's back to his room and could hear screaming coming from the hallway. The Certified Nurse Aide stated she walked down the hall and video recorded the screaming. The Certified Nurse Aide stated she arrived at Resident #1 room, the door was already opened, and she observed the Registered Nurse using both hands to grab Resident #1 by the shirt and pushed him up against the wall, and then close the door. The Certified Nurse [NAME] stated she stood outside of Resident #1's room and did not intervene because she was in shock and hadn't seen anyone abuse him before, so she kept recording the incident. The Certified Nurse Aide stated she heard the Registered Nurse say Why did you pee by the bed? You peed all over the new floor. You peed all over yourself and I'll have to clean this mess. Do you like the way it smells and tastes? The Certified Nurse Aide stated she opened the door and saw the Registered Nurse on the floor next to Resident #1's bed and she was cleaning up the urine with a white blanket. The Certified Nurse Aide stated she saw the Registered Nurse put the blanket in Resident #1 face at which time he responded stop it and the Registered Nurse stopped. The Certified Nurse Aide stated she walked out of the room (leaving Resident #1 and the Registered Nurse alone) and called the Former Director of Nursing at 6:04 PM. The Certified Nurse Aide stated Resident #1 was wearing gray jogger pants which had pee on his front area and his right leg. The Certified Nurse Aide stated Resident #1 tried to push the Registered Nurse away during the incident and his facial expression was scared. The Certified Nurse Aide stated she left the facility at the end of her shift around 6:00 PM. The Certified Nurse Aide stated the Registered Nurse was no longer working at the facility. The Certified Nurse Aide stated she provided the Former Director of Nursing the video and then deleted it at the request of the Administrator. The Certified Nurse Aide stated she had been trained in abuse/neglect and she was responsible for intervening if she witnessed a resident being abused. The Certified Nurse [NAME] stated she did not intervene because she was in shock and hadn't seen anyone abuse him before, so she kept recording the incident. The Certified Nurse Aide stated she was interviewed by the Former Director of Nursing and provided a handwritten statement about the incident. During an interview on 12-20-22 at 10:13 AM, the Former Director of Nursing stated she was not on duty on 12-4-22 when the incident occurred between the Registered Nurse and Resident #1. The Former Director of Nursing stated she was notified via text by the Certified Nurse Aide on 12-4-22 at 6:04 PM, reporting suspected abuse of Resident #1 by the Registered Nurse. The Former Director of Nursing stated the text message reflected the Registered Nurse forced Resident #1 to go into his room, he didn't want to go and she could hear how does that taste and smell. The Former Director of Nursing stated the Certified Nurse Aide sent her the video recording of the incident which she listened to and at the 13-second mark on the video she could hear stop, how does that taste, and smell-huh which was repeated twice. The Former Director of Nursing stated the Administrator was notified of the incident at 6:38 PM. The Former Director of Nursing stated she arrived at the facility around 7:00 PM and the Registered Nurse was no longer in the facility because her shift ended at 6:00 PM. The Former Director of Nursing stated at 7:12 PM she educated staff on abuse/neglect/exploitation and re-educated on who the Abuse Coordinator was and where to locate his number. The Former Director of Nursing stated at 8:09 PM, she and the Licensed Vocational Nurse performed a head-to-toe assessment on Resident #1. The Former Director of Nursing stated Resident #1 was non-verbal and could only answer minimal questions. The Former Director of Nursing stated Resident #1 stated yea when asked if he felt safe. The Former Director of Nursing stated Resident #1 did not appear to be traumatized and had a happy face during the assessment. The Former Director of Nursing stated Resident #1 did not have any marks, bruises, redness or trauma to his face or body. The Former Director of Nursing stated the Registered Nurse had told her Resident #1 could be potty trained. The Former Director of Nursing stated on 12-5-22, the Registered Nurse came to the facility and met with her and the Administrator at which time she provided a handwritten and signed statement of events that happened involving Resident #1 and herself. The Former Director of Nursing stated the Registered Nurse stated she had provided incontinent care to Resident #1 and she had cleaned the bathroom floor where he had urinated. The Former Director of Nursing stated the Registered Nurse stated she fell into Resident #1 while trying to get up. The Former Director of Nursing stated the Registered Nurse told her she held the towel up to Resident #1's face and told him You don't want to taste this. The Former Director of Nursing stated she disagreed with the facility's investigation finding of inconclusive and informed the Administrator and Owner that the Registered Nurse had indeed abused Resident #1 and she should have been reported to law enforcement and the Board of Nursing. The Former Director of Nursing stated she resigned from her position at the facility because she was not going to risk her nursing license for a facility administrator/owner who did not think the actions of the Registered Nurse constituted abuse. On 12-20-22 at 11:14 AM, Resident #1 was observed in his room on the memory care unit. Resident #1 was wearing a T-shirt and warm-up pants and was clean and well-groomed. During an interview on 12-20-22 at 11:14 AM, Resident #1 was asked basic questions and he was not able to answer correctly and stated yea-yea-yea and nodded his head in an up and down motion or no-no-no and also nodded his head side to side to all questions asked. During an interview on 12-21-22 at 11:13 PM, the Director of Rehabilitation stated Resident #1 was receiving physical therapy, occupational therapy, and speech therapy. The Director of Rehabilitation stated Resident #1 could verbalize or communicate through body/hand gestures and can say yea, yes, or no. The Director of Rehabilitation stated for the past month, staff and physical therapists had been working with Resident #1 and encouraged him to use the bathroom throughout the day and he pointed at the bathroom and was helped with toileting. The Director of Rehabilitation stated Resident #1 had not mastered the task, but the staff would continue trying. The Director of Rehabilitation stated the resident was special needs and he would not be able to understand what the Registered Nurse was saying to him and he would not have been able to learn how to use the bathroom after being told one time. The Director of Rehabilitation stated Resident #1 was not able to learn tasks completely. The Director of Rehabilitation stated in my professional opinion the Registered Nurse putting a urinated towel to [Resident #1's] face would be considered abuse and he would have reported the incident to the state himself if it had not been done. During an interview on 12-21-22 at 1:48 PM, the Registered Nurse stated she had been trained on abuse and neglect. The Registered Nurse stated she had worked on the memory care unit with Resident #1 on 12-4-22. The Registered Nurse stated she had worked the weekend shift from 6:00 AM to 6:00 PM. The Registered Nurse stated she checked on Resident #1 while he was in his room because he was continent but makes a mess if he doesn't get help when going to the bathroom. The Registered Nurse stated she had taken Resident #1 under her wing to help enhance his skills. The Registered Nurse stated Resident #1 peed all over the floor in the bathroom and left a puddle of urine. The Registered Nurse stated she tried to get Resident #1 to sit on the toilet so he could go tee-tee. The Registered Nurse stated she could not find a housekeeper, so she went to the shower room and got a towel and soap and began cleaning the bathroom floor. The Registered Nurse stated Resident #1 kept turning the bathroom light off so when she got up, she fell against him, and they both hit the wall. The Registered Nurse stated she walked Resident #1 to his bed and sat him down, showed him the urinated dirty towel, and told him this is what I was trying to clean up so you wouldn't get dirty and then she returned to the bathroom to continue cleaning up the floor. The Registered Nurse stated Resident #1's room was dark because he had turned off the light. The Registered Nurse stated she walked over to Resident #1 and put the towel up to his face so he could see what she was talking about and stated to him, You wouldn't want to drink pee and then turned around and saw the Certified Nurse Aide standing in the doorway. The Registered Nurse stated she placed the towel close enough to Resident #1's face so he could see it in the dark. The Registered Nurse stated she left the room and disposed of the towel and then returned and told Resident #1 that was dirty. The Registered Nurse stated she would not have made Resident #1 drink or smell the urine-soaked towel but did want him to see that the towel was dirty. The Registered Nurse stated Resident #1 is non-verbal but can communicate with hand gestures and can say hey, yes, and no. The Registered Nurse stated Resident #1 is capable of learning. The Registered Nurse stated she does not remember what time she left the facility, but it was sometime after her shift because the relief nurse had not arrived. The Registered Nurse stated she was contacted by the Administrator who asked her to return to the facility on [DATE] for an interview. The Registered Nurse stated she was interviewed by the Administrator and the Former Director of Nursing at which time she provided a handwritten and signed statement outlining the events involving Resident #1 and herself. The Registered Nurse stated she left the facility and was contacted by the Administrator on 12-6-22 asking that she return to the facility to continue the interview. The Registered Nurse stated once at the facility she told the Administrator I quit and left the facility. The Registered Nurse stated her handwritten statement was made of her own free will and she was not forced by anyone to write it and the accounts of the incident were true and correct to the best of her knowledge. The Registered Nurse stated she did not hold the urine-soaked towel to Resident #1 face maliciously but did it to teach him to ask for help. During an interview on 12-21-22 at 5:00 PM, the Owner stated the provider investigation for the incident involving the Registered Nurse and Resident #1 was inconclusive because her actions were not done in an abusive manner, and the Registered Nurse stated she wanted to educate Resident #1 and she wanted him to visualize what he had done so he could see his mess and what had occurred. The Owner stated the Registered Nurse put the towel close to Resident #1's face to educate him The Owner stated the Registered Nurse did nothing wrong and her actions were to educate Resident #1. The Administrator was notified on 12-20-22 at 4:40 PM, that an Immediate Jeopardy had been identified due to the above failure. The IJ Template was provided to the Administrator on 12-20-22 at 4:40 PM. The POR was accepted on 12-21-22 at 1:30 PM. The Plan of Removal reflected the following: Summary of Details Which Lead to Outcomes On 12-20-22 an abbreviated survey was initiated at [Crestview Healthcare Residence 1400 Lakeshore Drive, Waco, TX 76708]. On 12-20-22 a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the immediate jeopardy states as follows: ABUSE F607-Develop/Implement Abuse/Neglect Policies The facility failed to keep Resident #1 free from abuse on 12-4-22. On 12-5-22, the Administrator interviewed the Registered Nurse, at which time she wrote and presented a handwritten and signed statement admitting to having placed the urine-soaked towel to Resident #1's face. The Administrator failed to substantiate the abuse allegation, thus placing all other residents at risk for abuse. Identify residents who could be affected: All Residents Problem: Abuse Investigation, understanding what abuse is and drawing proper conclusions and substantiation of abuse investigation, taking into consideration, a written and signed admission of abuse by the preparator. Action Taken Abuse Prevention In-Service was conducted on 12-20-22 for the Administrator and all administrative staff at the facility. All residents are at risk for abuse and for the potential of an incomplete internal investigation. All internal and reportable investigations will be reviewed by our compliance attorney for additional review to ensure compliance with facility policy and HHSC Guidelines. Facility Assistant Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. Ongoing, an annual in-service on Abuse Prevention and a quarterly test regarding abuse prevention will be administered. To pass the test, each participant must score 100%, the staff member must attend the In-service again and take the post-test. (The staff must pass at 100% prior to working with residents). Abuse Prevention In-Service was conducted on 12-20-22 to all staff that was working at the facility. All staff scheduled to work on 12-21-22 will be in service prior to the start of their shift. All residents are at risk for abuse. All current employees will receive abuse prevention training before beginning their next scheduled shift, and a post-test will be administered. Staff must score 100% prior to working with residents. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. For current employees prior to the start of their next shift, and annual in service with a 100% post test to ensure understanding. Detailed Abuse Prevention training will be provided to all new hires upon hire and then annually by the administrator and/or designee, such as the assistant administrator. The post-test will be given, and staff must score 100%. If they don't the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass with flying colors. The administrator or designee will be responsible for teaching detailed training about abuse prevention and administering the post test with a pass rate of 100% for all new hires and then annually, quarterly and as needed. The QA committee will monitor. Start date 12-20-22/End date 12-21-23. Abuse Prevention testing will be done quarterly and on a PRN basis (as needed) to ensure staff is knowledgeable and their awareness and knowledge remain up to date. The post-test will be given and staff must score 100%. If they don't the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass with a 100%. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-23. New hires and agency staff prior to the start of their first initial shift with a pass rate of 100%. Inservice conducted on 12-20-22 with all staff on what abuse is and about preventing abuse and reporting all abuse cases and how to report them. New hires and/or agency staff will be educated on resident abuse before starting their initial shift at the facility. An abuse prevention post-test was given and completed by 12-21-22. All staff will be tested before starting their initial shift at the facility, including the post-test. The post-test will be given, and staff must score 100%. If they don't, the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass with 100%. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. New hires and agency staff prior to the start of their first initial shift. Education on what constitutes abuse will be completed on 12-21-22 with all facility staff working that day (at a mandatory meeting) and all other staff will be requested to come in for training before their next scheduled shift to complete this training. The post-test will be given, and staff must score 100%. If they don't, the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass 100%. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. New hires and agency staff prior to the start of their first initial shift. Involvement of Medical Director: The Medical Director was notified about the immediate Jeopardy on 12-20-22. The Administrator will review all complaints and investigations with the Medical Director. Involvement of QA: On 12-21-22 an Ad Hoc AQPI meeting has been held with the Medical Director, Facility Administrator, Asst. Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for the implementation process: The Administrator and the Assistant Administrator will be responsible for the implementation of all abuse prevention in-services and actual investigations. The New Process/system was started on 12-20-22. Who is responsible for monitoring the process: The facility Administrator-Corporate Managing Partner, will be responsible for monitoring the implementation of this new process of Abuse Prevention Education, Abuse Prevention Reporting, competent investigation summaries and conclusions, and submission to our Compliance Attorney for review. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 12-20-22. The Surveyor monitored the Plan of Removal on 12-21-22 as follows: During an interview on 12-21-22 at 1:06 PM, the As [TRUNCATED]

Based on observation, interview, and record review the facility failed to develop and implement abuse and neglect policies that prohibited and prevented one (Resident #1) of 16 residents from abuse. The facility failed to: Develop and implement abuse and neglect policies that prohibited and prevented Resident #1 from being abused by the Registered Nurse who placed a urine-soaked towel to Resident #1's face. On 12-20-22 at 4:29 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12-21-22 at 7:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of J identified due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of abuse, harm, and a decline in their psychosocial well-being. Findings Included: Record review of Resident #1 undated admission record reflected a [AGE] year-old male who was admitted to the facility on [DATE] and resided in room [ROOM NUMBER]-B. Resident #1 diagnoses included severe intellectual disabilities, fetal alcohol syndrome- (a condition that could lead to difficulty learning, remembering, or thinking, the condition could stunt the child's growth) dysmorphic (mental health condition in which you can't stop thinking about one or more perceived defects or [NAME] in your appearance), and major depressive disorder (a disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's care plan dated 8-13-2022, reflected impaired cognitive function and impaired thought process, communication problem, and was totally dependent on staff for ADL self-care. Record review of Resident #1's MDS evaluation dated 12-02-2022 revealed the BIMS score was blank which indicated the resident was unable to complete the interview. The MDS evaluation reflected supervision (oversight, encouragement or cueing) and one person physical assist was needed for toilet use. Resident #1's functional status was marked as total dependence. Resident #1's toileting hygiene was marked as required supervision or touching assistance {needed}. MDS evaluation reflected he[ Resident #1] had unclear speech-slurred or mumbled words and sometimes understood and responded adequately to simple, direct communication. The MDS evaluation reflected he [Resident #1] had short term and long-term memory problems and he was severely impaired (never/rarely made decisions) in cognitive skills for daily decision making. The MDS evaluation reflected behaviors present included fluctuated-inattention (difficulty focusing attention, easily distracted, had difficulty keeping track of what was being said, he [Resident #1]had a short and long term memory problems, and his cognitive skills for daily decision-making was severely impaired. The MDS evaluation reflected inattention (difficulty focusing, difficulty keeping track of what is being said) marked as the behavior being present (fluctuated-comes and goes, changes in severity). Record review of Texas Department of Aging and Disability Services Form 3613-A reflected Resident #1 as being the alleged victim of abuse and the Registered Nurse as being the alleged perpetrator. Record review of Texas Department of Aging and Disability Services Form 3613-A provided by the Administrator reflected the Investigation Findings to be Inconclusive as written under Investigation Summary: According to the Nurse's statement (statement attached), she showered the resident after he soiled himself with BM. After the shower, she put him to bed. Later, during her shift, she visited his room & noted urine all over his bathroom. The Nurse, having to clean it all up herself as housekeeping was no longer at the facility, was unhappy about it. She turned on the lights in his room & bathroom (to clean the urine on the floor). Which upset him, as he likes his room & bathroom dark while he is resting. According to the Nurse, this is when they bumped into each other. She continues to state, that this is when she attempted to put him back to bed so she could finish cleaning his mess in the soiled bathroom. In her statement, the Nurse does admit that she took the soiled towels & presented them close to his face, attempting to explain to him the outcome of his refusing to ask for help/assistance & to explain to him why he should ask for assistance. The Facility cannot substantiate if the nurse pushed the resident against the wall as per the Aide's statement (statement attached) or if they bumped into each other as per the Nurse's statement. The brief available recording, on the Aide's phone, was recorded from outside the room only (no visual is available to determine if pushing or bumping occurred) which does not provide us with facts but leaves us with conflicting statements from the Nurse and the Aide about this incident, including the occurrence with the soiled towel. The resident cannot recall the incident to shed clarity & perspective. The Aide who recorded the part of the alleged incident never entered the room where the alleged incident occurred. She remained in the hallway only. No visuals are available to collaborate her allegation vs the Nurse's statement about the chain of events. No resident abuse nor any of the allegation was substantiated. The form was signed by the Administrator and dated on 12-9-2022. Record review of a facility inservice dated 12-4-22/12-5-22 along with the facility abuse prohibition policy was attached to Texas Department of Aging and Disability Services Form 3613-A. The inservice reflected staff printed names, signatures, titles and department. Also attached was the name and contact information for the Abuse Coordinator. Record review of Resident #1's progress note documented by the Former DON, dated 12-4-22/20:32 (8:32 PM) reflected: Head-to-toe assessment performed by this DON in the presence of Charge Nurse LVN. Resident resting in bed upon arrival, easily aroused. Resident sits on side of bed and agrees to assessment. Resident is smiling, pleasant. He denies any pain or discomfort at this time. No visible signs of pain or acute distress noted. No bruising or injuries noted during assessment. Resident has tiny old brown discoloration area about 1'' to sternum (a partially T-shaped vertical bone that forms the anterior portion of the chest wall) area and scab to lower portion of knee cap. Resident skin is dry, warm to the touch. Resident appears to have expressive aphasia (disorder that affects how one communicates), speech somewhat garbled and unclear most often. He does not appear to comprehend most questions or commands and was able to ask this nurse for a drink of water. At times he used sign language, other times he used words. His speech is limited. Record review of a handwritten statement signed by the Certified Nurse Aide reflected On the day of 12-4-22 I heard a lot of noise coming from Resident #1 room so I went to see what was going on the nurse Registered Nurse was in there yelling and wouldn't respect his right when he told her leave the room so he tried to leave the room which you can hear in the video she closes the door slams him (I saw it) into wall and drags him to his bed he was going so scared he pee on his-self which upset her more he tells her move which you can hear in the video and she mocks [sic} him move as she cleans the pee off the floor she yells at him these are new floor and proceeds to rub it in his face and say do you like the way it smells, do like the way it taste as I recorded the incident I waked in and tried to fix the situation as I went and texted the Former Director of Nursing the videos and reported right away. Record review of a handwritten statement signed on 12-5-22 by the Registered Nurse reflected: I have taken him under my wing to help [with] his ADL'S. He cannot wipe his bottom well he will p [pee] has a BM or he cannot hit to toilet with urine. I have been working with resident to sit down on toilet to urinate & he will come & get me for his BMS [bowel movements]. Yesterday [12-4-22] he came & got me to help him. I noticed he had BM in his pants. I asked him if he wanted to shower & he said yes. After the shower we changed his urine and he laid down to sleep. Later in the shift during rounds he was in bathroom & I noticed he had urinated on the floor, all over the floor. I went to find the housekeeper out [sic] was not able to. I got wet towel [with] soap was cleaning the floor. Resident #1 does not like the floor wet or light on in his rm. Resident #1 kept coming into bathrm and turning light off where I could not see to clean his mess. I stood up & Resident #1 was behind me & I bumped into him & we hit the hall. I walked his [sic] back to his bed to prevent him from falling down. He continued to come to bathroom & he hit me in the back. I grabbed his arms & ask him not to hit on me or slap me. I walked him back to his bed. I went back to finish cleaning in bathrm & then took the dirty towel to show him why the floor needed cleaning. I did put the towel close to his face so he could see the mess. I did ask him not to urinate on the floor, to ask for help. I told him he could not want to taste this mess, the mess on the towel. He hugged me. Record review of the facility provided Abuse Prohibition Policy revised December 2019 reflected: Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect involuntary seclusion and misappropriation of property. No one may subject residents to abuse including but no limited to facility staff. Definition: Abuse-Willful infliction of physical injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental or 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. Definition: Physical Abuse-Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Inappropriate physical contact includes but is not limited to striking, pinching, kicking, shoving, bumping, sexual molestation and corporal punishment. Definition: Verbal Abuse-Includes the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Language that can be interpreted as threatening, malicious, inappropriate language, name calling, angry, or hostile tone. Verbal abuse would be considered inappropriate and detrimental to the resident emotional health and well-being. Definition: Mental Abuse-Includes but is not limited to humiliation, harassment, and threats of punishment or deprivation. During an interview on 12-20-22 at 9:10 AM, the Administrator stated he was notified by the Director of Nursing on 12-4-22 of the incident involving Resident #1's and the Registered Nurse who was working in the memory care unit. The Administrator stated the Former Director of Nursing went to the facility and began an investigation on 12-4-22. The Administrator stated he had listened to the video recording provided by the Certified Nurse Aide and he could barely hear someone say what's it taste like; what's it smell like. The Administrator stated he instructed the Certified Nurse Aide to destroy the video of the incident and had to have the video sent to him again by the Assistant Director of Nursing B. The Administrator stated he was not sure what the Certified Nurse Aide did while she was not working and did not want the video posted to social media. The Administrator stated on 12-5-22, he and the Former Director or Nursing interviewed the Registered Nurse at which time she provided a handwritten and signed statement of the events that had occurred with Resident #1. The Administrator stated that he reviewed the Registered Nurse's written statement. The Administrator stated the Registered Nurse quit on 12-6-22 before she could be terminated. The Administrator stated he had completed the Provider Investigation report on 12-9-22 and the findings were inconclusive. The Administrator stated after interviewing the Certified Nurse Aide and the Registered Nurse it was a she-said-she-said situation therefore he and the Owner could not substantiate the incident as abuse. The Administrator stated that the video recording did not show the Registered Nurse abusing Resident #1. The Administrator stated the incident was not abuse therefore he did not contact law enforcement was not notified. The Administrator stated staff had received abuse/neglect policy training on 12-4-22/12-5-22. The inservice reflected staff printed names, signatures, titles and department. Also attached was the name and contact information for the Abuse Coordinator. During an interview on 12-20-22 at 9:27 AM, the Certified Nurse Aide stated she was working in the memory care unit with the Registered Nurse on 12-4-22. The Certified Nurse Aide stated around 5:45 PM, she observed the Registered Nurse walk Resident #1's back to his room and could hear screaming coming from the hallway. The Certified Nurse Aide stated she walked down the hall and video recorded the screaming. The Certified Nurse Aide stated she arrived at Resident #1 room, the door was already opened, and she observed the Registered Nurse using both hands to grab Resident #1 by the shirt and pushed him up against the wall, and then close the door. The Certified Nurse [NAME] stated she stood outside of Resident #1's room and did not intervene because she was in shock and hadn't seen anyone abuse him before, so she kept recording the incident. The Certified Nurse Aide stated she heard the Registered Nurse say Why did you pee by the bed? You peed all over the new floor. You peed all over yourself and I'll have to clean this mess. Do you like the way it smells and tastes? The Certified Nurse Aide stated she opened the door and saw the Registered Nurse on the floor next to Resident #1's bed and she was cleaning up the urine with a white blanket. The Certified Nurse Aide stated she saw the Registered Nurse put the blanket in Resident #1 face at which time he responded stop it and the Registered Nurse stopped. The Certified Nurse Aide stated she walked out of the room (leaving Resident #1 and the Registered Nurse alone) and called the Former Director of Nursing at 6:04 PM. The Certified Nurse Aide stated Resident #1 was wearing gray jogger pants which had pee on his front area and his right leg. The Certified Nurse Aide stated Resident #1 tried to push the Registered Nurse away during the incident and his facial expression was scared. The Certified Nurse Aide stated she left the facility at the end of her shift around 6:00 PM. The Certified Nurse Aide stated the Registered Nurse was no longer working at the facility. The Certified Nurse Aide stated she provided the Former Director of Nursing the video and then deleted it at the request of the Administrator. The Certified Nurse Aide stated she had been trained in abuse/neglect and she was responsible for intervening if she witnessed a resident being abused. The Certified Nurse [NAME] stated she did not intervene because she was in shock and hadn't seen anyone abuse him before, so she kept recording the incident. The Certified Nurse Aide stated she was interviewed by the Former Director of Nursing and provided a handwritten statement about the incident. During an interview on 12-20-22 at 10:13 AM, the Former Director of Nursing stated she was not on duty on 12-4-22 when the incident occurred between the Registered Nurse and Resident #1. The Former Director of Nursing stated she was notified via text by the Certified Nurse Aide on 12-4-22 at 6:04 PM, reporting suspected abuse of Resident #1 by the Registered Nurse. The Former Director of Nursing stated the text message reflected the Registered Nurse forced Resident #1 to go into his room, he didn't want to go and she could hear how does that taste and smell. The Former Director of Nursing stated the Certified Nurse Aide sent her the video recording of the incident which she listened to and at the 13-second mark on the video she could hear stop, how does that taste, and smell-huh which was repeated twice. The Former Director of Nursing stated the Administrator was notified of the incident at 6:38 PM. The Former Director of Nursing stated she arrived at the facility around 7:00 PM and the Registered Nurse was no longer in the facility because her shift ended at 6:00 PM. The Former Director of Nursing stated at 7:12 PM she educated staff on abuse/neglect/exploitation and re-educated on who the Abuse Coordinator was and where to locate his number. The Former Director of Nursing stated at 8:09 PM, she and the Licensed Vocational Nurse performed a head-to-toe assessment on Resident #1. The Former Director of Nursing