Every finding on record at Cypress Springs Wellness & Rehabilitation

Based on observation, interviews, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 9 of 9 confidential residents reviewed for resident council. The facility failed to provide a private meeting area and ensure staff or visitors did not disturb the meeting. This failure could place residents at risk of not being able to voice concerns, fear of retaliation, and discomfort due to a lack of privacy. Findings include:During an observation on 08/18/26 at 10:30 a.m., a sign posted on the activity area doors stating a resident council meeting in progress. Do not enter.During a confidential group interview on 08/18/26 beginning at 10:34 a.m., LVN E walked through the doors on each side of the activity/dining room. The Medical Records staff walked in and had a blanket that she took to a resident. LVN E walked back through the meeting coming in one set of doors and exiting the other set across the room. During an interview on 08/18/26 at 10:38 a.m., 9 alert and oriented residents stated the resident council met in the activity/dining room. The residents stated they get interrupted all the time with everything, not just resident council meetings, but bingo etc. One resident stated he could not even play bingo because the staff comes through talking loud to each other and disrupting everything. He stated he just gave up on activities and went to his room. Residents stated the Activity Director placed a large sign at the entrance of both doors asking staff not to enter the area due to resident council being held, however, staff did not respect the sign. Record review of resident minutes dated 06/01/26-08/17/26 did not reflect any concerns with staff interrupting meeting. Record review of the grievance logs dated 06/01/26-08/17/26 did not reflect any concern regarding resident council meeting.During an interview on 08/18/26 at 10:56 a.m., Medical Records stated it was brought to her attention by the Business Office Manager, there was a resident sitting in the activity/dining area without any pants on. Medical Records stated she was not told there was a resident council meeting being held. Medical Records stated the Activity Director tried to stop her, but she was in a rush. Medical Records stated she did not pay attention to the sign on the door. Medical Records stated she was aware that staff had to be invited to come to the resident council meetings. Medical Records stated it was important to ensure the meeting was not interrupted because it was their right for privacy to be able to report any issues or concerns. During an interview on 08/18/26 at 11:02 a.m., LVN E stated she did not pay attention to the sign on the door the first time she came through the activity/dining area. LVN E stated the second time she was going back to her medication cart. LVN E stated she had been told many times throughout the years by different staff to not interrupt the resident council meeting. LVN E stated it was important to ensure the meeting was not interrupted to maintain their privacy and what they have to say. During an interview on 08/18/26 at 11:08 a.m., the Activity Director stated she had been employed at the facility since May 2026. The Activity Director stated the resident council was always held in the back of the activity/dining room. The Activity Director stated there was sign stating resident council Meeting in Progress. Do not enter please. The Activity Director stated she had only hosted two meetings and during those meetings staff went through the door interrupting the meeting. The Activity Director stated staff was redirected. The Activity Director stated she knew staff or visitors could only come to the resident council meeting if they were invited. The Activity Director stated it was important to ensure meetings were not interrupted to protect the residents' privacy. During an interview on 08/20/26 at 2:42 p.m., the DON stated she was aware of the two staff members coming into the resident council meeting without being invited. The DON stated she had spoken to the staff members to see why they interrupted the meeting. The DON stated Medical Records stated she did not know what was going on but she saw a resident without pants on and LVN E stated she thought it was an activity going on not an actual meeting. The DON stated it was important to ensure meetings were not interrupted to protect their rights. During an interview on 08/20/26 at 2:42 p.m., the Administrator stated she was not aware staff was interrupting resident council meetings until state surveyor intervention. The Administrator stated staff or visitors must be invited to attend the meetings. The Administrator stated there was not a system in place to ensure privacy. The Administrator stated it was important to ensure meetings were not interrupted to protect the residents' privacy and rights.Record review of the facility's policy titled Resident Rights revised 01/2026 reflected. To promote and protect the rights of all residents at the facility. the policy gave no relevant reference regarding resident council meeting privacy.

Based on interviews and record review, the facility failed to ensure residents had a right to personal privacy for 4 of 4 confidential residents reviewed for resident rights to receive personal mail. The facility did not ensure residents promptly received mail on Saturdays.This failure could place residents at risk with a decline in a resident's psychosocial well-being and quality of life.Findings include:During a confidential group interview at an undisclosed date and time, 4 residents stated they did not always receive their mail on Saturdays. The residents stated they had to wait until Monday when the Activity Director passed it out. During an interview on 08/18/26 at 11:08 a.m., the Activity Director stated she was unaware residents were not receiving their mail on Saturdays. The Activity Director stated the manager on duty was responsible for distributing mail to residents on Saturday. The Activity Director stated when she was the manager on duty, she did not deliver mail to residents on Saturday. The Activity Director did not know which mailbox belonged to the facility. The Activity Director stated there were times she delivered mail to residents from Saturday on Monday that was given to her by the Business Office Manager. The Activity Director stated it was important residents received their mail because it was their right. During an interview on 08/18/26 at 12:07 p.m., the Business Office Manager stated the locked mailbox was located outside. The Business Office Manager stated her and the Administrator were the only ones that had a key to the mailbox. The Business Office Manager stated she left the key with the manager on duty for that weekend. The Business Office Manager stated there were times mail was in the mailbox on Monday that should have been distributed on Saturday. The Business Office Manager stated it was important for residents to receive their mail because it was their right. During an interview on 08/20/26 at 12:54 p.m., the DON stated she was unaware residents were not receiving their mail on Saturdays. The DON stated she expected mail to be delivered on Saturdays. The DON stated she did not know a specific person who was responsible for checking the mailbox and distributing mail on the weekends. The DON stated it was important for residents to receive their mail because it was their right. During an interview on 08/20/26 at 2:42 p.m., the Administrator stated she expected mail to be delivered to residents on Saturdays. The Administrator stated the manager on duty was responsible for distributing mail on the weekends. The Administrator stated there was not a system in place to ensure mailbox would be checked and mailed passed out on Saturdays. The Administrator stated this failure could affect resident's rights. The policy provided by the facility gave no relevant reference regarding resident's promptly receiving mail.

Based on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 4 of 6 residents (Resident's #5, #25, #6, and #10) reviewed for accidents. 1.The facility failed to ensure Resident #5, and Resident #25 had fire retardant curtains in their rooms hanging on 08/17/26, 08/18/26 and 08/19/26. 2.The facility did not ensure aerosol and air freshener spray were not stored on Resident #6's dresser on 08/17/26, 08/18/26 and 08/19/26. 3.The facility failed to ensure Resident #10's room was free from Lysol and Febreze spray on 08/17/26. These failures could place residents at risk of injury. Findings included:1. Record review of Resident #5's face sheet, dated 08/20/26, reflected Resident #5 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included stroke, Anemia (a condition where your blood lacks enough healthy red blood cells or hemoglobin, impairing its ability to carry oxygen to your body's tissues),malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it actually consumes), dysphagia (difficulty or discomfort in swallowing), and high blood pressure. Record review of Resident #5's quarterly MDS assessment, dated 07/07/26, reflected Resident #5 made himself understood, and was understood by others. Resident #5's BIMs score was a 13 which indicated he was cognitively intact. The MDS indicated Resident #5 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and set up for eating.Record review of Resident #5's comprehensive care plan revised 05/17/26 reflected Resident #5 had potential risk for falls related to gait/balance problems, weaknesses, and poor safety awareness. The care plan interventions were for staff to anticipate the residents' needs.During an observation and interview on 08/17/26 at 8:59 a.m., Resident #5 was in bed with green sheer curtains hanging. Resident #5 said he was not aware what type of curtains were hung or if he needed certain types of curtains to be hung. During an observation on 08/18/26 at 11:23 a.m., Resident #5 had green sheer curtains hanging. During an observation and interview on 08/19/26 at 8:59 a.m., Resident #5 was in bed with curtains hanging. LVN A came into the room and verified curtains were hanging. She said she was not sure if the curtains were handing were fire retardant. She said she would go ask and let the surveyor know.2. Record review of Resident #25's face sheet, dated 08/20/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included stroke, heart failure (occurs when the heart muscle doesn't pump blood as well as it should), diabetes(high blood sugar), and muscle weakness.Record review of Resident #25's quarterly MDS dated [DATE] indicated she understood and was understood by others. The MDS indicated she had a BIMS score of 03 which meant she was severely cognitively impaired. The MDS indicated Resident #25 required assistance with her ADLs except with eating.Record review of Resident #25's comprehensive care plan last reviewed on 08/02/26, indicated Resident #25 had communication problems related to hearing deficit and history of a stroke. The interventions were for staff to anticipate and meet needs.During an observation on 08/17/26 at 11:35 a.m., Resident #25 had purple curtains hanging. During an observation on 08/18/26 at 9:33 a.m., Resident #25 had purple curtains hanging. Resident #25 said she was not aware what type of curtains were hanging but said her sister hung them at an unknown time. During an observation and interview on 08/19/26 at 8:59 a.m., Resident #5 and Resident #25 had curtains hanging. LVN A came into the room and verified curtains were hanging. She said she was not sure if the curtains were fire retardant. She said she would go ask and let this state surveyor know.During an observation and interview on 08/19/26 at 10:10 a.m., LVN A took Resident #5 and Resident #25's curtains down. She said she was told by management that the curtains were not fire retardant and should not be hanging because of the risk of fire.During an interview on 08/20/26 at 11:33 a.m., the Maintenance Supervisor said he was unaware that Resident #5 and Resident #25 had curtains hung in their rooms. He said when he was notified by LVN A he asked her to remove them because they were not fire retardant. He said he was responsible for the facility's safety. He said he made periodical rounds and had not noticed the curtains. He said if the curtains were not fire retardant and they had a fire in the facility those types of curtains could cause the fire to spread rapidly.3.Record review of Resident #6's face sheet, dated 08/20/26, reflected Resident #6 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory), stroke, and muscle weakness.Record review of Resident #6's admission MDS assessment, dated 05/18/26, reflected Resident #6 made himself understood and was understood others. Resident #6's BIMS score was 14, which reflected his cognition was intact. Record review of Resident #6's comprehensive care plan, revised on 05/15/26, reflected Resident #6 was at risk for falls related to psychotropic medication use. The care plan interventions included: anticipate needs and keep a safe environment.During an observation on 08/17/26 at 12:44 p.m., Resident #6 had an aerosol spray and air freshener spray which read, keep out of reach of children sitting on his bedside table.During an observation on 08/18/26 at 9:47 a.m., an aerosol spray and air freshener spray which read keep out of reach of children were sitting on Resident #6's bedside table.During an interview on 08/18/26 at 10:56 a.m., Resident #6 said he used aerosol spray and air freshener spray. He said he had not been told he could not have them in his room.During an interview and observation on 08/19/26 at 9:59 a.m., LVN A said all staff were responsible for ensuring items were stored properly and securely. LVN A said no residents should have aerosol spray or air freshener spray in their room. She said she had not noticed the items on Resident #6's table. LVN A said it was important to ensure items were not left on the resident table for all residents' safety. 4. Record review of Resident #10's face sheet, dated 08/19/26, reflected Resident #10 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #10's admission MDS assessment, dated 07/14/26, reflected Resident #10 made herself understood and understood others. Resident #10 had a BIMS score of 15, which reflected her cognition was intact.Record review of care plan dated 06/06/2026 revealed Resident #10 was at risk for falls related to vision problems. The intervention was for staff to anticipate and meet the residents' needs.During an observation on 08/17/26 at 11:36 a.m. Resident #10 had Lysol all-purpose cleaner (lavender &cotton blossom) and Febreze air mist (lilac sunrise).During an interview on 08/19/26 at 2:17 p.m., LVN A said all staff were responsible for ensuring items were locked and secured out of reach of the residents. She said she never noticed the items in Resident #10's bathroom. She said it was important to make sure things were properly stored and secured for resident safety. stored properly and securely During an interview on 08/19/26 at 2:16 p.m., the Dietary Manager said she conducted ambassador rounds daily except when she was caught up in the kitchen. She said her last rounds were Friday on 08/14/26. She said she did not see the items in Resident #5, #25, #6 or #10's room or bathroom. She said she had not made rounds this week. She said the items should not be in the facility for the residents' safety. During an interview on 08/20/26 at 2:17 p.m., the DON said all staff were responsible for ensuring items were stored properly and securely. She said the Maintenance Supervisor was responsible for ensuring residents did not have curtains hanging that were not fire retardant. The DON said she monitored rooms with random spot checks. The DON said it was important to ensure items were not left on the resident's table or non-retardant curtains were hung for residents' safety.During an interview on 08/20/26 at 2:47 p.m., the Administrator said she expected Lysol, aerosols sprays and Febreze air mist spray to be behind a locked door or not in the facility. She said all curtains should be fire retardant. She said the maintenance supervisor was supposed to do spot checks on things like curtains. The Administrator said she did random spot checks of rooms, but she expected ambassador rounds to be done daily by the assigned department head. The Administrator said it was important for residents' safety to ensure no items were left on the residents' table or in bathroom that were not safe, and to have fire retardant curtains hung. Record review of the facility's policy titled, Maintenance service, undated, revealed, Purpose: To protect the health and safety of residents, visitors, and Facility Staff. Policy: The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure: I. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner always. equipment in a safe and operable manner at all times. II. Functions of the Maintenance Department may include but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; B. Maintaining the building free from hazards. VIII. Maintenance Staff follow established safety regulations to ensure the safety and well-being of all concerned .

Based on interviews and record review, the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 6 (Resident #32) residents reviewed for psychoactive medications. The facility did not ensure written consent was obtained from the legal authorized representative to administer Zyprexa Oral Tablet 20 MG also known as Olanzapine for Resident #32. This failure could place residents at risk for receiving unnecessary antipsychotic medications without informed consent. Findings included: Record review of Resident #32's face sheet, dated 08/20/26 indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included Psychosis (a mental state where a person loses touch with reality), dementia (a decline in mental ability severe enough to interfere with daily life, encompassing memory loss, poor judgment, and communication changes) depression (sadness), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #32's quarterly MDS assessment, dated 05/23/26, indicated Resident #32 understood and was understood by others. Resident #32's BIMS score was 14, which indicated she was cognitively intact. The MDS indicated Resident #32 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and independent for eating. Resident #32 received antipsychotic medication during the 7-day look-back period. Record review of the comprehensive care plan, revised 08/02/26 indicated Resident #32 used psychotropic medications related to psychotic disorder. The intervention of the care plan indicated staff would give medication as ordered and would monitor/document for side effects and effectiveness. Record review of Resident #32's physician's orders, dated 1/14/26, indicated the resident had an order for Zyprexa Oral Tablet 20 MG (Olanzapine) Give 20 mg by mouth at bedtime related to psychotic disorder with delusions. Record review for Resident #32's medication administration record, dated 08/01/26 through 08/17/26, indicated she received Zyprexa Oral Tablet 20 MG (Olanzapine) Give 20 mg by mouth at bedtime related to psychotic disorder with delusions. Record review for Resident #32's consent form 3713 for use of psychotropic Zyprexa, give 20 mg by mouth at bedtime, was not documented in her chart. During an attempted interview on 08/19/26 at 9:50 p.m., Resident #32's family member did not answer the phone. During an interview on 08/19/26 at 9:55 p.m., Resident #32 said she was not aware of her medications but knew she took medication. During an interview on 08/19/26 at 10:04 a.m., the Medical Records staff brought the consent book, and it did not have form 3713 for Zyprexa signed for Resident #32. She said she let the DON know and she said she called the family member and he said he would come today (08/19/26) but she did not tell him what it was about. She said generally the nurse or DON handled that. During an interview on 08/19/26 at 11:49 a.m., LVN A said she was the nurse for Resident #32. She said consent should be obtained for all psychotropic medication before being given to allow the resident/responsible party an opportunity to decline or accept and to be aware of all possible side effects from the medications. LVN A said Resident #32 was given Zyprexa for her psychosis. She said Resident #32 was not able to sign form 3713 consents related to her cognition. During an interview on 08/20/26 at 2:18 p.m., the DON said consent should be signed before administering any psychoactive medication. The DON said one reason consent was obtained was to inform the residents/families about the risks and benefits before receiving medication. The DON said the charge nurse who received the order was responsible for obtaining consent, and she was the overseer. She said she was not aware Resident #32's form 3713 was not signed by the resident/or family member. The DON said failure to obtain the correct consent could cause the resident/ family not to have all the information about the medication or a choice about the resident's care. During an interview on 08/20/26 at 2:47 p.m., the Administrator said she expected the nurses to ensure the consent form was completed. She said she expected the DON or designee to ensure the HHSC Form 3713 was filled out correctly for psychotropic medications. The Administrator said consents should be done to inform residents/families of risks and/or benefits of medication or a choice to decline it. Record review of the facility's policy titled Psychotropic Medication Policy review date of 01/2025, indicated It is the facility's policy to implement the most desirable and effective intervention to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and or decreasing or negatively impacting the resident's quality of life. The licensed nurse will not administer the psychotropic medication until an informed consent form has been obtained and documented by the attending physician for the resident and or surrogate decision-making maker.

Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 residents (Residents #38) reviewed for baseline care plans. The facility did not include Resident #38's use of oxygen in her baseline care plan. These failures could place residents at risk of not receiving needed care and treatment.Findings Included:Record review of Resident #38's face sheet, dated 08/19/26, reflected Resident #38 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of upper lobe, right bronchus or lung (lung cancer). Record review of Resident #38's admission MDS assessment, dated 08/09/26, reflected Resident #38 made himself understood and understood others. Resident #38 had a BIMS score of 4, which reflected his cognition was severely impaired. During the 7-day look-back period the assessment did not reflect Resident #38 was not receiving oxygen. Record review of Resident #38's undated baseline care plan did not reflect oxygen use. Record review of Resident #38's physician order summary report, dated 08/19/26, reflected an active order for oxygen at 2L per minute via N/C every 12 hours as needed for SOB for comfort care with a start date of 08/06/26. During an interview and record review on 08/19/26 at 2:08 p.m., after reviewing Resident #38's electronic medical record, the MDS Coordinator stated RN F was responsible for ensuring oxygen was triggered because he was admitted with PRN oxygen orders. The MDS Coordinator stated it was important to ensure oxygen was triggered on the baseline care plan to make sure Resident #38 needs were met. During a telephone interview on 08/19/26 at 2:12 p.m., RN F stated the DON initiated the baseline care plan. RN F stated the DON asked her to go in and add Resident #38's weight and closed out the document. RN F stated she was not responsible for ensuring oxygen was triggered. During an interview on 08/20/26 at 12:54 p.m., the DON stated she expected oxygen to be care planned. The DON stated RN F should have ensured oxygen was triggered when she completed the assessment on admission. The DON stated she monitored baseline care plans by reviewing the care plans on the following day. The DON stated it could have been overlooked. The DON stated it was important to ensure oxygen was triggered on the baseline care plan because it was a communication with nursing staff about his care. During an interview 08/20/26 at 2:42 p.m., the Administrator stated she expected Resident #38's baseline care plan to include oxygen. The Administrator stated the DON or designee were responsible for monitoring and overseeing baseline care plans to ensure oxygen was noted. The Administrator stated it was important to ensure oxygen was triggered on the baseline care plan for coordination of care. Record review of the facility's policy titled, Care Planning, revised 06/2020, indicated, Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy Statement: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. II.Once the Baseline Care Plan is completed, the Facility must provide the resident and/or the resident's representative with a written summary of the Baseline Care Plan that includes: A. Initial goals of the resident, B. Summary of medications and dietary instructions, C. Services or treatments to be administered, D. Updated information based on completion of the Comprehensive Care Plan, as indicated, E. The Facility may choose to provide a copy of the Baseline Care Plan instead of a summary as long as it includes the required information. IV. The Baseline Care Plan will be updated to reflect changes in the resident's condition or needs occurring prior to the development of the Comprehensive Care Plan. VII. The medical record must contain evidence that the summary was given to the resident and/or resident's representative.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs, for 2 of 17 (Residents #6 and #10) residents reviewed for care plans.1. The facility failed to ensure Resident #10 was care planned for oxygen. 2.The facility failed to care plan medication for Resident #6 on 04/23/26 which included Hydroxyzine (for anxiety).These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. Record review of Resident #10's face sheet, dated 08/19/26, reflected Resident #10 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #10's admission MDS assessment, dated 07/14/26, reflected Resident #10 made herself understood and understood others. Resident #6 had a BIMS score of 15, which reflected her cognition was intact. Resident #10 received oxygen therapy. Record review of Resident #10's comprehensive care plan, dated 08/19/26, reflected Resident #10 had oxygen therapy related to dx of COPD. The care plan interventions included monitor for s/sx of respiratory distress and report to MD PRN, and oxygen settings via nasal prongs/mask at 2L as needed. Record review of Resident #10's physician order summary report, dated 08/19/26 reflected an active order for oxygen at 2L via N/C per minute every 12 hours as needed for oxygen with a start date 08/04/26. During an interview and record review on 08/19/26 at 12:02 p.m., the MDS Coordinator stated she had been in the role as an MDS Coordinator for two months. After reviewing Resident #10's electronic medical record, the MDS Coordinator stated she was responsible for ensuring oxygen was care planned. The MDS Coordinator stated the DON wrote the order for oxygen on 08/04/26 and the care plan should have been updated to reflect oxygen. The MDS Coordinator stated it was important the care plan address oxygen to ensure her needs were met. During an interview on 08/19/26 at 12:10 p.m., the Regional MDS Coordinator stated the collaboration of the MDS Coordinator, ADON, and DON were responsible for ensuring the care plan reflected oxygen. The Regional MDS Coordinator stated the care plan should have reflected oxygen at least by the net day of when the order was written. The [NAME] MDS Coordinator stated she monitored by weekly audits, but she could not recall if she reviewed Resident #10's care plan. The Regional MDS Coordinator stated it was important to ensure the care plan reflected oxygen because it reflected the care that was needed to provide for Resident #10. During an interview on 08/20/26 at 12:54 p.m., the DON stated she expected oxygen to be care planned. The DON stated the MDS Coordinator was responsible for ensuring the care plan reflected oxygen. The DON stated she monitored by random audits which would have been last Thursday (08/13/26). The DON stated she did not review Resident #10 care plan. The DON stated it was important to ensure Resident #10's care plan reflected oxygen to communicate with nursing staff about her care. During an interview on 08/20/26 at 2:42 p.m., the Administrator stated she expected Resident #10's care plan to reflect oxygen. The Administrator stated the DON, or designee, was responsible for ensuring oxygen was noted on the care plan. The Administrator stated it was important to ensure oxygen was care plan for coordination care. 2. Record review of Resident #6's face sheet, dated 08/20/26, reflected Resident #6 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included anxiety (feeling nervous, restless, or tense), dementia (loss of memory), stroke, and muscle weakness. Record review of Resident #6's admission MDS assessment, dated 05/18/26, reflected Resident #6 made himself understood and was understood others. Resident #6's BIMS score was 14, which reflected his cognition was intact. The MDS indicated he received antianxiety medications during the 7-day look back period. Record review of Resident #6's comprehensive care plan, last reviewed on 08/17/26, did not indicate medication of Hydroxyzine or anxiety care plan. Record review of Resident #6's physician orders dated 06/08/26 indicated Hydroxyzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 1 tablet by mouth at bedtime for antianxiety. Record review of Resident #6's medication administration record dated 08/01/26 through 08/17/26 revealed Resident #6 received: Hydroxyzine 25 MG, give 1 tablet by mouth at bedtime related to anxiety. During an observation and interview on 08/19/26 at 12:20 p.m., the MDS Coordinator said they worked on care plans as a team, but she was ultimately responsible. She looked in Resident #6's medical records and did not see a care plan for his hydroxyzine. She said it was an oversight as to why she missed care planning Resident #6's Hydroxyzine. She said care plans were done so the staff would know how to care for the residents. She said the risk could have been that the staff would not know he was on anxiety medication and for what to monitor. During an interview on 08/20/26 at 2:31 p.m., the DON said care plans were a team effort with the IDT. She said she and the MDS Coordinator were the overseers. She said they were made aware of any new orders or changes in the morning meetings and the electronic health records dashboard. She said care plans were done to direct and guide care of the residents. She said if care plans were not done properly, care could be missed. During an interview on 08/20/26 at 3:44 p.m., the Administrator said all disciplines should work together to complete a resident's care plan, but the MDS Coordinator was the overseer. She said care plans were the blueprint of residents' care. She said it was used so staff would know the care the residents needed. Record review of the facility's policy titled, Care Planning, revised 06/2020, indicated, Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy Statement: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. VIII.A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative. B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. X. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment, and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 2 residents (Resident #40) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #40. This failure could place residents at risk for declining and diminishing quality of life.Findings included: Record review of face sheet dated 08/19/2026 revealed Resident #40 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (CVA (cerebrovascular accident), stroke) and cognitive communication deficit (difficulty in communicating). Record review of care plan dated 12/02/2025 with the focus of communication problem related to CVA and stroke Resident #40 was unable to express thoughts at times. In the care plan it was listed for Resident #40 to use a communication board as visual for assistance with communication. Resident #40 was dependent on staff for meeting social needs with a goal to maintain involvement in cognitive stimulation and social activities. Record review of a Quarterly MDS dated [DATE] revealed Resident #40 was rarely or never understood by others and sometimes able to understand others. MDS assessment revealed Resident #40 had unclear speech. MDS indicated Resident #40 had an active diagnosis of communication deficit. Record review of BIMS assessment dated [DATE] revealed Resident #40 had a BIMS of 1 indicating severe cognitive impairment. Record review of order summary report dated 08/19/2026 revealed no order for a communication board for assistance with communication. Observation on 08/17/2026 at 11:10 a.m., revealed Resident #40 had no communication board for assistance with communication in Resident #40's room. Resident #40 was observed laying in bed awake looking at the television, which was frozen or paused, with a blank stare. When in Resident #40 room, Resident #40 did not smile often unless she was smiled at and did not have any spoken language. Interview on 08/17/2026 at 11:19 a.m., Resident #40 was unable to provide any information or converse in conversation when asked yes or no questions, detailed questions, or asked to point out wants and needs. Resident #40 did not vocalize any spoken words only sounds and was unable to make needs and wants known. Resident #40 did not point at the television, however, she just sat and stared when spoken to. Resident #40 shook her head in an unknown fashion in no particular response to conversation. Interview on 08/18/2026 at 10:20 a.m., CNA K revealed she did not use a communication board to communicate with Resident #40. CNA K stated she just used hand motions to point at objects, allowing Resident #40 to shake her head yes or no in regards to answering whether she wanted something or not. CNA K stated that Resident #40 had very little socialization and Resident #40 stayed in bed most days. Interview on 08/18/2026 at 10:30 a.m., LVN G stated he spoke to Resident #40 as if she spoke back, but she did not speak back. LVN G stated he does not use a communication board to communicate with Resident #40 for her daily care needs. LVN G stated due to Resident #40 not being able to communicate her wants and needs she was at risk of decreased quality of life. Interview on 08/20/2026 at 1:00 p.m., therapy revealed she felt Resident #40 needed a communication assistive device, but she does not have a communication board. Therapy stated that she was unsure why she did not have a communication board and was unaware that a communication board was in Resident #40's care plan. Interview on 08/20/2026 at 1:30 p.m., the DON revealed Resident #40 only used hand signals and shook her head. The DON stated Resident #40 was nonverbal and only used nonverbal cues by shaking her head yes or no. DON stated that Resident #40 was at risk of not receiving the care needed and meeting Resident #40's wants. DON stated she expected Resident #40 to have a communication board if it was on the care plan. DON stated she was at risk of decline and low quality of life. DON stated that she was not aware of why Resident #40 did not have a communication board. Interview on 08/20/2026 at 3:00 p.m., the Administrator, stated she expected Resident #40 to be provided with a communication device to meet and care for her activities of daily living. The Administrator stated Resident #40 was at risk not being able to communicate properly or if she needed something in an emergency. The Administrator stated that it was nursing responsibility to ensure that Resident #40 had a communication board to assist in her activities of daily living. Record review of facility's policy titled Resident Rights dated 1/2026, reflected. A facility must 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. The facility must protect and promote the rights of the resident. Be fully informed and participate in his or her treatment including being fully informed in a language that he or she can understand of his/her total health status including his/her medical condition; To ensure non-English-speaking residents an opportunity to convey their needs and preferences, facility staff with second language ability will be identified and utilized as interpreters on an as needed basis.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 2 residents (Resident #17) reviewed for quality of life. The facility failed to provide Resident #17 a shower on 08/15/2026 on his scheduled shower day. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life.Findings included: Record review of face sheet dated 08/19/2026 revealed Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of displaced fracture of medial condyle of left tibia (left lower leg break). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #17 had a BIMS score of 14. Assessment indicated Resident #17 was dependent on staff for shower or bathing him. Record review of care plan dated 06/26/2026 revealed Resident #17 had a focus area for ADL self-care performance deficit related to limited mobility with the goal to maintain current level of functioning personal hygiene. Record review of shower sheets dated 08/15/2026 revealed no shower documented for Resident #17 for his scheduled shower day. Observation and interview on 08/18/2026 at 11:20 a.m., revealed Resident #17 to be dressed in casual wrinkled clothing that had brown particles noted on his shirt with facial hair with a body odor. Resident #17 was up in his wheelchair watching television. Resident #17 stated he did not receive a shower on Saturday, although he was scheduled on Tuesday, Thursday, and Saturday. Resident #17 stated he went to dialysis on Monday, Wednesday, and Friday and he would like a shower at least three days a week. Resident #17 stated he was told there were not enough staff to give showers on Saturday. Resident #17 stated it was the heat of the summer and he frequently sweat and had wet clothes from riding to and from his appointments. Interview on 08/18/2026 at 1:45 p.m., CNA K revealed the only shower sheets available were the ones given daily. CNA K stated it was the nursing staff responsibility to give showers, notify the nurse if the shower was refused or not given. CNA K stated the shower sheet, and schedule book was located at north nurse station. Interview on 08/20/2026 at 1:30 p.m., attempted to call CNA L with no available voice mail recording. Interview on 08/20/2026 at 1:35 p.m., LVN G on duty stated the nursing staff scheduled were responsible for showers on each shift. Interview on 08/20/2026 at 2:15 p.m., LVN H stated she was the charge nurse responsible for ensuring showers were completed on Saturday 08/15/2026 but she was unsure who received showers on Saturday. LVN H stated CNA G was responsible for showering Resident #17. LVN H stated she could not recall what shower sheets were signed and she was not notified Resident #17 did not receive a shower when Resident #17 wanted one. LVN H stated she expected the CNA G to complete the showers who were scheduled for Saturday and to notify her if anyone was incomplete or refused to document the missed shower. Interview on 08/20/2026 at 1:58 p.m., the DON stated she expected CNA G to work to provide the shower. DON stated it was Resident #17's right to receive a shower whenever he wanted. DON stated she was unaware that Resident #17 wanted a shower more than twice a week. DON stated Resident #17 was at risk of poor hygiene and not meeting Resident #17 needs. Interview on 08/20/2026 at 3:02 p.m., the Administrator revealed Resident #17 should receive a shower at least once a week, offered a minimum of three times a week, and had the right to receive a shower at any time Resident #17 chose to have one with the assistance of needed nursing staff present. The Administrator stated that Resident #17 was at risk of uncleanliness and a reasonable person would want to be clean. Record review of Activities of Daily Living (ADLs) policy dated 01/2026 revealed The facility will ensure all residents receive the necessary services and support to maintain or improve their ability to perform ADLs, unless the resident(s)' clinical condition makes it nonviable. Definition: Activities of Daily Living (ADLs) include a. Bathing, b. Dressing, c. Grooming, d. Toileting, e. Transferring, f. Eating, and g. Mobility.

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences for 2 of 2 residents (Residents #10 and #22) reviewed for oxygen therapy. The facility failed to ensure Residents #10 and #22's oxygen concentrator filter was cleaned. This failure could place residents at risk for developing respiratory complications and a decreased quality of care.Findings include: 1. Record review of Resident #10's face sheet, dated 08/19/26, reflected Resident #10 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #10's admission MDS assessment, dated 07/14/26, reflected Resident #10 made herself understood and understood others. Resident #6 had a BIMS score of 15, which reflected her cognition was intact. Resident #10 received oxygen therapy. Record review of Resident #10's comprehensive care plan, dated 08/19/26, reflected Resident #10 had oxygen therapy related to dx of COPD. The care plan interventions included monitor for s/sx of respiratory distress and report to MD PRN, and oxygen settings via nasal prongs/mask at 2L as needed. Record review of Resident #10's physician order summary report, dated 08/19/26, reflected an active order to. clean filter every night shift every Sunday for oxygen with a start date 07/12/26. Record review of Resident #10's physician order summary report, dated 08/19/26, reflected an active order to. clean filter every night shift every Saturday for oxygen with a start date 08/01/26. During an observation and interview on 08/18/26 at 8:43 a.m., revealed Resident #10's oxygen concentrator filter had a thick, white, fuzzy material. Resident #10 stated she wore oxygen as needed for SOB. During an observation on 08/19/26 at 8:30 a.m., revealed Resident #10's oxygen concentrator filter had a thick, white, fuzzy material.2. Record review of Resident #22's face sheet, dated 08/19/26, reflected Resident #22 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #22's admission MDS assessment, dated 06/12/26, reflected Resident #22 made herself understood and understood others. Resident #22 had a BIMS score of 15, which reflected her cognition was intact. Resident #22 received oxygen therapy. Record review of Resident #22's undated comprehensive care plan, reflected Resident #22 had SOB related to hypoxia (deficiency in the amount of oxygen reaching the tissues). Record review of Resident #22's physician order summary report, dated 08/19/26, reflected an active order to. clean filter every night shift every Saturday for oxygen with a start date 08/08/26. During an observation on 08/18/26 at 9:30 a.m., revealed Resident #22's oxygen concentrator filter had a thick, white, fuzzy material. During an observation on 08/19/26 at 10:02 a.m., revealed Resident #22's oxygen concentrator filter had a thick, white, fuzzy material. During an interview on 08/19/26 at 10:05 a.m., LVN A stated the nurses on Sunday nights were responsible for changing/cleaning the filter. LVN A observed Resident #10 and #22's oxygen filter and stated, it's dirty. oxygen filter. LVN A stated it was important to ensure filters were cleaned to prevent a respiratory infection. During a telephone interview on 08/20/26 1:43 p.m., RN B stated she was Resident #10 and #22's 6p-6a charge nurse on 08/16/26. RN B stated she thought she had cleaned their filter. RN B stated it was important to ensure filters were cleaned to prevent a respiratory infection. During an interview on 08/20/26 at 12:54 p.m., the DON stated the nurse on the 6p-6a shift on either Saturday or Sunday was responsible for cleaning the filter. The DON stated she monitored by random spot checks. The DON stated she had noticed in the past and immediately verbally in serviced staff. The DON stated it was important that those tasks were completed to prevent a respiratory infection. During an interview on 08/20/26 at 2:42 p.m., the Administrator stated she expected oxygen filters to be cleaned every Sunday on the 6p-6a shift by the charge nurse. The Administrator stated the DON or designee were responsible for overseeing and monitoring. The Administrator stated it was important to ensure filters were cleaned to prevent a respiratory infection. Record review of the facility's Oxygen Administration, revised on 01/2026 reflected . to provide guidelines for the safe and effective administration of oxygen to prevent or reverse hypoxemia (low levels of oxygen in the blood) and ensure adequate tissue oxygenation. the policy gave no relevant reference regarding oxygen filters.

Based on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 1 of 12 residents (Resident #1) reviewed for behavioral health services. The facility failed to ensure Resident #1's physician orders for behavioral health services (psychological care services) were followed to ensure the resident was evaluated and treated for mental illness and behaviors. This failure could place residents at risk for diminished quality of life due to the lack of treatment and prevention to maintain resident safety.Findings included: Record review of face sheet dated 08/19/2026 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (decreased kidney functioning), anxiety (excessive worry), and mental disorder. Record review of care plan report dated 06/08/2026 revealed Resident #1 had the following focus areas:- diagnosis of anxiety with interventions to monitor behavior and report to MD side effects of medications. Care plan also had focus area for physical behaviors towards staff related to mental disorder and tremors with the intervention to provide physical and verbal cues to alleviate anxiety. - psychosocial well-being problem potential related to mental illness with the intervention to allow Resident #1 to answer questions, give him time to verbalize feelings perceptions and fears. - potential to demonstrate verbally abusive behaviors related to emotional illness with the intervention to intervene before agitation escalates. - Resident #1 resistive to care related to mental illness. - depression and antidepression medication with the intervention for psychiatric consult. Record review of comprehensive MDS dated [DATE] revealed Resident #1 had a BIMS of 02. MDS assessment revealed Resident #1 had behavioral symptoms of physical behaviors directed towards others and verbal behavioral symptoms directed towards others 1 to 3 days a week. MDS assessment indicated Resident #1 had an active diagnosis of mental disorder and anxiety. MDS assessment indicated he had severe mental illness. Record review of order summary report dated 08/19/2026 revealed order for psychiatric services to evaluate and treat including medication management started on 07/06/2026. Order for behavior monitoring every shift, interventions used and the outcome of the intervention with the start date of 08/01/2026. Record review on 08/20/2026 of electronic medication records revealed no visits documented by psychiatric services. Record review of progress notes dated 06/29/2026 revealed Resident #1 was screaming for help from the nurse and aid. The charge nurse documented she was unable to calm resident verbally and offered food for intervention. Documentation revealed PRN trazadone was given. Record review of psychiatric services referral consent was not signed until 8/19/2026. Observation and interview on 08/17/2026 at 11:01 a.m., Resident #1's call light was alarming as it had been pulled from the wall. Resident #1 was yelling at multiple staff to get out of his room, he did not need help and told them do not turn off the call light. Resident #1 said he felt the staff harassed him but he could not explain the situation. Resident #1 stated he wanted the facility to be investigated and felt that staff were out to get him. Resident #1 stated he could not describe any specific staff that had affected him or caused him anxiety. Resident #1 stated he just wanted to be left alone from the staff. Resident #1 appeared to be laying in his bed with the head of the bed elevated at 90 degrees with his eyes closed speaking. Resident #1 shook his head in an unhappy fashion when asked how his care was at the facility but was unable to describe his care in any other way. Observation on 08/17/2026 at 11:15 a.m., Resident #1 turned on call light repeatedly and staff were unable to determine Resident #1 wants or needs at the time. Resident #1 was verbally agitated yelling at multiple staff members to get out of his room. Interview on 08/18/2026 at 10:35 a.m., CNA K stated Resident #1 was verbally aggressive and physically resistant to ADL care and when she tried to turn his call light off. Interview on 08/19/2026 at 8:30 a.m., Resident #1 was on the call light, and it was revealed that CMA N stated Resident #1 frequently activated the call light, exhibited behaviors including yelling, resisted incontinent care and refused medications. CMA N stated that she felt he needed alternative placement. CMA N stated that his behaviors had been reported to the DON multiple times by several staff members. Interview on 08/19/2026 at 10:00 a.m., with LVN G revealed Resident #1 had behaviors ongoing since his admission to the facility. LVN G stated that Resident #1 had recently been sent to the hospital for psychiatric evaluation. LVN G stated that the nursing staff were instructed to speak to Resident #1 calmly in an in-services when it was reported to the DON of Resident #1 behaviors that were noted. LVN G stated that Resident #1 had been physically aggressive with him but had with other staff members but could not recall who. LVN G stated that Resident #1 was at increased risk of neglect, abuse and abuse to staff and other residents due to the lack of behavioral health services. Interview on 08/19/2026 at 10:30 a.m., the SW revealed she had not spoken to resident since he was admitted to the facility in May because she started in June. SW stated that Resident #1 was at risk of worsening mental health condition, and she believed it was important he was seen and referred to psychiatric services. SW stated that she was aware of Resident #1 behavior and concerned with the need for referral for psychiatric consultation, however, she had not completed one. Interview on 08/20/2026 at 1:30 p.m., the DON revealed Resident #1 went to the hospital in July for suspected psychosis. DON stated she was aware Resident #1 had gotten a new order for Lorazepam (antianxiety medication) for anxiety after his emergency room visit. DON stated she reviewed documentation which revealed that he still had behaviors. Interview on 08/20/2026 at 2:00 p.m., the DON stated she expected the staff to address Resident #1 behaviors and notify the doctor if no interventions were successful to de-escalate the behavior. DON stated that she was aware of Resident #1 behaviors. DON stated that she expected her staff to be in-serviced on how to address behaviors. DON stated that she believed a psychiatric referral would be beneficial. DON stated Resident #1 behaviors put him at risk of abuse. Interview on 08/20/2026 at 3:03 p.m., the Administrator stated Resident #1 would have benefited from psych services since admission to the facility and was unaware why it had not been completed prior to the signed psychiatric consult date. Administrator stated Resident #1 was at risk of abuse or abusing other residents. Administrator stated the DON was responsible for ensuring proper services were provided. The Administrator stated the SW and DON should have collaborated in the daily morning meeting and care plan. Administrator stated she expected the DON to address Resident #1 behaviors and contact the provider for evaluation and treatment to ensure Resident #1 had the highest level of psychosocial well-being in the facility. Record review of Behavior - Management policy dated 01/2026 revealed To ensure that Facility Staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implements appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 3 controlled substance medications reviewed for pharmacy services. The facility failed to ensure an accurate system was maintained to account for and reconcile 1 controlled substance medication (Lorazepam). This failure could place residents at risk of not having medications available for use, medications errors, drug diversions, and inaccurate records. Findings included: Observation on 08/20/2026 at 8:35 a.m., of the narcotic refrigerator revealed an unopened vial of Lorazepam IV Injection 2mg/ mL(anti-anxiety medication) inside the nurse medication room. The Lorazepam was assigned to the facility and was untampered with. Interview on 08/20/2026 at 8:40 a.m., LVN A revealed she was not aware of the Lorazepam that was locked inside the fridge when she unlocked the narcotic lock for observation. LVN A found the unopened Lorazepam and stated she did not do a narcotic count sheet for this vial that was located in the refrigerator. LVN A stated that the Lorazepam was supposed to be reconciled to prevent drug discrepancies. LVN A stated she was unsure when pharmacy had visited last, but stated that often medications were delivered on the night shift and put away at night. LVN A stated she was unable to provide documentation of when the Lorazepam had been delivered by the pharmacy and what its purpose was. Record review on 08/20/2026 at 8:45 a.m. both of the nurse cart narcotic count book revealed no narcotic sheet labeled for Lorazepam that was located in the refrigerator. Interview on 08/20/2026 at 8:50 a.m., the DON stated she believed the Lorazepam, that was locked in the refrigerator, was supposed to be in the pharmacy's locked e-kit (emergency medication kit) box that required a code for entry. Interview on 08/20/2026 at 1:35 p.m., the Pharmacist stated the facility was at potential risk for drug diversion when controlled substance medications are not reconciled. The Pharmacist stated she had monthly visits when she checked the refrigerator for controlled substances to be reconciled. The Pharmacist stated she was responsible for checking the refrigerator each audit to ensure there was no drug diversions only once a month. The Pharmacist stated it was unlikely that the controlled substance medications could be stolen. The Pharmacist stated she completed a monthly audit for facility accuracy of records but did not identify a specific number of controlled substances she reviewed. The Pharmacist could not confirm when the Lorazepam was delivered or who delivered it. Interview on 08/20/2026 at 2:09 p.m., the DON stated the facility was at risk of drug diversion because the nursing staff were not reconciling the Lorazepam that was located in the refrigerator. The DON stated that she expected the process of receiving a narcotic drug was for the nurse on duty to call pharmacy as soon as they received the narcotic that required refrigeration to receive a code to open e-kit, and after the narcotic was stored, for the ekit to be locked back. The DON stated that if the pharmacy brought the Lorazepam during the monthly routine audit, she expected them to place the Lorazepam in the ekit. The DON stated she expected staff to check the refrigerator daily for any and all medications for expiration, refrigerator temperature, ensuring it was locked, and signing the tracking report and reconcile all narcotic medications. Interview on 08/20/2026 at 3:06 PM, the Administrator stated she was unaware of the lorazepam that was in the locked refrigerator that belonged in the e-kit. The Administrator stated the medication was at risk of drug diversion. The Administrator stated she expected whoever received the Lorazepam to follow procedures, including contacting the pharmacy to ensure it was locked properly in the ekit in the refrigerator. The Administrator stated the DON was responsible for pharmacy services and the DON was responsible to notify her when a pharmacy event occurred. Record review of the facility's Medication Storage policy dated January 2026 revealed controlled substance storage (schedule II) 1. Schedule II medications must be stored in a separately locked, permanently affixed compartment within the medication cart or medication room. 2. This compartment must: 3. be non-removable 4. Use a separate key or combination lock 5. Be assessable only to authorized personnel 6. Controlled substances must be counted and reconciled per facility-controlled substance policy.

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 6 residents (Resident #5) reviewed for laboratory services. The facility failed to ensure Resident #5's Complete Blood Count also known as CBC ( a common blood test that evaluates overall health and detects various disorders, such as anemia, infection, and leukemia) was drawn every month as ordered, and magnesium ( a test that measures the level of the mineral magnesium in your blood to check nerve and muscle function, electrolyte balance, or kidney health) level was drawn every Monday as ordered by the physician.These failures could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. Findings included:Record review of Resident #5's face sheet, dated 08/20/26, reflected Resident #5 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included stroke, Anemia (a condition where your blood lacks enough healthy red blood cells or hemoglobin, impairing its ability to carry oxygen to your body's tissues),malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it actually consumes), dysphagia (difficulty or discomfort in swallowing), and high blood pressure. Record review of Resident #5's quarterly MDS assessment, dated 07/07/26, reflected Resident #5 understood, and was understood by others. Resident #5's BIMs score was a 13 which indicated he was cognitively intact. Record review of Resident #5's comprehensive care plan revised 05/17/26 reflected Resident #5 had potential fluid imbalance related to gastrostomy tube (a medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids, and medications when eating by mouth is not safe or possible), impaired cognition, and disease process. The care plan interventions were for staff to obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated.Record review of Resident #5's physician's orders dated 08/03/26 indicated lab, CBC with differential every month on Monday starting on 08/03/26. Report to the physician if lab out of range.Record review of Resident #5's physician's orders dated 08/01/26 indicated lab, Magnesium level to be drawn every Monday starting on 08/03/26. Report to the physician if lab out of range.Record review of Resident #5's electronic medical record did not indicate Resident #5 had a CBC drawn since labs were ordered 08/03/26.Record review of Resident #5's electronic medical record did not indicate Resident #5 had a Magnesium level drawn since labs were ordered 08/03/26.During an interview on 08/20/26 at 8:29 p.m., LVN A said when labs were ordered, the nurses completed the orders in the electronic system, and the lab drew them. She said they placed the new order on the 24-hour report for the nurses to follow up. She said she did not know if they had a monitoring system for the labs process. She said she was not aware of Resident #5 missing any labs. She said the failure to follow up on labs could potentially cause the residents to miss a medication or something else they might need.During an interview on 08/20/26 at 1:30 p.m., the MDS Coordinator looked in the electronic medical records system, and did not see the most recent lab that should have been ordered, but saw the most recent order dated 08/03/26 for Magnesium to be drawn every Monday, and CBC to be drawn on 08/03/26. She said the last Magnesium was drawn on 8/3/26, and the last CBC was drawn on 5/19/26. She said they should follow the physician's orders.During a phone interview on 08/20/26 at 1:31 p.m., the facility's physician said he expected labs to be done as ordered. He said he could not recall why the lab was ordered for Resident #5, but knew CBC and Magnesium were for monitoring anemia and other systems in the body. During an interview on 08/20/26 at 2:18 p.m., the DON said she expected labs to be drawn as ordered by the physician's order. The DON said the nurses were responsible for putting the order in the electronic system and placing on the 24-hour report. She said the lab provider was responsible for coming the next day to draw the lab. She said nurses could see any pending lab on their electronic system. She said she monitored the labs daily by reviewing their electronic system. The DON said she was not aware Resident #5 had missed labs. The DON said it was important to ensure labs were drawn as ordered by the physician to ensure the resident's health was monitored by those lab values.During an interview on 08/20/26 at 2:47 p.m., the Administrator said she expected labs to be drawn as ordered. She said the nurses were responsible for filling out the lab slip and following the physician's orders. She said nurse management were responsible for ensuring lab had been drawn as ordered. The Administrator said it was important for labs to be drawn as ordered by the physician for the welfare of the resident's health. Record review of the facility's policy titled Laboratory, Diagnostic and Radiology Services, dated January 2026, indicated, .to ensure that laboratory, diagnostic, and radiology services are provided in a timely, safe, and effective manner to meet residents' medical needs in accordance with evidence-based practice guidelines and regulatory requirements. Procedure: I. Ordering and Documentation A. All laboratory, diagnostic, and radiology orders must be documented in the electronic health record (EHR) to facilitate timely coordination and review of results. Ill. Notification and Follow-Up of Results: C. Documentation: The Licensed Nurse will document the time when results were reported to the ordering practitioner and the ordering practitioner's response or additional orders, if any.