stated Resident #1 was non-verbal and could only answer minimal questions. The Former Director of Nursing stated Resident #1 stated yea when asked if he felt safe. The Former Director of Nursing stated Resident #1 did not appear to be traumatized and had a happy face during the assessment. The Former Director of Nursing stated Resident #1 did not have any marks, bruises, redness or trauma to his face or body. The Former Director of Nursing stated the Registered Nurse had told her Resident #1 could be potty trained. The Former Director of Nursing stated on 12-5-22, the Registered Nurse came to the facility and met with her and the Administrator at which time she provided a handwritten and signed statement of events that happened involving Resident #1 and herself. The Former Director of Nursing stated the Registered Nurse stated she had provided incontinent care to Resident #1 and she had cleaned the bathroom floor where he had urinated. The Former Director of Nursing stated the Registered Nurse stated she fell into Resident #1 while trying to get up. The Former Director of Nursing stated the Registered Nurse told her she held the towel up to Resident #1's face and told him You don't want to taste this. The Former Director of Nursing stated she disagreed with the facility's investigation finding of inconclusive and informed the Administrator and Owner that the Registered Nurse had indeed abused Resident #1 and she should have been reported to law enforcement and the Board of Nursing. The Former Director of Nursing stated she resigned from her position at the facility because she was not going to risk her nursing license for a facility administrator/owner who did not think the actions of the Registered Nurse constituted abuse. On 12-20-22 at 11:14 AM, Resident #1 was observed in his room on the memory care unit. Resident #1 was wearing a T-shirt and warm-up pants and was clean and well-groomed. During an interview on 12-20-22 at 11:14 AM, Resident #1 was asked basic questions and he was not able to answer correctly and stated yea-yea-yea and nodded his head in an up and down motion or no-no-no and also nodded his head side to side to all questions asked. During an interview on 12-21-22 at 11:13 PM, the Director of Rehabilitation stated Resident #1 was receiving physical therapy, occupational therapy, and speech therapy. The Director of Rehabilitation stated Resident #1 could verbalize or communicate through body/hand gestures and can say yea, yes, or no. The Director of Rehabilitation stated for the past month, staff and physical therapists had been working with Resident #1 and encouraged him to use the bathroom throughout the day and he pointed at the bathroom and was helped with toileting. The Director of Rehabilitation stated Resident #1 had not mastered the task, but the staff would continue trying. The Director of Rehabilitation stated the resident was special needs and he would not be able to understand what the Registered Nurse was saying to him and he would not have been able to learn how to use the bathroom after being told one time. The Director of Rehabilitation stated Resident #1 was not able to learn tasks completely. The Director of Rehabilitation stated in my professional opinion the Registered Nurse putting a urinated towel to [Resident #1's] face would be considered abuse and he would have reported the incident to the state himself if it had not been done. During an interview on 12-21-22 at 1:48 PM, the Registered Nurse stated she had been trained on abuse and neglect. The Registered Nurse stated she had worked on the memory care unit with Resident #1 on 12-4-22. The Registered Nurse stated she had worked the weekend shift from 6:00 AM to 6:00 PM. The Registered Nurse stated she checked on Resident #1 while he was in his room because he was continent but makes a mess if he doesn't get help when going to the bathroom. The Registered Nurse stated she had taken Resident #1 under her wing to help enhance his skills. The Registered Nurse stated Resident #1 peed all over the floor in the bathroom and left a puddle of urine. The Registered Nurse stated she tried to get Resident #1 to sit on the toilet so he could go tee-tee. The Registered Nurse stated she could not find a housekeeper, so she went to the shower room and got a towel and soap and began cleaning the bathroom floor. The Registered Nurse stated Resident #1 kept turning the bathroom light off so when she got up, she fell against him, and they both hit the wall. The Registered Nurse stated she walked Resident #1 to his bed and sat him down, showed him the urinated dirty towel, and told him this is what I was trying to clean up so you wouldn't get dirty and then she returned to the bathroom to continue cleaning up the floor. The Registered Nurse stated Resident #1's room was dark because he had turned off the light. The Registered Nurse stated she walked over to Resident #1 and put the towel up to his face so he could see what she was talking about and stated to him, You wouldn't want to drink pee and then turned around and saw the Certified Nurse Aide standing in the doorway. The Registered Nurse stated she placed the towel close enough to Resident #1's face so he could see it in the dark. The Registered Nurse stated she left the room and disposed of the towel and then returned and told Resident #1 that was dirty. The Registered Nurse stated she would not have made Resident #1 drink or smell the urine-soaked towel but did want him to see that the towel was dirty. The Registered Nurse stated Resident #1 is non-verbal but can communicate with hand gestures and can say hey, yes, and no. The Registered Nurse stated Resident #1 is capable of learning. The Registered Nurse stated she does not remember what time she left the facility, but it was sometime after her shift because the relief nurse had not arrived. The Registered Nurse stated she was contacted by the Administrator who asked her to return to the facility on [DATE] for an interview. The Registered Nurse stated she was interviewed by the Administrator and the Former Director of Nursing at which time she provided a handwritten and signed statement outlining the events involving Resident #1 and herself. The Registered Nurse stated she left the facility and was contacted by the Administrator on 12-6-22 asking that she return to the facility to continue the interview. The Registered Nurse stated once at the facility she told the Administrator I quit and left the facility. The Registered Nurse stated her handwritten statement was made of her own free will and she was not forced by anyone to write it and the accounts of the incident were true and correct to the best of her knowledge. The Registered Nurse stated she did not hold the urine-soaked towel to Resident #1 face maliciously but did it to teach him to ask for help. During an interview on 12-21-22 at 5:00 PM, the Owner stated the provider investigation for the incident involving the Registered Nurse and Resident #1 was inconclusive because her actions were not done in an abusive manner, and the Registered Nurse stated she wanted to educate Resident #1 and she wanted him to visualize what he had done so he could see his mess and what had occurred. The Owner stated the Registered Nurse put the towel close to Resident #1's face to educate him The Owner stated the Registered Nurse did nothing wrong and her actions were to educate Resident #1. The Administrator was notified on 12-20-22 at 4:40 PM, that an Immediate Jeopardy had been identified due to the above failure. The IJ Template was provided to the Administrator on 12-20-22 at 4:40 PM. The POR was accepted on 12-21-22 at 1:30 PM. The Plan of Removal reflected the following: Summary of Details Which Lead to Outcomes On 12-20-22 an abbreviated survey was initiated at [Crestview Healthcare Residence 1400 Lakeshore Drive, Waco, TX 76708]. On 12-20-22 a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the immediate jeopardy states as follows: ABUSE F607-Develop/Implement Abuse/Neglect Policies The facility failed to keep Resident #1 free from abuse on 12-4-22. On 12-5-22, the Administrator interviewed the Registered Nurse, at which time she wrote and presented a handwritten and signed statement admitting to having placed the urine-soaked towel to Resident #1's face. The Administrator failed to substantiate the abuse allegation, thus placing all other residents at risk for abuse. Identify residents who could be affected: All Residents Problem: Abuse Investigation, understanding what abuse is and drawing proper conclusions and substantiation of abuse investigation, taking into consideration, a written and signed admission of abuse by the preparator. Action Taken Abuse Prevention In-Service was conducted on 12-20-22 for the Administrator and all administrative staff at the facility. All residents are at risk for abuse and for the potential of an incomplete internal investigation. All internal and reportable investigations will be reviewed by our compliance attorney for additional review to ensure compliance with facility policy and HHSC Guidelines. Facility Assistant Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. Ongoing, an annual in-service on Abuse Prevention and a quarterly test regarding abuse prevention will be administered. To pass the test, each participant must score 100%, the staff member must attend the In-service again and take the post-test. (The staff must pass at 100% prior to working with residents). Abuse Prevention In-Service was conducted on 12-20-22 to all staff that was working at the facility. All staff scheduled to work on 12-21-22 will be in service prior to the start of their shift. All residents are at risk for abuse. All current employees will receive abuse prevention training before beginning their next scheduled shift, and a post-test will be administered. Staff must score 100% prior to working with residents. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. For current employees prior to the start of their next shift, and annual in service with a 100% post test to ensure understanding. Detailed Abuse Prevention training will be provided to all new hires upon hire and then annually by the administrator and/or designee, such as the assistant administrator. The post-test will be given, and staff must score 100%. If they don't the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass with flying colors. The administrator or designee will be responsible for teaching detailed training about abuse prevention and administering the post test with a pass rate of 100% for all new hires and then annually, quarterly and as needed. The QA committee will monitor. Start date 12-20-22/End date 12-21-23. Abuse Prevention testing will be done quarterly and on a PRN basis (as needed) to ensure staff is knowledgeable and their awareness and knowledge remain up to date. The post-test will be given and staff must score 100%. If they don't the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass with a 100%. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-23. New hires and agency staff prior to the start of their first initial shift with a pass rate of 100%. Inservice conducted on 12-20-22 with all staff on what abuse is and about preventing abuse and reporting all abuse cases and how to report them. New hires and/or agency staff will be educated on resident abuse before starting their initial shift at the facility. An abuse prevention post-test was given and completed by 12-21-22. All staff will be tested before starting their initial shift at the facility, including the post-test. The post-test will be given, and staff must score 100%. If they don't, the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass with 100%. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. New hires and agency staff prior to the start of their first initial shift. Education on what constitutes abuse will be completed on 12-21-22 with all facility staff working that day (at a mandatory meeting) and all other staff will be requested to come in for training before their next scheduled shift to complete this training. The post-test will be given, and staff must score 100%. If they don't, the staff member must attend the training again and retest. They will not be allowed to work with residents until they pass 100%. The Administrator or designee will be responsible and the Corporate Managing Partner will monitor. Start date 12-20-22/End date 12-21-22. New hires and agency staff prior to the start of their first initial shift. Involvement of Medical Director: The Medical Director was notified about the immediate Jeopardy on 12-20-22. The Administrator will review all complaints and investigations with the Medical Director. Involvement of QA: On 12-21-22 an Ad Hoc AQPI meeting has been held with the Medical Director, Facility Administrator, Asst. Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for the implementation process: The Administrator and the Assistant Administrator will be responsible for the implementation of all abuse prevention in-services and actual investigations. The New Process/system was started on 12-20-22. Who is responsible for monitoring the process: The facility Administrator-Corporate Managing Partner, will be responsible for monitoring the implementation of this new process of Abuse Prevention Education, Abuse Prevention Reporting, competent investigation summaries and conclusions, and submission to our Compliance Attorney for review. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 12-20-22. The Surveyor monitored the Plan of Removal on 12-21-22 as follows: During an interview on 12-21-22 at 1:06 PM, the Assistant Director of Nursing A stated she works the memory care unit where Resident #1 lives. The Assistant Director of Nursing A stated she was not working on the day of the incident, nor was she involved in the investigation but was asked by the Forme [TRUNCATED]

Based on observation, interview, and record review the facility failed to keep one of twelve residents free of accident hazards and supervision. The facility failed to: Ensure Resident #2, who had exit seeking behaviors and resided on the secure unit, did not elope from the facility on 12-18-22. An Immediate Jeopardy (IJ) was determined to have existed on 12-18-22. The IJ was determined to be past noncompliance because the facility had implemented actions that corrected the noncompliance before the investigation began on 12-20-22. These failures placed residents at risk of accidents, harm, a decline in their psychosocial well-being, hospitalization or death. Findings Included: Record review of Resident #2's Admission Record dated 5-11-22 reflected, Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included schizoaffective disorder (a condition where symptoms of both psychotic and mood disorders are present together during one episode or within a two week period of each other), bipolar (a mental health condition that causes extreme mood swings that include emotional highs), epileptic (disorder of the brain characterized by repeated seizures) seizures (a sudden, uncontrolled electrical disturbance in the brain), hypertension (blood pressure that is higher than normal), abnormal gait and mobility, psychosis. Record review of Resident #2's MDS assessment dated [DATE] revealed Resident #2's BIMS score was 00 which indicated severe cognitive impairment. Resident #2 usually understood, had difficulty communicating some words or finishing thoughts but was able if prompted or given time. Resident #2 required supervision and one-person physical assist when moving around off the unit. The MDS further reflected Resident #2 had a behavior of wandering with a presence and frequency occurring 1 to 3 days during the look back period of the assessment. Record review of Resident #2's Care Plan dated 10-4-22 reflected Resident #2 is exhibiting exit seeking behaviors. [Resident #2] has the potential to wander. Resident #2 will now reside on the Secure Unit. Most of her wandering will be on the unit and in hallways, occasionally will try to push exit doors open, exit door alarm will sound (regular alarm and amplifier alarm) and staff would redirect Resident #2 the unit. Date Initiated: 10/05/2022. Resident #2 has impaired cognitive function or impaired thought processes related to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Difficulty making decisions, impaired decision making Date Initiated: 06/27/2022. Resident #2 has a communication problem r/t dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Resident #2 Seizure Disorder r/t Disease process epilepsy (a broad term used for a brain disorder that causes seizures) Date Initiated: 06/27/2022. Resident #2 has a history of falls as evidenced by actual fall on 05/10/2022. Record review of Resident #2's elopement evaluation dated 10-3-2022 reflected that upon admission the resident had a diagnosis of dementia The evaluation reflected yes was marked for elopement history/community risk, for reported documented episodes of elopement and/or attempts to elope, signs of compromised decisional capacity and substantially impaired judgment and/or physical status limitations that would place the resident at risk in the community. Resident #2's representative requested that the resident be monitored on the elopement protocol. The evaluation reflected behavioral observations included the resident would hang around facility exits and/or stairways, the resident verbalized a serious/strong intent to leave the facility in the absence of an appropriate discharge plan, responded poorly to staff re-direction when roaming into areas that were off limits or unauthorized, and had the physical ability to leave the building. The evaluation further reflected Resident #2 was at risk to elope and should be placed on the elopement risk protocol. Record review of Resident #2's progress notes dated 10-25-22 reflected resident open exit door on unit and went out the door, resident brought back in facility by staff, no side effects observed, reorient to surroundings effective for a short time, pace back and forth in hall constantly and go to door and try handle, redirect from door resist redirection. Record review of Resident #2's progress notes dated 10-26-22 reflected resident has been monitored q 15 minutes for exiting out secure door on 10-25-22 at 11:11 am. Monitoring to last 24 hrs if no other problems. Record review of Resident #2's progress notes dated 11-16-22 reflected resident ambulate in hall constantly, redirect from other residents room, forgetful about surroundings. Record review of Resident #2's progress notes dated 11-27-22 reflected resident ambulating in hall constantly, redirect from exit doors and other resident rooms, effective for short while. Alert and orient to self forgetful about time, date and surrounding. Record review of Resident #2's progress notes dated 12-18-22 and documented by LVN A reflected Patient eloped from the facility on 12/18/22. The patient's family stated that the patient was reportedly found outside the facility. police were notified by family and facility staff. I immediately check doors and windows on the unit. The exit doors were secure and alarms had not sounded. However, a window in the dining room on the secure unit was open. The patient was last seen at 9:45 am and the incident occurred at approximately 10:40 am. Record review of the facility's Provider Investigation Report (Form 3613-A) dated 12-18-22 reflected the incident occurred on 12-18-22 at 9:30 AM. Resident #2 had a minimal functional ability, was independently ambulatory, was not interviewable, did not have the capacity to make informed decisions, and had a history of wandering. The investigation summary reflected: The investigation revealed that apparently the resident exited through a Secure dining room window. The Resident has never attempted to leave the unit/facility through a window. All facility room windows were and are shut closed. She managed to get through the Secure dining room window somehow. She was noted shortly before that incident to be on the unit with no unusual behaviors. Since she exited through the dining room window, no alarm was triggered & therefore she was able to exit unnoticed by staff. No other resident exited the facility at that time. All doors are regularly tested for functioning. Secure hall doors (both exit doors and the one leading to the courtyard) have an additional loud alarm to alert staff in case of an elopement while they provide care in room with door closed. Resident #2 has a history of wandering & occasional exit seeking and resides on the Secure Unit. She has been Care Planned for wandering and occasional exit seeking. Staff witness statements are attached. The facility feels that this incident is highly unusual incident as an attempt to exit through a window is not a normal incident. Exit doors and residents when exhibiting exit seeking behaviors are usually monitored and re-directed by staff when re-direction is required. Record review of a handwritten statement dated 12-18-22 from Resident #2's FMA reflected, At approximately 9:45 AM I was going down a near by street to a convenience store when I noticed what looked like [Resident #2] when I got closer and saw it was her [Resident #2]. I checked on her well being wrapped her up and took her to FMA's residence. Record review of a handwritten statement signed and dated (11-18-22) from HK reflected, I saw he [sic] come out of [Resident #4's] room around 10:45 [AM] because I was mopping The Dinning [sic] Area. When I heard people knocking at the glass doors thre [sic] thing to beat us up because [Resident #2] was found off the facility. No alarms went off and we make sure we see who goes in n [sic] out. So we went to go check the windows. Found that a dinning [sic] area that is closed up and the lights are off. Way at the far end of that room the window was opened. Doors are closed and no one is allowed back there. Record review of an undated handwritten statement from CNA A reflected, When I came early this morning [Resident #2] already a wake [sic]. She's back and forth walking to the hall, room to room. We always told her get out to other room because that's not her room. She eat [sic] breakfast in the tv area. The last I saw her wearing a green jacket. She always changing her clothes. The door all closed and no alarm. Record review of an undated handwritten and signed statement from LVN A reflected, the patient [Resident #2] received 8am meds and ate breakfast. No alarms (door) went off. However, the pts family came to the secure doors being irate and threatening to assault me because they stated their family member had gotten out of the facility. I went to find out how the pt exited the building and the housekeeper alerted me to a raised window in the dining room on secure unit. The door in the dining area was not locked and the patient went out through the window. Record review of an undated handwritten statement signed by the HKS reflected, On 12-18-22, roughly around 11:00am my housekeeper come [sic] to me and stated that [Resident #2's] family members were threatening them due to her being found out of the building. As I did not hear any door alarms going off I made rounds to check all the doors. All the doors were working properly. As I was checking the secure dining room door I noticed the window leading to the parking lot was open. I secured the window down as instructed and checked all the remaining windows on secure [sic]. I did not find any others open. As I was closing the window on secure [sic] I noticed the footprint outside the window that was open and informed [DRS ]of it. Record review of a handwritten statement signed and dated 12-18-22 from the DRS reflected, around 11-11:15 [AM][sic] I received [sic] a call from Administrator stating a resident eloped. I immediately came to work and proceed to round and check all windows and doors to ensure that the [sic] was secured. While rounding [HKS] points out a footprint outside window on secure dining room. Notified Administrator right away. During an interview on 12-21-22 at 9:40 AM, the Administrator stated he was notified at 10:50 AM that Resident #2 had eloped from the secure unit of the facility. The Administrator stated FMA was driving down a nearby street to a convenience store and found Resident #2 at 9:45 AM in the parking lot of the store. The Administrator stated family called the facility and talked to LVN A who informed him Resident #2 was found outside of the facility. The Administrator stated he was notified by the HKS that the dining room window in the secure unit was opened and a footprint was found outside of the window. The Administrator stated he was told by the HKS the window was not secured and was missing the bolts on the windowpane. The Administrator stated Resident #2 was mobile and able to get around on her own and did not need an assistive device to do so. The Administrator stated Resident #2 had attempted to get out of the facility before, but the door alarm sounded, and she was brought back by staff. The Administrator stated keypads on the secure unit were checked and found to be in working order, and doors/alarms were checked and in working order. The Administrator stated the secure unit did have a camera but after reviewing the footage the camera did not pick up the dining room window. The Administrator stated Resident #2 was not brought back to the facility and did not know if she had sustained any injuries while she was out of the facility. The Administrator stated he had received elopement training on 12-18-22, ensuring all residents are accounted for and monitor exit seeking behaviors, and check all windows to make sure they were secured. During an interview on 12-21-22 at 10:10 AM, the HKS stated his duties included checking locked doors daily, door push bars to make sure the alarm went off, training staff and also helping with housekeeping duties as needed. The HKS stated he had not check the windows in the secure unit. The HKS stated he was working in his office on the day Resident #2 eloped from the facility. The HKS stated on 12-18-22, he was notified by the HK around 11:00 AM that Resident #2's family was outside of the facility and they were upset and threatening staff because Resident #2 had left the facility and no one knew she was gone. The HKS stated he went to the secure unit and checked all the doors to make sure they were locked because he did not hear any alarm go off. The HKS stated all doors were locked and working properly. The HKS stated when he walked into the dining room of the secure unit, he noticed the window at the far end was open about halfway up and also saw a footprint outside the window. The HKS stated on 12-18-22 he notified the Administrator and the DRS. The HKS stated he saw a hole on the left and right sides of the windowpane and the bolts were missing. The HKS stated on 12-18-22 he put bolts on each side of the windowpane to secure them. The HKS stated all windows on the secure unit open about 4-6 inches and then are stopped by a bolt on both sides of the windowpane. The HKS stated he did not know why or how the bolts were removed from the windowpane in the secure unit. The HKS stated he had received elopement training on 12-18-22, ensuring all residents are accounted for and monitor exit seeking behaviors, and check all windows to make sure they were secured. During an interview on 12-21-22 at 10:54 AM, the DRS stated he was notified on 12-18-22 at 11:00 AM by the HKS that Resident #2 had eloped. The DRS stated he arrived at the facility around 11:15 AM and began checking every single window/door on the secure unit. The DRS stated all windows in the residents' rooms on the secure unit had bolts on both sides of the windowpanes. The DRS stated the HKS showed him the window that was open in the dining room and the footprint that was outside the window. The DRS stated all doors/alarms were checked and all were in working order. The DRS stated a code on the keypad is needed to enter and exit the secure unit and that door was also secured. The DRS stated the alarm in the secure unit is quite loud and can be heard in the unit. The DRS stated there are cameras throughout the secure unit. The DRS stated when he checked the video, he noted the cameras not to be recording and the camera angle did not catch the dining room window. The DRS stated he did not know how long the cameras has not been in working order. The DRS stated new cameras have been ordered and will arrive by 12-28-22 and be installed immediately. The DRS stated he will be responsible for viewing all secure unit videos to ensure that all residents are safe and cameras are in working order. The DRS stated he has not seen Resident #2 trying to open windows but has seen her wandering the halls. He also stated Resident #2 is independent (high level) and doesn't need assistive devices to walk and she is verbal and able to communicate her needs. DRS stated he received elopement training on 12-18-22,ensuring all residents are accounted for and monitor exit seeking behaviors, and check all windows to make sure they were secured, ensuring all residents are accounted for and monitor exit seeking behaviors, and check all windows to make sure they were secured. During an interview on 12-21-22 at 12:00 PM, the MS stated was responsible for all maintenance issues in the facility. The MS stated the facility had undergone some remodeling about 4-6 months ago and all windows were checked, and all bolts were secured to the windowpanes. The MS stated during the remodel there was no reason for any of the bolts to be removed from the windowpanes in the dining hall of the secure unit because the remodeling consisted of new flooring. The MS stated a socket or wrench would need to be used to take the bolts out of the windowpanes. The MS stated all tools are locked in a tool room and he and the HKS are the only ones with access. The MS stated he had not received any reports of bolts missing from any windows in the secure unit. The MS stated that on 12-18-22, the HKS and DRS had checked all windows in the secure unit to make sure that all bolts on the windowpanes were in place and secured. The MS stated bolts on the windowpane allowed the windows to open 4-6 inches. The MS stated the secured windows in the secure unit are not part of the egress requirements. The MS stated he did not check windowpanes unless there was a report of it needing to be fixed. The MS stated the DRS and HKS had checked all windowpanes on 12-18-22 to ensure they were secured. MS stated he received elopement training on 12-18-22, ensuring all residents are accounted for and monitor exit seeking behaviors, and check all windows to make sure they were secured. During an interview on 12-21-22 at 12:30 PM, FMB stated she was called by FMA and told Resident #2 had left the facility (unaccompanied) and had been found around 9:30 AM near an apartment complex near a store on a nearby street. FMB stated FMA told her Resident #2 was shaking and had white stuff on her lips. FMB stated Resident #2 had beeno taken to FMC's home. FMB stated she observed Resident #2 to have swelling to her ankle and white stuff on her lips. FMB stated Resident #2 was wearing a short sleeve shirt and sweatpants and house shoes when she was found. FMB stated on 12-18-22 around 10:45 AM, she, FMA and FMC had gone to the facility to notify the staff of the incident and to pick up Resident #2 personal belongings as she would not be returning to the facility. FMB stated Resident #2 does understand what is being said and she can verbalize some of her needs. FMB stated Resident #2 has dementia. FMB stated Resident #2 is able to get around without assistance. During an interview on 12-21-22 at 12:48 PM, FMA stated she had gone to the convenience store on a nearby street when she saw Resident #2 walking in an empty lot near the store. FMA stated she was not sure if it was Resident #2 until she turned around and approached her. FMA stated she had gotten out of her car and approached Resident #2 and saw her shivering and she had white stuff on her mouth/nose area. FMA stated she wrapped Resident #2 in a jacket and placed her in the car and took her to FMB's home. FMA stated Resident #2 was wearing a T-shirt (bare-armed), warmup pants, and house shoes when she found her. FMA stated Resident #2 did not have any identification on her when she was found and due to her dementia Resident #2 does not remember her name. FMA stated that had she not been visiting a friend who lives near the convenience store she would have never seen or found Resident #2. FMA stated family members went to the facility to notify them of the incident and also called law enforcement. FMA stated the facility staff did not know Resident #2 was gone until they were notified by the family. FMA stated she spoke with an unknown female staff member and informed her Resident #2 was found outside of the facility and the staff member responded, Oh she's gone. FMA stated Resident #2 did not have a history of leaving the facility and to her knowledge Resident #2 walked back and forth down the hallways. During an interview on 12-21-22 at 12:55 PM, CNA B stated she was assigned to work the secured unit on daily basis. CNA B had worked in the secure unit on 12-18-22 from 6:00 AM to 9:40 AM. CNA B stated Resident #2 had breakfast around 8:00 AM in the small dining room located near the nurse's station. CNA B stated she had provided peri-care to Resident #2 around 9:30 AM and that was the last time she saw her. CNA stated Resident #2 had been acting normal and she had not exhibited exiting behaviors, nor had she given any verbal cues about leaving the facility. CNA B stated Resident #2 walked up and down the hallways in the secure unit but had not attempted to open windows to leave the facility. CNA B stated she was told by another staff member that Resident #2 had escaped out the window and the family was upset. CNA B stated Resident #2 resided on the regular unit but after she tried to leave, she was moved to the secure unit. The CNA stated Resident #2 was independent and able to walk around on her own without physical assistance or assistive devices. CNA B stated Resident #2 was able to communicate her needs. CNA B stated a code for the keypad was needed in order to enter and exit the secure unit and when the door is opened it made a loud noise. CNA B stated the windows in the memory care unit do not have alarms. CNA B stated that on 12-18-22 she had been trained on elopement, ensuring all residents are accounted for and monitor exit seeking behaviors, and check all windows to make sure they were secured. During an interview on 12-21-22 at 1:06 PM, ADON B stated she had not been working on the day Resident #2 eloped. ADON B stated Resident #2 had not had a history of elopement attempts but does wander around the secure unit. ADON B stated Resident #2 was able to walk around on her own and does not require assistance. ADON B stated she received the elopement training when she returned to the facility on [DATE]. ADON B stated all windows in the memory care unit had been checked after the incident occurred. ADON B stated all department heads will check all windows in the secure unit to make sure they are closed and secured. During an interview on 12-21-22 at 1:46 PM, the Detective stated he received the incident report involving Resident #2. The Detective stated the facility did not commit a criminal offense and Resident #2 was not injured so no one was going to be arrested or charged with a criminal offense. The Detective stated the case was closed. During an interview on 12-21-22 at 3:53 PM, ADON A stated she had been notified by LVN B that Resident #2's family was at the door and wanted to come inside [the secure unit]. ADON A stated FMA told her Resident #2 had been found near a convenience store and then taken to FMB's home. The ADON stated the camera in the secure unit did not point in the direction of the window Resident #2 eloped from therefore it had not shown Resident #2 getting out. The ADON A stated she was told Resident #2 had complained about her ankle hurting. The ADON A stated Resident #2 was not brought back to the facility so an injury assessment was not done. The ADON stated Resident #2 is independent and can walk around the unit on her own. The ADON A stated after Resident #2 moved to the secure unit she was more confused, wandered more and exhibited exiting behaviors. The ADON stated Resident #2 is able to answer direct questions. The ADON A stated she was told the HK clocked in at 9:30 AM and she saw Resident #2 in the secure unit. The ADON A stated LVN A and CNA A were working on the secure unit when the incident occurred. ADON A stated she had been told the dining room window was open and Resident #2 got out through there. ADON A stated staff did not know Resident #2 was not in the facility until notified by the family. The ADON stated a keypad code is needed to enter and exit the secure unit. ADON A stated on 12-18-22 she provided an elopement in-service to all staff member who were working. During an interview on 12-21-22 at 4:50 PM, the DRS stated that on 12-18-22 he had checked all video equipment, doors, windows, alarms and keypads and all were found to be in working condition. Observation on 12-21-22 at 4:51 PM revealed the code to the keypad for the secure unit to be in working order. The DRS entered the door code before entering the secure unit. Observation on 12-21-22 at 4:53 PM revealed all windows in the dining room to be secured with bolts on each side of the windowpanes. Observation on 12-21-22 at 4:58 PM revealed all windows in the residents' rooms of the secure unit to be bolted on both sides of the windowpanes. Observation on 12-21-22 at 5:15 PM revealed the exit door in the secure unit to be in working condition. The DRS pushed the exit door open, and the alarm sounded (loud). Observation revealed a code to the keypad was needed to turn off the alarm. During an interview on 12-21-22 at 5:18 PM, LVN B stated she was working the morning shift on 12-18-22 when Resident #2 eloped from the facility. LVN B stated she was notified by LVN A that Resident #2's family was at the door saying Resident #2 had left the facility. LVN B stated she began to check all rooms in the secure unit to ensure that all other residents were safe. LVN B stated elopement in-services had been provided on 12-18-22 by ADON A and the Administrator after the incident. Record review of an in-service dated 12-18-22 reflected, Daily: Staff: to make sure secure exit door alarm [sic], to check to ensure windows are secure on the secure unit, keep dining room doors open at all times, also monitor all secure unit residents for exit seeking behaviors. Signatures of staff in-services included: LVN B, CNA A, CAN B LVN A, DRS, Administrator, ADON A, HKS, and ADON B. Record review of a monitoring log titled Window and door daily checkoff reflected columns with the following information: date, check if ok, concerns if not ok, reported to who, initials. Entries were noted on the following dates: 12-18-22, 12-19-22, 12-20-22, 12-21-22, and 12-23-22. Record review of an order reflected a wireless security camera system with 4 cameras had been ordered on 12-19-22. Record review of a typed/signed statement from the Owner dated 12-22-22 reflected, When I check the facility doors for safety, functionality and security, I always check for the 15 egress self-release, alarm activation, strobes functionally when available (secure unit and laundry exit door by time clock), and I check the functionally of keypad as well. Last, we check for a clear egress behind the door and for the door properly latching as well. Record review of an undated Secure Unit Policy reflected the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for resident who are at risk for elopement. Staff will identify residents who are at risk for elopement, staff will place residents who are at risk for wandering near the nurses station or close observation, care plan interventions, and a detailed monitoring plan for residents who are at high risk for elopement. Record review of an undated Secure Unit policy reflected It is the policy of the facility to ensure the safety and well-being of residents on the secure unit. Staff on the secure unit shall check on residents at least every two hours. Residents exhibiting exit-seeking behaviors shall be closely monitored and redirected, 1 to 1 supervision may be warranted at times when redirection is not effective. Review of the temperature for Waco, Tx on 12-18-22 low was listed at 42 degrees and high of 55 degrees. Review of the miles from the facility to the near by convenience store where Resident #2 was found to be 0.5 miles. Review of the posted speed limit to the street near the convenience store was found to be 50 miles per hour. During the exit interview on 12-23-22 at 11:30 AM, the Administrator stated all staff had been re-trained on elopement procedures. The Administrator stated a new camera system had been ordered and would be installed upon arrival. The Administrator stated all department heads are to check all windows in the secure unit to ensure that they are secure. The Administrator stated housekeeping will also be responsible for checking the windows in the secure unit to ensure they are all secured.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 residents (Residents #1-20) and one of one hall (secure), in that: 1. The facility failed to have designated staff working with COVID-positive residents and allowed staff to work with both the COVID-19 positive (Residents #1-5) and COVID-negative (Residents #6-20) residents on the same hall. 2. The facility failed to quarantine Resident #6 who was readmitted from the hospital. 3. The facility failed to assess residents 3x's a day for signs & symptoms of COVID-19. 4. Staff were observed delivering dinner trays without sanitizing their hands in between each tray delivery. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/19/2020 at 9:23 P.M. While the IJ was removed on 11/25/2020 at 2:39 P.M., the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures could place residents at risk for extended discomfort, physical and psychosocial decline, and death. Findings include: 1. The facility failed to have designated staff working with COVID-19 positive residents and allowed staff to work with both the COVID-positive (Residents #1-5) and COVID-negative (Residents #6-20) residents on the same hall, which was divided by double doors. Review of facility self-reported incidents reflected the following COVID-positive test results reported to the State Agency: 11/16/2020 four staff tested positive for COVID positive one on Saturday, 2 on Sunday and one on Monday. Observation on 11/18/2020 at 2:07 pm revealed Activity Assistance and Housekeeper in the COVID unit. Activity Assistant cracked the COVID unit door and asked surveyor if the charge nurse is at the nurse's station. Observation on 11/18/2020 at 2:35 pm revealed LVN CN donning full PPE in secure unit and entered the COVID unit. Observation on 11/18/2020 at 2:50 pm revealed LVN CN exited the COVID unit without PPE and enter the non-COVID unit. In an interview on 11/18/2020 at 1:20 pm the DON stated they have 1 CNA that works the COVID unit at all times. She also stated she has one dedicated staff that works the weekends only in the COVID unit. In an interview on 11/18/2020 at 2:40 pm Hospitality Aide A stated LVN CN was the charge nurse for both the COVID unit and the secure unit. In an interview on 11/18/2020 at 3:00 pm LVN CN stated she is the dedicated staff for both the COVID unit and secure unit. Observation on 11/19/2020 at 7:40 am of the COVID unit revealed an area near residents room where doffing is in the main hallway of the COVID unit. Observation on 11/19/2020 at 07:45 am revealed LVN CN leaving the COVID unit to the non-COVID secured unit with an over bed table; the overbed table was not observed being cleaned prior to going to non-COVID unit. Observation on 11/19/2020 at 8:21 am revealed the Activity assistant going to the COVID unit in full PPE from the non-COVID unit. In an interview on 11/19/2020 at 8:53 am CNA CN stated, she goes on the COVID unit in the morning before 8:00 am because the Activity assistant works on the COVID unit Monday through Friday 8:00 am to 4:00 pm. CNA CN also stated after 8:00 am, she comes back on the secure unit to continue her day's work and later after 4:00 pm back to the COVID unit for dinner and get the Residents ready for night shift. She stated LVN CN went on the COVID unit this morning, so she didn't have to go there. In an interview on 11/19/2020 at 10:11 am, LVN CN she took breakfast to the Residents on the COVID unit while the CNA CN served breakfast on the secure unit. She stated, she goes to the COVID unit every 2 hours to check on the Residents and then back to the secured unit. She then stated, the Activity assistant usually work on the COVID unit from 8:00 am to 4:00 pm and then CNA CN goes to the COVID unit until 6:00 pm. Observation on 11/19/2020 at 8:04 am revealed the Housekeeper and Housekeeping supervisor donning PPEs went on the COVID unit. At about 8:20 am, both staff came back to the memory care unit from the COVID unit. Observation on 11/19/2020 at 08:38 am, the Housekeeper donned PPEs and went back to the COVID-19 unit taking mop pads. Observation on 11/19/2020 at 8:50 am, the floor tech was observed going to the COVID-19 unit to spray disinfectant after which he went back through the general population in secure unit and into the laundry room. In an interview on 11/19/2020 at 10:31 am, the Housekeeper stated she was assigned to the COVID unit and the Secure unit. She stated, she cleans the COVID unit before cleaning the Secured unit. In an interview on 11/19/2020 at 3:49 am, the Housekeeping Supervisor stated she entered the COVID unit through the double doors (through the secured unit) and came back the same way and was wearing PPEs. She also stated, I was told by the nurses, specifically the DON that housekeepers can go on the COVID unit clean the rooms and later clean rooms on the Secure unit as long as they are in full PPEs. I don't see any issues with that. Observation on 11/19/2020 at 9:07 am revealed the DON donning PPE and went in the COVID unit and went into a Resident's room then she was observing entering the secure unit. Observation on 11/19/2020 at 10:36 am revealed the Activity assistant returned to the COVID unit. In an interview on 11/19/2020 at 11:15 am the Activity assistant stated she had been working back and forth in the COVID Monday through Thursday from 8:00 am to 4:00 pm and on Fridays she works as activity assistant on the Secure unit. She stated she was seen going back to the COVID unit because she had to go to the general public to use the restroom and then return to the COVID unit. She also stated the nurse assigned to the Secured unit was the same nurse assigned to the COVID unit and during the shift the nurse goes back and forth to check on the residents on the COVID unit. She stated, at the beginning of COVID they were told to exit through the back door but now people exit the same way they enter. In an interview on 11/19/2020 at 3:07 P.M. RN A stated the policy is once you enter you have to leave through the back door and come back through the same door. That is what I was told to do when I worked back there. There is a problem if you enter and exit the same door; it's cross-contamination. She stated she knew it wasn't right and I offered my suggestions and explained my set up from another facility but they said this was ok to do. In an interview on 11/19/2020 at 7:05 pm, LVN A stated there was one resident on the COVID unit. She stated she goes on the COVID unit last, she makes sure she had all the proper PPE on (mask, gown, gloves, shoes and head covers, goggle). She stated she could not say if it was okay or not to go on the COVID unit and back to the general population. She stated she was not sure, she doesn't know and doesn't make the rules. In an interview on 11/20/2020 at 2:35 pm, LVN B stated she goes back and forth multiple times from the Secure unit to the COVID unit checking on residents during her 12 hours shift (6am-6pm). She also stated, I feel it is not right, that's cross contamination. In an interview on 11/20/2020 at 12:31 pm, the DON stated, We have designated CNAs who go through the back door but due to the staffing problems we are not able to get the staff. We use one nurse who does PPEs correctly. We have not been able to have a designated nurse. We admit these patient from another facility. Nobody told me that there should be designated nurse, the administrator did not tell me. The administrator was responsible to read the update and notify me. She stated, as long as the staff is in full PPEs, they can go back and forth from the COVID unit to the Secure unit. 2. The facility failed to quarantine Resident #6 who was readmitted from the hospital. Review of Resident #6's face sheet revealed a [AGE] years old female DOB 05/01/1947 original admission date of [DATE] and readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 00 and a staff assessment was done reflecting memory problems. Review of Resident #6's Care Plan revealed the resident was on the secure unit due to wandering, the resident had actual respiratory infection as evidence by COVID-19 positive test result dated 07/21/2020. Observation on 11/19/2020 at 7:43 am revealed Resident #6 sitting in the dining room on the secure unit eating breakfast. Another Resident was sitting in the dining area near Resident #6 not [MEDICATION NAME] social distancing. Review of Resident #6's clinical records reflected the resident was sent to the hospital on [DATE] and was readmitted to the facility on [DATE] due to Pneumonia. The resident was not quarantined for 14 days as per emergency rules guidelines. Observation on 11/19/2020 from 7:45 am to 7:18 pm revealed no isolation set up at Resident #6's door, not sign at the door cautioning staff the resident was being quarantined. In an interview on 11/19/2020 at 6:49 pm, CNA A stated new admission who are not COVID-19 positive are put on the same precaution as COVID-19 positive as far as wearing the PPE. She also stated, Resident #6 went to the hospital about a week ago and was in the room by herself. CNA stated, Resident #6 was not being quarantined, we do not wear PPEs for her, I do not think she is supposed to be quarantined, they didn't tell us about her. In an interview on 11/19/2020 at 7:05 pm, LVN A stated Resident #6 went to the hospital and spent about 2-3 days in the hospital. She also stated, everybody that goes to the hospital, readmission or new admission was supposed to be quarantined for 14 days. She then stated, usually there was a sign at the door to alert staff but there was none at Resident #6's door. She stated she was not sure why there was no sign or isolation set up at Resident #6's door but she would find out from the DON. In an interview on 11/20/2020 at 2:35 pm, LVN B stated she was the nurse who admitted Resident #6 when she returned from the hospital. She stated, I do not know why I did not put Resident #6 on quarantine, I was supposed to get the isolation set up together, educate the Staff and put the sign on the door. In an interview on 11/19/2020 at 4:15 pm, the DON stated, there was no warm area for presumptive residents, they were in the room by themselves. She also stated, readmission, new admissions even with a negative COVID test result were isolated in their room for 14 days. On 11/20/2020 at 12:31 pm, the DON stated she was aware of the CDC guidelines and Resident #6 should be quarantined for 14 days, an isolation cart and a sign should be at her door, she was not available, she was out of time when Resident #6 was readmitted . She stated all of the staff have be in-serviced about quarantine. She stated, I am aware of hot and cold, I can't remember warm zone, there is a lot going on. The hot zone was where we have the COVID Residents. 3. The facility failed to assess resident's 3x's a day for signs & symptoms of COVID. Review on 11/18/2020 at 3:00 p.m. of resident electronic vital record logs and/or TAR for COVID-19 monitoring revealed that vitals were only being checked once or twice a day or sometimes not at all. There was no evidence that screening or monitoring for symptoms of COVID-19 including COVID-19 positive residents. Record review of Resident #1's face sheet revealed a [AGE] year-old male was admitted to facility on 11/09/2020 with the following Diagnoses: [REDACTED]. Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 15 indicating cognitively intact. Review of care plans for Resident #1 reflected no comprehensive care plan in the EMR; only that he was a fall risk. Record review of Resident #1's treatment sheet reflected the following information: tx in place in lieu of hospitalization due to COVID-19 Skilled Nursing care for the assessment and mgt of COVID-19 Droplet Isolation precautions q shift one time a day for COVID-19 -Start Date-11/10/2020 Record review of Resident #1's electronic vital record logs reflected the following information: 11/09/2020, vitals were checked one time 11/10/2020, vitals were checked two times 11/11/2020, vitals were checked one time 11/12/2020, vitals were checked two times 11/13/2020, vitals were checked two times 11/14/2020, vitals were checked one time 11/15/2020, vitals were checked two times 11/16/2020, vitals were checked one time 11/17/2020, vitals were checked two times 11/18/2020, vitals were checked one time Record review of Resident #2's face sheet revealed a [AGE] year-old male was admitted to facility on 11/16/2020 with the following Diagnoses: [REDACTED]. Record review of Resident #2's MDS dated [DATE] reflect a blank BIMS score. Review of care plans for Resident #2 reflected no comprehensive care plan in the EMR, only that he was fall risk. Record review of Resident #2's electronic vital record logs reflected the following information: 11/16/2020, vitals were checked one time 11/18/2020, vitals were checked one time Record review of Resident #3's face sheet revealed an [AGE] year-old male admitted to facility on 03/01/2019 with the following Diagnoses: [REDACTED]. Record review of Resident #3's MDS dated [DATE] reflected a BIMS score of 02, indicating severely impaired cognition. Review of Resident #3's Care Plan with an initiation date of 03/19/2020 a focus area of [MEDICAL CONDITION] Pandemic reflected Residents will be screened daily for Temperature, cough and shortness of breath Review of Resident #3's TAR for the month of November with a start date of 07/30/2020 and every shift reflected the following: Monitor for S/S of COVID 19 including but not limited to temp above 100.4, sore throat, loss of taste/smell. Resp.-SOB, Cough, Congestion, decreased 02 sat. GI-Nausea, Vomiting, Diarrhea, flu like symptoms of Fatigue, muscle and body aches and headaches being around someone who has tested positive. Contact MD/NP, DON and ADON if these are noted. The TAR reflected the shifts of 6AM - 6 PM and 6 PM - 6AM. The TAR did not reflect vitals were being checked 3 times a day. Review of Resident #4's face sheet revealed a [AGE] year-old male admitted to facility on 11/04/2020 with the following Diagnoses: [REDACTED]. Review of Resident #4's active physician orders [REDACTED]. TX in place in lieu of hospitalization due to COVID-19 Skilled nursing care for the assessment & mgt of COVID-19 Droplet Isolation precautions q shift one time a day for COVID-19 Review of care plans for Resident #4 reflected no comprehensive care plan in the EMR, only that he has potential for falls. Review of Resident #4's electronic vital record logs reflected the following information: 11/04/2020, vitals checked one time 11/05/2020, vitals checked three times 11/07/2020, vitals checked two times 11/09/2020, vitals checked two times 11/10/2020, vitals checked two times 11/13/2020, vitals checked one time 11/14/2020, vitals checked one time 11/15/2020, vitals checked one time In an interview on 11/18/2020 at 1:20 pm the DON stated they were assessing for signs and symptoms of COVID on every shift and there were two shifts, 6:00 am - 6:00 pm and from 6:00 pm -6:00 am. In an interview on 11/19/2020 at 4:15 pm the DON stated that they only assess for signs and symptoms two times per day because it is impossible for nursing staff to assess all residents 3 times per day because that was too much work. In an interview on 11/20/2020 at 11:07 am the Administrator stated that she was unaware of additional guidelines related to dedicated staff, hot/warm/cold zone, resident screening three times per day, and facility specific emergency preparedness plan. The Administrator was referred to the COVID-19 Emergency Rules for guidance. 4. Staff were observed delivering meal trays without sanitizing their hands in between each tray delivery. Observation on 11/19/2020 at 8:05 A.M. revealed RN A wearing gloves, buttering resident's toast bread and then went and assisted another resident with feeding, wearing same gloves and not sanitizing hands in between. Observation on 11/19/2020 at 6:05 P.M. revealed several staff in the central hall handling and serving meal trays to residents without washing their hands and/or using hand sanitizer in between each task. In an interview on 11/19/2020 at 3:07 P.M. RN A stated that she assisted residents with setting up their trays and with feeding them breakfast this morning. She stated she was wearing gloves and that gloves are supposed to be changed out in between residents due to cross contamination. Review of in-service dated 11/17/2020 conducted by DON and titled Key Moments for Hand Hygiene Reflected the following information: Your 5 moments for hand hygiene at the point of care: 1. Before patient contact 2. Before a clean/aseptic procedure 3. After bodily fluid exposure risk 4. After patient contact 5. After contact with patient surroundings Review of undated policy titled (Facility)Healthcare and Rehabilitation Emerging Infectious Disease revealed the following information: The facility's Infection Preventionist (IPCP) will research the specific signs, symptoms, incubation period, and route of infection, the risks of exposure and the recommendations for skilled nursing care centers as provided by the CDC Activate quarantine interventions for residents (and staff) with suspected exposure as directed by local and state public health authorities, and in keeping guidance from the CDC If needed, food, laundry and medications will be delivered to the COVID isolation wing of the facility. Deliveries will not be through the central wing due to cross contamination. Deliveries will be through a separate entrance. Staff will report to work through the separate entrance of the building. Review of Title 40, Part 1, Chapter 19, Subchapter CC COVID-9 Emergency Rule reflected the following information: (b) A nursing facility must have a COVID-19 response plan that includes the following: (1) Cohorting plans that include designated space for COVID-19 negative, quarantine, and isolation cohorts. (2) Spaces for staff to don and doff PPE that minimize the movement of staff through other areas of the facility. (d) A nursing facility must screen according to the following timeframes: (1) each resident at least three times a day, occurring at least once each shift (e) A nursing facility must cohort residents based on the residents' COVID-19 status (f) A resident with unknown COVID-19 status must be quarantined an monitored for fever and symptoms of COVID-19 per CDC guidelines (h) A nursing facility must implement a staffing policy requiring the following: (1) The facility must designate staff to work with each cohort and staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort (2) Staff may not work with more than one cohort. (i) All NF staff must wear a facemask while in the facility. Staff who are caring for COVID-19 positive residents and those caring for residents with unknown COVID-19 status must wear N95 mask, gown, gloves, and goggles or face shield. A Plan of Removal was first submitted by the Administrator on 11/20/2020 at 3:33 p.m. and the following POR was accepted on 11/23/2020 at 12:30 p.m. The IJ template was emailed to the Administrator at 9:39 p.m. Plan of Removal Corrective Action - 1. The COVID Emergency Response plan was revised on 11/20/2020 The administrator is responsible for monitoring all actions in this plan by directing and observing staff to follow the revised policies and procedures concerning the emergency COVID plan. We added and addressed the particulars about the following topics: Co-horting, including details about the zones and the location of the zones such as the covid unit being on secure, behind locked doors etc Admission process before a covid+, or a PUI arrives at the facility Screening of residents three times daily PPE requirements for staff when covid+ is existent in the facility Daily communication with staff about covid+ through the EMAR dashboard and various other methods Non-compliant residents on isolation Designated staff General social distancing 2. The resident was quarantined as of 11/19/2020 and eating in her room on 11/20/2020. A warm zone was set up in the secure unit and she was placed in the room. An in-service was done to management explaining the difference in a cool, warm and hot zone by the Administrator on Friday November 20th. The management team will have a list of staff that hadn't received in-service on these dates and assure the in-service is given and highlighted on the list all of the staff to assure 100% compliance as soon as they return to work. The management team: Don or designee, housekeeping supervisor, dietary supervisor, therapy supervisor will in-service their staff by Saturday November 21, 2020. Any staff that didn't work these particular days will be trained as soon as they return to work. Newly hired staff will receive training before they assume duties on the floor. 3. The facility contacted a staffing agency to provide dedicated staff on the COVID unit 24 hours a day on an immediate basis. The agency nurses will receive training on all components of the Plan of Removal- assessing 3 times day, sanitizing hands in between each tray delivery and the emergency response plan prior to the first shift they work by the DON or designee to assure compliance. The facility will staff each day with a dedicated staff the hours/shift we are able to and supplement with agency staff. 4. The residents started being assessed 3 times a day beginning on 11/19/2020 and will continue until the COVID pandemic is over or different guidance is provided by HHSC. Any new nursing staff will be trained on this component by the Don or designee. The DON or designee will monitor nursing personnel; existing and new staff to ensure the process is effective and the implementation continues. 5. Nursing Staff were in-serviced by the staff development RN starting on 11/19/2020 concerning sanitizing hands in between each tray delivery for any staff involved in tray delivery. This will be completed by November 20 and will continue for any staff involved in delivering food trays to residents. A list will be kept for any staff that has not worked to make sure those staff involved in delivering of trays are trained immediately and appropriately when they return to work. Newly hired staff will be trained for this component before they assume duties if they are involved in delivery of food trays. Residents Identified: Any resident coming back from a hospital or new admissions will be quarantined and stay in their room [ROOM NUMBER] days. Measures: 1. The management team has received a copy of the revised policy and will be read and Administrator will review the policy with the management team for direction and answer any questions that could arise. 2. The management team will in-service their staff with the requirements of the revised emergency response plan beginning November 19 and completed by November 20th . Any staff that did not work during these days will be trained as soon as they return to work. Newly hired staff will be trained by the supervisor on this component of the POR before performing duties. 3. The facility will continue to hire staff for the Covid unit and in-service the fact they are classified as dedicated staff , what the term dedicated staff means as well as the components of the POR. The training/in-service will be conducted to new staff by the DON/designee before they assume duties on the Covid unit and compliance will be monitored by the DON and/or designee. 4. Nurses will be in-serviced on assessing the residents 3 times a day for Covid symptoms including temperature by the DON and Staff Development. This started immediately on November 19 and was completed on November 20th. Any nurse that did not work on these two days will be in-service immediately when reporting for work by the DON or her designee Physician orders [REDACTED]. 5. New staff involved in tray delivery will be in-serviced on sanitizing hands in between each tray delivery by the staff development nurse and in general orientation, whichever comes first before assuming duties of passing trays. Monitoring 1. Administrator will stay abreast of any updates needed to update the Covid emergency plan. The changes will be read from the provider letters from HHSC and THCA. The Administrator will call or email questions if needed from the program manager and or designee. The changes will be communicated to management staff and in-service will be planned for the staff involved for the changes by the department heads. The Administrator will follow the training by the department heads for timely in-service. 2. All nursing staff including Agency staffing will be monitored by DON or designee to make sure they are following the rules for the COVID unit. 3. The HR will recruit for additional staff for the COVID unit. The ADM/DON will determine the number of staff needed based on residents needs and number of COVID residents. 4. The DON or designee will monitor the nurses and documentation to assure the assessment of the 3 times a day for monitoring of residents through review of documentation on a daily basis for the next two week, every two weeks if the daily monitoring is satisfactory. We will continue to monitor documentation every two weeks until the pandemic is over. 5. The DON or designee will monitor for sanitizing hands in between delivery of trays for the staff involved in delivering trays to the residents. 