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards of food safety in 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure [NAME] A properly wore her hair restraint while preparing food in the kitchen on 08/17/26.This deficient practice could place residents at risk for food contamination.Findings include:During an observation on 08/17/26 at 10:03 a.m., during initial kitchen rounds, [NAME] A was not wearing her hair restraint properly, ensuring she covered all her hair, while she was preparing and cooking food. During an interview on 08/17/26 at 11:00 a.m., [NAME] A said all kitchen staff were responsible for wearing hair restraints while in the kitchen. [NAME] A said her ears were bothering her so she moved her hairnet off her ears therefore causing her hair to be out of the hair net. [NAME] A said if hair nets were not worn properly, then hair could fall in the resident's food.During an interview on 08/17/26 at 11:10 a.m., the Dietary Manager said anyone working, or being in the kitchen area, was expected to wear appropriate hair restraints such as hair nets. She said hair nets should cover all parts of the staff's hair. She said she was responsible for ensuring staff was wearing their hairnets properly. She said the risk was hair could get into the food while being prepared or served.During an interview on 08/20/26 at 12:48 p.m., the Dietitian said all staff should wear hair nets while in the kitchen. She said the Dietary Manager was responsible for ensuring staff were following policies and procedures regarding hair restraints. She said the negative consequences of not wearing hair restraints was that hair could fall into the resident's food.During an interview on 08/20/26 at 2:22 p.m., the DON said everyone that entered or worked in the kitchen should have a hairnet. She said hairnets were worn to prevent hair from getting in the food. She said the Dietary Manager was the overseer of the kitchen.During an interview on 08/20/26 at 2:47 p.m., the Administrator said he expected the kitchen staff to follow the policy. The Administrator said the Dietary Manager was responsible for monitoring and overseeing the kitchen. She said if someone did not have proper protection (hairnet/beard guard) they could potentially get hair in the food. Record review of the facility's policy titled, Kitchen Sanitation revised January /2026, indicated, Purpose: To maintain the highest standard of cleanliness and sanitation in the facility's kitchen and food service areas, ensuring the safety and well-being of our residents by preventing foodborne illness and complying with all state, local, and federal regulations. Policy: This policy applies to all staff in the dietary department, including dietary managers, cooks, dietary aides, registered dietitians, and any other staff or contractors working in or around the kitchen area. Procedure: I. Staff Hygiene: All kitchen staff must: C. Hairnets while in the kitchens, beard guard when needed, may where a cap with a hair net under a cap

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food and nutrition. (Resident #43 and Resident #44).The facility failed to ensure the refrigerator for Resident #43 and Resident # 44 did not contain expired food.This failure could place residents at risk for food borne illnesses.Findings included:1. Record review of Resident #43's face sheet dated 08/19/2026 indicated he was a 86- year-old male who admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease with Early Onset (signs may include memory loss, confusion, trouble with familiar tasks, mood changes, and language problems), depression (a type of mood disorder where you feel sad, hopeless, or irritable most of the time for at least two weeks, and it interferes with daily life), anxiety, chronic obstructive pulmonary disease (long-term lung condition that makes it harder to breathe because the airways and air sacs in your lungs are damaged), difficulty in walking, lack of coordination, and repeated falls. Record review of Resident #43's MDS assessment dated [DATE] indicated that he had a BIMS score of 10 which meant he had moderately impaired cognition. The MDS also indicated the resident required assistance of 1 staff for bed mobility, transfers, toileting, eating, and bathing. During an interview and observation on 08/17/2026 at 12:45 PM, Resident #43 stated his family would bring food in and put it in the refrigerator for him. The refrigerator contained 2 pepperoni and cheese Lunchables that expired June 27, 2026, 3 ham and cheese Lunchables that expired August 11, 2026, and 2 protein pack Lunchables with cheese and walnuts that expired July 16, 2026. Resident #43 stated he last ate anything out of that refrigerator two months ago. He stated he had not felt bad afterwards, and he remembered eating cheese and some kind of meat. Resident #43 stated staff members looked in the refrigerator all the time and then wrote something on the paper that was posted on the outside of his refrigerator.During an observation on 8/18/26 at 9 AM, Resident #43's refrigerator, in his room, still contained expired items (2 pepperoni and cheese Lunchables that expired June 27, 2026, 3 ham and cheese Lunchables that expired August 11, 2026, and 2 protein pack Lunchables with cheese and walnuts that expired July 16, 2026). 2. Record review of Resident #44's face sheet dated 08/19/2026 indicated she was an [AGE] year-old female who admitted on [DATE] with the diagnoses of diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), dysphagia (difficulty swallowing), dementia (the loss of cognitive functioning that interferes with daily life and activities), anxiety (persistent, excessive fear or worry that interferes with daily life, characterized by symptoms like rapid heart rate, dizziness, restlessness, and insomnia), depression (a serious, common mood disorder causing persistent sadness, loss of interest, and physical symptoms that impair daily life), and macular degeneration (an eye disease that affects central vision and people with macular degeneration can't see things directly in front of them).Record review of Resident #44's MDS assessment dated [DATE] indicated that she had a BIMS score of 15 which meant she had normal cognitive status. The MDS also indicated the resident required moderate assistance of 1 staff for bed mobility. She required maximum assistance of 2 staff with transfers, toileting, dressing, bathing and resident was independent with eating. During an interview and observation on 08/17/2026 at 11:13 AM, Resident #44 said her family brought food to her when they visited. She said that different staff checked inside of her refrigerator daily and wrote the temperature on the side of the refrigerator on a piece of paper. The refrigerator contained [NAME] and [NAME] Butter that expired May 24, 2026, and 1 Chocolate and Vanilla Snack Pack best by March 9, 2026. Resident #44 said she had not used the butter in over a month and it had been two months since she ate any pudding out of the refrigerator. Resident #44 said she did not feel bad after eating the items and her stomach had been fine.During an interview on 08/19/2026 at 10:50 AM, CNA D said the housekeeping department was responsible for checking resident refrigerators. She said she had not noticed the refrigerators being checked on a regular routine. During an interview on 08/19/2026 at 10:58 AM, LVN A stated that it was the responsibility of the nursing department on the 6PM to 6AM shift to check the refrigerator temperatures, and to check for expired food. LVN A said that spoiled food could cause the residents to become sick in some situations.During an interview on 08/20/2026 at 1:50 PM, the DON said that she was also the Infection Preventionist and she was responsible for ensuring that no expired items were in the refrigerators. She said that residents could be placed at risk of foodborne illness or an upset stomach if they ate expired food and could lead to hospitalizations. She said she expected staff to clean out expired food from the personal refrigerators of all residents, and to ask the residents for their permission prior to discarding any expired items.During an interview on 08/20/2026 at 2:50 PM, the Administrator said it was the responsibility of the hallway Ambassador to check daily Monday through Friday, and make sure items were not expired in personal refrigerators in the resident rooms. She said the Ambassador had a checklist, and that task was part of the checklist. She said the charge nurse on the hallway should have also been checking to ensure that there were no expired items. She said the DON, or designee, should monitor at least weekly that the ambassador sheets were checked off for all residents and signed by theperson responsible for ambassador rounds. The Administrator said the DON or designee should spot check the personal refrigerators weekly. She said that residents could get sick if they ate expired food.Record review of the facility's policy, titled Residents Personal Refrigerator dated 1/2026, indicated . Facility Staff will monitor the resident refrigerator weekly.facility designated staff will check individual food items for expiration dates and discard outdated food promptly from the residents' refrigerators clean and remove expired food as needed .

Based on interview and record review, the facility failed to maintain medical records in accordance with the accepted professional standards and practices that are complete and accurately documented for 1 of 1 (Resident #35) residents reviewed for administration. Resident #35's EMR did not contain complete and accurate documentation that reflected room changes completed from 06/2026-08/2026. This failure could result in the resident or responsible party not being notified of room change or notified of the reason for room changeThe findings included: Record review of Resident #35's face sheet dated 08/17/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included Dementia (a term for decline in memory, language and other thinking skills that interfere with daily life), anemia (a medical condition where the blood lacks healthy red blood cells to carry oxygen to the body's organs), diabetes type II (a chronic condition where the body resists insulin causing sugar to build up in the blood), hyperlipidemia (elevated cholesterol levels), hypertension (high blood pressure), ASCHD (a condition where fatty plaque build-up in the arteries and restricts blood flow), and MDD (pervasive sadness that intrudes upon daily life). Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed Resident #35 had no hearing, vision, or communication deficits, was understood by others and understood others with a BIMS score of 15 which indicated intact cognition. Resident #35 required the use of a wheelchair for mobility, set-up assistance in eating and was totally dependent on staff for toileting, bathing, dressing, bed mobility and transfers. Record review of Resident #35's census record revealed room changes occurred on 06/19/2026 and 07/02/2026. Record review of Resident #35's EMR, which included progress notes, assessments and miscellaneous documents, revealed no documentation that the resident or responsible party was notified of the room changes or the reason for the room changes. During an interview on 08/17/2026 at 2:17 p.m., Resident #35 stated that he was notified by the Maintenance Supervisor that he would have to move to a different room while the renovations took place but was unable to recall the exact date of this notification. Resident #35 stated he was notified of the room change for the renovations about 1 1/2 week before he was moved, and he was moved back to his current room once the renovations were completed. During an interview on 08/18/2026 at 7:47 a.m., the Social Worker stated she was not aware of the facility guidelines for room changes, but that she would talk to the resident or the responsible party if a room change was necessary. The Social Worker stated she only worked part-time at the facility and assumed the nursing staff spoke with the resident or the responsible party if she was not present. The Social Worker stated that because of the renovations, the facility had been temporarily relocating the residents while their room was being renovated, and upon completion, returned the resident to their original room. The Social Worker stated she did not feel it was necessary to document temporary room changes, and that she would complete a Room Change Assessment if the room change was a permanent change. The Social Worker stated that Resident #35 had already returned to his permanent room when she began to work at this facility, and he had not mentioned a concern to her about room change notification. During an interview on 08/18/2026 at 2:00 p.m., the Maintenance Supervisor stated he recalled notifying Resident #35 that he would be moved because they were getting ready to renovate his floor and repaint the room, but could not recall the exact date. The Maintenance Supervisor stated he tried to give the residents a few days' prior notice to prepare them for the pending room change. The Maintenance Supervisor stated that to his knowledge, the medical staff completed any required documentation to reflect the room changes. During an interview on 08/18/2026 at 3:39 p.m., the DON statedt she expected the Social Worker to discuss the room change with the resident or the responsible party and to document the notification and reason for the room change. The DON stated if a room change occurred when the Social Worker was not working, then an administrative staff member should complete the notification and facility required Room Change Assessment. The DON stated no residents were moved without their consent, and to her knowledge, no resident required a 5-day notice of intent to move because they all agreed to the moves or the move was at their request. During an interview on 08/18/2026 at 4:30 p.m., the Administrator stated that she was not aware that the Social Worker had not completed the Room Change Assessment for resident room changes or documented the room changes in the EMR. The Administrator stated it was important for room changes to be documented in the EMR to ensure accurate records and to ensure that Residents' Rights were not being violated. The Administrator stated each department was responsible for the accuracy and completeness of the medical records, and she is ultimately responsible for ensuring documentation accurately reflects the resident. The Administrator stated that to her knowledge, no residents were moved without their consent and prior verbal notification. Record review of the facility's policy titled, Room or Roommate Change, Operational Manual - Social Services, Revised January 2026, revealed Procedure II A., when the resident is being moved at the request of the Facility, the notice of a change in room assignment will be in writing and will include the reason(s) for such change., and VI., Information regarding room transfers will be documented in the resident's medical record.

Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #37, and Resident #4) reviewed for administration.The facility failed to maintain Resident #37's and Resident #4's hospice binder with form 3074 (Texas Medicaid Physician Certification of Terminal Illness form. In which a doctor used it to state that a patient has a terminal illness with a life expectancy of six months or less).This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included:1. Record review of Resident #37's face sheet, dated 08/20/26, reflected Resident #37 was an [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability that interferes with daily life), Osteomyelitis (an infection and inflammation of the bone and bone marrow), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life).Record review of Resident #37's significant change MDS assessment, dated 05/27/26, reflected Resident #37 understood, and was understood by others. Resident #37 BIMs score was a15 which indicated he was cognitively intact. The MDS indicated Resident #37 was on hospice services. Record review of Resident #37's comprehensive care plan revised 07/09/26 indicated Resident #37 had a terminal prognosis and was on hospice services. The intervention was to adjust provisions of ADLS to compensate for residents' changing abilities, encourage participation to the extent the resident wishes to participate, assess resident coping strategies and respect resident wishes, and consult with physicians and Social Services to have Hospice care for residents in the facility.Record review of Resident #37's physician orders dated 05/21/26 indicated an order for hospice.Record review of Resident #37's hospice binder on 08/20/26 at 11:09 a.m., revealed it did not have the Physician certification of the terminal illness, form 3074.2. Record review of Resident #4's face sheet, dated 08/20/26, reflected Resident #4 was an [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability that interferes with daily life), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life).Record review of Resident #4's quarter MDS assessment, dated 07/28/26, reflected Resident #4 understood, and was understood by others. Resident #4 BIMs score was a12 which indicated she had moderate cognitive impairment. The MDS indicated Resident #4 was on hospice services. Record review of Resident #4's comprehensive care plan revised 07/09/26 indicated Resident #4 had a terminal prognosis and was on hospice services. The intervention was to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met.Record review of Resident #4's physician orders dated 03/27/26 indicated an order for hospice for senile degeneration of the brain.Record review of Resident #4's hospice binder on 08/20/26 at 11:09 a.m., revealed it did not have the physician certification of the terminal illness (form 3074).During a phone interview on 08/19/26 at 10:58 a.m., the hospice nurse said the binders at the facility should contain supporting notes or documentation needed for Resident #37 and Resident #4. She said the binder should at least have the face sheet, election form, code status, certification of terminal illness, plan of care, and medications. She said they meet every two weeks on Monday for the Interdisciplinary group meetings and said the documentation should be updated at least the following week after the Interdisciplinary group meetings. She looked at the office's records, and said Resident #37's and Resident #4's last Interdisciplinary group meeting was 08/10/26. She said the recertification should also be in the facility's chart the week of the termination of the recertification period. She said they both should have the last termination in their chart. She said once a resident comes on hospice service it should be delivered to the facility within 72 hours and once on services it should be updated every 90 days. She looked and did not see Resident #37's nor Resident #4's physician terminal illness form 3074. She said she would bring over the information to the facility and place it in the resident's binder. She said it was important to have the binders at the facility updated to help the facility know the care and services the hospice staff were providing. During an interview on 08/19/26 at 10:39 a.m., LVN A said she was not sure of all the information that needed to be included in the hospice binder. She said she thought the hospice binder should include the name of the hospice, diagnosis, face sheet, and code status. She said management was responsible for ensuring the hospice binders were updated. She said any information the hospice company had for Resident #37 should be at the facility for effective communication because their care was combined. During an interview on 08/20/26 at 2:17 p.m., the DON said she expected the hospice binders or electronic medical records to be updated with all required material. She said the terminal form should be in the hospice binder or electronic medical record. She said hospice should correlate with the facility nurses to see about any changes in resident care. She said she was responsible for ensuring the hospice binder or electronic medical records were updated. She said she reviewed the resident's charts periodically, but was not aware Resident #32 nor Resident #4 did not have all required information in the binder or electronic medical records. She said the risk could be miscommunication on care between hospice and the facility.During an interview on 08/20/26 at 2:47 p.m., the Administrator said any information the hospice company had should be updated in the facility's hospice binder or electronic medical records. She said she expected all information needed to be in the hospice binder or electronic medical records. She said the DON was responsible for ensuring all hospice documents were up to date. She said the binder or electronic medical records should be updated for effective communication and continuity of care. Record review of the facility's policy titled End of Life Care, dated 01/2026 indicated To provide a process to assist the resident in fulfilling their spiritual, physical, and emotional needs, and to provide emotional support to families of residents with a terminal illness. VI. Coordination with Hospice A. If Hospice care is involved, the residents' plan will reflect hospice interventions. B. Social Services Staff will coordinate with Hospice Staff to ensure that the resident's needs are communicated to the Hospice.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, reviewed for physical environment. The facility failed to secure loose baseboard in the kitchen as observed on 08/17/26 and 08/20/26.This failure could put the facility at risk of falls or an unsafe environment. Findings included During an observation on 08/17/26 at 10:03 a.m., during initial kitchen rounds, it was revealed that the baseboard in the storage room had come loose and was hanging away from the wall.During an interview on 08/17/26 at 11:10 a.m., the Dietary Manager said she noticed the baseboard in the storage room had come loose and was hanging away from the wall last week. She said she had not reported it to the Maintenance Supervisor. She said she was supposed to fill out a work order and report any maintenance problems to the maintenance supervisor. She said she would report it today (08/17/26).During an observation on 08/20/26 at 11:30 a.m., the baseboard in the storage room was still loose and hanging from the wall.During an interview on 08/20/26 at 11:45 a.m., the Maintenance Supervisor said he was not aware of the baseboard in the storage area being loose from the wall. He said if the kitchen had an issue, they were supposed to enter the information into their reporting system. He looked in the system and said he did not have a work order for the baseboard in the storage area of the kitchen.During an interview and observation on 08/20/26 at 12:45 p.m., the Dietitian said she was not aware of any baseboard peeling in the storage room in the kitchen. The Dietitian was shown the baseboard peeling away from the wall in the kitchen's storage room, and she said the Dietary Manager should have filled out a work order when she noted that the baseboard was peeling away from the wall. She said it was important for all things in the kitchen to be in proper order and function for safety reasons.During an interview on 08/20/26 at 2:18 p.m., the DON said she expected staff to report any building issues to the maintenance man. She said staff were supposed to write about any issues in the reporting system as soon as they saw them. She said if the baseboard remained loose, moisture could get in and lead to mold. During an interview on 08/20/26 at 2:47 p.m., the Administrator said she did not expect the baseboard to be loose in the facility including the kitchen area. She said she expected staff, when they saw any issues such as baseboards being loose, to fill out a work order. She said the Maintenance Supervisor was the overseer of the building repairs. She said it was important to have a safe and homelike environment.Record review of the facility's policy titled, Maintenance Work Order, revised 01/2026, revealed, Policy: All maintenance work must be documented and managed through formal work orders in TELS (Platform by Direct Supply) to ensure timely and proper completion, enabling effective oversight of the Maintenance Director's performance and accountability for all assigned tasks.Record review of the facility's policy titled, Maintenance service, undated, revealed, Purpose: To protect the health and safety of residents, visitors, and Facility Staff. Policy: The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure: I. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner always.