6. The monthly QAPI committee will evaluate the processes to determine whether each component (1-5) is followed and make a report during the monthly QA with the medical director. The medical director's advice will be sought on how to change the process if the initial process is not successful. Monitoring of the facility's Plan of Removal was conducted from 11/23/2020 - 11/25/2020. Observation on 11/23/2020 at 7:12P.M. of the secure unit revealed Resident #6's room with the door closed and a sign that read 'STOP DO NOT ENTER.' The floor was boxed off with yellow tape and full PPE (gowns, masks, face shields/goggles) was located outside the door along with a hand sanitizer dispenser. Observation on 11/23/2020 at 7:30P.M. revealed the COVID unit with a sign that read STOP DO NOT ENTER' and instructions outside the door that gave visual directions for respirator fitting instructions step by step and yellow PPE gowns that are washable. They are to be placed in sugar bags located out back after use to be sent to laundry for wash. Please write your name on the gown you use. Observation on 11/23/2020 at 7:33P.M. revealed PPE supplies fully stocked in portable containers drawers outside the COVID unit. Observation on 11/23/2020 at 7:35P.M. revealed LVN C with a med cart on the COVID unit with full PPE preparing meds. Observation on 11/23/2020 at 7:37P.M. revealed a CNA A at the end of the hall donning PPE in the COVID unit. In an interview on 11/23/2020 at 7:42P.M. CNA D in memory care stated that Resident #6 was in the warm zone due to a recent hospitalization and that she possible could have been exposed while in the hospital. She stated the hot zone is for COVID positive residents and the cold zone is non-COVID. She stated before she provided care for Resident #6 it was important to wash your hands and wear full PPE to avoid the spread of possible infection. She stated the PPE is located outside her door, she wears a gown, mask, goggles or face mask, and gloves; after providing care she makes sure she takes everything off, place them in a red biohazard bag, washes hands and leaves the room. She also stated Resident #6 was now using disposable dishware and utensils. She stated that the COVID unit used dedicated staff which means they only stay on that unit and they have a nurse and a CNA. They have one entrance and one exit which was the back door and they were not allowed to come back into the facility, they must go home. She stated it was important for them to stay in the COVID unit so they don't spread germs She stated that vitals were now to be checked three times a day to assess for signs or symptoms of COVID, which were temperature checks and o2 sats. She also stated that when she arrived she picked up dinner trays and was inserviced on washing her hands as often as possible or using sanitizer in between tray handling either when serving or picking up to prevent the spread of germs. In an interview on 11/23/2020 at 7:58P.M. LVN A stated she is the charge nurse on memory care. She was inserviced on the hot zone which are COVID positive, the warm zone is suspected, and the cold zone is non-COVID. She stated that Resident #6 is in the warm zone due to a return from a recent hospitalization and that full PPE is required before entering Resident #6's room because it is unknown if she was exposed while at the hospital. After providing care and exiting, PPE is placed in a bio bag and hands need to be washed. She stated the COVID unit has dedicated staff and they have to stay back there and provide care only to COVID infected residents and cannot return to general population for COVID safety. She stated dedicated staff leave out the back door. She stated that she was inserviced on handling meal trays between each task due to cross-contamination. She stated that vitals are being checked three times a day which is asking residents if they have any COVID symptoms of a cough, body aches, headache, and temperatures are being checked with o2 sats. In an interview on 11/23/2020 at 8:10 PM central area CNA E stated that she was inserviced on the COVID zones which the hot zone is COVID positive, the warm zone is presumptive, and the cold zone is a COVID free zone. She stated that PPE is too be worn even in the warm zone because they may or may not have COVID. She stated that dedicated staff in COVID hall only take care of the COVID residents and they now exit out the back door and enter in memory care. She stated once they exit the back door of the COVID wing, they cannot come back into the facility because it is a COVID risk. She stated temperatures are being checked three times per day and they are looking for signs and symptoms of COVID which may be a cough, problems breathing, vomiting, or sore throat. She stated that it is important to use hand sanitizer during meal service to prevent he spread of cross contamination in between residents and trays. In an interview on 11/23/2020 at 8:32PM central area CNA F stated she was told about the three zon (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure the governing body established and implemented policies regarding the management and operation of the facility. Management A did not have an effective system in place to fund payment for employees' paychecks and vendors. Management A could not make payroll on scheduled paydays and could not pay vendors timely.[NAME]in the local and surrounding towns would not cash facility staff payroll checks due to insufficient funds. Management A had been having payroll problems for approximately 2 months and problems paying vendors for approximately 2 months. The facility had over $16,562.10 owed due to unpaid vendor payments. An Immediate Jeopardy was determined to exist 9/16/2019 until 11/1/2019. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure placed the residents at risk of not receiving care and services to meet their needs. Findings include: In an interview on 11/13/2019 at 12:32 p.m., Cook A stated that she had issues with being paid in a timely manner. Cook A stated that the last time she had an issue was in (MONTH) 2019. Cook A stated that in (MONTH) 2019 the facility had to get her checked wired to her and it took about 2 weeks for her to get that paycheck. Cook A stated that she was worried; however, she was able to manage. In an interview on 11/13/2019 at 2:51 p.m., CNA C stated that she had issues with her paychecks. CNA C stated that the last time she had issues was in (MONTH) 2019. CNA C stated that she was unable to cash her paychecks and had to have it wired to an account. CNA C stated that she had tried to take her paychecks to her local bank and since it had the facility's name on it the bank would not accept it. CNA C stated that there was a time that they did not have large briefs and had to place a couple of small briefs on a bariatric resident that required a large brief. CNA C stated that she had heard that the DON would purchase supplies, with her own money, that they needed to carry out every day CNA tasks. In an interview on 11/13/2019 at 3:16 p.m., CNA D stated that she had duties as the restorative aide and would handle the central supply. CNA D explained that her role with central supply would be to inform the DON what supplies staff would need. CNA D stated that they would run out of briefs, barrier cream, and wipes. CNA D stated that they would be waiting for two weeks to receive a new shipment of supplies and would be told that the facility was on a vendor hold waiting for the Management A to pay for the last shipment. CNA D stated in (MONTH) 2019 was when they had issues with staff members calling in due to not receiving paychecks in a timely manner. CNA D stated that after the checks would bounce they would have the money wired to an account and then would have to wait for an additional two weeks. In an interview on 11/13/2019 at 4:00 p.m., Staffing coordinator stated there were issues with the staff calling in due to paychecks bouncing at the bank. Staffing coordinator stated that she or CNA D would come in to handle the gaps in coverage. Staffing coordinator stated that they had received paychecks recently and there would be a note on their paychecks for staff to go to a specific bank and there would be a guarantee that they would be able to cash the paycheck. Staffing coordinator stated that they would have about 5 call-ins; however, other staff members would pitch in to have the shifts covered. Staffing coordinator stated that they were under Management A when pay check issues were occurring. Staffing coordinator stated that call-ins have decreased recently due to paychecks were cleared in a timely manner. Staffing coordinator stated that they have not had issues with supplies because the DON would purchase supplies, with her own money, so that they would have what they would need to care for the residents. In an interview on 11/14/2019 at 9:53 a.m., Human Resources stated when she would receive an invoice she would send it to the administrator for approval and then would email Management A representative and then would only hear from Management A if they needed more information. Human Resources stated that Management A representative would explain that she would receive the invoice and then would distribute to the correct department and could not identify who the facility could speak with. Human Resources stated that Management A would not inform when invoices were paid. Human Resources stated that she would receive phone calls from vendors explaining that they had not received payment. Human Resources stated the staff would come to her when paychecks were not clearing at their bank and she would inform the administrator and then Management A would wire the funds to the staff. Human Resources stated that this occurred primarily during (MONTH) 2019 through (MONTH) 2019. Human Resources stated that on (MONTH) 1, 2019 Management A had stopped communicating with the facility about the past due invoices. In an interview on 11/14/2019 at 10:12 a.m., Dietary Manager stated that staff would call in or quit due to paychecks bouncing. Dietary Manager stated that staff would explain that they did not have money to pay for gas so she would provide gas money out of her own pocket. Dietary Manager stated that the time that this occurred was (MONTH) 2019 to (MONTH) 2019 and has improved recently. Dietary Manager stated that employees are being paid timely and she does not have as many issues with call ins or no call no shows. Dietary Manager stated she also had trouble getting paid on time and would have to wait to be paid through the wire transfer. Dietary Manager stated that some staff would wait 3-10 days to 2-3 weeks, past pay day, to be paid. In an interview on 11/14/2019 at 10:46 a.m., DON stated in (MONTH) 2019 the staff's paychecks were late and then would have delays when the paycheck funds were being wired. DON stated that paper checks were being issued and then they would bounce saying insufficient funds and after staff would inform HR and the Administrator, the funds would be wired. DON stated there were times that she would work the floor when staff would call in and had to work in the kitchen when a cook called in the last minute. DON stated that this was close to a pay period because the cook was upset about his paycheck not clearing at the bank. DON stated that paychecks were late and did have some staff that were upset about it; however, recently there have not been issues with paychecks. DON stated that staff all over the building were calling in because of paycheck issues. DON stated that she had ordered supplies; however, the truck did not come due to the medical supply company had a hold on their account due to non-payment. DON stated that at the end of (MONTH) 2019 there was an issue with supplies running out and she wanted to make sure that they did not run out, while on vacation, so she purchased approximately $2,000 worth of supplies from her personal account. DON stated that on several occasions she has had to run to the store to purchase the needed supplies with her own money. In an interview on 11/14/2019 at 11:51 a.m., Administrator stated that at this time they were unable to contact Management A because the number had been disconnected prior to (MONTH) 1,2019. Administrator stated that HR Director would receive the invoices and then send them to Management A and then the vendors would have received payment from Management [NAME] Administrator stated that he would pay for the needed items from his own pocket and then would be reimbursed from Management [NAME] Administrator stated that License Holder A stepped in to ensure that staff were being paid by making an agreement with a bank and ensured funding so that staff would be able to cash their checks at this bank. Administrator stated that Management A discontinued on 10/31/2019 and Management B started on 11/1/2019. Administrator stated that since Management B stepped in they ensured that past due amounts for the phone, cable, internet, and utilities were paid. Administrator stated that he is unsure of the amount that was paid. Administrator stated that the previous company to supply medical supplies was Medical Supply Company A; however, the facility was cut off because of non-payment. In an interview on 11/14/2019 at 11:51 a.m., Food Supply A representative stated that she worked in accounts receivable and sees that the facility still had an outstanding balance for the invoice number provided of $562.10. Food Supply A representative stated that she would not be able to provide a total amount the facility owed; however, explained that Food Supply A is not delivering to the facility due to non-payment. In an interview on 11/14/2019 at 1:21 p.m., Medical Supply Company A representative stated that she is the CFO of the company. CFO stated that the facility had a credit hold and have sent the balances to collections. CFO stated that there was a balance of $16,000 that had gone unpaid. CFO stated that the company had stopped delivering to the facility on [DATE]. Review of Daily Staffing sheet dated 9/12/2019 reflected: - 6-2 shift reflected out of 12 employees scheduled there was one call in and one no call no show. - 2-10 shift reflected out of 11 employees scheduled there were 3 call staff who called in. Review of Daily Staffing sheet dated 9/13/2019 reflected: - 6-2 shift reflected out of 11 employees scheduled there were 3 staff who called in. - 2-10 shift reflected out of 11 staff scheduled there were 4 staff who called in and 1 no call no show. Review of Daily Staffing sheet dated 9/14/2019 reflected: - 6-2 shift reflected out of 12 employees scheduled there were 3 call ins. - 2-10 shift reflected out of 12 staff scheduled there was 1 call in and 2 no call no show. - 10-6 shift reflected out of 9 staff scheduled there was 1 no call no show. Review of Daily Staffing sheet dated 9/15/2019 reflected: - 6-2 shift reflected out of 12 employees scheduled there were 3 call-ins and 1 no call no show. - 2-10 shift reflected that out of 13 employees scheduled there were 6 call ins and 2 no call no shows. - 10-6 shift reflected that out of 9 employees scheduled there was 1 call in and 1 no call no show. Review of Daily Staffing sheet dated 9/15/2019 reflected: - 6-2 shift reflected out of 11 employees scheduled there was 2 call in and 1 no call no show. - 2-10 shift reflected that out of 12 employees scheduled there were 4 call ins. - 10-6 shift reflected that out of 9 employees scheduled there was 1 call in and 1 no call no show. It was determined the above failures was a past non-compliance Immediate Jeopardy to the residents residing in the facility from 9/16/2019 - 11/1/2019. The IJ template was provided to the Administrator on 11/14/2019 at 5:30 p.m. The facility took the following actions to correct the non-compliance on 11/1/2019 1. License Holder A assumed temporary responsibility for vendor payments and payroll. 2. HUD appointed temporary emergency management, Management B, for the facility to take effect on 11/1/2019. 3. Management B guaranteed payroll and vendor payments are delivered in a timely manner. 4. Management B has compiled current bills and is ensuring they are paid immediately. 5. Management B has established vendor contracts to extend from other facilities, they are operating, to ensure that the needed supplies for care and food are delivered. 6. Management B coordinated with a local bank to ensure staff can cash their paychecks immediately when issued. In an interview on 11/14/2019 at 3:00 p.m., Management B representative stated that this management company had been in place since 11/1/2019. Management B representative stated that they were asked to step in, by HUD, due to previous management issues. Management B representative stated that License Holder A still holds the license to the facility and Management B serves as an intermediary between License Holder A and the facility. Management B representative stated that, since they have stepped in, they have made an agreement with a local bank so staff would be able to cash paychecks immediately until payroll shifts to a direct deposit system which is standard with other facilities they manage. Management B representative stated that he accounts set up with vendors at other facilities and has ensured supplies to be delivered at this facility. Management B representative stated he has ensured food and supplies will continue to be delivered as well as guaranteed payroll. Review of a HUD memo dated 10/25/2019 reflected Management B was appointed as temporary emergency management for the facility effective 11/1/2019. The approval was based on the necessity to ensure proper managerial systems.

Based on observation, interview and record review the facility failed to treat each resident with respect, dignity and care in a manner and in an environment that promoted enhancement of his/her quality of life, while protecting the rights of the resident for one of 10 residents reviewed (Resident #1). CNA A took explicit photos and videos of Resident #1 without her consent and posted them to her social media account. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/14/2019. While the IJ was removed on 11/15/2015, the facility remained out of compliance at a level of actual harm with a scope identified as pattern. This failure could cause residents to have a decreased self-worth, decreased amount of privacy, and a dignified existence. Findings include: Review of Resident #1's face sheet reflected that the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly MDS, dated [DATE] reflected Resident #1 could not complete the BIMS interview. Review of Section F, Functional status, reflected that the resident required supervision of one staff member for dressing. Review of Section I, Active [DIAGNOSES REDACTED]. Review of Resident #1's care plan, with an initiation date of 7/11/2017, reflected Resident #1 had impaired cognition, impaired thought processes, and difficulty to make safe and informed decisions as evidence by inattention and disorganized thinking related to a [DIAGNOSES REDACTED].#1 had a communication deficit related to neuroleptic induced Parkinsonism and [MEDICAL CONDITION]. Resident #1 had an activity of daily living self-care performance deficit as evidence by aggressive behavior related to intermittent [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #1 required various levels of assistance due to fluctuating cognition and willingness to allow staff to assist her. Resident #1 could become agitated toward staff at times. Observation on 11/13/2019 at 12:08 p.m. revealed Resident #1 in the dining room eating lunch. Observation revealed Resident #1 was dressed appropriately for the season and no smells or odors were noted. In an interview on 11/13/2019 at 10:00 a.m. Administrator stated that they had received an anonymous phone call on 11/8/2019 that CNA A at the facility had a video or a photo posted to her social media of Resident #1. Administrator stated they called the CNA A in that day to interview her about the allegation. Administrator stated CNA A explained that she had not posted the video. Administrator stated that they looked at the CNA A's Facebook page to see if anything was posted or deleted and could not find anything. Administrator stated they had suspended CNA A pending investigation as per policy. Administrator stated they had received another phone call and then it was explained the video was on CNA A's Instagram. Administrator stated that they were able to get the video and immediately called local law enforcement. On 11/11/2019 CNA A came into the facility for additional interview and the police department were present at the facility to confiscate her phone. Administrator stated that they would be terminating CNA A today (11/13/2019). Administrator described the video of Resident #1 walking in her room with her wheelchair with no clothes covering her. Administrator stated anyone who had worked with Resident #1 would know that this is her due to her stature and her unsteady gait. Administrator stated that he does not know why someone would take or post anything like this. Administrator stated that this made him sick that this occurred. In a telephone interview on 11/13/2019 at 11:11 a.m., CNA A stated that she had never uploaded a video to her social media accounts and stated that she did not have videos of Resident #1. CNA A stated that she had a conflict with a couple of girls, who do not work at the facility. CNA A stated that when she went back to the facility to be re-interviewed, the police came and confiscated her phone. In an interview on 11/14/2019 at 1:00 P.M., DON stated that after they initially talked with CNA A about the allegation, CNA B came forward and informed the DON that she received a video of CNA A's Instagram from another CNA who worked at another facility. DON stated that when they received this additional evidence they called the CNA A back into the facility and that is when the local law enforcement came to the facility and confiscated her phone. In an interview on 11/14/2019 at 1:18 p.m., via phone interview, Detective stated that he worked in the special crime unit. Detective stated that he handled sexually related and invasive video crimes. Detective stated that he received the case recently and CNA A went to the department and demanded to get her phone returned to her. Detective stated that when he interviewed CNA A he looked through the phone and was unable to locate the video in question. Detective stated that CNA A's phone was in process of getting downloaded from another unit. Detective stated that CNA A explained that prior to the second interview, at the facility, she was told that police had been called. Detective stated that even though, at this time, the video was not located on her phone CNA A had other videos on her phone of the same resident (Resident #1). Detective described the video of Resident #1 sitting in a common area and this video showed that Resident #1 had urinated on herself and a puddle had formed under the resident's wheelchair. Detective stated that CNA A admitted that she took the video of when Resident #1 had urinated on herself and stated that she thought it was funny. In an interview on 11/14/2019 at 3:37 p.m., Resident #1's family member stated that he was informed of what had occurred at the facility. Family member stated that he does not understand why this happened or why this staff member would do something like this. Family member stated he was very upset and knows his wife would feel ashamed and embarrassed. In an interview on 11/14/2019 at 3:53 p.m., Administrator stated that he had not re-inserviced staff about HIPPA, cell phone, or the social media policy. Administrator stated that he would conduct in-services on payday (11/19/19) and was going to conduct an in-service regarding cell phone use, HIPPA, and social media on the next payday. Administrator stated the QAPI committee meets once a month and they were due for their next meeting on 11/15/2019. Administrator stated that they had not met at a QAPI committee to discuss the recent investigation regarding the video of Resident #1 that was posted to social media. Surveyor observed on 11/14/2019 at 4:57 p.m., on CNA B's phone revealed a video from CNA A's Instagram page. Video reflected Resident #1 walking in her room using her wheelchair as a walking aide. In the explicit video Resident #1 was observed to be unclothed to include pants, shirt, and any underwear. Surveyor observed to see Resident #1 breast in the video. On the video a statement was observed which reflected The[***]I deal with with laughing emojis. In an interview on 11/14/2019 at 4:57 p.m., CNA B stated that she had been working at the facility for about 7-8 months. CNA B stated that she became aware of the video on CNA A's Social Media B because someone from another facility texted her a screen recording of the video from CNA A's Social Media B account. CNA B stated that the video showed CNA A's Social Media B with her name on the top right corner. CNA B stated that the video shows a caption of The[***]I deal with and laughing emojis. CNA B identified Resident #1 as the resident in the video. CNA B stated Resident #1 appeared to be naked in the video walking in her room with a wheelchair. CNA B stated that she had not been re-inserviced on social media policy or cell phone use policy. CNA B stated that when she first observed this video this made her upset because Resident #1 is not alert and oriented and is unaware of what was going on. Review of facility policy signed by CNA A on 8/21/2019, undated, titled Protecting Resident Privacy and Prohibiting Mental Abuse: Photographs and Audio/Video Prevention Policy. Policy reflected that each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or cause by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). Unauthorized photographs or video recording of nursing home residence are forbidden and subject to disciplinary actions including termination and possible criminal charges. This included social media networks, multimedia messages, private messages and any other electronic platform that can transfer image or video. Remember, treating a nursing home resident in any manner that does not uphold a resident's feelings of self-worth and individuality dehumanizes/patronizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident(s). Any photograph, audio and video taken without written consent is a violation of the resident's rights to privacy and confidentiality. The Administrator was notified on 11/14/2019 at 5:30 p.m. an Immediate Jeopardy situation had been identified due to above failures. The IJ template was provided to the Administrator on 11/14/2019 at 5:30 p.m. The following Plan of Removal was submitted by the administrator on 11/14/2018 at 7:50 p.m. and accepted by the Survey Team at 8:00 p.m. Actions Take/Planned 1) Supplemental QAPI meeting held by management company owner and facility QAPI team members on 11-14-19 at 5:45pm. Systems addressed, and issue/s covered were the use of Personal Cell Phones by staff and possible inappropriate posting of resident information to social media. a) QAPI team members after the adjournment of the meeting at 6pm completed their guardian rounds and using a new audit rule ruled out that any other residents felt that their personal information had been posted to social media without their express permission. (All inter-viewable residents audited and no residents identified as having this type of exposure) All 78 residents interviewed with the question Have you felt like your privacy has ever been jeopardized due to phone usage around you. All residents who could respond answered No by 6:45pm on 11-14-19. b) New postings from the administrator on main entry and by the employee timeclock re-addressing the use of personal cell phones while on the clock. Postings completed prior to 6:00pm on 11-14-19. c) Locked storage boxes purchased for each active nurses station to provide a safe place for employees to lock up their personal cell phones. Completed before 7:10pm on 11-14-19. d) The resident in question was placed on every 15 minutes checks for monitoring psycho-social. Initiated on 11-14-19 and will continue until deemed unnecessary by her attending physician. e) Staff cell phone use added to manager on duty assignments. Added 11-14-19. f) All remaining staff not working at the time of this abatement plan will not be allowed to work the floor before receiving the re-training on Social Media and Personal Cell Phone use. Initiated for most staff 11-14-19 by 6:00pm. 10-6 shift tonight will be by 10pm on 11-14-19. 6-2 shift for tomorrow will be by 6am on 11-15-19. Facility will conduct a weekly, for a period of one-month abbreviated QA/QAPI meetings with the Medical Director and/or their designee present to monitor continued compliance. These meetings initiated on 11-14-19 and will recur for 1 month. This area of focus will be added to the daily Monitoring Management Tool to further monitor compliance. Any issues noted on the Tool will be reviewed with the Administrator/Owner and Medical Director and will be corrected. Quarterly QA/QAPI Committee will provide oversight. The administrator/owner and or their designee/s will monitor this abatement plan for compliance daily. Oversight will be provided daily by owner of the management company and/or his designee. The survey team monitored the plan of removal as followed: Review of Quality Assurance Performance and Improvement Meeting sign in sheet reflected that the QAPI committee met on 11-14-2019 at 5:45 p.m. and adjourned by 6:05 p.m. Observation on 11/15/2019 at 10:00 a.m. cell phone policy was posted was posted on the front door of the facility. Undated posting reflected please be reminded of the facility personal cellphone use policy: cellphone use is only permitted on breaks and scheduled lunch breaks. Any violations can result in disciplinary action including, but not limited to, termination. Observation on 11/15/2019 at 12:05 p.m. revealed cell phone policy posted by the employee time clock. Observations on 11/15/2019 at 12:00 p.m. and 12:15 p.m. revealed lock boxes were present in the medication rooms by each nurses' station. During interviews on 11/15/2019 between 12:08 p.m. and 12:30 p.m., 2 CNAs, 2 CMAs, 2 LVNs, one Medical Record, one Restorative Aide, and 2 cooks all verified their participation in and signatures on in-serving to do with the cell phone policy. All staff members stated that they are unable to have their cell phone with them and have the options of placing their cell phones in the locked boxes or to leave their phones in their personal vehicles. Review of Resident #1 behavior log dated for 11/14/2019 reflected that behavior monitoring started at 10:15 p.m. and reflected that Resident #1 behavior was being monitored every 15 minutes. The administrator was informed on 11/15/19 at 12:54 p.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm and a scope identified as pattern.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for 1 of 5 residents reviewed for supervision during mealtime related to a [DIAGNOSES REDACTED]. (Resident #1) On [DATE] Resident #1, who had a [DIAGNOSES REDACTED]. The resident overfilled her mouth and was found to be unresponsive at approximately 8:02 AM. Emergency Cardiopulmonary Resuscitation (CPR) was initiated by staff and the resident was sent to the hospital. This was determined to be past non-compliance at Immediate Jeopardy (IJ) level on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the complaint investigation. This failure could place 4 residents who eat in their rooms with supervision and/or assistance at risk for choking and/or aspiration. Findings include: Review of Resident #1's Admission Record dated [DATE] reflected a [AGE] year old female with [DIAGNOSES REDACTED]. (Pharyngeal phase dysphagia results from a weakness or lack of coordination of the pharyngeal muscles; aspiration is most likely to occur in this phase.) Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a Staff Assessment for Mental Status with a score of 3 which indicated the resident was severely impaired for cognitive skills for daily decision making. (never/rarely made decisions). Under Subtitle Functional Status the resident was coded as needing extensive assistance with eating. Review of Resident #1's Care Plan dated [DATE] for Diet revealed the following: Diet; Mechanical Soft (texture). Interventions included to setup tray with each meal and assist or feed when needed or requested. There were no interventions related to the resident requiring extensive assistance during eating per MDS documentation. Review of Resident #1's Speech Therapy Evaluation and Plan of Treatment dated [DATE] (no physician signature) reflected the Resident was referred due to exacerbation of decreased oral/pharyngeal function, decreased safety during oral intake, coughing/chokng during oral intake, risk for aspiration and dysphagia plaing patient at risk for aspiration, compromised general health, futrther decline in function and weight loss. Recommendations included: Supervision for oral intake=Close supervision Review of a facility Nursing Summary for Resident #1 dated [DATE] reflected chewing and swallowing problems. Review of a facility incident report dated [DATE] revealed the following documentation by Licensed Vocational Nurse (LVN) F: At 0802 Medication Aide alerted me to resident unresponsive with fluid puddled on her chest and flowing from her mouth. I quickly yelled for help and attempted to lower the head of her bed. After lowering the head of her bed I felt for a pulse and was able to feel a pulse. I yelled to have someone call 911. I swept fluid and contents out of her mouth and began CPR. Other staff came to assist in laying resident on the ground. I continued CPR for ,[DATE] compressions, swept her mouth again and turned her on her side and attempted to activate her gag reflex with no success. I pounded on her back in attempt to have her cough up what was keeping her from breathing. I swiped and attempted to clear her throat and to activate her gag reflex without success. We laid her down and I continued CPR with the assistance from other staff doing respirations. Other staff was able to apply oxygen in an attempt to help her breathe. When oxygen was applied it came out of her nose with additional fluid. We continued CPR, attempting to clear her mouth and activate her gag reflex until another nurse took over CPR. Other staff gathered her paperwork for the EMT's (Emergency Medical Technicians). The other nurse continued CPR and oxygen continued to be applied. I returned to do CPR to give the other nurse a break until EMTs arrived. They continued CPR and worked on her and were able to find a pulse. EMT's left with her at 0835. (sic) Resident was taken to hospital at 0835. (8:35 AM) During an interview on [DATE] at 11:20 AM, LVN F stated, Normally the CNA (Certified Nurse Aide) passes trays and would set the tray away from this resident (Resident #1) and then the MA (Medication Aide) would go in to assist her to eat. She needed help because she would eat too fast and overfill her mouth. The MA took a little longer to get in to her because she had some new medications to pass so it was a few minutes. When the MA went in to feed her, the resident had reached the tray and begun feeding herself. The MA got me and when I went in the resident had her head slumped to her chest with liquid dribbling down her chin. I quickly assessed and started CPR and we called 911. Another staff helped me continue CPR on the floor. I did a sweep of her mouth and removed some food. The EMTs got there and she had a pulse when she left for the hospital. The hospital never called, but her family told me she had aspirated something and was on a vent. (Ventilator) They decided to take her off and she died . During an interview on [DATE] at 6:55 AM CNA B stated, We just know our residents. I've been working here a long time. It's usually in the chart and we pass it along in report. (information regarding resident's care levels). Resident #1 could feed herself and there wasn't anything specific that said she had to be fed, but we knew she would eat too fast and so we either sat with her while she ate or fed her ourselves. MA C would pass her medications and then go in to feed her all the time. We would put Resident #1's tray so she couldn't reach it until someone was with her. That CNA D had been working here a while and we felt she should have known. She said she had seen Resident #1 feed herself so she thought she could just set her up with her tray. During an interview on [DATE] at 7:50 AM, CNA J stated, At one time there was a note above her bed. It said up at 90 degrees when fed. Aspiration precautions on another. This was a few months ago. In a further interview on [DATE] at 11:00 AM, CNA B stated that at one time there had been a sign above Resident #1's bed that said the resident was to be up at 90 degrees when eating. She did not recall a sign that said the resident must be fed. But when the resident was moved to the B bed, the signs didn't get moved. I am not sure when that was. MA C and CNA D were not available in person or by phone for interviews. Messages were left, but no phone calls were returned. CNA D no longer works at the facility. Review of staff handwritten statements dated [DATE] provided to surveyors on [DATE] revealed the following: CNA D: (time 8:00 AM) I work 6a-2p and started my shift. I was assigned hall trays today. I placed and set up Resident #1's tray ready for her to eat her breakfast. She was sitting up at 90 degree angle when I left the room to continue pushing the rest of the resident's trays. MA C: (time 8:02 AM) During my morning pill pass, I was on my way into the room to administer medications to Resident #1. After I entered the room with the meds, I noticed she had food running down her mouth and she was grey. I shook the resident and called her name. She did not respond so I went and got my charge nurse, LVN F, who was at the nurses station. Review of a current (undated) facility policy titled Assistance with Meals reflected the following highlights: Resident shall receive assistance with meals in a manner that meets the individual needs of each resident. Review of a current (undated) facility policy titled Assisting the Impaired Resident with In-Room Meals reflected the following Purpose: the purpose of this procedure is to provide appropriate support for residents who need assistance with eating. Review of a current (undated) facility policy titled, Resident Assessment Instrument reflected the following Policy Statement: Policy Interpretation and Implementation step #3: The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity and step # 4: Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. Review of a current (undated) facility policy titled, Care Area Assessments reflected the highlight that Care Area Assessments (CAAs) will be used to help analyze data obtained from the MDS and to develop individualized care plans. CAAs are the link between assessment and care planning. Review of a current facility Abuse prevention Program policy dated Revised 2006, Treatment/Management reflected the following element: 1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. In an interview on [DATE] at 10:00 AM the Administrator stated that on [DATE], Resident #1 had choked while unsupervised during a meal and was sent to the hospital and later died . He stated, She had a pulse and was alive when sent out with CPR in progress with EMTs. It was determined this failure placed Resident #1 in an IJ situation on [DATE]. The facility Administrator was notified on [DATE] at 11:35 AM. The following corrective actions had been taken following the incident on [DATE]: In an interview on [DATE] at 11:00 AM, CNA B stated, The day Resident #1 choked ([DATE]) LVN A came in at 2:00 PM and she gathered all the nurses and CNAs who work from both shifts and reviewed which residents needed assistance and to not leave a food tray with them until we were ready to go in and feed them. She frequently reminded us about this. On [DATE] at 4:00 PM in an interview, LVN A stated, Yes, after the incident with Resident #1, I conducted an inservice on [DATE] at 2:00 PM with staff from both shifts (day and evening) to be sure they knew which residents needed assistance and to not leave trays with them until they are ready to feed the resident. As we get new residents in, who may need assistance, I refresh them on these basics. On [DATE] at 8:25, AM, MA E stated, We had an inservice on the different diets and what they consisted of such as pureed or mechanical soft. On [DATE] at 8:35 AM, three CNAs (CNAs G, H, and I) stated they now make rounds and get report from the off going shift about the residents they will care for which includes the amount of required assistance with ADLs. Review of incident and accident reports from [DATE] through [DATE] revealed no further incidents of choking. Observations of breakfast on [DATE] between 7:30 AM and 9:00 AM on the Secure Unit, East and Center Hall revealed 4 residents with the [DIAGNOSES REDACTED]. The residents were fed by staff or staff set up and staff observed the resident eating the meal. No choking was observed. The facility provided a list on [DATE] identifying 17 residents with a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for 1 of 5 residents reviewed for supervision during mealtime related to a [DIAGNOSES REDACTED]. (Resident #1) On [DATE] Resident #1, who had a [DIAGNOSES REDACTED]. The resident overfilled her mouth and was found to be unresponsive at approximately 8:02 AM. Emergency Cardiopulmonary Resuscitation (CPR) was initiated by staff and the resident was sent to the hospital. This was determined to be past non-compliance at Immediate Jeopardy (IJ) level on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the complaint investigation. This failure could place 4 residents who eat in their rooms with supervision and/or assistance at risk for choking and/or aspiration. Findings include: Review of a current facility Abuse prevention Program policy dated Revised 2006, Treatment/Management reflected the following element: 1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. Review of Resident #1's Admission Record dated [DATE] reflected a [AGE] year old female with [DIAGNOSES REDACTED]. (Pharyngeal phase dysphagia results from a weakness or lack of coordination of the pharyngeal muscles; aspiration is most likely to occur in this phase.) Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a Staff Assessment for Mental Status with a score of 3 which indicated the resident was severely impaired for cognitive skills for daily decision making. (never/rarely made decisions). Under Subtitle Functional Status the resident was coded as needing extensive assistance with eating. Review of Resident #1's Care Plan dated [DATE] for Diet revealed the following: Diet; Mechanical Soft (texture). Interventions included to setup tray with each meal and assist or feed when needed or requested. There were no interventions related to the resident requiring extensive assistance during eating per MDS documentation. Review of Resident #1's Speech Therapy Evaluation and Plan of Treatment dated [DATE] (no physician signature) reflected the Resident was referred due to exacerbation of decreased oral/pharyngeal function, decreased safety during oral intake, coughing/chokng during oral intake, risk for aspiration and dysphagia plaing patient at risk for aspiration, compromised general health, futrther decline in function and weight loss. Recommendations included: Supervision for oral intake=Close supervision Review of a facility Nursing Summary for Resident #1 dated [DATE] reflected chewing and swallowing problems. Review of a facility incident report dated [DATE] revealed the following documentation by Licensed Vocational Nurse (LVN) F: At 0802 Medication Aide alerted me to resident unresponsive with fluid puddled on her chest and flowing from her mouth. I quickly yelled for help and attempted to lower the head of her bed. After lowering the head of her bed I felt for a pulse and was able to feel a pulse. I yelled to have someone call 911. I swept fluid and contents out of her mouth and began CPR. Other staff came to assist in laying resident on the ground. I continued CPR for ,[DATE] compressions, swept her mouth again and turned her on her side and attempted to activate her gag reflex with no success. I pounded on her back in attempt to have her cough up what was keeping her from breathing. I swiped and attempted to clear her throat and to activate her gag reflex without success. We laid her down and I continued CPR with the assistance from other staff doing respirations. Other staff was able to apply oxygen in an attempt to help her breathe. When oxygen was applied it came out of her nose with additional fluid. We continued CPR, attempting to clear her mouth and activate her gag reflex until another nurse took over CPR. Other staff gathered her paperwork for the EMT's (Emergency Medical Technicians). The other nurse continued CPR and oxygen continued to be applied. I returned to do CPR to give the other nurse a break until EMTs arrived. They continued CPR and worked on her and were able to find a pulse. EMT's left with her at 0835. (sic) Resident was taken to hospital at 0835. (8:35 AM) During an interview on [DATE] at 11:20 AM, LVN F stated, Normally the CNA (Certified Nurse Aide) passes trays and would set the tray away from this resident (Resident #1) and then the MA (Medication Aide) would go in to assist her to eat. She needed help because she would eat too fast and overfill her mouth. The MA took a little longer to get in to her because she had some new medications to pass so it was a few minutes. When the MA went in to feed her, the resident had reached the tray and begun feeding herself. The MA got me and when I went in the resident had her head slumped to her chest with liquid dribbling down her chin. I quickly assessed and started CPR and we called 911. Another staff helped me continue CPR on the floor. I did a sweep of her mouth and removed some food. The EMTs got there and she had a pulse when she left for the hospital. The hospital never called, but her family told me she had aspirated something and was on a vent. (Ventilator) They decided to take her off and she died . During an interview on [DATE] at 6:55 AM CNA B stated, We just know our residents. I've been working here a long time. It's usually in the chart and we pass it along in report. (information regarding resident's care levels). Resident #1 could feed herself and there wasn't anything specific that said she had to be fed, but we knew she would eat too fast and so we either sat with her while she ate or fed her ourselves. MA C would pass her medications and then go in to feed her all the time. We would put Resident #1's tray so she couldn't reach it until someone was with her. That CNA D had been working here a while and we felt she should have known. She said she had seen Resident #1 feed herself so she thought she could just set her up with her tray. During an interview on [DATE] at 7:50 AM, CNA J stated, At one time there was a note above her bed. It said up at 90 degrees when fed. Aspiration precautions on another. This was a few months ago. In a further interview on [DATE] at 11:00 AM, CNA B stated that at one time there had been a sign above Resident #1's bed that said the resident was to be up at 90 degrees when eating. She did not recall a sign that said the resident must be fed. But when the resident was moved to the B bed, the signs didn't get moved. I am not sure when that was. MA C and CNA D were not available in person or by phone for interviews. Messages were left, but no phone calls were returned. CNA D no longer works at the facility. Review of staff handwritten statements dated [DATE] provided to surveyors on [DATE] revealed the following: CNA D: (time 8:00 AM) I work 6a-2p and started my shift. I was assigned hall trays today. I placed and set up Resident #1's tray ready for her to eat her breakfast. She was sitting up at 90 degree angle when I left the room to continue pushing the rest of the resident's trays. MA C: (time 8:02 AM) During my morning pill pass, I was on my way into the room to administer medications to Resident #1. After I entered the room with the meds, I noticed she had food running down her mouth and she was grey. I shook the resident and called her name. She did not respond so I went and got my charge nurse, LVN F, who was at the nurses station. Review of a current (undated) facility policy titled Assistance with Meals reflected the following highlights: Resident shall receive assistance with meals in a manner that meets the individual needs of each resident. Review of a current (undated) facility policy titled Assisting the Impaired Resident with In-Room Meals reflected the following Purpose: the purpose of this procedure is to provide appropriate support for residents who need assistance with eating. Review of a current (undated) facility policy titled, Resident Assessment Instrument reflected the following Policy Statement: Policy Interpretation and Implementation step #3: The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity and step # 4: Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. Review of a current (undated) facility policy titled, Care Area Assessments reflected the highlight that Care Area Assessments (CAAs) will be used to help analyze data obtained from the MDS and to develop individualized care plans. CAAs are the link between assessment and care planning. In an interview on [DATE] at 10:00 AM the Administrator stated that on [DATE], Resident #1 had choked while unsupervised during a meal and was sent to the hospital and later died . He stated, She had a pulse and was alive when sent out with CPR in progress with EMTs. It was determined this failure placed Resident #1 in an IJ situation on [DATE]. The facility Administrator was notified on [DATE] at 11:35 AM. The following corrective actions had been taken following the incident on [DATE]: In an interview on [DATE] at 11:00 AM, CNA B stated, The day Resident #1 choked ([DATE]) LVN A came in at 2:00 PM and she gathered all the nurses and CNAs who work from both shifts and reviewed which residents needed assistance and to not leave a food tray with them until we were ready to go in and feed them. She frequently reminded us about this. On [DATE] at 4:00 PM in an interview, LVN A stated, Yes, after the incident with Resident #1, I conducted an inservice on [DATE] at 2:00 PM with staff from both shifts (day and evening) to be sure they knew which residents needed assistance and to not leave trays with them until they are ready to feed the resident. As we get new residents in, who may need assistance, I refresh them on these basics. On [DATE] at 8:25, AM, MA E stated, We had an inservice on the different diets and what they consisted of such as pureed or mechanical soft. On [DATE] at 8:35 AM, three CNAs (CNAs G, H, and I) stated they now make rounds and get report from the off going shift about the residents they will care for which includes the amount of required assistance with ADLs. Review of incident and accident reports from [DATE] through [DATE] revealed no further incidents of choking. Observations of breakfast on [DATE] between 7:30 AM and 9:00 AM on the Secure Unit, East and Center Hall revealed 4 residents with the [DIAGNOSES REDACTED]. The residents were fed by staff or staff set up and staff observed the resident eating the meal. No choking was observed. The facility provided a list on [DATE] identifying 17 residents with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision to prevent accidents for six (6) of eight (8) residents reviewed for supervision that reside on the secure unit (Res #15, #16, #22, #24, #27 and #33) when: A. 1. Resident #22 was grabbed by her shirt collar and necklace and slung to the ground by Resident #16 who falsely believed she had stolen her necklace on [DATE]. As a result, Resident #22 sustained a Cerebral (Brain) Bleed and died on [DATE]. Resident #16 was allowed to remain on the Secure Unit and continued to exhibit out of control/agitated behaviors that were inadequately supervised from [DATE] to [DATE]. The facility did not identify the incident as neglect related to resident to resident altercation, seek emergent psychiatric care for Resident #16, or protect the other residents on the secure unit from Resident #16 until surveyor intervention on [DATE]. A. 2. Resident #15 sustained a closed head injury when she was struck in the head with a large ceramic by Resident #16 who had a known history of physical aggression and hospitalization s in acute psychiatric hospitals due to her aggression and behaviors. The facility did not provide adequate supervision for Resident #16's continued physical aggression after the incidents on [DATE] and [DATE] until surveyor intervention on [DATE]. B. Resident #27 became physically aggressive and attempted to strangle Resident #33, which required staff to forcibly intervene. Resident #27 continued to make verbal and physical threats of intent to strangle Resident #33 and other residents on the unit; and was not adequately supervised until her discharge to a psychiatric facility on [DATE]. C. The facility failed to ensure the secure unit's nursing supply room that contained hazardous chemicals was locked. Resident #24, who was confused and wandering, entered the unlocked room unnoticed by staff until surveyor intervention. These deficient practices resulted in the identification of an IJ on [DATE] at 7:00 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a severity of harm with a scope identified as a pattern. These deficient practices could affect a facility census of 26 residents on the secure unit by placing them at risk for possible preventable injuries from resident to resident altercations resulting in serious injuries and/or death; and 17 confused residents on the secure unit that wander at risk for exposure and/or consumption of potentially hazardous chemicals due to easy access to an unlocked storage room. The Findings include: A. 1. Review of Resident #22's Face Sheet reflected a [AGE] year old African American female admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she was 64 inches tall and weighed 107 pounds. She had a BIMS score of 5 indicating her cognition was severely impaired. Resident #22 wandered daily and had no physical behavioral symptoms directed toward others. Resident #22 walked with the assistance of one person and used a wheel chair. Review of Resident #22's Care Plan dated [DATE] reflected resident had problems with impaired cognition and thought process related to Senile Dementia. It further reflected resident was able to walk and perform Activities of Daily Living (ADL's) with the assist of one person. Review of Resident #22's Behavioral Medicine/Progress Note dated [DATE] reflected PNP assessed resident to be oriented to person, have a pleasant/blunted mood, logical and coherent thought, no psychotic thoughts, memory deficit, speech and language within normal limits, and have no risk of harm to herself or others. Review of Resident #22's Progress Notes date [DATE] at 10:06 AM reflected RN A's nursing notes regarding the altercation between Resident #22 and Resident #16: Resident (#22) was ambulating down hallway when another resident (#16) grabbed her by her necklace and shirt collar, causing her to fall and hit the back of head. 07:15 AM Neuros started and WNL (within normal limits) 08:00 AM Neuro changes observed, pupils fixed and restricted, vomited x2 08:20 AM Contacted ambulance to send to ER (emergency room ) 08:30 AM Unable to arouse with sternal rub, awaiting ambulance 08:40 AM Ambulance here resident (#22) respirations WNL, no respiratory distress noted. Review of a facility incident report dated Saturday [DATE] at 0702 and completed by RN A reflected Resident (#22) was,ambulating into the dining room with a staff member when another Resident (#16) grabbed her by her necklace and collar of her shirt pulling her down causing her to fall landing on coccyx hitting the back of he head. Further review reflected Immediate Action Taken included Resident #22 was assessed, Neuro checks were initiated and with in normal limits at first, but then at 8:00 AM, Neuro changes, Resident vomited two (2) times and at 0820 Called EMT(emergency medical treatment) to send to ER. Resident taken to Hospital. Review of Resident #22's Resident/Discharge and Referral Record (not dated) reflected resident was transferred from the Facility to the Hospital due to, Syncope (fainting), unresponsiveness and vomiting. Further review of Resident #22's Progress Notes dated [DATE] at 9:23 PM reflected Resident (#22) was diagnosed with [REDACTED]. Review of Hospital Records dated [DATE] reflected Resident #22 had a CT (computerized tomography) scan done: Large subdual hematoma overlying the left hemisphere resulting in 9 mm (millimeter) of left right midline shift .an acute CVA (cerebrovascular accident) is not identified at this time nor is evidence of herniation. Further review of Hospital Records reflected the ER Physician's Final [DIAGNOSES REDACTED]. Review of Inpatient Hospice Facility Records dated [DATE] reflected Resident #22 had been admitted on [DATE] with a [DIAGNOSES REDACTED]. Observation on [DATE] at 2:35 PM at the Inpatient Hospice Facility revealed Resident #22 to be a petite elderly African American female lying supine in bed, in an unresponsive (coma) state. In an interview on [DATE] at 2:35 PM the Hospice RN at the Inpatient Hospice Facility stated Resident #22's death was imminent per the Hospice Doctor's assessment due to the Subdural Hemorrhage and she was expected to die within days. In an interview on [DATE] at 5:00 PM the Hospice Receptionist at Inpatient Hospice Facility stated Resident #22 died on [DATE] at 10:15 AM. Review of Resident #16's Face Sheet reflected a [AGE] year old Hispanic female admitted on [DATE] and readmitted on [DATE] from a psychiatric hospital. Resident #16's [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE] reflected she was 62 inches tall and weighed 149 pounds. It further reflected she had a BIMS score of 12 indicating her cognition was moderately impaired. Resident #16 had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #16 had verbal behavioral symptoms directed toward others. She significantly disrupted care or living environment. Resident #16 walked with the assistance of one person and used a wheel chair. Review of Resident #16's Physician order [REDACTED]. 1. Ativan 1 mg give 0.5 ml intramuscular every one hour as needed for severe agitation related to Schizoaffective Disorder. 2. Haldol 1 ml give intramuscular every six hours as needed for severe agitation related to Schizoaffective Disorder. Review of Resident #16's Care Plan dated [DATE] and revised on [DATE] reflected Resident #16 had been having verbal and physical behaviors toward others for over 1 ½ years as follows. Resident exhibits verbally and physically abusive behaviors at times and is at risk for harm. Further review of Resident #16's Care Plan dated [DATE] and revised on [DATE] reflected on-going problems with aggressive behaviors as follows; exhibits physical aggression and abusive behaviors to other residents and Staff. Resident throws things and directly kicks others. Residents and others are at risk for harm .Behaviors are related to: Schizophrenia, Dementia, Ineffective coping skills related to Dementia, Poor impulse control. Further review of the care plan reflected the following interventions; 1. Provide 1:1 (one-to-one) care during aggressive behavior monitor and while waiting for transfer to Geri psych facility. 2. Follow thru with transfer to facility that can address and evaluate psychiatric and psychological needs. Review of Resident #16's Behavioral Medicine/Progress Notes by PNP reflected resident was exhibiting on-going aggressive behaviors to other residents and her agitation and psychosis was worsening. 1. [DATE] Staff report patient hit another resident (Resident #15) with an object several days ago .She says she is being burned and bitten in the middle of the night. She reports auditory hallucination. These voices tell her others are talking about her. She is paranoid and delusional about other residents in the home. 2. [DATE] Staff report patient has had continuing agitation, aggression and resistance to care. She has pulled off another resident's jewelry. She is verbally and physically abusive. She did not feel that she had acted inappropriately towards other residents. She is easily agitated and difficult to redirect. 3. [DATE] Patient returned from (psychiatric hospital) on [DATE]. Since then, she has been agitated and accusing the staff of abuse. She has accused other residents of raping her and murdering her family members. She has been resistant to verbal redirection .She is very paranoid about several other residents. She says that, (unsampled female resident) rapes me. She comes to my room after spraying herself with something to make her invisible. Review of Facility Accident and Incident Reports reflected Resident #16's was exhibiting aggressive behaviors dangerous to other residents prior to the altercation she had with Resident #22. 1. [DATE] at 14:45 PM Resident#16 came by another resident and slapped her in the face (right side) and yelled at her that the blanket she had belonged to her. Resident #16 stated, she stole my blanket. 2. [DATE] at 15:30 PM Resident #16 entire incident was witnessed by nurse, resident just got up and punched other resident in the right eye. Resident #16 stated, I hit her because she killed my grandson 3. [DATE] at 09:36 PM Resident #16 hit Resident #15 in the head with a ,[DATE] pound rock. Resident #15 taken to the hospital and sustained a Hematoma to back of head with a [DIAGNOSES REDACTED]. Review of Hospital Psychiatric Consult dated [DATE] reflected Resident #16 had been sent from the Nursing Facility to the Hospital ER for prior resident altercations as follows: Resident (#16) threw a rock at another resident and was becoming aggressive violent. Further review reflected Resident stated she had been in the state hospital off and on and had gotten electroshock therapy in the past. Review of Resident #16's Progress Notes dated [DATE] at 5:34 PM reflected the following: Resident followed an aide into the shower and began to verbally assault her, then physically assaulted her. Resident was sent out to Hospital ER for evaluation due to verbal/physical aggression towards staff/residents and then transferred to a Psychiatric Hospital [DATE] for treatment of [REDACTED]. Review of Psychiatric Hospital Patient Discharge Summary Report dated [DATE] reflected Resident #16 was admitted to the Psychiatric Hospital, Geri-Psych Unit on [DATE] at 5:12 PM with [DIAGNOSES REDACTED]. Further review reflected Resident #16 was admitted to the Psychiatric Hospital due to, Increased paranoia and delusional thinking leading to verbal and physical abuse of staff. The patient was found to have a Urinary Tract Infection, Dehydration and Gastroenteritis. Review of Facility Accident and Incident Reports dated [DATE] at 07:00 reflected RN A's description of the altercation between Resident #22 and #16 as follows; Resident (#16) was in her wheel chair and rolled up to another Resident (#22) and grabbed her necklace and shirt collar and pulled her causing (Resident #22) to fall. (Resident #16) stated (Resident #22) tried to choke her and she slung her. A staff member was present at this time and (Resident #22) did not touch her. Further review of Resident #16's Progress Notes dated [DATE] at 09:56 AM reflected RN A's nursing note, 0700 Resident(#16) was rolling down hall in wheel chair and grabbed another resident (#22) by her necklace and shirt collar causing the other resident to fall .noted with increased behaviors of agitation .Attempted to kick nurse X2 .Administered Ativan 2 ml as needed intramuscular .Received call back from Family Practice doctor, informed him of increased behaviors and incident of physical aggressiveness towards other resident. No new orders. Review of Resident #16's Progress Notes after the altercation with Resident #22 dated [DATE] at 07:00 PM reflected Resident #16 remained on the Secure Unit without 1:1 (one-to-one) observation and other residents remained exposed to her unpredictable aggressive behaviors. Nursing notation reflected her acting out behavior at that time as, Exit seeking, punching the key pad .redirection ineffective, will not accept any reasoning. In an interview on [DATE] at 09:30 AM CNA L stated she was with Resident #22 when she fell and watched the altercation between Resident #22 and Resident #16. She stated she was escorting Resident #22 to the dining room, holding her hand and resident was behind her because the dining room hall entry was narrow and other residents were passing by. She further stated that she then felt a hard forceful pull. She further stated that she looked back and Resident #16 had come up from behind and had, grabbed Resident #22 by the collar and necklace and was slinging her back and forth and slung her back down .I watched her fall back and her head hit first .loud enough so others heard it at the nurses' station .I'm there screaming Nurse. She further stated the nurse came and checked Resident #22 all over and she seemed fine at first and was able to eat a full breakfast but then about 1 hour later when Resident #22 was in the shower she vomited and then became unresponsive very quickly and so the nurse called emergency services and they came in about 20 minutes. She further stated Resident #16 thinks everything everybody has is hers. She further stated Resident #16 hit Resident #15 with a decorative rock in the head a few months ago and Resident #15 had to go to the hospital. She further stated Resident #16 had aggressive physical behaviors towards residents, all the time .she is impulsive and unpredictable. She further stated Resident #16 was placed on 1:1 observations for approximately 45 minutes to one hour after the altercation with Resident #22, to make sure she wouldn't do it again. She further stated she had not received any special training for management of aggressive behaviors from the facility. She further stated she had asked if she needed to write a statement or an incident report regarding the incident and the RN A told her no she would enter the information into the computer. In an interview on [DATE] at 4:45 PM RN A, charge nurse of the Secure unit, stated CNA L was leading Resident #22 by the hand and Resident #16 was self-propelling herself past Resident #22 in her wheel chair. She further stated that Resident #16 reached up and grabbed Resident #22 by her long necklace and slung Resident #22 pulling her down. She further stated Resident #22 fell back on her back hitting her head on the floor. She further stated she heard the fall but did not see it and ran from the nurses' station to the dining area where the altercation happened. She further stated she then assessed Resident #22 and performed neuro checks and Resident #22 appeared normal and without injury. She further stated that Resident #22 then ate a full breakfast in the dining room, and was taken for a shower. She further stated that Resident #22 then vomited x1 while being dressed in the shower and then again when taken to the nurses' station in her wheel chair. She further stated it was about