Based on observation, interview, and record review, the facility failed to establish policies regarding smoking areas, and smoking safety for 1 of 1 smoking area. 1. The facility failed to provide an unlocked, designated red metal receptacle with a self-closing cover for safe disposal of cigarette butts removed from metal ashtrays. 2. The facility did not ensure the designated metal ashtray was fully functional and equipped with a self-closing cover, as the ashtray was broken with missing metal, and staff placed trash in the ashtray containing cigarette butts, creating a potential fire hazard. This failure could place residents and staff at risk of fire and burn injury.Findings included: Observation on 08/19/2026 at 1:30p.m., during the scheduled smoke break, revealed there was a red receptacle with a lock on it. There were two self-closing ashtrays with trash in them (paper from empty cigarette container), and one self-closing ashtray that was broken with missing metal and not fully functional. Interview on 08/19/2026 at 1:35 p.m., the [NAME] stated she was responsible for the 1:15 p.m. smoke break. The [NAME] stated that she was not aware what the red receptacle was used for and did not have a key to unlock it. The [NAME] stated that she just worked in the kitchen and was not trained in smoking. The [NAME] stated that she put trash in the self-closing ashtrays because there was nowhere else to put it, and no trash can was located in the designated smoking area. The [NAME] stated there was a risk of fire with putting the cigarette butts and trash in the same receptacle. Interview on 08/19/2026 at 1:40 p.m., LVN G stated he assisted the [NAME] with smoke breaks. LVN G stated that the [NAME] was responsible for disposing of the trash in the trash can that was located outside of the designated smoking area to prevent fire risk. LVN G stated there was not supposed to be paper products in the cigarette butt ashtray receptacle. LVN G stated that there was no training on smoke breaks and the procedures to take to prevent a fire. Interview on 08/19/2026 at 2:55 p.m., the Maintenance Director stated he was not aware of the use of the red receptacle and did not have a key for it. The Maintenance Director stated that he placed the cigarette butts that were in the ashtrays in the trash that was separate from the ashtrays. The Maintenance Director stated that he was responsible for cleaning out the cigarette butt ashtrays every morning. The Maintenance Director stated that he was aware that some staff put trash in the cigarette butt receptacle, but was not aware what staff members. The Maintenance Director stated that he was not aware of any training required to take the residents out to smoke. The Maintenance Director stated that he expected staff to place trash in the trashcan that was located outside of the smoking area, and only put cigarette butts in the ashtrays to properly distinguish the fire. The Maintenance Director stated that there was a risk of fire due to improper disposal of cigarette butts. Interview on 08/20/2026 at 2:13 p.m., the DON stated the cigarette receptacle was only to be used for cigarette butts. The DON stated there was a risk of fire. The DON stated she was unsure if there was education required for the staff to take the residents out to smoke to prevent fire hazards. Interview on 08/20/2026 at 3:10 p.m., the Administrator stated that she was unaware that trash was placed in the cigarette receptacle. The Administrator stated trash did not go in cigarette butt receptacle, and there was a risk of fire. The Administrator stated she did not have process for training those who took the residents out to smoke. The Administrator stated it was the Maintenance Director's responsibility to ensure there was no trash in the self-closing ashtrays and that the red trash can was fully functional. Record review of Smoking Policy- Resident dated 11/2023 did not provide relevant information regarding safe receptacle for cigarette butts separate from facility trash. Smoking policy revealed only To respect resident choice to smoke and maintain a safe healthy environment for both smokers and non-smokers. Cigarette butts are disposed of only in provided receptacles.

Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained free of accidents and hazards for 1 of 1 resident (Resident #2) reviewed for accident hazards. The facility failed to ensure a safe transfer for Resident #2 when CNA C and CNA D performed a transfer without utilizing a gait belt on 07/06/2026. This failure could place residents at risk of injury or harm.Findings included: Record review of Resident #2's face sheet dated 07/07/2026 indicated he was an [AGE] year-old male and admitted to the facility on [DATE]. Resident #2 had diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that blocks air flow and causes difficulty breathing), hypertension (high blood pressure), Difficulty in walking, unspecified dementia (forgetfulness), depression Record review of Resident #2's comprehensive MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 3 which indicated he had severe cognitive impairment. The MDS indicated Resident #2 required partial/moderate assistance from staff with toilet transfers. Record review of Resident #2's care plan dated 05/17/2026 indicated he has an ADL self-care performance deficit related to cognitive impairment and weakness. Interventions indicated transfer: sit to stand: maximum assist, chair/bed to chair: maximum assist, Toilet transfer: Substantial/max assist, tub/shower transfer: maximum assist, Toilet Use: frequently incontinent of bowel and bladder, requires Substantial/max assist with toileting hygiene. During observation on 07/06/2026 at 11:36 AM, CNA C and CNA D attempted to transfer Resident #2 from the wheelchair to the toilet. CNA C attempted to place Resident #2's hands on the wall railing to assist him with standing while transferring, but Resident #2 could not grasp onto the railing with stability. CNA C grabbed under Resident #2's arms and pulled him to a standing position, CNA C then pivoted him toward the toilet . CNA D then pulled down Resident #2's brief and pants as CNA C lowered him to the toilet. After Resident #2 was done using the toilet, CNA C then grabbed under Resident #2's arms and lifted him to a standing position while CNA D pulled up Resident #2's brief and pants while holding on to the back of his shirt then continued to lower Resident #2 into the wheelchair. During an interview on 07/07/2026 at 1:32 PM, CNA D stated Resident #2 was a two-person assist and a gait belt transfer. CNA D stated she should have used a gait belt for the transfer to prevent a fall or injury while transferring Resident #2. During an interview on 07/07/2026 at 1:45 PM, CNA C stated Resident #2 was a two-person assist. She stated she knew she was supposed to apply the gait belt when transferring a resident, but she did not apply one that day, because she was nervous and not prepared. CNA C stated the purpose of a gait belt was to help the residents keep their balance without staff having to pull on body parts or clothing. CNA said a gait belt should be used with all transfers to ensure resident safety and prevent injuries or falls. During an interview on 07/07/2026 at 3:35 PM, the DON stated Resident #2 was a two-person assist. The DON stated a gait belt should be utilized during transfers to prevent any injuries or falls. The DON said she expected all clinical staff to ensure appropriate and proper transfers were done by utilizing the gait belt. The DON said she was ultimately responsible to ensure the staff was using the gait belt during transfers. During an interview on 07/07/2026 at 4:45 PM, the Administrator stated she expected the gait belt to be used during transfers to prevent injuries and falls and help stabilize the residents. The Administrator said all staff were responsible for ensuring the residents are free of injuries and prevent falls. The Administrator said she expected the clinical staff to use the gait belt for transfers and use appropriate transferring techniques to ensure safety for residents and the staff. Record review of the facility's policy Transfer of Residents revised on 06/2020, indicated . Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift .

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for respiratory care and services. The facility failed to properly store Resident #1's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress.Findings include: Record review of Resident #1's face sheet, dated 07/07/2026, indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included chronic obstructive pulmonary disease (a group of lung diseases that blocks air flow and causes difficulty breathing), anemia (a blood disorder where there is a lack of healthy hemoglobin carrying red blood cells), urinary retention. Record review of Resident #1's admission MDS assessment, dated 07/02/2026, indicated Resident #1 understood others and made himself understood. The assessment indicated Resident #1 was cognitively intact with a BIMS score of 14. The assessment indicated Resident #1 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #1 was dependent on bed mobility, transfers, dressing, toilet use, and showering. Record review of Resident #1's care plan, dated 06/29/2026, indicated Resident #1 had an impaired respiratory status related to chronic obstructed pulmonary disease. The care plan interventions included provide nebulizer therapy as ordered. Record review of Resident #1's order summary report, dated 07/07/2026, indicated Resident #1 received Ipratropium- Albuterol solution 0.5-2.5 (3) mg/3ml via nebulizer every 6 hours as needed for shortness of breath and/or wheezing. During an observation and interview on 07/06/2026 at 09:15 a.m., Resident #1 was lying in bed with his eyes closed. Resident #1's nebulizer mask was laying on the table at bedside uncovered. During an observation on 07/06/2026 at 10:15 a.m., Resident #1 was lying in bed. The nebulizer mask was laying on the table at bedside uncovered. During an observation on 07/06/2026 at 2:11 p.m., Resident #1 was asleep in bed. The nebulizer mask was laying on the table at bedside uncovered. During an interview and observation on 07/06/2026 at 3:16 p.m., LVN A stated she was Resident #1's 6a-6p charge nurse, LVN A stated Resident #1 had an order for PRN nebulizer treatments. LVN A observed Resident #1's nebulizer mask on the bedside table, not covered. LVN A stated Resident #1's nebulizer mask should be covered when not in use. LVN A stated she administered Resident 1's breathing treatments today, but failed to place the back in the plastic bag after usage. LVN A stated all nursing staff were responsible for ensuring infection control was provided for each resident. LVN A stated these failures could potentially put residents at risk for respiratory infection. During an interview on 07/06/2026 at 4:24 p.m., the DON said she expected Resident #1's nebulizer mask to be stored in a bag when not in use. The DON stated the charge nurses were responsible for nebulizers treatments and ensuring proper infection control precautions were utilized. The DON said the charge nurses were responsible for monitoring to ensure respiratory equipment was returned to the designed bag after each use. The DON stated she was responsible for monitoring the charge nurses. The DON said these failures could potentially cause an increase in the risk of infection due to cross contamination. During an interview on 07/07/2026 at 4:40 p.m., the Administrator said she expected nebulizers to be stored in bags when not in use to decrease any chances of cross contamination. The Administrator stated this was monitored by the clinical staff. The Administrator stated these failures put residents at risk for respiratory infection due to particles that could accumulate on the mask. Record review of the facility's Oxygen Administration policy, revised June 2020 indicated, . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent, neglect, and abuse of residents, for 1 of 7 residents (Resident #1) reviewed for abuse. 1. Resident #1 alleged CNA B was rough, while providing incontinent care as pushed her left shoulder causing her to almost hit her head on the rail during care. CNA A witnessed the alleged abuse and failed to report timely to the abuse coordinator on 03/09/2025. 2. The facility did not ensure the ADON and DON notified the abuse coordinator of an allegation of abuse reported by CNA C on 3/09/2025 at 6:07 a.m. via a text message concerning Resident #1. The Abuse coordinator was made aware of the ADON and DON's knowledge of the abuse allegation on 4/10/2025 by the surveyor. 3. The ADON and DON failed to protect Resident #1 by allowing CNA B to provide care to residents starting on 3/09/2025 at 10:00 p.m. and ending on 3/10/2025 at 6:00 a.m. 4. The facility failed to ensure CNAs A, B and D received abuse training upon hire prior to receiving care duties. An Immediate Jeopardy (IJ) was identified on 04/10/25 at 4:40 p.m. The IJ template was provided to the facility on [DATE] at 5:16 p.m. While the IJ was removed on 04/11/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021 indicated, . Residents have the right to be free from abuse . This included but is not limited to freedom from . verbal or physical abuse . 1. Protect residents from abuse . by anyone including, but not necessarily limited to a. facility staff .6. Provide staff orientation and training/orientation programs that included topics such as abuse prevention, identification and reporting of abuse . Record review of the facility's policy Abuse Investigation and Reporting, revised 7/2017, reflected . All reports of resident abuse . shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management . Reporting . 2. An alleged violation of abuse . will be reported immediately, but not later than: a. Two hours if the alleged violation involves abuse . Record review of Resident #1's face sheet, dated 04/14/25, reflected Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis (chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, stiffness, and swelling), and PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 usually made herself understood, and usually understood others. Resident #1's BIMS score was 15, which indicated her cognition was intact. Resident #1 required supervision/touching assistance with oral care and substantial/maximum assistance with personal hygiene and upper body dressing. Resident #1 was dependent with shower/bathing, toileting, and lower body dressing. Record review of the comprehensive care plan, revised 07/22/24, reflected Resident #1 had a history of fabrication against staff at times regarding care and how they talk to her, and periodically makes derogatory posts regarding facility on social media without informing the Administrator of a care issue. The care plan interventions included Resident #1 will be encouraged to be honest/truthful in all situations, and two staff members will be present, if possible, when interacting with the resident and/or providing care. Record review of a text message dated 3/09/2025 at 6:07 a.m., reflected CNA C sent a message to the DON and ADON stating Hey, I had some stuff reported to me. The message reflected CNA A told CNA C that she was wanting to leave because the way CNA B treated patient and she did not want to report it because CNA A was new, and she did not like conflict. The message stated, she said nothing physical but there is a way you treat patients and there is not, she kept telling me don't say nothing, but these are people. The message reflected the ADON responded first by saying Yes ma'am. Thank you. I appreciate anything being reported. We will follow up. Can you tell the nurse that's there right now I am getting dressed to head that way . The message reflected the DON responded by saying Thank you!!! Tell CNA A it is ok, and it will be fixed, and I will text her as well . Record review of a witness statement dated 03/09/25 written by CNA C reflected it was reported to CNA C by CNA A that CNA B was inappropriate to patients. The statement reflected that CNA A felt so uncomfortable to witness what she had witnessed by CNA B that she would just quit. Record review of a witness statement dated 03/10/25 written by CNA A reflected she witnessed CNA B being rough when handing Resident #1 when it came to changing Resident #1's brief and making rude comments towards Resident #1. The statement also stated that CNA B pushed Resident #1 and shoved her too close to the bed rail where she could hear Resident #1 stating she was having trouble being handled roughly. Record review of a March 2025 schedule reflected CNA B provided care to residents starting on 3/09/2025 at 10:00 p.m. and ending on 3/10/2025 at 6:00 a.m. Record review of CNA A's personnel file indicated she was hired on 01/27/25 and did not receive her abuse training until 03/26/25. Record review of CNA B's personnel file indicated she was hired on 03/21/24 and did not receive her abuse training until 03/27/24. Record review of CNA D's personnel file indicated she was hired on 02/14/24 and did not receive her abuse training until 03/02/25. During an interview on 04/10/25 at 8:15 a.m., Resident #1 stated an incident occurred about a month ago where two staff members came in to provide incontinent care and CNA B pushed her left shoulder causing her to almost hit her head on the rail. Resident #1 stated the staff member also called me lazy. During an interview on 04/10/25 at 8:44 a.m., the Administrator stated he was the abuse coordinator. The Administrator stated he learned of the incident between CNA A, CNA B and Resident #1 the morning of 03/10/25. The Administrator stated the DON told him on 03/10/25 CNA C called her to let her know CNA A was going to quit because she witnessed CNA B been rough to Resident #1 during incontinent care. The Administrator stated the DON called CNA A on 03/10/25 to the facility to gather more information and that was when he learned CNA B shoved Resident #1 to the bed rail. The Administrator stated he called CNA B on 03/10/25 and suspended her pending investigation. During an interview on 04/10/25 at 9:08 a.m., the ADON stated when she came in the morning of 03/10/25 she found a statement written by CNA C stating during shift report on 03/09/25 CNA A reported to her that she witnessed CNA B being inappropriate to residents. The ADON stated at that time she found the statement on 03/10/25 the Administrator and DON were already made aware of the allegation. During an interview on 04/10/25 at 9:15 a.m., the DON stated she received a call from CNA C on 03/10/25 stating CNA A was wanting to quit because she witnessed CNA B being inappropriate to residents. The DON stated she called and asked her to come in on 03/10/25 to speak to her and the Administrator and that was when they learned of the incident. During a telephone interview on 04/10/25 at 1:08 p.m., CNA A stated she witnessed CNA B on 03/09/25 being rough and shoving Resident #1 to the bed rail almost hitting her head while providing incontinent care. CNA A stated she could hear Resident #1 telling CNA B she was being too rough, but CNA B continued to provide care. CNA A stated CNA B would never let her assist her with providing care to Resident #1. CNA A stated she just stood there and kept Resident #1 from hitting her head on the pull up bar. CNA A stated this incident occurred after midnight on 03/09/25 during rounds. CNA A stated she had just started working at the facility and did not feel comfortable reporting the issue to the Administrator or DON because she felt like there would be repercussions so instead, she reported the incident to CNA C during shift report. During a telephone interview on 04/10/25 at 1:30 p.m., CNA C stated during shift report on 03/09/25 CNA A told her she had witnessed CNA B being inappropriate to residents. CNA C stated CNA A would not go into details what she had witnessed but she knew it was bad enough for CNA A wanting to quit. CNA C stated as soon as CNA A reported the allegation to her, she sent a group text to the DON and ADON informing them of the allegation. CNA C stated she did not know the proper protocol regarding how to report the allegation and she did not want to bother the Administrator. CNA C stated the ADON came in the morning of 03/09/25 to work the floor and told CNA C to write a statement and she would give it to the Administrator. CNA C stated she wrote the statement and handed to the ADON. During an interview on 04/10/25 at 2:44 p.m., the ADON stated she did not remember receiving a text from CNA C on 03/09/25 reporting the allegation between CNA B and Resident #1. The ADON stated she did come in on 03/09/25 for a short period but she did not recall telling CNA C to write a statement re: the incident. The ADON stated she did not go in Resident #1's room while she was at the facility on 03/09/25. After the state surveyor showed her the text message, she continued to state she did not remember receiving or responding to the text message. The ADON stated she should have notified the Administrator immediately. The ADON stated not reporting an allegation of abuse put residents at risk for further abuse. During an interview on 04/10/25 at 3:27 p.m., the DON stated she did not remember receiving a text from CNA C until the state surveyor brought it to her attention. The DON stated she went back and read the message and realized she had responded. The DON stated she was probably still asleep when she responded to the text when CNA C sent at 6 a.m. The DON stated she received text messages all day, every day and it was hard to remember every conversation with her staff especially if she was half asleep. The DON stated she should have notified the Administrator immediately. The DON stated not reporting an allegation of abuse put residents at risk for possible harm and abuse. During an interview on 04/10/25 at 3:46 p.m., the Administrator stated he was not aware of the text between CNA C, DON and the ADON until the state surveyor brought it to his attention. The Administrator stated he expected to be notified immediately to report to HHSC and start an investigation. The Administrator stated if he had of known about the allegation on 03/09/25, CNA B would have not worked the 10:00 p.m. shift starting on 3/09/2025 and ending on 3/10/2025 at 6:00 a.m. The Administrator stated he monitored abuse by daily random rounds and ensured staff was in serviced on abuse and neglect monthly and instructed all staff to notify him any time doesn't matter 24/7. The Administrator stated he expected abuse training to be completed upon hire before the employee takes the floor. The Administrator stated not reporting an allegation of abuse or completing abuse trainings could potentially put residents at risk for continued abuse. During an interview on 04/10/25 at 5:00 p.m., the BOM stated she was responsible for ensuring staff completed their training upon hire. The BOM stated corporate manually put the trainings in a system and sometimes there was a delay. The BOM stated she did an audit back in March and realized abuse trainings had not been completed for CNAs A and D. The BOM stated it was not much of a risk for staff not to complete their trainings upon hire because they were verbally educated on Abuse and Neglect on hire. The BOM stated there was not a policy specific to when abuse training should be conducted. During a telephone interview on 04/11/25 at 9:32 a.m., CNA B stated she was not handling Resident #1 roughly or trying to hit her head on the pull up bar during incontinent care. CNA B stated she never heard Resident #1 stating she was rough during care. CNA B stated she always rolled Resident #1 over, lifted her hip a little and had her to grab the pull up bar to place a brief under her. CNA B stated she has never told any staff member not to assist them. CNA B stated she still did not know why she was terminated on 03/17/25. This was determined to be an Immediate Jeopardy (IJ) on 04/10/25 at 4:40 p.m., The Administrator was notified, provided with the IJ template on 04/10/25 at 5:16 p.m. and a Plan of Removal was requested. The facility's plan of removal was accepted on 04/11/25 at 8:10 a.m. and included the following: On 04/10/25 an abbreviated survey was initiated at the facility. On 04/10/25 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 alleged immediate jeopardy states as follows: F 607 Develop/Implement Abuse/Neglect The facility failed to: C.N.A. A failed to notify the Abuse Coordinator immediately of an abuse allegation. Protect Resident #1 and other vulnerable residents from the alleged perpetrator. The perpetrator was allowed to continue working their shift. Facility DON and ADON failed to notify Abuse Coordinator of alleged abuse on 3/9/25 when it was reported to them at approximately 6am on March 9th. Facility failed to ensure that all employees received Abuse training prior to working on the floor. Identify residents who could be affected. All Residents have the potential to be affected. The Facility census on 04/10/25 was 32. Resident #1 was interviewed by the Administrator, DON and ADON on 3/10/25 to determine if there were any negative outcome, resident was showing no signs visible signs of emotional distress and did not verbalize any feelings of fear and denied any physical contact by the perpetrator. On 3/11/25 the Psychologist interviewed resident and she did not voice any concerns to him. The facility SW also interviewed the resident on 3-11-25 and she voiced no physical harm was done. On 3/12/25 resident stated to night nurse that she was happy with staff now. A care plan meeting was also held with resident and her family memeber on 3/13/25 and no new concerns were brought forward. Identify responsible staff/ what action taken to prevent further abuse: . ADON, MDS coordinator and Administrator will conduct 100% resident rounds to determine if further allegations of abuse are alleged. This will be completed by 04/11/25. Safe surveys will be conducted by Social Worker, Human Resources and Activity Director for all cognitive residents. This will be completed by 04/11/25. C.N.A. A was a new employee and was educated on Abuse, neglect and reporting by DON on 3/10/25. C.N.A. B and D were suspended on 3/10/25 and terminated on 3/17/25. DON and ADON were given a final written warning stating any further failures would result in termination and were re-educated by Administrator on 4/10/25. In-Service conducted. The Abuse Coordinator was educated on 04/10/25 by the Regional Director of Clinical Services on how to investigate allegations of abuse, reporting of abuse and the importance of a thorough investigation and written documentation of statements and in-services. In-servicing was initiated by Administrator on Abuse investigation, notification, and immediate removal of the perpetrator 04/10/25 for the DON and ADON. In-service will be provided to all staff on Immediate Notification of Allegations to Facility Abuse Coordinator or designee when not in facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities by DON and ADON on 4/10/25 and completed by 4/11/25. Agency staff that work in the facility or staff on PTO or LOA will have in-servicing completed prior to working the floor by the DON/ADON. Abuse and Neglect training will be a part of the new hire orientation effective immediately and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse and resident protection from abuse and will be completed at time of hire by HR/DON and verified by Administrator. Any staff member who is an alleged perpetrator for any allegation will be suspended immediately pending investigation and will be escorted out of the facility immediately by the senior staff member on duty or law enforcement and will not be allowed to return to the building until the investigation is complete. The police were notified of the allegation of abuse on 4/10/25 by the Administrator. Implementation Date of Changes 04/10/25 Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 04/10/25. Involvement of QA QAPI will review and approve Plan of Removal on 04/11/25. Who is responsible for the implementation of the process? Administrator On 04/11/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the safe surveys for all residents who were cognitively intact were completed on 04/11/25. No additional concerns were identified. Record review of a resident list reflected 100% resident rounds was initiated on 04/10/25 and completed on 04/11/25 to determine if further allegations of abuse were alleged. No additional concerns were identified. Record review of a form titled Team Member Counseling Form reflected the DON and ADON were given a final written warning stating any further failures would result in termination and were re-educated by Administrator on 4/10/25. Record review of the facility orientation checklist reflected abuse and neglect training will be a part of the new hire orientation. During an interview on 04/11/25 at 9:46 a.m., Resident #1 was lying in bed tearful related to the law enforcement called out to the facility to speak to her about the abuse. Resident #1 stated she spoke to someone yesterday and did not want to speak about it today. Resident #1 stated the staff here has treated her nice and was good to her. During interviews conducted on 04/11/25 between 9:56 a.m. and 11:54 a.m., reflected CNA A, CNA E, CNA F, CNA K, MA G, RN H, RN Q, Housekeeping L, [NAME] M, Housekeeping N, COTA O, CNA P, BOM, Dietary Manager, MDS Coordinator, Maintenance Director from all shifts were in-serviced on and could verbalize understanding of in-service on immediate notification of allegations to facility abuse coordinator or designee when not in facility or available, investigating allegations of abuse and neglect, reporting of abuse neglect and misappropriation, and notification of proper local and state entities on 04/10/25. During a telephone interview on 04/11/25 at 10:10 a.m., the Medical Director stated he was notified of the IJ on 04/10/25 and attended a QAPI meeting via phone over the IJ and subsequent plan of removal on 04/11/25. During an interview and record review of the in-service presented by the Administrator on 04/11/25 beginning at 10:39 a.m. and 10:52 a.m., reflected the DON and ADON were in-serviced on and could verbalize understanding of in-serviced on abuse investigation, notification, and immediate removal of the perpetrator on 4/10/25. During an interview and record review of the in-service presented by the Regional Director of Clinical Services on 04/11/25 at 10:56 a.m., reflected the Administrator was in-serviced on and could verbalize understanding on how to investigate allegations of abuse, reporting of abuse and the importance of a thorough investigation and written documentation of statements and in-services on 04/10/25. During an interview on 04/11/25 at 10:39 a.m., the DON stated there has not been any new admits currently. The Administrator was notified the Immediate Jeopardy was removed on 04/11/25 at 12:15 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 5 of 5 residents reviewed for abuse. (Residents #1, #2, #3, #4 and #5) The facility did not immediately implement interventions to protect Resident #s 2, 3, 4, and 5 for approximately 14 hours after Resident #1 threatened to harm them while holding a homemade prison like shank. Resident #1 stood outside of Resident #2's room and threatened to harm him. Resident #2 was afraid Resident #1 was going to hit him. An Immediate Jeopardy (IJ) situation was determined to have existed on 03/18/20 to 3/20/20. It 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 survey. This failure could place residents at risk of abuse, injury, or death. Findings included: 1. A face sheet dated 04/28/20 indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 was cognitively intact, he understood others, and made his needs known. He had no behaviors during the review period. Resident #1 required supervision assistance with most ADLs and he was continent of bowel and bladder. A care plan last revised on 03/17/20 was previously updated on 12/31/19 indicated Resident #1 had poor impulse control. He exhibited verbally abusive behaviors and would yell and cuss at staff and residents. Interventions included to explain to the resident why his behavior was inappropriate, intervene as necessary to protect the rights and safety of others, and notify the nurse of any problems. The care plan noted Resident #1 refused a psychological consult. An incident report initiated on 03/18/20 at 7:30 p.m. and revised on 03/25/20 at 9:43 a.m. by the ADON indicated the nurse was notified of a resident arguing with another resident. Resident #1 was in his wheelchair outside of another resident's room. Resident #1 said I will kill this black man and Resident #1 would not move from the other resident's door. Resident #1 said he did not have to move, and they would have to call the police. Resident #1 said Resident #2 ran over him as they passed in the hallway. The nurse was able to calm Resident #1 down and took him where he wanted to go. Resident #1 continued to make remarks that if he saw him [AGE] years ago he would have gotten out of his truck and dropped him without any problem. Resident #2 was in his room with the door shut and Resident #1 was removed from the area. A witness statement dated 03/19/20 by CNA A indicated on 03/18/20 Resident #3 called for her because Resident #1 was sitting outside of Resident #2's room. CNA A asked Resident #1 to go back to his hall. Resident #1 said I ain't gotta go nowhere. I'm tired of this black mother f***er and his sh*t. CNA A called for the nurse and the nurse came and talked to Resident #1 into going back to his own hall. A witness statement dated 03/19/20 by CNA A indicated she heard Resident #1 say I'm gonna get CNA D, the DON, the administrator, and I'm gonna get that fat Resident #4 and may get Resident #3. Resident #1 also said how easy it would be with everyone having to stay in their room. CNA A said she saw a homemade weapon in Resident #1's hand and he kept gripping it and the weapon had a sharp metal end on it. The way Resident #1 kept gripping the weapon over and over was like he was getting ready to start to do something. CNA A said she made sure she kept up with the residents and the people he talked about hurting. CNA A said she was scared, and she was put in a position that Resident #1 might hurt her while she was at work. During an interview on 04/28/20 at 2:34 p.m., CNA A said she worked 03/18/20 from 2:00 p.m. to 10:00 p.m. She said Resident #3 notified her about a commotion with Resident #1 and Resident #2. CNA A said she went down the hall Resident #2 resided and Resident #1 was outside of Resident #2's room saying, get your black a** out here. She said she tried to redirect Resident #1, but he said he was not going anywhere. She said Resident #2 was in his room with the door closed and the residents were yelling at each other. She said Resident #2 was yelling at Resident #1 to go back to his room. CNA A said the charge nurse for the back section of the facility was at lunch, so she alerted the charge nurse at the front of the facility. She said LVN C came to the hall and was able to get Resident #1 to leave the hall. CNA A said LVN C went back to the front of the facility. She said Resident #1 was upset because he accused Resident #2 of running into him at the nursing station. CNA A said she saw Resident #1 sitting in his wheelchair in the dining room and he was upset. She said she saw Resident #1 holding a shank in his hand and it was positioned next to him in the wheelchair. She said the shank had a white handle and it had a shiny metal sharp end. She said Resident #1 said he was going to take some people out, including CNA D, the DON, the administrator, Resident #2, Resident #3, and Resident #4. CNA A said he continued to grip the shank while he listed the people he was going to take out. She said she was not sure what time the incidents occurred, and she was not sure which incident occurred first. She said it was normal for Resident #1 to be mouthy, but it was the first time he threatened people or had a weapon. She said she was scared to report what she saw and what she heard because she was afraid Resident #1 would know she reported him, and he would come after her. She said CNA D was working at the front of the facility and she was watching out for her. CNA A said Resident #2 stayed in his room the rest of the evening and Resident #1 stayed in his room, in the dining room, or at the nursing station the rest of the shift. She said she spoke with CNA B and CNA B said she would call the DON the next morning to report the incidents. CNA A said she knew she should have immediately reported the allegations, but she was so frightened by Resident #1 and his behavior that evening and was afraid he would retaliated against her. She said she placed residents and staff at risk because she did not immediately report the abuse allegations. She said she called the DON on 03/19/20 at 1:45 p.m. and notified her of the allegations. She said she received one to one in-servicing by the DON about abuse allegations and immediately reporting any abuse or neglect allegation to the administer or the DON. She said all the staff were in-serviced on abuse, abuse coordinator, neglect, exploitation, resident to resident abuse, and reporting any allegation immediately to the administrator or DON. CNA A said Resident #1 had a history of [REDACTED]. She said Resident #1 had no prior altercations with Resident #2. During an interview on 04/28/20 at 9:08 a.m., the DON said they notified the medical director, ombudsman, and obtained an emergency detention order to send Resident #1 to the hospital for evaluation because the resident was unwilling to go to the hospital for a psychological evaluation. A mental health warrant for emergency detention dated 03/19/20 for Resident #1 indicated any health or peace officer was commanded to apprehend Resident #1 and transport him to a local hospital for examination. A one to one monitoring form dated 03/19/20 to 03/20/20 indicated Resident #1 was placed on one to one monitoring on 03/19/20 at 2:00 p.m. The form indicated Resident #1 was monitored continuously until 03/19/20 at 6:15 p.m. when he was transferred to a local hospital by emergency medical personnel. The monitoring from indicated Resident #1 returned to the facility on [DATE] at 4:10 p.m. and was monitored continuously until 03/20/20 at 6:15 p.m. when the sheriff's department arrived to transport Resident #1 to the homeless shelter. A hospital crisis screening form dated 03/19/20 indicated Resident #1 was pleasant and said the night before he was near the ice machine at the facility when Resident #2 almost hit him. Resident #1 said he told Resident #2 he needed to slow down and Resident #2 began to berate him. Resident #1 said he had his room inspected and searched for a knife by staff and then staff came back with a warrant and informed him he had to go to the hospital. Resident #1 denied having homicidal ideations and said he was calm after the argument with Resident #2. Resident #1 said he did not threaten to harm anyone. A discharge notice dated 03/20/20 for Resident #1 indicated Resident #1 was immediately discharged from the facility due to the safety of residents and/or staff was endangered. Resident #1 signed the discharge notice. 2. A face sheet dated 04/28/20 indicated Resident #2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #2 had moderately impaired cognition, understood others and made his needs known. He had no behaviors during the review period. Resident #2 required supervision assistance with most ADLs. He was continent of bowel and bladder. A care plan last revised on 03/09/20 indicated Resident #2 had a history of [REDACTED]. Staff should intervene before agitation escalate, guide the resident away from the source of distress, and monitor and document behaviors. A safe survey dated 03/20/20 indicated Resident #2 said he was not scared of no man, but he felt threatened by Resident #1. Resident #2 said he would not let Resident #1 hurt him and he started carrying a belt in a bag on his wheelchair, so he could protect himself if needed. Resident #2 said he felt better that Resident #1 was no longer in the facility. During an observation and interview on 04/28/20 at 12:20 p.m., Resident #2 was sitting in his room. He said he remembered the incident with Resident #1. He said the incident occurred a while ago but he and Resident #1 had words near the nursing station. Resident #2 said he went to his room. He said sometime later Resident #1 was in the hall outside of his door yelling and cussing at him to come out of his room and Resident #1 was threatening him. He said Resident #1 had a Coke can and was threatening to throw it at him. Resident #2 said he told Resident #1 to go back to his room but he did not. He said he shut his door during the altercation and someone finally came and got Resident #1. Resident #2 said he thought police got him away from his room. He said Resident #1 did not like him because he was black. Resident #2 said Resident #1 would tell him he was nothing but a n**ger. Resident #2 said Resident #1 was a white, Caucasian, German, Nazi. He said he was not afraid of Resident #1, but he was afraid Resident #1 was going to throw the Coke can at him. Resident #2 said he kept his belt rolled up in his wheelchair after Resident #1 came down to his room in case he needed to protect himself from Resident #1. Resident #2 said he no longer kept the belt rolled up in his wheelchair and was wearing his belt again. Resident #2 pointed to the belt he was wearing on his pants. Resident #2 said he was glad Resident #1 was no longer at the facility. A witness statement dated 03/19/20 by CNA B indicated on 03/18/20 CNA B worked the 2:00 p.m. to 10:00 p.m. shift and saw Resident #2 at the nursing station using the phone and Resident #1 was making rude comments to Resident #2. Resident #1 said he hated a f***ing n**ger and the mother f***er (referring to Resident #2) needed to get off the damn phone. CNA B reported what Resident #1 said to Resident #2 to CNA A. CNA A said that was how Resident #1 acted. CNA B later answered Resident #1's call light and Resident #1 said Resident #2 should not have been on the phone at the nursing station earlier and again said he hated f***ing n**gers. Resident #1 said he used to have a knife, but he threw it away and he knew it was best that he threw it away because if he would not have thrown it away, he would hurt CNA D or Resident #2. Resident #1 said it would not bother him to hurt someone because he had already been in the penitentiary and prison did not scare him. CNA B told Resident #1 that he should not think like that and Resident #1 agreed. CNA B told CNA A what Resident #1 said, and CNA A said she saw Resident #1 with a knife earlier. CNA A told CNA B to call the DON first thing the next morning, but her phone was not working, and she was not able to call the DON. During an interview on 04/28/20 at 4:23 p.m., CNA B said she worked for a staffing agency and worked at the facility on 03/18/20 from 2:00 p.m. to 10:00 p.m. She said during the shift she saw Resident #2 using the phone at the nursing station. She said Resident #1 was near the nursing station and said, I can't stand that n**ger and said Resident #2 did not need to be using the phone. CNA B said she reported what Resident #1 said about Resident #2 to CNA A. She said CNA A said Resident #1 was like that. CNA B said later on she answered Resident #1's call light. She said Resident #1 asked her about getting his soup warmed and then he said Resident #2 better be glad that he threw away his knife. She said Resident #1 said he would have hurt CNA D and Resident #2 if he did not throw the knife away. She said Resident #1 said he was in prison and he was not scared of prison. CNA B said she told Resident #1 he did not need to think like that and Resident #1 said she was right. She said she left the room and told CNA A what Resident #1 said about CNA D, Resident #2, and the knife. She said CNA A said she saw Resident #1 earlier with a homemade knife. CNA B said CNA A told her to call the DON first thing the next morning and report the allegations about Resident #1. She said she attempted to call the DON the next morning, but her phone was not working and once her phone began working the DON called her on 03/19/20 around 2:00 p.m. She said she was in-serviced by the DON about abuse allegations and immediately reporting any abuse or neglect allegation to the administer or the DON. She said she also was in-serviced by the facility on abuse, abuse coordinator, neglect, exploitation, resident to resident abuse, and reporting any allegation immediately to the administrator or DON. She said she did not see Resident #1 outside of Resident #2's room that evening. She said Resident #2 stayed in his room and she did not see Resident #1 go down Resident #2's hall. She said Resident #1 would easily get upset and yell at staff but that was the first time she witnessed Resident #1 verbally abuse Resident #2. A witness statement dated 03/19/20 by LVN C indicated on 03/18/20 LVN C was called to the south wing of the facility by CNA A because Resident #1 was sitting in front of another resident's room (Resident #2). Resident #1 accused Resident #2 of running over him in his wheelchair. LVN C said Resident #1 was calm but would not move after LVN C asked him to move. LVN C explained to Resident #1 that it would be best for him to go back to his side of the facility. Resident #1 agreed and said if it was [AGE] years ago he would be able to drop him with no problem. LVN C was able to redirect Resident #1 back up the hall and Resident #1 began talking to other residents about the situation. Resident #1 remained calm and continued talking to other residents about how Resident #2 was rude and disrespectful. LVN C said she was able to redirect the residents with what was on the new about coronavirus. There were no other problems throughout the shift. During an interview on 04/29/20 at 10:15 a.m., LVN C said she worked for a staffing agency and worked at the facility on 03/18/20 from 2:00 p.m. to 10:00 p.m. She said she worked the front section of the facility and around 7:30 p.m., CNA A called her to the back of the facility because the charge nurse for the back section of the facility was at lunch. She said Resident #1 was sitting in his wheelchair in the hall outside of Resident #2's room. She said Resident #2's door was closed and Resident #1 was upset because he said Resident #2 came by him when he was by the break room and ran over him. She said Resident #1 was calm but upset because Resident #2 would not come out of his room. She said she asked Resident #1 to go back to his hall and Resident #1 refused. LVN C said she told Resident #1 she had a lot of work to do and she needed him to go back to his hall. She said Resident #1 agreed and she pushed Resident #1 back to the break room where he started talking to other residents about Resident #2 being rude. She said she told Resident #1 he did not need to be talking about other residents and redirected Resident #1 to another subject. She said before she went back to the front of the facility she told CNA A if there were any other issues to notify her. She said she was not notified of any other changes and was not told about Resident #1 having a weapon or threatening other residents or staff. LVN C said she would have immediately reported Resident #1's actions to the DON if she would have known about Resident #1's threats or his homemade shank. She said Resident #1 did say if he was [AGE] years younger he would have been able to drop Resident #2 with no problem, but she did not take that as a threat and did not report it. She said she was in-serviced on abuse and neglect by the staffing agency and in-serviced by the DON at the facility. She said she worked with Resident #1 before and Resident #1 would get upset with her one minute and be fine the next. She said she was not aware of any prior altercations between Resident #1 and Resident #2. 3. A face sheet dated 04/28/20 indicated Resident #3 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A safe survey dated 03/20/20 for Resident #3 indicated Resident #3 felt uneasy with Resident #1 in the facility and worried about being prepared to fight Resident #1 or Resident #1 fighting another resident. Resident #3 said Resident #1 was a bully and he was no longer worried because Resident #1 was gone from the facility. During an interview on 04/28/20 at 5:54 p.m., Resident #3 said he and Resident #1 resided at another facility together. He said he was not afraid of Resident #1 but Resident #1 was a dangerous man and he knew how to make weapons. Resident #3 said he worried about other residents' safety and was glad Resident #1 was no longer at the facility. 4. A face sheet dated 04/28/20 indicated Resident #4 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A safe survey dated 03/20/20 for Resident #4 indicated Resident #4 felt uncomfortable because Resident #2 had a belt wrapped around his knuckles and said he had to protected himself from Resident #1 and had the belt in case Resident #1 came after him. During an interview on 04/28/20 at 1:53 p.m., Resident #4 said she was sitting in the doorway of her room and Resident #1 was at the nursing station with a drink. She said Resident #2 went by Resident #1 and she heard Resident #2 say, f*** you mother f***er, and continued to his room. She said Resident #1 went to Resident #2's room and said, come out mother f***er, let's settle this. She said Resident #2 was hollering for Resident #1 to go to his room but Resident #1 did not move. Resident #4 said CNA A went to Resident #2's room and tried to get Resident #1 to leave the area but Resident #1 rolled back to the other side of the hall. Resident #4 said Resident #1 came back up to the nursing station and did not go back to Resident #2's room. Resident #4 said she was not afraid of Resident #1, but she felt uncomfortable around Resident #2. She said the next day Resident #2 had a belt around his fist and said he was protecting himself from Resident #1. She said she did not feel threatened by Resident #1 and she had not heard Resident #1 threaten any of the residents. 5. A face sheet dated 04/28/20 indicated Resident #5 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A safe survey dated 03/20/20 for Resident #5 indicated Resident #5 was scared when Resident #1 started to yell and cuss and slammed doors. Resident #5 said she was happy Resident #1 was gone. During an interview on 04/28/20 at 1:26 p.m., Resident #5 said Resident #1 resided in the room across from her and would come to her room and talk often. She said Resident #1 was nice to her but Resident #1 did not like Resident #2. She said she did not hear Resident #1 threaten anyone. The facility's provider investigation report dated 03/25/20 indicated on 03/19/20 at 1:45 p.m., the DON received a call from CNA A about an incident that occurred on 03/18/20 at 7:30 p.m. regarding Resident #1. The report indicated CNA A said she was concerned for the residents and staff because Resident #1 threatened to cut CNA D with his shank and CNA A saw the shank in Resident #1's hand. The report indicated CNA A said Resident #1 threatened to harm Resident #2 and sat in front of Resident #2's room waiting for Resident #2 to come out. CNA A said Resident #1 said he was going to also get others. CNA A said she did not immediately report the incident because she was scared Resident #1 would have known she was the one that reported him, and she did not want Resident #1 retaliating against her. The report indicated CNA A said she watched out for CNA D because she worked in the front of the facility away from Resident #1 and she did not want CNA D to get hurt. CNA A said Resident #2 was safe because he stayed in his room for the rest of the night. The report indicated CNA D was contacted and not allowed to work the floor and Resident #1 and #2 were in their rooms and kept apart. Resident #1 was placed on one to one monitoring until he was transferred out of the facility. The administrator and physician were notified. A detention warrant was obtained for Resident #1 and Resident #1 was transferred to a local hospital for a psychiatric evaluation. Safe surveys were conducted with residents and revealed residents were scared, threatened, uncomfortable, and uneasy with Resident #1 residing in the facility. The report indicated a homemade weapon was found in Resident #1's room. Resident #1 returned to the facility and was discharged to a homeless shelter per Resident #1's request. Resident #1 was unwilling to transfer to another nursing facility, assisted living, or inpatient psychiatric hospital. Resident #1 was denied by several apartments due to his criminal background. The ombudsman was notified of Resident #1's discharge. Staff were addressed regarding immediately reporting abuse allegations and staff were in-serviced on abuse, abuse coordinator, neglect, exploitation, resident to resident abuse, and reporting any allegation immediately to the administrator or DON. A local inpatient behavior hospital was scheduled to come to the facility and in-service staff about behaviors and how to deal with behaviors, but the in-service was rescheduled due to COVID-19. The facility investigation findings were confirmed. A witness statement dated 03/21/20 by RN G indicated Resident #5 told her she was glad Resident #1 was gone from the facility. Resident #5 said Resident #1 came to her room all the time and did things that made her mad and scared her, but she never said anything because she feared what Resident #1 might have done to her. RN G asked Resident #5 to elaborate and Resident #5 said Resident #1 would come to her room and put his hand on her knee and called her mom, which she hated. Resident #5 said Resident #1 always talked about hurting people or killing people who crossed him, and she did not want to cross Resident #1 or have him mad at her. During an interview on 04/28/20 at 6:08 p.m., RN G said Resident #1 had a history of [REDACTED]. She said she had not heard Resident #1 threaten anyone or witness him with a weapon. She said was not aware of any history of altercations between Resident #1 and Resident #2. She said she was in Resident #5's room on 03/21/20 and Resident #5 said, I hate to say this, but I'm glad Resident #1 is gone. RN G said Resident #5 continued to tell her that she was scared of Resident #1 but was too afraid to report it to staff. She said Resident #5 said Resident #1 would talk about hurting people that crossed him and she said she was not going to cross him. During an interview on 04/29/20 at 1:35 p.m., CNA F said she worked for a staffing agency and worked on 03/18/20 from 10:00 p.m. to 6:00 a.m. at the facility. She said she was told Resident #1 and Resident #2 were arguing on the evening shift but was not notified about Resident #1 threatening other residents and staff or about Resident #1 having a weapon. She said Resident #1 came to the nursing station a few times during the shift and was rude to staff. CNA F said she worked with Resident #1 a few times and it was normal for him to interact rudely with staff. CNA F said she did not witness Resident #1 cuss or yell at residents. She said Resident #1 did not make any threats towards residents or staff and did not mention any residents or staff. She said Resident #1 went back to his room and did not go down the hall where Resident #2 resided. She said Resident #2 stayed in his room during the entire shift. CNA F said if she was notified about Resident #1 making threats towards other residents and staff or if she saw Resident #1 with a weapon, she would have immediately notified the nurse, DON, and administrator. During an interview on 04/28/20 at 6:20 p.m., CNA D said she worked on 03/18/20 from 2:00 p.m. to 10:00 p.m. She said she worked in the front wing of the facility and did not work with Resident #1. She said she heard the commotion from the front of the facility when Resident #1 was outside of Resident #2's room because they were loud. She said she was not aware of Resident #1's threats towards her until the next day. CNA D said she did not know why Resident #1 targeted her because her and Resident #1 got along well. She said Resident #1's threats made her feel uneasy. CNA D said Resident #1 could be nice and quickly become upset, but she had not heard him threaten other residents or staff. She said she was not aware of Resident #1 yelling or cussing at Resident #2. She said she would immediately report any threats towards residents or if she saw a resident with a weapon to the administrator or DON. During an interview on 04/28/20 at 11:20 a.m., the ADON said she was working as the charge nurse on 03/19/20 from 6:00 a.m. to 2:00 p.m. She said sometime before 1:45 p.m., Resident #1 approached her and asked if he was in trouble. The ADON said she asked Resident #1 why he would be in trouble. She said Resident #1 said he and Resident #2 argued the previous evening after Resident #2 almost ran over him. The ADON said Resident #1 did not say anything about sitting in front of Resident #2's room, threatening residents, or having a homemade weapon. She said she went to notify the administrator and DON of what Resident #1 said but they were at lunch. She said she began investigating, made sure Resident #1 and Resident #2 were separated, and spoke to Resident #2. She said Resident #2 had a belt in his wheelchair and he said he would use it if Resident #1 kept threatening him. The ADON said by that time, CNA A had called the DON and they were aware of the allegations. She said staff should have reported the allegations immediately and not waited until the next day. She said Resident #1 had a history of [REDACTED].#1 being verbally aggressive with Resident #2. During an interview on 04/28/20 at 9:08 a.m., the administrator and DON said Resident #1 had a history of [REDACTED]. She said Resident #1 had no history of threatening Resident #2. The DON said on 03/19/20 at 1:45 p.m., she received a call from CNA A indicating she was concerned for the residents and staff because Resident #1 threatened to hurt CNA D, Resident #2, and several other residents on 3/18/19 around 7:30 p.m. The DON said CNA A said she saw Resident #1 holding a shank in his hand and the way he was gripping it, things got real. The DON said CNA A said Resident #1 and Resident #2 were arguing and Resident #1 sat in front of Resident #2's door and threatened to harm him. The DON said CNA A said she did not immediately report the allegations because she was scared Resident #1 would know she reported him. The DON said CNA A said she had to work with Resident #1 and she did not want him retaliating against her. The DON said CNA A said she watched out for CNA D and Resident #2 stayed in his room the rest of the shift. The DON said CNA D was scheduled to come in to work at 2:00 p.m. and they got in touch with her and made sure she did not work the floor. She said they placed Resident #1 on one to one monitoring and ensured Resident #2 stayed in his room. The administrator said they gathered statements from staff who worked the evening shift on 3/18/20. The administrator said the police were contacted and they obtained permission from Resident #1 to check his room for possible weapons. The administrator said Resident #1 told the police officer and staff if he had a shank, they would never find it. The administrator said a homemade weapon, scissors and metal utensils were found in the resident's drawer. She said she removed all potential weapons from Resident #1's room. She said she verbally in-serviced CNA A, CNA B (agency staff), and LVN C (agency staff) one on one about immediately reporting and went over the abuse guidelines. She said all staff were in-serviced on the facility's abuse policy, the abuse coordinator, definitions of abuse, neglect, exploitation, resident to resident abuse, and the administrator and DON should immediately be notified of any abuse or neglect allegations. The DON said an inpatient behavioral hospital was scheduled to come to the facility to in-service staff about resident behaviors and how to deal with behaviors but due to COVID-19, the in-service would be rescheduled when visiting restrictions were lifted. The DON said emergency medical services (EMS) arrived to transport Resident #1 to the local hospital and Resident #1 said he was ready to leave the facility and wanted to get his own apartment. The DON said she reported the incident to the state and called Resident #1's insurance case manager and they began working on finding alternative placement for Resident #1. The DON said Resident #1 said he wanted to return to the community, but several apartments denied him due to his criminal history. She said Resident #1 refused to go to another nursing facility or assisted living. The DON said on 03/20/20 she was in contact with the case manager at the hospital and they wanted to send Resident #1 back to the facility because they felt he was not a danger. The DON said she tried to explain to the hospital case manager that Resident #1 threatened residents and staff and she would be jeopardizing other residents' safety if Resident #1 returned. The DON said the medical director also felt Resident #1 was a threat to others and readmission was not recommended. The DON said Resident #1 was discharged from the hospital and transported back to the facility by hospital security. She said they kept Resident #1 in the front lobby on one to one monitoring and issued an immediate discharge due to his behaviors and threats towards other residents. They said they discussed alternative placement with Resident #1, he refused to move to another nursing facility or assisted living and refused to go to an inpatient behavioral hospital. The DON said Resident #1 said he had lived at a homeless shelter before and requested to be taken back to that homeless shelter. The administrator said they gathered his belongings, medications, medical records, and they filled a cooler with food and snacks. She sai(TRUNCATED)