one hour between the time of the resident to resident altercation and when Resident #22 began to vomit. She further stated that after that Resident #22 became unresponsive within minutes. She further stated she called 911 as soon as Resident #22 showed signs of neurological injury and the ambulance picked Resident#22 up within about 20 minutes from her call. She further stated that when the ambulance picked Resident #22 up she was unresponsive and was breathing without distress. She further stated that Resident #16's agitation had escalated that day and Resident #16 kept saying Resident #22 had choked her and was accusing the staff of killing her baby and taking things out of her room. She further stated she notified the RVP the morning of the incident [DATE] as well as the DON, both resident families and both resident Family Practice Doctors. In an interview on [DATE] at 12:00 PM Resident #16's PNP stated she had not been informed about Resident #16's altercation with Resident #22 until [DATE] when the Facility was placed on Immediate Jeopardy. She further stated that if she had of she would have immediately sent Resident #16 to the ER because that was the second time Resident #22 had assaulted another resident. In an interview on [DATE] at 12:10 PM LVN Z stated he didn't think Resident #16 was appropriately placed on the secure unit because, one minute she can be sweet as tea and the next minute she can be hell on wheels. He further stated, I try to keep an eye on her at all times .she is unpredictable. Paranoid .she has hallucinations (sees kids under beds and patrol cars outside) .that's been ongoing since I've been here about five months. He further stated, the facility due to inconsistent management, and constant turnover of staff had no real structure for direction or assistance with Resident Care Problems. In an interview on [DATE] at 12:45 PM CNA N stated she had worked on the Secure unit for approximately seven years and Resident # 16's behaviors had always been physically aggressive. She further stated, that when residents' behaviors got out of control, we just give them a shot .we get no special training back here. In an interview on [DATE] at 7:00 PM the Regional DON (acting as the interim facility DON) stated she was told by RN A that Resident #16 grabbed Resident #22 by the collar and necklace and that Resident #22 pulled back, lost her balance and fell , hitting her buttocks first. She further stated, I didn't see it as a resident to resident altercation . In an interview on [DATE] at 10:15 AM the Regional DON stated she had started one week before the incident with Resident #22 and Resident #16. She further stated she did not know Resident #16. She further stated she received her information regarding the incident from the charge nurse (RN A) who did not witness the fall on [DATE] at around 8:00 AM, and did not interview any of the direct care staff who were with Resident #22 and #16 when the altercation occurred. When asked if it would be the expectation of any of her staff conducting an investigation to interview the staff that were on duty when an incident occurred, the Regional DON stated, I see what you mean, I didn't do a thorough assessment and if I had of I would have approached this situation differently. The Regional DON confirmed she had not asked about Resident #16's past history of physical aggression as part of her investigation, and did not know Resident #16 had been fixated on Resident #22 and the necklace she was wearing during the hours before the incident. In an interview on [DATE] at 10:15 AM the Administrator stated, we all know psych patients and Dementia Patients don't mix .were not going to admit any more psych patients any more .were thinking about separating them now. In an interview on [DATE] at 3:30 PM Resident #16's Psychologist stated that she did not specifically recall being informed that Resident #16's behavior was related to Resident #22's fall. She further stated that if she had of been aware that her aggressive behavior was related to Resident #22's fall and due to resident to resident altercation she would have recommended alternative placement. She further stated, The last several months Resident #16's behaviors had been escalating and her psych meds were being adjusted but not yet effective. She further stated, Were not able to control her behavior in that environment. In an interview on [DATE] at 4:45 PM the Social Worker stated the facility had such a rapid turnover for the last two years that communication had broken down over time and staff was less aware of her Social Worker role and she wasn't kept informed of resident to resident altercations. In an interview on [DATE] at 2:00 PM the Administrator stated, I didn't find out about the fall until after you guys (surveyors) got here. The previous administrator left that Friday ([DATE]). I arrived the following Monday ([DATE]) .When I found out later in the week that Resident #22 had gone into a coma I went and talked to the Regional DON. She was here, I wasn't .She told me she had a fall and fell back on her head but that Resident #16 pulled her necklace .it didn't make sense so I asked could she have fallen over the wheelchair? I was trying to figure out how she hit her head. He further stated, I didn't hear any of that bologna about Resident #16 mugging Resident #22. I just thought it was one resident wanting to take other resident's jewelry. At the time, I didn't know Resident #16's history until you guys (surveyors) started talking about her aggressive history. Once I started hearing that I thought maybe she should get moved out. I understand that when you're dealing with a resident with an aggressive history and psychotic issues it's a whole different ball game .If I had of been here when the fall happened the minute the Resident (#22) was sent to the Hospital I would have called the state .I guess the DON may not be quite as careful as I would be coming from my side of the fence. A. 2. Review of a Face Sheet for Resident #15 reflected she was [AGE] years old with an original admitted to the facility of [DATE] and [DIAGNOSES REDACTED]. Review of an annual MDS for Resident #15 dated [DATE] reflected she had moderate cognitive impairment, required extensive assistance of one staff member for activities of daily living, she was incontinent of bowel and bladder, she could self propel her wheelchair that was adapted to allow her to use handles to propel short distances; and had behaviors that included attempting to throw herself out of her wheelchair, occasional verbal aggression, and delusions. Review of a Care plan for Resident #15 dated [DATE] and updated on [DATE] reflected the following: - Focus Verbal and Physically Aggressive Behaviors: -Goal-Resident's verbal behaviors will not interfere with the delivery of staff care; Resident's verbal aggression will not result in harm or injury to self or others. Resident will not throw herself out of her wheelchair when she is upset with staff or other residents. -Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates the behaviors. Assess resident's coping skills and support system. Psychiatric/Psychogeriatric consults as indicated. Review of printed electronic facility incident reports from ,[DATE] through ,[DATE] reflected Resident #15 had no incidents of physical aggression towards residents. Review of a printed electronic facility incident report dated Saturday [DATE] and completed by LVN Z reflected the following: Informed by staff that resident (Resident #16) hit Resident #15 in the head with a rock. Resident #16 entered Resident #15 ' s room and hit her in the back of the head with a rock. First Aid administered and resident sent to the hospital for evaluation of hematoma. DON/Administrator notified on [DATE] at 10:20 AM. Review of a hospital discharge summary for Resident #15 dated [DATE] reflected You have a [DIAGNOSES REDACTED]. Review of nurses' notes for Resident #15 dated [DATE] reflected: resident returned from the hospital with no new orders. Monitor resident for abnormal symptoms. Review of Resident #16's Behavioral Medicine/Progress Notes by PNP reflected resident was exhibiting on-going aggressive behaviors to other residents and her agitation and psychosis was worsening: [DATE] Staff report patient hit another resident (Resident #15) with an object several days ago .She says she is being burned and bitten in the middle of the night. She reports auditory hallucination. These voices tell her others are talking about her. She is paranoid and delusional about other residents in the home. In a confidential staff telephone interview on [DATE] at 3:52 PM, it was stated Resident #15 was not hit with a rock on [DATE]; but instead it was a large ceramic ash tray with a cross on it that belonged to Resident #16 and was kept it in her room. The staff member added the ash tray was moved to a drawer in the nurse's station after the incident. In an interview on [DATE] at 12:00 PM, LVN Z stated he not aware of the exact object Resident #16 struck Resident #15 with, but since it was reported it was a rock that is what he documented and didn't think any more about it since both residents were sent out for evaluation. LVN Z did not know if the incident was investigated by the administrator employed at the time. In an interview on [DATE] at 10:13 AM the Regional DON (acting as the facility interim DON), stated she was unaware of Resident #16's physical aggression and that she had hit another resident (Resident #15) in the head reportedly with a rock. The Regional DON stated how did she get a rock?! The Regional DON also stated she was unaware of Resident #16's frequent physical aggression; to her knowledge Resident #16 resisted care, but didn't have much to do with the other residents. Review of a physician's orders [REDACTED]. Review of a nurses' note signed by the previous ADON dated [DATE] reflected Resident being transitioned off the secure unit today. Met potential roommate and spent the morning with her. No behaviors noted. Will continue forward as planned. Family requested move. In an interview on [DATE] at 1:00 PM, Resident # 15 was asked if she liked her new room and she stated she loved it. When asked if she felt safe on her new hall/unit and with her new roommate Resident #15 smiled and stated very safe. B. Review of a closed record Face Sheet for Resident #27 reflected she was [AGE] years old with an original admitted d of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] for Resident #27 reflected she was ambulatory without assistance, severe cognitive impairment, she was incontinent of bowel and bladder, and required assistance of one staff for all activities of daily living. Resident #27 had behaviors of physical aggression towards residents and staff. Resident throws things, kicks, and hits. Review of physician orders [REDACTED]. -Haldol 2 mg. tablet every 12 hours as needed for agitation related to Schizoaffective Disorder-Bipolar -Haldol Solution 5 mg./ml Inject intramuscularly every 6 hours as needed for severe agitation -Haldol 1 mg. tablet every two hours as needed for agitation. Review of a care plan for Resident #27 dated [DATE] reflected: -Focus: Resident exhibits physical aggression and abusive behaviors towards others. Resident throws things and directly kicks others. Residents and others are at risk for harm and not having their needs met in a timely manner. Behaviors are related to Dementia, Poor Impulse Control and ineffective coping skills. -Goal: Resident will not harm self or others. The resident will have fewer episodes of behavior and will communicate understanding of need to control physically aggressive behavior through the review date. -Interventions: Analyze of key time, places, circumstances, triggers, and what de-escalates behaviors and document. Modify Environment: Follow through with transfer to facility that can address and evaluate psychiatric and psychological needs. Review of a facility electronic incident report with a date and time of [DATE], 10:45 AM, reflected the following: Resident #27 was coming out of the dining room and another resident (Resident #33) was yelling. Resident (#27) ran up on her (Resident #33) and grabbed her by the throat while screaming at her to shut up. As resident (#27) was moved away she grabbed another resident and became combative. Haldol injection given. The incident was revised on [DATE] and reflected the following documentation under the section Agencies/People Notified: No notifications found. Review of electronic nurses' notes for Resident #27 dated [DATE] at 11:02 AM, reflected the following: Resident (#27) was strangling one resident (#33) was redirected and then she grabbed another resident by the arm and started dragging him. Resident (#27) then started punching/kicking. Verbal redirection ineffective. PRN Haldol injection given. In an interview on [DATE] at 4:30 PM, LVN X stated she was a charge nurse for the secure unit and knew Resident #27 well. LVN X stated Resident #27 would pace the halls of the secure unit and repeatedly slap her face and have frequent episodes of verbal and physical aggression, which included gesturing she was going to choke someone. LVN X stated she was the charge nurse on duty on [DATE] when Resident #27 was trying to strangle Resident #33 and then attacked another resident. LVN X went on to say Resident #27 would get furious at Resident #33 because she would scream loudly and frequently throughout the day. LVN X stated on the day of the strangling incident Resident #33 was screaming and Resident #27 ran up to Resident #33 and placed both of her hands around her (Resident #33) neck and was squeezing. At the same time Resident #27 was attempting to strangle Resident #33

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit neglect, and abuse of residents for five (5) of twenty five (25) residents reviewed for behaviors and physical aggression (Resident #15, #16, #27, #27, #33) when: A. 1. Resident #22 was grabbed by her shirt collar and necklace and slung to the ground by Resident #16 who falsely believed she had stolen her necklace. As a result, Resident #22 sustained a Cerebral (Brain) Bleed and died 6 days later. Resident #16 was allowed to remain on the Secure Unit and continued to exhibit out of control/agitated behaviors that were inadequately supervised. The facility did not identify the incident as abuse/neglect related to resident to resident altercation, seek emergent psychiatric care for Resident #16, or protect the other residents on the secure unit from Resident #16 until surveyor intervention. A. 2. Resident #15 was struck in the head with a large ceramic object by Resident #16. Both residents resided on the secure unit and were sent to the hospital for evaluation. Resident #16 was admitted to an acute psychiatric hospital and Resident #15 was treated and released with a [DIAGNOSES REDACTED]. The facility did not identify the incident as abuse/neglect or put safety measures in place to protect other residents from Resident #16's physical aggression. B. Resident #27 became physically aggressive and attempted to strangle Resident #33, which required staff to forcibly intervene. Resident #27 continued to make verbal and physical threats of intent to strangle Resident #33 and other residents on the secure unit until her discharge to a psychiatric facility approximately one month after the incident. The facility did not seek emergent psychiatric care for Resident #27, identify the incident as neglect, or put safety measures in place to prevent residents from Resident #27. This deficient practice resulted in the identification of an IJ on [DATE] at 7:00 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a severity of harm with a scope identified as a pattern. These deficient practices could affect 26 residents who resided in the secured unit by placing them at risk for abuse and neglect that is not thoroughly investigated resulting in lack of interventions put in place to protect and/or prevent further abuse and/or neglect resulting in serious injuries and/or death. Findings include: Review of the facility's Abuse and Neglect Clinical Protocol dated 2205 and revised [DATE] reflected the following: -Assessments and Recognition. 1. The nurse will assess the individual and document relative findings. Assessments will include- a. Injury assessment b. All current medications, especially anticoagulants,c. other platelet inhibitors d. Vital signs, e. behaviors over the past 24 hours (bruise could be related to movement disorder or physical aggression. 2. Nurses will report findings to the physician. As needed the physician will assess the resident to verify or clarify findings, especially if the cause or source of the injury is unclear . 4. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents with unmanaged problematic behavior, or problems related to staff knowledge, skill, or performance that might affect how the residents are cared for. 5. long with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect; for example .inappropriate management of problematic behavior. Cause Identification: 1. The staff with physician's input will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes . Treatment/Management: 1. The facility management and staff will institute measures to address the needs of resident and minimize the possibility of abuse/neglect. 2. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and neglect and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 3. The physician will order measures required to address the consequences of an abuse situation such as a psychological evaluation. 4. The physician and staff will address causes of problematic resident behavior where possible, such as mania, [MEDICAL CONDITION], and medication side effects. Review of the facility's policy entitled Resident-to-Resident Altercations dated 2001 and revised ,[DATE] reflected the Policy Statement: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. The policy reflected the Interpretation and Implementation: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation; b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; c. Notify each resident's representative (sponsor) and Attending Physician of the incident; d. Review the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents; e. Consult with the Attending Physician to identify treatable conditions such as acute [MEDICAL CONDITION] that may have caused or contributed to the problem; f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness; h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and k. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. Review of the facility's Abuse and Neglect Clinical Protocol dated 2205 and revised [DATE] reflected the following: -Assessments and Recognition. 1. The nurse will assess the individual and document relative findings. Assessments will include- a. Injury assessment b. All current medications, especially anticoagulants,c. other platelet inhibitors d. Vital signs, e. behaviors over the past 24 hours (bruise could be related to movement disorder or physical aggression. 2. Nurses will report findings to the physician. As needed the physician will assess the resident to verify or clarify findings, especially if the cause or source of the injury is unclear . 4.) The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents with unmanaged problematic behavior, or problems related to staff knowledge, skill, or performance that might affect how the residents are cared for. along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect; for example .inappropriate management of problematic behavior. Cause Identification: 1. The staff with physician's input will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. Treatment/Management: 1. The facility management and staff will institute measures to address the needs of resident and minimize the possibility of abuse/neglect. 2. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and neglect and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 3. The physician will order measures required to address the consequences of an abuse situation such as a psychological evaluation. 4. The physician and staff will address causes of problematic resident behavior where possible, such as mania, [MEDICAL CONDITION], and medication side effects. Review of the facility's Accident and Incident -Investigating and Reporting Policy dated 2001 and revised on [DATE] reflected the following: all accidents involving residents, employees, visitors, etc. occurring on our premises shall be investigated and reported to the Administrator. -The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The following data shall be included on the Report of Incident Form -the date and time the incident took place -the nature of the injury/illness i.e bruise, fall, etc -circumstances surrounding the incident -where the incident took place -the name/s of the witnesses and their accounts of the incident -the injured's account of the incident -the date and time the injured person's attending physician was notified as well as the time the physician responded and his/her instructions -the condition of the injured -the disposition of the injured (i.e. transferred to hospital -any corrective action taken -follow up information -other pertinent information as necessary -The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of the Incident/Accident form and submit the original to the DON within 24 hours of the incident. A. 1. Review of Resident #22's Face Sheet reflected a [AGE] year old African American female admitted on [DATE] and [DIAGNOSES REDACTED]. Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she was 64 inches tall and weighed 107 pounds. She had a BIMS score of 5 indicating her cognition was severely impaired. Resident #22 wandered daily and had no physical behavioral symptoms directed toward others. Resident #22 walked with the assistance of one person and did not use an assistive device. Review of Resident #22's Care Plan dated [DATE] reflected resident had problems with impaired cognition and thought process related to Senile Dementia. It further reflected resident was able to walk and perform Activities of Daily Living (ADL's) with the assist of one person. Review of Resident #22's Behavioral Medicine/Progress Note dated [DATE] reflected PNP assessed resident to be oriented to person, have a pleasant/[MEDICATION NAME] mood, logical and coherent thought, no psychotic thoughts, memory deficit, speech and language within normal limits, and have no risk of harm to herself or others. Review of Resident #22's Progress Notes date [DATE] at 10:06 AM reflected RN A's nursing notes regarding the altercation between Resident #22 and Resident #16: Resident (#22) was ambulating down hallway when another resident (#16) grabbed her by her necklace and shirt collar, causing her to fall and hit the back of head. 07:15 AM Neuros started and WNL (within normal limits) 08:00 AM Neuro changes observed, pupils fixed and restricted, vomited x2 08:20 AM Contacted ambulance to send to ER (emergency room ) 08:30 AM Unable to arouse with sternal rub, awaiting ambulance. 08:40 AM Ambulance here resident (#22) respirations WNL, no respiratory distress noted. Review of facility incident reports from ,[DATE] through ,[DATE] reflected Resident #22 had no incidents of physical aggression towards residents. Review of a facility incident report dated Saturday [DATE] at 0702 and completed by RN A reflected Resident (#22) was, ambulating into the dining room with a staff member when another Resident (#16) grabbed her by her necklace and collar of her shirt pulling her down causing her to fall landing on coccyx hitting the back of he head. Further review reflected Immediate Action Taken included Resident #22 was assessed, Neuro checks were initiated and with in normal limits at first, but then at 8:00 AM, Neuro changes, Resident vomited two (2) times and at 0820 Called EMT(emergency medical treatment) to send to ER. Resident taken to Hospital. Review of Resident #22's Resident/Discharge and Referral Record (not dated) reflected resident was transferred from the Facility to the Hospital due to, [MEDICAL CONDITIONS], unresponsiveness and vomiting. Review of Resident #22's Progress Notes dated [DATE] at 9:23 PM reflected Resident (#22) was diagnosed with [REDACTED]. Review of Hospital Records dated [DATE] reflected Resident #22 had a CT (computerized tomography) scan done: Large subdual hematoma overlying the left hemisphere resulting in 9 mm (millimeter) of left right midline shift .an [MEDICAL CONDITION] is not identified at this time nor is evidence of herniation. Review of Hospital Records reflected the ER Physician's Final [DIAGNOSES REDACTED]. Review of Inpatient Hospice Facility Records dated [DATE] reflected Resident #22 had been admitted on [DATE] with a [DIAGNOSES REDACTED]. Observation on [DATE] at 2:35 PM revealed at the Inpatient Hospice Facility revealed Resident #22 to be a petite elderly African American female lying supine in bed, in an unresponsive (coma) state. In an interview on [DATE] at 2:35 PM the Hospice RN at the Inpatient Hospice Facility stated Resident #22's death was imminent per the Hospice Doctor's assessment due to the Subdural Hemorrhage and she was expected to die within days. In an interview on [DATE] at 5:00 PM the Hospice Receptionist at Inpatient Hospice Facility stated Resident #22 died on [DATE] at 10:15 AM. Review of Resident #16's Face Sheet reflected a [AGE] year old Hispanic female admitted on [DATE] and readmitted on [DATE] from a psychiatric hospital. Resident #16's [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE] reflected she was 62 inches tall and weighed 149 pounds. It further reflected she had a BIMS score of 12 indicating her cognition was moderately impaired. Resident #16 had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #16 had verbal behavioral symptoms directed toward others. She significantly disrupted care or living environment. Resident #16 walked with the assistance of one person and used a wheel chair. Review of Resident #16's Care Plan dated [DATE] and revised on [DATE] reflected on-going problems with aggressive behaviors as follows; exhibits physical aggression and abusive behaviors to other residents and Staff. Resident throws things and directly kicks others. Residents and others are at risk for harm .Behaviors are related to: [MEDICAL CONDITION], Dementia, Ineffective coping skills related to Dementia, Poor impulse control. Further review of the care plan reflected the following interventions: 1. Provide 1:1 (one-to-one) care during aggressive behavior monitor and while waiting for transfer to Geri psych facility. 2. Follow thru with transfer to facility that can address and evaluate psychiatric and psychological needs. Review of Facility Accident and Incident Reports reflected Resident #16's was exhibiting aggressive behaviors dangerous to other residents prior to the altercation she had with Resident #22. 1. [DATE] at 14:45 PM Resident #16 came by another resident and slapped her in the face (right side) and yelled at her that the blanket she had belonged to her. Resident #16 stated, she stole my blanket. 2. [DATE] at 15:30 PM Resident #16 entire incident was witnessed by nurse, resident just got up and punched other resident in the right eye. Resident #16 stated, I hit her because she killed my grandson. 3. [DATE] at 09:36 PM Resident #16 hit Resident #15 in the head with a ,[DATE] pound rock. Resident #15 taken to the hospital and sustained a Hematoma to back of head with a [DIAGNOSES REDACTED]. Review of Hospital Psychiatric Consult dated [DATE] reflected Resident #16 had been sent from the Nursing Facility to the Hospital ER for prior resident altercations as follows: Resident (#16) threw a rock at another (Resident #15) and was becoming aggressive violent. Further review reflected Resident stated she had been in the state hospital off and on and had gotten electroshock therapy in the past. Further review of Resident #16's Progress Notes dated [DATE] at 09:56 AM reflected RN A's nursing note, 0700 Resident(#16) was rolling down hall in wheel chair and grabbed another resident (#22) by her necklace and shirt collar causing the other resident to fall .noted with increased behaviors of agitation .Attempted to kick nurse X2 .Administered [MEDICATION NAME] 2 ml as needed intramuscular .Received call back from Family Practice doctor, informed him of increased behaviors and incident of physical aggressiveness towards other resident. No new orders. Review of a facility incident report dated Saturday [DATE] and completed by RN A reflected the following: Resident was in her wheel chair rolled up to another resident (resident #22) and grabbed her necklace shirt collar and pulled her causing the other resident to fall. Informed by staff that resident (Resident #16) hit Resident #15 in the head with a rock. Resident #16 stated Resident #22 had tried to choke her and she (Resident #16)slung (Resident #22). A staff member was present at this time and the other resident did not touch Resident #16. Review of Resident #16's Progress Notes after the altercation with Resident #22 dated [DATE] at 07:00 PM reflected Resident #16 remained on the Secure Unit without 1:1 (one-to-one) observation and other residents remained exposed to her unpredictable aggressive behaviors. Nursing notation reflected her acting out behavior at that time as, Exit seeking, punching the key pad .redirection ineffective, will not accept any reasoning. Observation on [DATE] at 8:00 PM in the smoking area of Secure Unit revealed Resident #16 smoking a cigarette sitting in her wheelchair on one-to-one supervision with CNA D. Resident was alert, unwilling to engage in conversation with surveyor. Resident #16 repeatedly stated, My left arm kind of hurts. In an interview on [DATE] at 09:30 AM CNA L stated she was with Resident #22 when she fell and watched the altercation between Resident #22 and Resident #16. She stated she was escorting Resident #22 to the dining room, holding her hand and resident was behind her because the dining room hall entry was narrow and other residents were passing by. She further stated that she then felt a hard forceful pull. She further stated that she looked back and Resident #16 had come up from behind and had, grabbed Resident #22 by the collar and necklace and was slinging her back and forth and slung her back down .I watched her fall back and her head hit first .loud enough so others heard it at the nurses' station .I'm there screaming Nurse. She further stated the nurse came and checked Resident #22 all over and she seemed fine at first and was able to eat a full breakfast but then about 1 hour later when Resident #22 was in the shower she vomited and then became unresponsive very quickly and so the nurse called emergency services and they came in about 20 minutes. She further stated Resident #16 thinks everything everybody has is hers. She further stated Resident #16 hit Resident #15 with a decorative rock in the head a few months ago and Resident #15 had to go to the hospital. She further stated Resident #16 had aggressive physical behaviors towards residents, all the time .she is impulsive and unpredictable. She further stated Resident #16 was placed on 1:1 observations for approximately 45 minutes to one hour after the altercation with Resident #22, to make sure she wouldn't do it again. She further stated she had not received any special training for management of aggressive behaviors from the facility. She further stated she had asked if she needed to write a statement or an incident report regarding the incident and the RN A told her no she would enter the information into the computer. In an interview on [DATE] at 4:45 PM RN A, charge nurse of the Secure unit, stated CNA L was leading Resident #22 by the hand and Resident #16 was self-propelling herself past Resident #22 in her wheel chair. She further stated that Resident #16 reached up and grabbed Resident #22 by her long necklace and slung Resident #22 pulling her down. She further stated Resident #22 fell back on her back hitting her head on the floor. She further stated she heard the fall but did not see it and ran from the nurses' station to the dining area where the altercation happened. She further stated she then assessed Resident #22 and performed neuro checks and Resident #22 appeared normal and without injury. She further stated that Resident #22 then ate a full breakfast in the dining room, and was taken for a shower. She further stated that Resident #22 then vomited x1 while being dressed in the shower and then again when taken to the nurses' station in her wheel chair. She further stated it was about one hour between the time of the resident to resident altercation and when Resident #22 began to vomit. She further stated that after that Resident #22 became unresponsive within minutes. She further stated she called 911 as soon as Resident #22 showed signs of neurological injury and the ambulance picked Resident#22 up within about 20 minutes from her call. She further stated that when the ambulance picked Resident #22 up she was unresponsive and was breathing without distress. She further stated that Resident #16's agitation had escalated that day and Resident #16 kept saying Resident #22 had choked her and was accusing the staff of killing her baby and taking things out of her room. She further stated she notified the RVP the morning of the incident [DATE] as well as the DON, both resident families and both resident Family Practice Doctors. In an interview on [DATE] at 12:00 PM Resident #16's PNP stated she had not been informed about Resident #16's altercation with Resident #22 until [DATE] when the Facility was placed on Immediate Jeopardy. She further stated that if she had of she would have immediately sent Resident #16 to the ER because that was the second time Resident #22 had assaulted another resident. She further stated she had no idea who made the decision to accept and readmit Resident #16 back into the Nursing Facility after the Psychiatric hospitalization . She further stated, They just accepted her back .they hadn't had a DON or ADON in quite a while .I guess it was due to no leadership .there was nobody there to say no at the time. In an interview on [DATE] at 3:30 PM Resident #16's Psychologist stated that she did not specifically recall being informed that Resident #16's behavior was related to Resident #22's fall. She further stated that if she had of been aware that her aggressive behavior was related to Resident #22's fall and due to resident to resident altercation she would have recommended alternative placement. She further stated, The last several months Resident #16's behaviors had been escalating and her psych meds were being adjusted but not yet effective. She further stated, Were not able to control her behavior in that environment. In an interview on [DATE] at 4:45 PM the Social Worker stated the facility had such a rapid turnover for the last two years that communication had broken down over time and staff was less aware of her Social Worker role and she wasn't kept informed of resident to resident altercations. She further stated, residents with behaviors, elopement risk, and dementia are all housed on the Secure Unit .I don't agree with that at all .You can't have these type of residents together .you just can't manage it It's not safe. She further stated the facility needed to provide training to the nursing staff regarding management of residents with aggressive behaviors. She further stated the facility used to be an incredible place and now it has taken a nose dive. In an interview on [DATE] at 9:30 AM the Administrator and RVP stated the facility had not reported any incidents. In an interview on [DATE] at 7:00 PM the Regional DON stated she was told by RN A that Resident #16 grabbed Resident #22 by the collar and necklace and that Resident #22 pulled back, lost her balance and fell , hitting her buttocks first. She further stated, I didn't see it as a resident to resident altercation so we didn't report it. In an interview on [DATE] at 10:15 AM the Regional DON stated she had started one week before the incident with Resident #22 and Resident #16. She further stated she did not know Resident #16. She further stated she received her information regarding the incident from the charge nurse (RN A) who did not witness the fall on [DATE] at around 8:00 AM, and did not interview any of the direct care staff who were with Resident #22 and #16 when the altercation occurred. She further stated, I see what you mean, I didn't do a thorough assessment and if I had of I would have approached this situation differently. In an interview on [DATE] at 2:00 PM the Administrator stated, I didn't find out about the fall until after you guys (surveyors) got here. The previous administrator left that Friday ([DATE]). I arrived the following Monday ([DATE]) .When I found out later in the week that Resident (#22) had gone into a coma I went and talked to (Regional DON). She was here, I wasn't .She told me she had a fall and fell back on her head but that Resident (#16) pulled her necklace .I understand that when you're dealing with a resident with an aggressive history and psychotic issues it's a whole different ball game .If I had of been here when the fall happened the minute the Resident (#22) was sent to the Hospital, I would have called the state .I guess (Regional DON) may not be quite as careful as I would be coming from my side of the fence. A. 2. Review of a Face Sheet for Resident #15 reflected she was [AGE] years old with an original admitted to the facility of [DATE] and [DIAGNOSES REDACTED]. Review of an annual MDS for Resident #15 dated [DATE] reflected she had moderate cognitive impairment, required extensive assistance of one staff member for activities of daily living, she was incontinent of bowel and bladder, she could self-propel her wheelchair that was adapted to allow her to use handles to propel short distances; and had behaviors that included attempting to throw herself out of her wheelchair, occasional verbal aggression, and delusions. Review of a Care plan for Resident #15 dated [DATE] and updated on [DATE] reflected the following: - Focus Verbal and Physically Aggressive Behaviors: -Goal-Resident's verbal behaviors will not interfere with the delivery of staff care; Resident's verbal aggression will not result in harm or injury to self or others. Resident will not throw herself out of her wheelchair when she is upset with staff or other residents. -Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates the behaviors. Assess resident's coping skills and support system. Psychiatric/Psychogeriatric consults as indicated. Review of facility incident reports from ,[DATE] through ,[DATE] reflected Resident #15 had no incidents of physical aggression towards residents. Review of a facility incident report dated Saturday [DATE] and completed by LVN Z reflected the following: Informed by staff that resident (Resident #16) hit Resident (#15) in the head with a rock. Resident (#16) entered Resident (#15)'s room and hit her in the back of the head with a rock. First Aid administered and resident sent to the hospital for evaluation of hematoma. DON/Administrator notified on [DATE] at 10:20 AM. Review of a hospital discharge summary for Resident #15 dated [DATE] reflected You have a [DIAGNOSES REDACTED]. Review of nurses' notes for Resident #15 dated [DATE] reflected: resident returned from the hospital with no new orders. Monitor resident for abnormal symptoms. In a confidential staff telephone interview on [DATE] at 3:52 PM, it was stated Resident #15 was not hit with a rock on [DATE]; but instead it was a large ceramic ash tray with a cross on it that belonged to Resident #16 and was kept in her room. The staff member added the ash tray was moved to a drawer in the nurse's station after the incident. In an interview on [DATE] at 12:00 PM LVN Z stated he was not aware of the exact object Resident #16 struck Resident #15 with, but since it was reported it was a rock that was what he documented and didn't think any more about it since both residents were sent out for evaluation. In an interview on [DATE] at 10:13 AM the Regional DON, acting as interim DON, stated she was unaware of Resident #16's physical aggression and that she had hit another resident (Resident #15) in the head reportedly with a rock. The Regional DON stated how did she get a rock? The Regional DON also stated she was unaware of Resident #16's frequent physical aggression; to her knowledge Resident #16 resisted care, but didn't have much to do with the other residents. Review of a physician's orders [REDACTED]. Review of a nurses' note signed by the previous ADON dated [DATE] reflected Resident being transitioned off the secure unit today. Met potential roommate and spent the morning with her. No behaviors noted. Will continue forward as planned. Family requested move. In an interview on [DATE] at 1:00 PM, Resident #15 was asked if she liked her new room and she stated she loved it. When asked if she felt safe on her new hall/unit and with her new roommate Resident #15 smiled and stated very safe. B. Review of a closed record Face Sheet for Resident #27 reflected she was [AGE] years old with an original admitted d of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. <

Based on observation, interview, and record review the facility failed to ensure all allegations of neglect, or abuse are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures including to the state survey and recertification agency and thoroughly investigated for five (5) of twenty five (25) residents reviewed for abuse and neglect (Resident #16, #22, #15, #27, and #33 when: A. 1. Resident #22 was a [AGE] year old African American female who resided on the secure unit due to impaired cognition and elopement risk. Resident #22 was grabbed by her shirt collar and necklace and slung to the ground by Resident #16 who falsely believed she had stolen her necklace on [DATE]. As a result, Resident #22 sustained a cerebral (brain) bleed and died on [DATE]. This incident was not thoroughly investigated or reported to the state agency. A. 2. Resident #16 was paranoid, delusional (false belief contrary to reality) and had a history of [REDACTED]. The facility failed to ensure other residents remained safe and free from Resident #16's physically aggressive behaviors. The facility failed to adequately investigate a life threatening altercation between Resident #22 and Resident #16 and allowed Resident #16 to remain on the secure unit exposing other residents to her dangerous behaviors. A. 3. Resident #15 was struck in the head with a large ceramic object by Resident #16. Both residents resided on the secure unit were sent to the hospital for evaluation. Resident #16 was admitted to an acute psychiatric hospital and Resident #15 was treated and released with a [DIAGNOSES REDACTED]. The facility did not thoroughly investigate or report the incident to the state agency. Both residents were readmitted to the secure unit. B. Resident #27 became physically aggressive and attempted to strangle Resident #33, which required staff to forcibly intervene. The facility did not investigate the incident. Resident #27 continued to make verbal and physical threats of intent to strangle Resident #33 and other residents on the unit until her discharge to a psychiatric facility on [DATE]. This deficient practice resulted in the identification of an IJ on [DATE] at 7:00 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a severity of harm with a scope identified as a pattern. These deficient practices could affect a 25 residents on the secured unit by placing them at risk for abuse/neglect that was not thoroughly investigated resulting in lack of interventions put in place to protect and/or prevent further abuse and/or neglect possibly resulting in serious injuries and/or death. The Findings include: A. 1. Review of Resident #22's Face Sheet reflected a [AGE] year old African American female admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she was 64 inches tall and weighed 107 pounds. She had a BIMS score of 5 indicating her cognition was severely impaired. Resident #22 wandered daily and had no physical behavioral symptoms directed toward others. Resident #22 walked with the assistance of one person and did not use an assistive device. Review of Resident #22's Care Plan dated [DATE] reflected resident had problems with impaired cognition and thought process related to Senile Dementia. It further reflected resident was able to walk and perform Activities of Daily Living (ADL's) with the assist of one person. Review of Resident #22's Behavioral Medicine/Progress Note dated [DATE] reflected PNP assessed resident to be oriented to person, have a pleasant/[MEDICATION NAME] mood, logical and coherent thought, no psychotic thoughts, memory deficit, speech and language within normal limits, and have no risk of harm to herself or others. Review of Resident #22's Progress Notes date [DATE] at 10:06 AM reflected RN A's nursing notes regarding the altercation between Resident #22 and Resident #16: Resident (#22) was ambulating down hallway when another resident (#16) grabbed her by her necklace and shirt collar, causing her to fall and hit the back of head. 07:15 AM Neuros started and WNL (within normal limits) 08:00 AM Neuro changes observed, pupils fixed and restricted, vomited x2 08:20 AM Contacted ambulance to send to ER (emergency room ) 08:30 AM Unable to arouse with sternal rub, awaiting ambulance 08:40 AM Ambulance here resident (#22) respirations WNL, no respiratory distress noted. Review of a facility incident report dated Saturday [DATE] at 7:02 AM and completed by RN A reflected Resident (#22) was, ambulating into the dining room with a staff member when another Resident (#16) grabbed her by her necklace and collar of her shirt pulling her down causing her to fall landing on coccyx hitting the back of he head. Further review reflected Immediate Action Taken included Resident #22 was assessed, Neuro checks were initiated and with in normal limits at first, but then at 8:00 AM, Neuro changes, Resident vomited two (2) times and at 0820 Called EMT(emergency medical treatment) to send to ER. Resident taken to Hospital. Review of Resident #22's Resident/Discharge and Referral Record (not dated) reflected resident was transferred from the Facility to the Hospital due to, [MEDICAL CONDITIONS], unresponsiveness and vomiting. Further review of Resident #22's Progress Notes dated [DATE] at 9:23 PM reflected Resident (#22) was diagnosed with [REDACTED]. Review of Hospital Records dated [DATE] reflected Resident #22 had a CT (computerized tomography) scan done: Large subdual hematoma overlying the left hemisphere resulting in 9 mm (millimeter) of left right midline shift .an [MEDICAL CONDITION] is not identified at this time nor is evidence of herniation. Further review of Hospital Records reflected the ER Physician's Final [DIAGNOSES REDACTED]. Review of Inpatient Hospice Facility Records dated [DATE] reflected Resident #22 had been admitted on [DATE] with a [DIAGNOSES REDACTED]. Observation on [DATE] at 2:35 PM at the Inpatient Hospice Facility revealed Resident #22 to be a petite elderly African American female lying supine in bed, in an unresponsive (coma) state. In an interview on [DATE] at 2:35 PM the Hospice RN at the Inpatient Hospice Facility stated Resident #22's death was imminent per the Hospice Doctor's assessment due to the Subdural Hemorrhage and she was expected to die within days. In an interview on [DATE] at 5:00 PM the Hospice Receptionist at Inpatient Hospice Facility stated Resident #22 died on [DATE] at 10:15 AM. A. 2. Review of Resident #16's Face Sheet reflected a [AGE] year old Hispanic female admitted on [DATE] and readmitted on [DATE] from a psychiatric hospital. Resident #16's [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE] reflected she was 62 inches tall and weighed 149 pounds. It further reflected she had a BIMS score of 12 indicating her cognition was moderately impaired. Resident #16 had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #16 had verbal behavioral symptoms directed toward others. She significantly disrupted care or living environment. Resident #16 walked with the assistance of one person and used a wheel chair. Review of Resident #16's Physician order [REDACTED]. 1. [MEDICATION NAME] 1 mg give 0.5 ml intramuscular every one hour as needed for severe agitation related to [MEDICAL CONDITION] Disorder. 2. [MEDICATION NAME] 1 ml give intramuscular every six hours as needed for severe agitation related to [MEDICAL CONDITION] Disorder. Review of Resident #16's Care Plan dated [DATE] and revised on [DATE] reflected Resident #16 had been having verbal and physical behaviors toward others for over 1 ½ years as follows. Resident exhibits verbally and physically abusive behaviors at times and is at risk for harm. Further review of Resident #16's Care Plan dated [DATE] and revised on [DATE] reflected on-going problems with aggressive behaviors as follows; exhibits physical aggression and abusive behaviors to other residents and Staff. Resident throws things and directly kicks others. Residents and others are at risk for harm .Behaviors are related to: [MEDICAL CONDITION], Dementia, Ineffective coping skills related to Dementia, Poor impulse control. Further review of the care plan reflected the following interventions; 1. Provide 1:1 (one-to-one) care during aggressive behavior monitor and while waiting for transfer to Geri psych facility. 2. Follow thru with transfer to facility that can address and evaluate psychiatric and psychological needs. Review of Resident #16's Behavioral Medicine/Progress Notes by PNP reflected resident was exhibiting on-going aggressive behaviors to other residents and her agitation and [MEDICAL CONDITION] was worsening. 1. [DATE] Staff report patient hit another resident (Resident #15) with an object several days ago .She says she is being burned and bitten in the middle of the night. She reports auditory hallucination. These voices tell her others are talking about her. She is paranoid and delusional about other residents in the home. 2. [DATE] Staff report patient has had continuing agitation, aggression and resistance to care. She has pulled off another resident's jewelry. She is verbally and physically abusive. She did not feel that she had acted inappropriately towards other residents. She is easily agitated and difficult to redirect. 3. [DATE] Patient returned from (psychiatric hospital) on [DATE]. Since then, she has been agitated and accusing the staff of abuse. She has accused other residents of raping her and murdering her family members. She has been resistant to verbal redirection .She is very paranoid about several other residents. She says that, (unsampled female resident) rapes me. She comes to my room after spraying herself with something to make her invisible. Review of Facility Accident and Incident Reports reflected Resident #16's was exhibiting aggressive behaviors dangerous to other residents prior to the altercation she had with Resident #22. 1. [DATE] at 14:45 PM Resident#16 came by another resident and slapped her in the face (right side) and yelled at her that the blanket she had belonged to her. Resident #16 stated, she stole my blanket. 2. [DATE] at 15:30 PM Resident #16 entire incident was witnessed by nurse, resident just got up and punched other resident in the right eye. Resident #16 stated, I hit her because she killed my grandson 3. [DATE] at 09:36 PM Resident #16 hit Resident #15 in the head with a ,[DATE] pound rock. Resident #15 taken to the hospital and sustained a Hematoma to back of head with a [DIAGNOSES REDACTED]. Review of Hospital Psychiatric Consult dated [DATE] reflected Resident #16 had been sent from the Nursing Facility to the Hospital ER for prior resident altercations as follows; Resident (#16) threw a rock at another resident and was becoming aggressive violent. Further review reflected Resident stated she had been in the state hospital off and on and had gotten electroshock therapy in the past. Review of Resident #16's Progress Notes dated [DATE] at 5:34 PM reflected the following: Resident followed an aide into the shower and began to, verbally assault her, then physically assaulted her. Resident was sent out to Hospital ER for evaluation due to verbal/physical aggression towards staff/residents and then transferred to a Psychiatric Hospital [DATE] for treatment of [REDACTED]. Review of Psychiatric Hospital Patient Discharge Summary Report dated [DATE] reflected Resident #16 was admitted to the Psychiatric Hospital, Geri-Psych Unit on [DATE] at 5:12 PM with [DIAGNOSES REDACTED]. Further review reflected Resident #16 was admitted to the Psychiatric Hospital due to, Increased paranoia and delusional thinking leading to verbal and physical abuse of staff. The patient was found to have a Urinary Tract Infection, Dehydration and Gastroenteritis. Review of Facility Accident and Incident Reports dated [DATE] at 07:00 reflected RN A's description of the altercation between Resident #22 and #16 as follows; Resident (#16) was in her wheel chair and rolled up to another Resident (#22) and grabbed her necklace and shirt collar and pulled her causing (Resident #22) to fall. (Resident #16) stated (Resident #22) tried to choke her and she slung her. A staff member was present at this time and (Resident #22) did not touch her. Further review of Resident #16's Progress Notes dated [DATE] at 09:56 AM reflected RN A's nursing note, 0700 Resident(#16) was rolling down hall in wheel chair and grabbed another resident (#22) by her necklace and shirt collar causing the other resident to fall .noted with increased behaviors of agitation .Attempted to kick nurse X2 .Administered [MEDICATION NAME] 2 ml as needed intramuscular .Received call back from Family Practice doctor, informed him of increased behaviors and incident of physical aggressiveness towards other resident. No new orders. Review of Resident #16's Progress Notes after the altercation with Resident #22 dated [DATE] at 07:00 PM reflected Resident #16 remained on the Secure Unit without 1:1 (one-to-one) observation and other residents remained exposed to her unpredictable aggressive behaviors. Nursing notation reflected her acting out behavior at that time as, Exit seeking, punching the key pad .redirection ineffective, will not accept any reasoning. In an interview on [DATE] at 09:30 AM CNA L stated she was with Resident #22 when she fell and watched the altercation between Resident #22 and Resident #16. She stated she was escorting Resident #22 to the dining room, holding her hand and resident was behind her because the dining room hall entry was narrow and other residents were passing by. She further stated that she then felt a hard forceful pull. She further stated that she looked back and Resident #16 had come up from behind and had, grabbed Resident #22 by the collar and necklace and was slinging her back and forth and slung her back down .I watched her fall back and her head hit first .loud enough so others heard it at the nurses' station .I'm there screaming Nurse. She further stated the nurse came and checked Resident #22 all over and she seemed fine at first and was able to eat a full breakfast but then about 1 hour later when Resident #22 was in the shower she vomited and then became unresponsive very quickly and so the nurse called emergency services and they came in about 20 minutes. She further stated Resident #16 thinks everything everybody has is hers. She further stated Resident #16 hit Resident #15 with a decorative rock in the head a few months ago and Resident #15 had to go to the hospital. She further stated Resident #16 had aggressive physical behaviors towards residents, all the time .she is impulsive and unpredictable. She further stated Resident #16 was placed on 1:1 observations for approximately 45 minutes to one hour after the altercation with Resident #22, to make sure she wouldn't do it again. She further stated she had not received any special training for management of aggressive behaviors from the facility. She further stated she had asked if she needed to write a statement or an incident report regarding the incident and the RN A told her no she would enter the information into the computer. In an interview on [DATE] at 4:45 PM RN A, charge nurse of the Secure unit, stated CNA L was leading Resident #22 by the hand and Resident #16 was self-propelling herself past Resident #22 in her wheel chair. She further stated that Resident #16 reached up and grabbed Resident #22 by her long necklace and slung Resident #22 pulling her down. She further stated Resident #22 fell back on her back hitting her head on the floor. She further stated she heard the fall but did not see it and ran from the nurses' station to the dining area where the altercation happened. She further stated she then assessed Resident #22 and performed neuro checks and Resident #22 appeared normal and without injury. She further stated that Resident #22 then ate a full breakfast in the dining room, and was taken for a shower. She further stated that Resident #22 then vomited x1 while being dressed in the shower and then again when taken to the nurses' station in her wheel chair. She further stated it was about one hour between the time of the resident to resident altercation and when Resident #22 began to vomit. She further stated that after that Resident #22 became unresponsive within minutes. She further stated she called 911 as soon as Resident #22 showed signs of neurological injury and the ambulance picked Resident#22 up within about 20 minutes from her call. She further stated that when the ambulance picked Resident #22 up she was unresponsive and was breathing without distress. She further stated that Resident #16's agitation had escalated that day and Resident #16 kept saying Resident #22 had choked her and was accusing the staff of killing her baby and taking things out of her room. She further stated she notified the RVP the morning of the incident [DATE] as well as the DON, both resident families and both resident Family Practice Doctors. In an interview on [DATE] at 12:00 PM Resident #16's PNP stated she had not been informed about Resident #16's altercation with Resident #22 until [DATE] when the Facility was placed on Immediate Jeopardy. She further stated that if she had of she would have immediately sent Resident #16 to the ER because that was the second time Resident #22 had assaulted another resident. In an interview on [DATE] at 12:10 PM LVN Z stated he didn't think Resident #16 was appropriately placed on the secure unit because, one minute she can be sweet as tea and the next minute she can be hell on wheels. He further stated, I try to keep an eye on her at all times .she is unpredictable. Paranoid .she has hallucinations (sees kids under beds and patrol cars outside) .that's been ongoing since I've been here about five months. He further stated, the facility due to inconsistent management, and constant turnover of staff had no real structure for direction or assistance with Resident Care Problems. In an interview on [DATE] at 12:45 PM CNA N stated she had worked on the Secure unit for approximately seven years and Resident # 16's behaviors had always been physically aggressive. She further stated, that when residents' behaviors got out of control, we just give them a shot .we get no special training back here. In an interview on [DATE] at 9:30 AM the Administrator and RVP stated the facility had not reported any incidents. In an interview on [DATE] at 7:00 PM the Regional DON (acting as the interim facility DON) stated she was told by RN A that Resident #16 grabbed Resident #22 by the collar and necklace and that Resident #22 pulled back, lost her balance and fell , hitting her buttocks first. She further stated, I didn't see it as a resident to resident altercation so we didn't report it. In an interview on [DATE] at 10:15 AM the Regional DON stated she had started one week before the incident with Resident #22 and Resident #16. She further stated she did not know Resident #16. She further stated she received her information regarding the incident from the charge nurse (RN A) who did not witness the fall on [DATE] at around 8:00 AM, and did not interview any of the direct care staff who were with Resident #22 and #16 when the altercation occurred. When asked if it would be the expectation of any of her staff conducting an investigation to interview the staff that were on duty when an incident occurred, the Regional DON stated, I see what you mean, I didn't do a thorough assessment and if I had of I would have approached this situation differently. The Regional DON confirmed she had not asked about Resident #16 ' s past history of physical aggression as part of her investigation, and did not know Resident #16 had been fixated on Resident #22 and the necklace she was wearing during the hours before the incident. In an interview on [DATE] at 10:15 AM the Administrator stated, we all know psych patients and Dementia Patients don't mix .were not going to admit any more psych patients any more .were thinking about separating them now. In an interview on [DATE] at 3:30 PM Resident #16's Psychologist stated that she did not specifically recall being informed that Resident #16's behavior was related to Resident #22's fall. She further stated that if she had of been aware that her aggressive behavior was related to Resident #22's fall and due to resident to resident altercation she would have recommended alternative placement. She further stated, The last several months Resident #16's behaviors had been escalating and her psych meds were being adjusted but not yet effective. She further stated, Were not able to control her behavior in that environment. In an interview on [DATE] at 4:45 PM the Social Worker stated the facility had such a rapid turnover for the last two years that communication had broken down over time and staff was less aware of her Social Worker role and she wasn't kept informed of resident to resident altercations. In an interview on [DATE] at 2:00 PM the Administrator stated, I didn't find out about the fall until after you guys (surveyors) got here. The previous administrator left that Friday ([DATE]). I arrived the following Monday ([DATE]) .When I found out later in the week that Resident #22 had gone into a coma I went and talked to the Regional DON. She was here, I wasn't .She told me she had a fall and fell back on her head but that Resident #16 pulled her necklace .it didn't make sense so I asked could she have fallen over the wheelchair? I was trying to figure out how she hit her head. He further stated, I didn't hear any of that bologna about Resident #16 mugging Resident #22. I just thought it was one resident wanting to take other resident's jewelry. At the time, I didn't know Resident #16's history until you guys (surveyors) started talking about her aggressive history. Once I started hearing that I thought maybe she should get moved out. I understand that when you're dealing with a resident with an aggressive history and psychotic issues it's a whole different ball game .If I had of been here when the fall happened the minute the Resident (#22) was sent to the Hospital I would have called the state .I guess the DON may not be quite as careful as I would be coming from my side of the fence. A. 3. Review of a Face Sheet for Resident #15 reflected she was [AGE] years old with an original admitted to the facility of [DATE] and [DIAGNOSES REDACTED]. Review of an annual MDS for Resident #15 dated [DATE] reflected she had moderate cognitive impairment, required extensive assistance of one staff member for activities of daily living, she was incontinent of bowel and bladder, she could self propel her wheelchair that was adapted to allow her to use handles to propel short distances; and had behaviors that included attempting to throw herself out of her wheelchair, occasional verbal aggression, and delusions. Review of a Care plan for Resident #15 dated [DATE] and updated on [DATE] reflected the following: - Focus Verbal and Physically Aggressive Behaviors: -Goal-Resident's verbal behaviors will not interfere with the delivery of staff care; Resident's verbal aggression will not result in harm or injury to self or others. Resident will not throw herself out of her wheelchair when she is upset with staff or other residents. -Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates the behaviors. Assess resident's coping skills and support system. Psychiatric/Psychogeriatric consults as indicated. Review of printed electronic facility incident reports from ,[DATE] through ,[DATE] reflected Resident #15 had no incidents of physical aggression towards residents. Review of a printed electronic facility incident report dated Saturday [DATE] and completed by LVN Z reflected the following: Informed by staff that resident (Resident #16) hit Resident #15 in the head with a rock. Resident #16 entered Resident #15's room and hit her in the back of the head with a rock. First Aid administered and resident sent to the hospital for evaluation of hematoma. DON/Administrator notified on [DATE] at 10:20 AM. Review of a hospital discharge summary for Resident #15 dated [DATE] reflected You have a [DIAGNOSES REDACTED]. Review of nurses' notes for Resident #15 dated [DATE] reflected: resident returned from the hospital with no new orders. Monitor resident for abnormal symptoms. Review of Resident #16's Behavioral Medicine/Progress Notes by PNP reflected resident was exhibiting on-going aggressive behaviors to other residents and her agitation and [MEDICAL CONDITION] was worsening. 1. [DATE] Staff report patient hit another resident (Resident #15) with an object several days ago .She says she is being burned and bitten in the middle of the night. She reports auditory hallucination. These voices tell her others are talking about her. She is paranoid and delusional about other residents in the home. In a confidential staff telephone interview on [DATE] at 3:52 PM, it was stated Resident #15 was not hit with a rock on [DATE]; but instead it was a large ceramic ash tray with a cross on it that belonged to Resident #16 and was kept it in her room. The staff member added the ash tray was moved to a drawer in the nurse ' s station after the incident. In an interview on [DATE] at 12:00 PM, LVN Z stated he not aware of the exact object Resident #16 struck Resident #15 with, but since it was reported it was a rock that is what he documented and didn't think any more about it since both residents were sent out for evaluation. LVN Z did not know if the incident was investigated by the administrator employed at the time. In an interview on [DATE] at 10:13 AM the Regional DON (acting as the facility interim DON), stated she was unaware of Resident #16's physical aggression and that she had hit another resident (Resident #15) in the head reportedly with a rock. The Regional DON stated how did she get a rock?! The Regional DON also stated she was unaware of Resident #16's frequent physical aggression; to her knowledge Resident #16 resisted care, but didn't have much to do with the other residents. Review of a physician's orders [REDACTED]. Review of a nurses' note signed by the previous ADON dated [DATE] reflected Resident being transitioned off the secure unit today. Met potential roommate and spent the morning with her. No behaviors noted. Will continue forward as planned. Family requested move. In an interview on [DATE] at 1:00 PM, Resident # 15 was asked if she liked her new room and she stated she loved it. When asked if she felt safe on her new hall/unit and with her new roommate Resident #15 smiled and stated very safe. B. Review of a closed record Face Sheet for Resident #27 reflected she was [AGE] years old with an original admitted d of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #27 reflected she was ambulatory without assistance, severe cognitive impairment, she was incontinent of bowel and bladder, and required assistance of one staff for all activities of daily living. Resident #27 had behaviors of physical aggression towards residents and staff. Resident throws things, kicks, and hits. Review of physician orders [REDACTED]. -[MEDICATION NAME] 2 mg. tablet every 12 hours as needed for agitation related to [MEDICAL CONDITION] Disorder-[MEDICAL CONDITION] -[MEDICATION NAME] Solution 5 mg./ml Inject intramuscularly every 6 hours as needed for severe agitation -[MEDICATION NAME] 1 mg. tablet every two hours as needed for agitation. Review of a care plan for Resident # 27 dated [DATE] reflected: -Focus: Resident exhibits physical aggression and abusive behaviors towards others. Resident throws things and directly kicks others. Residents and others are at risk for harm and not having their needs met in a timely manner. Behaviors are related to Dementia, Poor Impulse Control and ineffective coping skills. -Goal: Resident will not harm self or others. The resident will have fewer episodes of behavior and will communicate understanding of need to control physically aggressive behavior through the review date. -Interventions: Analyze of key time, places, circumstances, triggers, and what de-escalates behaviors and document. Modify Environment: Follow through with transfer to facility that can address and evaluate psychiatric and psychological needs. Review of a facility electronic incident report dated [DATE] at 10:45 AM reflected the following: Resident (#27) was coming out of the dining room and another resident (#33) was yelling. Resident (#27) ran up on her (Resident #33) and grabbed her by the throat while screaming at her to shut up. As resident (#27) was moved away she grabbed another resident and became combative. [MEDICATION NAME] injection given. The incident was revised on [DATE] and reflected the following documentation under the section Agencies/People Notified: No notifications found. Review of electronic nurses' notes for Resident #27 dated [DATE] at 11:02 AM reflected the following: Resident (#27) was strangling one resident (#33) was redirected and then she grabbed another resident by the arm and started dragging him. Resident (#27) then started punching/kicking. Verbal redirection ineffective. PRN [MEDICATION NAME] injection given. In an interview on [DATE] at 4:30 PM, LVN X stated she was a charge nurse for the secure unit and knew Resident #27 well. LVN X stated Resident #27 would pace the halls of the secure unit and repeatedly slap her face and have frequent episodes of verbal and physical aggression, which included gesturing she was going to choke someone. LVN X stated she was the charge nurse on duty on [DATE] when Resident #27 was trying to strangle Resident #33 and then attacked another resident. LVN X went on to say Resident #27 would get furious at Resident #33 because she would scream loudly and frequ

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect and abuse of residents for five (5) of twenty-five (25) residents reviewed for abuse/neglect (Residents #22, #16, #15, #27, and #33) when: A. 1. The facility failed to protect Resident #22 from Resident #16, who grabbed Resident #22 by the shirt collar and necklace and slung her to the ground. Resident #22 sustained a cerebral (brain) bleed on [DATE] and died on [DATE]. The facility placed Resident #16 on one-to-one supervision for about an hour after the incident, but failed to continue the supervision and send her to a psychiatric hospital until Surveyor interventions on [DATE]. The facility failed to protect the other residents in the facility from Resident #16 from [DATE] to [DATE]. Resident #16 was paranoid, delusional (false belief contrary to reality) and had a history of [REDACTED]. A. 2. Resident #15 was struck in the head with a large ceramic object by Resident #16. Both residents resided on the secure unit and were sent to the hospital for evaluation. Resident #16 was admitted to an acute psychiatric hospital and Resident #15 was treated and released with a [DIAGNOSES REDACTED]. Both residents were readmitted to the secure unit. The facility did not identify the incident as neglect or put preventative measures in place to protect residents on the secure unit from Resident #16. B. Resident #27 became physically aggressive and attempted to strangle Resident #33, which required staff to forcibly intervene. Resident #27 continued to make verbal and physical threats of intent to strangle Resident #33 and other residents on the unit until her discharge to a psychiatric facility approximately one month later. The facility did not identify the incident as abuse/neglect, seek emergent psychiatric care or put preventative measures in place to protect the other residents on the secure unit from Resident #27. These deficient practices could affect 26 residents on the secure unit by placing them at risk for abuse/neglect from residents with behaviors that are dangerous to others and could cause serious injuries and death. These failures resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm that is not IJ with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective system. Findings include: A. 1. Review of Resident #22's Face Sheet reflected a [AGE] year old African American female admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she was 64 inches tall and weighed 107 pounds. She had a BIMS score of 5 indicating her cognition was severely impaired. Resident #22 wandered daily and had no physical behavioral symptoms directed toward others. Resident #22 walked with the assistance of one person and did not use an assistive device. Review of Resident #22's Care Plan dated [DATE] reflected resident had problems with impaired cognition and thought process related to Senile Dementia. It further reflected resident was able to walk and perform Activities of Daily Living (ADL's) with the assist of one person. Review of Resident #22's Progress Notes date [DATE] at 10:06 AM reflected RN A's nursing notes regarding the altercation between Resident #22 and Resident #16: Resident (#22) was ambulating down hallway when another resident (#16) grabbed her by her necklace and shirt collar, causing her to fall and hit the back of head. 07:15 AM Neuros started and WNL (within normal limits) 08:00 AM Neuro changes observed, pupils fixed and restricted, vomited x2 08:20 AM Contacted ambulance to send to ER (emergency room ) 08:30 AM Unable to arouse with sternal rub, awaiting ambulance 08:40 AM Ambulance here resident (#22) respirations WNL, no respiratory distress noted. Review of a facility incident report dated Saturday [DATE] at 0702 and completed by RN A reflected Resident (#22) was, ambulating into the dining room with a staff member when another Resident (#16) grabbed her by her necklace and collar of her shirt pulling her down causing her to fall landing on coccyx hitting the back of he head. Further review reflected Immediate Action Taken included Resident #22 was assessed, Neuro checks were initiated and with in normal limits at first, but then at 8:00 AM, Neuro changes, Resident vomited two (2) times and at 0820 Called EMT(emergency medical treatment) to send to ER. Resident taken to Hospital. Review of Resident #22's Resident/Discharge and Referral Record (not dated) reflected resident was transferred from the Facility to the Hospital due to, [MEDICAL CONDITIONS], unresponsiveness and vomiting. Further review of Resident #22's Progress Notes dated [DATE] at 9:23 PM reflected Resident (#22) was diagnosed with [REDACTED]. Review of Hospital Records dated [DATE] reflected Resident #22 had a CT (computerized tomography) scan done: Large subdual hematoma overlying the left hemisphere resulting in 9 mm (millimeter) of left right midline shift .an [MEDICAL CONDITION] is not identified at this time nor is evidence of herniation. Further review of Hospital Records reflected the ER Physician's Final [DIAGNOSES REDACTED]. Review of Inpatient Hospice Facility Records dated [DATE] reflected Resident #22 had been admitted on [DATE] with a [DIAGNOSES REDACTED]. Observation on [DATE] at 2:35 PM at the Inpatient Hospice Facility revealed Resident #22 to be a petite elderly African American female lying supine in bed, in an unresponsive (coma) state. In an interview on [DATE] at 2:35 PM the Hospice RN at the Inpatient Hospice Facility stated Resident #22's death was imminent per the Hospice Doctor's assessment due to the Subdural Hemorrhage and she was expected to die within days. In an interview on [DATE] at 5:00 PM the Hospice Receptionist at Inpatient Hospice Facility stated Resident #22 died on [DATE] at 10:15 AM. Review of Resident #16's Face Sheet reflected a [AGE] year old Hispanic female admitted on [DATE] and readmitted on [DATE] from a psychiatric hospital. Resident #16's [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS assessment dated [DATE] reflected she was 62 inches tall and weighed 149 pounds. It further reflected she had a BIMS score of 12 indicating her cognition was moderately impaired. Resident #16 had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #16 had verbal behavioral symptoms directed toward others. She significantly disrupted care or living environment. Resident #16 walked with the assistance of one person and used a wheelchair. Review of Resident #16's Physician order [REDACTED]. 1. [MEDICATION NAME] 1 mg give 0.5 ml intramuscular every one hour as needed for severe agitation related to [MEDICAL CONDITION] Disorder. 2. [MEDICATION NAME] 1 ml give intramuscular every six hours as needed for severe agitation related to [MEDICAL CONDITION] Disorder. Review of Resident #16's Care Plan dated [DATE] and revised on [DATE] reflected Resident #16 had been having verbal and physical behaviors toward others for over 1 ½ years as follows. Resident exhibits verbally and physically abusive behaviors at times and is at risk for harm. Further review of Resident #16's Care Plan dated [DATE] and revised on [DATE] reflected on-going problems with aggressive behaviors as follows: exhibits physical aggression and abusive behaviors to other residents and Staff. Resident throws things and directly kicks others. Residents and others are at risk for harm .Behaviors are related to: [MEDICAL CONDITION], Dementia, Ineffective coping skills related to Dementia, Poor impulse control. Further review of the care plan reflected the following interventions: 1. Provide 1:1 (one-to-one) care during aggressive behavior monitor and while waiting for transfer to Geri psych facility. 2. Follow thru with transfer to facility that can address and evaluate psychiatric and psychological needs. Review of Resident #16's Behavioral Medicine/Progress Notes by PNP reflected resident was exhibiting on-going aggressive behaviors to other residents and her agitation and [MEDICAL CONDITION] was worsening: 1. [DATE] Staff report patient hit another resident with an object several days ago .She says she is being burned and bitten in the middle of the night. She reports auditory hallucination. These voices tell her others are talking about her. She is paranoid and delusional about other residents in the home. 2. [DATE] Staff report patient has had continuing agitation, aggression and resistance to care. She has pulled off another resident's jewelry. She is verbally and physically abusive. She did not feel that she had acted inappropriately towards other residents. She is easily agitated and difficult to redirect. 3. [DATE] Patient returned from (psychiatric hospital) on [DATE]. Since then, she has been agitated and accusing the staff of abuse. She has accused other residents of raping her and murdering her family members. She has been resistant to verbal redirection .She is very paranoid about several other residents. She says that, (unsampled female resident) rapes me. She comes to my room after spraying herself with something to make her invisible. Review of Facility Accident and Incident Reports reflected Resident #16's was exhibiting aggressive behaviors dangerous to other residents prior to the altercation she had with Resident #22. 1. [DATE] at 14:45 PM Resident#16 came by another resident and slapped her in the face (right side) and yelled at her that the blanket she had belonged to her. Resident #16 stated, she stole my blanket. 2. [DATE] at 15:30 PM Resident #16 entire incident was witnessed by nurse, resident just got up and punched other resident in the right eye. Resident #16 stated, I hit her because she killed my grandson 3. [DATE] at 09:36 PM Resident #16 hit Resident #15 in the head with a ,[DATE] pound rock. Resident #15 taken to the hospital and sustained a Hematoma to back of head with a [DIAGNOSES REDACTED]. Review of Hospital Psychiatric Consult dated [DATE] reflected Resident #16 had been sent from the Nursing Facility to the Hospital ER for prior resident altercations as follows: Resident (#16) threw a rock at another resident and was becoming aggressive violent. Further review reflected Resident stated she had been in the the state hospital off and on and had gotten electroshock therapy in the past. Review of Resident #16's Progress Notes dated [DATE] at 5:34 PM reflected the following: Resident followed an aide into the shower and began to, verbally assault her, then physically assaulted her. Resident was sent out to Hospital ER for evaluation due to verbal/physical aggression towards staff/residents and then transferred to a Psychiatric Hospital [DATE] for treatment of [REDACTED]. Review of Psychiatric Hospital Patient Discharge Summary Report dated [DATE] reflected Resident #16 was admitted to the Psychiatric Hospital, Geri-Psych Unit on [DATE] at 5:12 PM with [DIAGNOSES REDACTED]. Further review reflected Resident #16 was admitted to the Psychiatric Hospital due to Increased paranoia and delusional thinking leading to verbal and physical abuse of staff. The patient was found to have a Urinary Tract Infection, Dehydration and Gastroenteritis. Review of Facility Accident and Incident Reports dated [DATE] at 7:00 AM reflected RN A's description of the altercation between Resident #22 and #16 as follows: Resident (#16) was in her wheel chair and rolled up to another Resident (#22) and grabbed her necklace and shirt collar and pulled her causing (Resident #22) to fall. (Resident #16) stated (Resident #22) tried to choke her and she slung her. A staff member was present at this time and (Resident #22) did not touch her. Further review of Resident #16's Progress Notes dated [DATE] at 09:56 AM reflected RN A's nursing note, 0700 Resident(#16) was rolling down hall in wheel chair and grabbed another resident (#22) by her necklace and shirt collar causing the other resident to fall .noted with increased behaviors of agitation .Attempted to kick nurse X2 .Administered [MEDICATION NAME] 2 ml as needed intramuscular .Received call back from Family Practice doctor, informed him of increased behaviors and incident of physical aggressiveness towards other resident. No new orders. Review of Resident #16's Progress Notes after the altercation with Resident #22 dated [DATE] at 07:00 PM reflected Resident #16 remained on the Secure Unit without 1:1 (one-to-one) observation and other residents remained exposed to her unpredictable aggressive behaviors. Nursing notation reflected her acting out behavior at that time as Exit seeking, punching the key pad .redirection ineffective, will not accept any reasoning. Observation on [DATE] at 8:00 PM in the smoking area of Secure Unit revealed Resident #16 smoking a cigarette sitting in her wheelchair on one-to-one supervision with CNA D. Resident was alert, unwilling to engage in conversation with surveyor. Resident #16 repeatedly stated, My left arm kind of hurts. In an interview on [DATE] at 09:30 AM CNA L stated she was with Resident #22 when she fell and watched the altercation between Resident #22 and Resident #16. She stated she was escorting Resident #22 to the dining room, holding her hand and resident was behind her because the dining room hall entry was narrow and other residents were passing by. She further stated that she then felt a hard forceful pull. She further stated that she looked back and Resident #16 had come up from behind and had, grabbed Resident #22 by the collar and necklace and was slinging her back and forth and slung her back down .I watched her fall back and her head hit first .loud enough so others heard it at the nurses' station .I'm there screaming Nurse. She further stated the nurse came and checked Resident #22 all over and she seemed fine at first and was able to eat a full breakfast but then about 1 hour later when Resident #22 was in the shower she vomited and then became unresponsive very quickly and so the nurse called emergency services and they came in about 20 minutes. She further stated Resident #16 thinks everything everybody has is hers. She further stated Resident #16 hit Resident #15 with a decorative rock in the head a few months ago and Resident #15 had to go to the hospital. She further stated Resident #16 had aggressive physical behaviors towards residents, all the time .she is impulsive and unpredictable. She further stated Resident #16 was placed on 1:1 observations for approximately 45 minutes to one hour after the altercation with Resident #22, to make sure she wouldn't do it again. She further stated she had not received any special training for management of aggressive behaviors from the facility. She further stated she had asked if she needed to write a statement or an incident report regarding the incident and the RN A told her no she would enter the information into the computer. In an interview on [DATE] at 4:45 PM RN A, charge nurse of the Secure unit, stated CNA L was leading Resident #22 by the hand and Resident #16 was self-propelling herself past Resident #22 in her wheel chair. She further stated that Resident #16 reached up and grabbed Resident #22 by her long necklace and slung Resident #22 pulling her down. She further stated Resident #22 fell back on her back hitting her head on the floor. She further stated she heard the fall but did not see it and ran from the nurses' station to the dining area where the altercation happened. She further stated she then assessed Resident #22 and performed neuro checks and Resident #22 appeared normal and without injury. She further stated that Resident #22 then ate a full breakfast in the dining room, and was taken for a shower. She further stated that Resident #22 then vomited x1 while being dressed in the shower and then again when taken to the nurses' station in her wheel chair. She further stated it was about one hour between the time of the resident to resident altercation and when Resident #22 began to vomit. She further stated that after that Resident #22 became unresponsive within minutes. She further stated she called 911 as soon as Resident #22 showed signs of neurological injury and the ambulance picked Resident#22 up within about 20 minutes from her call. She further stated that when the ambulance picked Resident #22 up she was unresponsive and was breathing without distress. She further stated that Resident #16's agitation had escalated that day and Resident #16 kept saying Resident #22 had choked her and was accusing the staff of killing her baby and taking things out of her room. She further stated she notified the RVP the morning of the incident [DATE] as well as the Regional DON, both resident families and both resident Family Practice Doctors. In an interview on [DATE] at 12:00 PM Resident #16's PNP stated she had not been informed about Resident #16's altercation with Resident #22 until [DATE] when the Facility was placed on Immediate Jeopardy. She further stated that if she had of she would have immediately sent Resident #16 to the ER because that was the second time Resident #22 had assaulted another resident. She further stated she had no idea who made the decision to accept and readmit Resident #16 back into the Nursing Facility after the Psychiatric hospitalization . She further stated They just accepted her back .they hadn't had a DON or ADON in quite a while .I guess it was due to no leadership .there was nobody there to say no at the time. In an interview on [DATE] at 12:10 PM LVN Z stated he didn't think Resident #16 was appropriately placed on the secure unit because, one minute she can be sweet as tea and the next minute she can be hell on wheels. He further stated, I try to keep an eye on her at all times .she is unpredictable. Paranoid .she has hallucinations (sees kids under beds and patrol cars outside) .that's been ongoing since I've been here about five months. He further stated, the facility due to inconsistent management, and constant turnover of staff had no real structure for direction or assistance with Resident Care Problems. In an interview on [DATE] at 12:45 PM CNA N stated she had worked on the Secure unit for approximately seven years and Resident # 16's behaviors had always been physically aggressive. She further stated, that when residents' behaviors got out of control, we just give them a shot .we get no special training back here. In an interview on [DATE] at 9:30 AM the Administrator and RVP stated the facility had not reported any incidents. In an interview on [DATE] at 7:00 PM the Regional DON stated she was told by RN A that Resident #16 grabbed Resident #22 by the collar and necklace and that Resident #22 pulled back, lost her balance and fell , hitting her buttocks first. She further stated, I didn't see it as a resident to resident altercation so we didn't report it. In an interview on [DATE] at 10:15 AM the Regional DON stated she had started one week before the incident with Resident #22 and Resident #16. She further stated she did not know Resident #16. She further stated she received her information regarding the incident from the charge nurse (RN A) who did not witness the fall on [DATE] at around 8:00 AM, and did not interview any of the direct care staff who were with Resident #22 and #16 when the altercation occurred. She further stated, I see what you mean, I didn't do a thorough assessment and if I had of I would have approached this situation differently. In an interview on [DATE] at 10:15 AM the Administrator stated, we all know psych patients and Dementia Patients don't mix .were not going to admit any more psych patients any more .were thinking about separating them now. In an interview on [DATE] at 3:30 PM Resident #16's Psychologist stated that she did not specifically recall being informed that Resident #16's behavior was related to Resident#22's fall. She further stated that if she had of been aware that her aggressive behavior was related to Resident #22's fall and due to resident to resident altercation she would have recommended alternative placement. She further stated, The last several months Resident #16's behaviors had been escalating and her psych meds were being adjusted but not yet effective. She further stated, Were not able to control her behavior in that environment. In an interview on [DATE] at 3:00 PM the Administrator stated, Believe me this will effect our screening of Residents prior to admitting them .Oh this is going to go legal. In an interview on [DATE] at 4:45 PM the Social Worker stated the facility had such a rapid turn over for the last two years that communication had broken down over time and staff was less aware of her Social Worker role and she wasn't kept informed of resident to resident altercations. She further stated, residents with behaviors, elopement risk, and dementia are all housed on the Secure Unit .I don't agree with that at all .You can't have these type of residents together .you just can't manage it It's not safe. She further stated the facility needed to provide training to the nursing staff regarding management of residents with aggressive behaviors. She further stated the facility used to be an incredible place and now it has taken a nose dive. In an interview on [DATE] at 2:00 PM the Administrator stated I didn't find out about the fall until after you guys (surveyors) got here. The previous administrator left that Friday ([DATE]). I arrived the following Monday ([DATE]) .When I found out later in the week that (Resident #22) had gone into a coma I went and talked to (the Regional DON). She was here, I wasn't .She told me she had a fall and fell back on her head but that (Resident #16) pulled her necklace .it didn't make sense so I asked could she have fallen over the wheelchair? I was trying to figure out how she hit her head. He further stated, I didn't hear any of that bologna about (Resident #16) mugging (Resident #22). I just thought it was one resident wanting to take other resident's jewelry. At the time, I didn't know (Resident #16)'s history until you guys (surveyors) started talking about her aggressive history. Once I started hearing that I thought maybe she should get moved out. I understand that when you're dealing with a resident with an aggressive history and psychotic issues it's a whole different ball game .If I had of been here when the fall happened the minute the (Resident #22) was sent to the Hospital I would have called the state .I guess (the Regional DON) may not be quite as careful as I would be coming from my side of the fence. A. 2. Review of a Face Sheet for Resident #15 reflected she was [AGE] years old with an original admitted to the facility of [DATE] and [DIAGNOSES REDACTED]. Review of an annual MDS for Resident #15 dated [DATE] reflected she had moderate cognitive impairment, required extensive assistance of one staff member for activities of daily living, she was incontinent of bowel and bladder, she could self propel her wheelchair that was adapted to allow her to use handles to propel short distances; and had behaviors that included attempting to throw herself out of her wheelchair, occasional verbal aggression, and delusions. Review of a Care plan for Resident #15 dated [DATE] and updated on [DATE] reflected the following: - Focus Verbal and Physically Aggressive Behaviors: -Goal-Resident's verbal behaviors will not interfere with the delivery of staff care; Resident's verbal aggression will not result in harm or injury to self or others. Resident will not throw herself out of her wheelchair when she is upset with staff or other residents. -Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates the behaviors. Assess resident's coping skills and support system. Psychiatric/Psychogeriatric consults as indicated. Review of printed electronic facility incident reports from ,[DATE] through ,[DATE] reflected Resident #15 had no incidents of physical aggression towards residents. Review of a printed electronic facility incident report dated Saturday [DATE] and completed by LVN Z reflected the following: Informed by staff that resident (#16) hit Resident (#15) in the head with a rock. Resident (#16) entered Resident (#15)'s room and hit her in the back of the head with a rock. First Aid administered and resident sent to the hospital for evaluation of hematoma. DON/Administrator notified on [DATE] at 10:20 AM. Review of a hospital discharge summary for Resident #15 dated [DATE] reflected You have a [DIAGNOSES REDACTED]. Review of nurses' notes for Resident #15 dated [DATE] reflected: resident returned from the hospital with no new orders. Monitor resident for abnormal symptoms. Review of Resident #16's Behavioral Medicine/Progress Notes by PNP reflected resident was exhibiting on-going aggressive behaviors to other residents and her agitation and [MEDICAL CONDITION] was worsening: [DATE] Staff report patient hit another resident (#15) with an object several days ago .She says she is being burned and bitten in the middle of the night. She reports auditory hallucination. These voices tell her others are talking about her. She is paranoid and delusional about other residents in the home. In a confidential staff telephone interview on [DATE] at 3:52 PM, it was stated Resident #15 was not hit with a rock on [DATE]; but instead it was a large ceramic ash tray with a cross on it that belonged to Resident #16 and was kept it in her room. The staff member added the ash tray was moved to a drawer in the nurse's station after the incident. In an interview on [DATE] at 12:00 PM, LVN Z stated he not aware of the exact object Resident #16 struck Resident #15 with, but since it was reported it was a rock that is what he documented and didn't think any more about it since both residents were sent out for evaluation. LVN Z did not know if the incident was investigated by the administrator employed at the time. In an interview on [DATE] at 10:13 AM the Regional DON (acting as the facility interim DON), stated she was unaware of Resident #16's physical aggression and that she had hit another resident (Resident #15) in the head reportedly with a rock. The Regional DON stated how did she get a rock?! The Regional DON also stated she was unaware of Resident #16's frequent physical aggression; to her knowledge Resident #16 resisted care, but didn't have much to do with the other residents. Review of a physician's orders [REDACTED]. Review of a nurses' note signed by the previous ADON dated [DATE] reflected Resident being transitioned off the secure unit today. Met potential roommate and spent the morning with her. No behaviors noted. Will continue forward as planned. Family requested move. In an interview on [DATE] at 1:00 PM, Resident # 15 was asked if she liked her new room and she stated she loved it. When asked if she felt safe on her new hall/unit and with her new roommate Resident #15 smiled and stated very safe. B. Review of a closed record Face Sheet for Resident #27 reflected she was [AGE] years old with an original admitted d of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS [DATE] for Resident # 27 reflected she was ambulatory without assistance, severe cognitive impairment, she was incontinent of bowel and bladder, and required assistance of one staff for all activities of daily living. Resident #27 had behaviors of physical aggression towards residents and staff. Resident throws things, kicks, and hits. Review of physician orders [REDACTED]. -[MEDICATION NAME] 2 mg. tablet every 12 hours as needed for agitation related to [MEDICAL CONDITION] Disorder-[MEDICAL CONDITION] -[MEDICATION NAME] Solution 5 mg./ml Inject intramuscularly every 6 hours as needed for severe agitation -[MEDICATION NAME] 1 mg. tablet every two hours as needed for agitation. Review of a care plan for Resident # 27 dated [DATE] reflected: -Focus: Resident exhibits physical aggression and abusive behaviors towards others. Resident throws things and directly kicks others. Residents and others are at risk for harm and not having their needs met in a timely manner. Behaviors are related to Dementia, Poor Impulse Control and ineffective coping skills. -Goal: Resident will not harm self or others. The resident will have fewer episodes of behavior and will communicate understanding of need to control physically aggressive behavior through the review date. -Interventions: Analyze of key time, places, circumstances, triggers, and what de-escalates behaviors and document. Modify Environment: Follow through with transfer to facility that can address and evaluate psychiatric and psychological needs. Review of a facility electronic incident report with a date and time of [DATE], 10:45 AM, reflected the following: -Resident (#27) was coming out of the dining room and another resident (#33) was yelling. Resident (#27) ran up on her (Resident #33) and grabbed her by the throat while screaming at her to shut up. As resident (#27) was moved away she grabbed another resident and became combative. [MEDICATION NAME] injection given. The incident was revised on [DATE] and reflected the following documentation under the section Agencies/People Notified: No notifications found. Review of electronic nurses' notes for Resident #27 dated [DATE] at 11:02 AM, reflected the following: Resident (#27) was strangling one resident (#33) was redirected and then she grabbed another resident by the arm and started dragging him. Resident (#27) then started punching/kicking. Verbal redirection ineffective. PRN [MEDICATION NAME] injection given. In an interview on [DATE] at 4:30 PM LVN X stated she was a charge nurse for the secure unit and knew Resident #27 well. LVN X stated Resident #27 would pace the halls of the secure unit and repeatedly slap her face and have frequent episodes of verbal and physical aggression, wh