Based on observation, interview, and record review, the facility failed to implement written policies that prevent abuse for 5 of 5 residents reviewed for abuse. (Residents #1, #2, #3, #4 and #5) The facility did follow their policy by not protecting Resident #s 2, 3, 4, and 5 for approximately 14 hours after Resident #1 threatened to harm them while holding a homemade prison like shank. Resident #1 stood outside of Resident #2's room and threatened to harm him. Resident #2 was afraid Resident #1 was going to hit him. An Immediate Jeopardy (IJ) situation was determined to have existed on 03/18/20 to 3/20/20. It 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 survey. This failure could place residents at risk of abuse, injury, or death. Findings included: The facility's abuse policy last updated on 07/17/19 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Mental/psychological abuse is defined as mistreatment within the definition of abuse means to inappropriately treat or exploit a resident, not resulting in physical harm, including, but not limited to humiliation, harassment, threats of punishment, deprivation, or intimidation. Emergency situations that pose a threat to resident health and safety include weapons that could be used to hurt or threaten residents that an individual carries and does not immediately remove from the nursing facility after being asked to do so by staff. Employees are required to report all incident of possible abuse, mistreatment, or neglect of any resident, crimes against a resident or misappropriation of a resident's property immediately to their supervisor or administrator, DON, ADON, or charge nurse. 1. A face sheet dated 04/28/20 indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 was cognitively intact, he understood others, and made his needs known. He had no behaviors during the review period. Resident #1 required supervision assistance with most ADLs and he was continent of bowel and bladder. A care plan last revised on 03/17/20 was previously updated on 12/31/19 and indicated Resident #1 had poor impulse control. He exhibited verbally abusive behaviors and would yell and cuss at staff and residents. Interventions included to explain to the resident why his behavior was inappropriate, intervene as necessary to protect the rights and safety of others, and notify the nurse of any problems. The care plan noted Resident #1 refused a psychological consult. An incident report initiated on 03/18/20 at 7:30 p.m. and revised on 03/25/20 at 9:43 a.m. by the ADON indicated the nurse was notified of a resident arguing with another resident. Resident #1 was in his wheelchair outside of another resident's room. Resident #1 said I will kill this black man and Resident #1 would not move from the other resident's door. Resident #1 said he did not have to move, and they would have to call the police. Resident #1 said Resident #2 ran over him as they passed in the hallway. The nurse was able to calm Resident #1 down and took him where he wanted to go. Resident #1 continued to make remarks that if he saw him [AGE] years ago he would have gotten out of his truck and dropped him without any problem. Resident #2 was in his room with the door shut and Resident #1 was removed from the area. A witness statement dated 03/19/20 by CNA A indicated on 03/18/20 Resident #3 called for her because Resident #1 was sitting outside of Resident #2's room. CNA A asked Resident #1 to go back to his hall. Resident #1 said I ain't gotta go nowhere. I'm tired of this black mother f***er and his sh*t. CNA A called for the nurse and the nurse came and talked to Resident #1 into going back to his own hall. A witness statement dated 03/19/20 by CNA A indicated she heard Resident #1 say I'm gonna get CNA D, the DON, the administrator, and I'm gonna get that fat Resident #4 and may get Resident #3. Resident #1 also said how easy it would be with everyone having to stay in their room. CNA A said she saw a homemade weapon in Resident #1's hand and he kept gripping it and the weapon had a sharp metal end on it. The way Resident #1 kept gripping the weapon over and over was like he was getting ready to start to do something. CNA A said she made sure she kept up with the residents and the people he talked about hurting. CNA A said she was scared, and she was put in a position that Resident #1 might hurt her while she was at work. During an interview on 04/28/20 at 2:34 p.m., CNA A said she worked 03/18/20 from 2:00 p.m. to 10:00 p.m. She said Resident #3 notified her about a commotion with Resident #1 and Resident #2. CNA A said she went down the hall Resident #2 resided and Resident #1 was outside of Resident #2's room saying, get your black a** out here. She said she tried to redirect Resident #1, but he said he was not going anywhere. She said Resident #2 was in his room with the door closed and the residents were yelling at each other. She said Resident #2 was yelling at Resident #1 to go back to his room. CNA A said the charge nurse for the back section of the facility was at lunch, so she alerted the charge nurse at the front of the facility. She said LVN C came to the hall and was able to get Resident #1 to leave the hall. CNA A said LVN C went back to the front of the facility. She said Resident #1 was upset because he accused Resident #2 of running into him at the nursing station. CNA A said she saw Resident #1 sitting in his wheelchair in the dining room and he was upset. She said she saw Resident #1 holding a shank in his hand and it was positioned next to him in the wheelchair. She said the shank had a white handle and it had a shiny metal sharp end. She said Resident #1 said he was going to take some people out, including CNA D, the DON, the administrator, Resident #2, Resident #3, and Resident #4. CNA A said he continued to grip the shank while he listed the people he was going to take out. She said she was not sure what time the incidents occurred, and she was not sure which incident occurred first. She said it was normal for Resident #1 to be mouthy, but it was the first time he threatened people or had a weapon. She said she was scared to report what she saw and what she heard because she was afraid Resident #1 would know she reported him, and he would come after her. She said CNA D was working at the front of the facility and she was watching out for her. CNA A said Resident #2 stayed in his room the rest of the evening and Resident #1 stayed in his room, in the dining room, or at the nursing station the rest of the shift. She said she spoke with CNA B and CNA B said she would call the DON the next morning to report the incidents. CNA A said she knew she should have immediately reported the allegations, but she was so frightened by Resident #1 and his behavior that evening and was afraid he would retaliated against her. She said she placed residents and staff at risk because she did not immediately report the abuse allegations. She said she called the DON on 03/19/20 at 1:45 p.m. and notified her of the allegations. She said she received one to one in-servicing by the DON about abuse allegations and immediately reporting any abuse or neglect allegation to the administer or the DON. She said all the staff were in-serviced on abuse, abuse coordinator, neglect, exploitation, resident to resident abuse, and reporting any allegation immediately to the administrator or DON. CNA A said Resident #1 had a history of [REDACTED]. She said Resident #1 had no prior altercations with Resident #2. During an interview on 04/28/20 at 9:08 a.m., the DON said they notified the medical director, ombudsman, and obtained an emergency detention order to send Resident #1 to the hospital for evaluation because the resident was unwilling to go to the hospital for a psychological evaluation. A mental health warrant for emergency detention dated 03/19/20 for Resident #1 indicated any health or peace officer was commanded to apprehend Resident #1 and transport him to a local hospital for examination. A one to one monitoring form dated 03/19/20 to 03/20/20 indicated Resident #1 was placed on one to one monitoring on 03/19/20 at 2:00 p.m. The form indicated Resident #1 was monitored continuously until 03/19/20 at 6:15 p.m. when he was transferred to a local hospital by emergency medical personnel. The monitoring from indicated Resident #1 returned to the facility on [DATE] at 4:10 p.m. and was monitored continuously until 03/20/20 at 6:15 p.m. when the sheriff's department arrived to transport Resident #1 to the homeless shelter. A hospital crisis screening form dated 03/19/20 indicated Resident #1 was pleasant and said the night before he was near the ice machine at the facility when Resident #2 almost hit him. Resident #1 said he told Resident #2 he needed to slow down and Resident #2 began to berate him. Resident #1 said he had his room inspected and searched for a knife by staff and then staff came back with a warrant and informed him he had to go to the hospital. Resident #1 denied having homicidal ideations and said he was calm after the argument with Resident #2. Resident #1 said he did not threaten to harm anyone. A discharge notice dated 03/20/20 for Resident #1 indicated Resident #1 was immediately discharged from the facility due to the safety of residents and/or staff was endangered. Resident #1 signed the discharge notice. 2. A face sheet dated 04/28/20 indicated Resident #2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #2 had moderately impaired cognition, understood others and made his needs known. He had no behaviors during the review period. Resident #2 required supervision assistance with most ADLs. He was continent of bowel and bladder. A care plan last revised on 03/09/20 indicated Resident #2 had a history of [REDACTED]. Staff should intervene before agitation escalate, guide the resident away from the source of distress, and monitor and document behaviors. A safe survey dated 03/20/20 for Resident #2 indicated Resident #2 said he was not scared of no man, but he felt threatened by Resident #1. Resident #2 said he would not let Resident #1 hurt him and he started carrying a belt in a bag on his wheelchair, so he could protect himself if needed. Resident #2 said he felt better that Resident #1 was no longer in the facility. During an observation and interview on 04/28/20 at 12:20 p.m., Resident #2 was sitting in his room. He said he remembered the incident with Resident #1. He said the incident occurred a while ago but he and Resident #1 had words near the nursing station. Resident #2 said he went to his room. He said sometime later Resident #1 was in the hall outside of his door yelling and cussing at him to come out of his room and Resident #1 was threatening him. He said Resident #1 had a Coke can and was threatening to throw it at him. Resident #2 said he told Resident #1 to go back to his room, but he did not. He said he shut his door during the altercation and someone finally came and got Resident #1. Resident #2 said he thought police got him away from his room. He said Resident #1 did not like him because he was black. Resident #2 said Resident #1 would tell him he was nothing but a n**ger. Resident #2 said Resident #1 was a white, Caucasian, German, Nazi. He said he was not afraid of Resident #1, but he was afraid Resident #1 was going to throw the Coke can at him. Resident #2 said he kept his belt rolled up in his wheelchair after Resident #1 came down to his room in case he needed to protect himself from Resident #1. Resident #2 said he no longer kept the belt rolled up in his wheelchair and was wearing his belt again. Resident #2 pointed to the belt he was wearing on his pants. Resident #2 said he was glad Resident #1 was no longer at the facility. A witness statement dated 03/19/20 by CNA B indicated on 03/18/20 CNA B worked the 2:00 p.m. to 10:00 p.m. shift and saw Resident #2 at the nursing station using the phone and Resident #1 was making rude comments to Resident #2. Resident #1 said he hated a f***ing n**ger and the mother f***er (referring to Resident #2) needed to get off the damn phone. CNA B reported what Resident #1 said to Resident #2 to CNA A. CNA A said that was how Resident #1 acted. CNA B later answered Resident #1's call light and Resident #1 said Resident #2 should not have been on the phone at the nursing station earlier and again said he hated f***ing n**gers. Resident #1 said he used to have a knife, but he threw it away and he knew it was best that he threw it away because if he would not have thrown it away, he would hurt CNA D or Resident #2. Resident #1 said it would not bother him to hurt someone because he had already been in the penitentiary and prison did not scare him. CNA B told Resident #1 that he should not think like that and Resident #1 agreed. CNA B told CNA A what Resident #1 said, and CNA A said she saw Resident #1 with a knife earlier. CNA A told CNA B to call the DON first thing the next morning, but her phone was not working, and she was not able to call the DON. During an interview on 04/28/20 at 4:23 p.m., CNA B said she worked for a staffing agency and worked at the facility on 03/18/20 from 2:00 p.m. to 10:00 p.m. She said during the shift she saw Resident #2 using the phone at the nursing station. She said Resident #1 was near the nursing station and said, I can't stand that n**ger and said Resident #2 did not need to be using the phone. CNA B said she reported what Resident #1 said about Resident #2 to CNA A. She said CNA A said Resident #1 was like that. CNA B said later on she answered Resident #1's call light. She said Resident #1 asked her about getting his soup warmed and then he said Resident #2 better be glad that he threw away his knife. She said Resident #1 said he would have hurt CNA D and Resident #2 if he did not throw the knife away. She said Resident #1 said he was in prison and he was not scared of prison. CNA B said she told Resident #1 he did not need to think like that and Resident #1 said she was right. She said she left the room and told CNA A what Resident #1 said about CNA D, Resident #2, and the knife. She said CNA A said she saw Resident #1 earlier with a homemade knife. CNA B said CNA A told her to call the DON first thing the next morning and report the allegations about Resident #1. She said she attempted to call the DON the next morning, but her phone was not working and once her phone began working the DON called her on 03/19/20 around 2:00 p.m. She said she was in-serviced by the DON about abuse allegations and immediately reporting any abuse or neglect allegation to the administer or the DON. She said she also was in-serviced by the facility on abuse, abuse coordinator, neglect, exploitation, resident to resident abuse, and reporting any allegation immediately to the administrator or DON. She said she did not see Resident #1 outside of Resident #2's room that evening. She said Resident #2 stayed in his room and she did not see Resident #1 go down Resident #2's hall. She said Resident #1 would easily get upset and yell at staff but that was the first time she witnessed Resident #1 verbally abuse Resident #2. A witness statement dated 03/19/20 by LVN C indicated on 03/18/20 LVN C was called to the south wing of the facility by CNA A because Resident #1 was sitting in front of another resident's room (Resident #2). Resident #1 accused Resident #2 of running over him in his wheelchair. LVN C said Resident #1 was calm but would not move after LVN C asked him to move. LVN C explained to Resident #1 that it would be best for him to go back to his side of the facility. Resident #1 agreed and said if it was [AGE] years ago he would be able to drop him with no problem. LVN C was able to redirect Resident #1 back up the hall and Resident #1 began talking to other residents about the situation. Resident #1 remained calm and continued talking to other residents about how Resident #2 was rude and disrespectful. LVN C said she was able to redirect the residents with what was on the new about coronavirus. There were no other problems throughout the shift. During an interview on 04/29/20 at 10:15 a.m., LVN C said she worked for a staffing agency and worked at the facility on 03/18/20 from 2:00 p.m. to 10:00 p.m. She said she worked the front section of the facility and around 7:30 p.m., CNA A called her to the back of the facility because the charge nurse for the back section of the facility was at lunch. She said Resident #1 was sitting in his wheelchair in the hall outside of Resident #2's room. She said Resident #2's door was closed and Resident #1 was upset because he said Resident #2 came by him when he was by the break room and ran over him. She said Resident #1 was calm but upset because Resident #2 would not come out of his room. She said she asked Resident #1 to go back to his hall and Resident #1 refused. LVN C said she told Resident #1 she had a lot of work to do and she needed him to go back to his hall. She said Resident #1 agreed and she pushed Resident #1 back to the break room where he started talking to other residents about Resident #2 being rude. She said she told Resident #1 he did not need to be talking about other residents and redirected Resident #1 to another subject. She said before she went back to the front of the facility she told CNA A if there were any other issues to notify her. She said she was not notified of any other changes and was not told about Resident #1 having a weapon or threatening other residents or staff. LVN C said she would have immediately reported Resident #1's actions to the DON if she would have known about Resident #1's threats or his homemade shank. She said Resident #1 did say if he was [AGE] years younger he would have been able to drop Resident #2 with no problem, but she did not take that as a threat and did not report it. She said she was in-serviced on abuse and neglect by the staffing agency and in-serviced by the DON at the facility. She said she worked with Resident #1 before and Resident #1 would get upset with her one minute and be fine the next. She said she was not aware of any prior altercations between Resident #1 and Resident #2. 3. A face sheet dated 04/28/20 indicated Resident #3 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A safe survey dated 03/20/20 for Resident #3 indicated Resident #3 felt uneasy with Resident #1 in the facility and worried about being prepared to fight Resident #1 or Resident #1 fighting another resident. Resident #3 said Resident #1 was a bully and he was no longer worried because Resident #1 was gone from the facility. During an interview on 04/28/20 at 5:54 p.m., Resident #3 said he and Resident #1 resided at another facility together. He said he was not afraid of Resident #1 but Resident #1 was a dangerous man and he knew how to make weapons. Resident #3 said he worried about other residents' safety and was glad Resident #1 was no longer at the facility. 4. A face sheet dated 04/28/20 indicated Resident #4 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A safe survey dated 03/20/20 for Resident #4 indicated Resident #4 felt uncomfortable because Resident #2 had a belt wrapped around his knuckles and said he had to protected himself from Resident #1 and had the belt in case Resident #1 came after him. During an interview on 04/28/20 at 1:53 p.m., Resident #4 said she was sitting in the doorway of her room and Resident #1 was at the nursing station with a drink. She said Resident #2 went by Resident #1 and she heard Resident #2 say, f*** you mother f***er, and continued to his room. She said Resident #1 went to Resident #2's room and said, come out mother f***er, let's settle this. She said Resident #2 was hollering for Resident #1 to go to his room but Resident #1 did not move. Resident #4 said CNA A went to Resident #2's room and tried to get Resident #1 to leave the area but Resident #1 rolled back to the other side of the hall. Resident #4 said Resident #1 came back up to the nursing station and did not go back to Resident #2's room. Resident #4 said she was not afraid of Resident #1, but she felt uncomfortable around Resident #2. She said the next day Resident #2 had a belt around his fist and said he was protecting himself from Resident #1. She said she did not feel threatened by Resident #1 and she had not heard Resident #1 threaten any of the residents. 5. A face sheet dated 04/28/20 indicated Resident #5 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A safe survey dated 03/20/20 for Resident #5 indicated Resident #5 was scared when Resident #1 started to yell and cuss and slammed doors. Resident #5 said she was happy Resident #1 was gone. During an interview on 04/28/20 at 1:26 p.m., Resident #5 said Resident #1 resided in the room across from her and would come to her room and talk often. She said Resident #1 was nice to her but Resident #1 did not like Resident #2. She said she did not hear Resident #1 threaten anyone. The facility's provider investigation report dated 03/25/20 indicated on 03/19/20 at 1:45 p.m., the DON received a call from CNA A about an incident that occurred on 03/18/20 at 7:30 p.m. regarding Resident #1. The report indicated CNA A said she was concerned for the residents and staff because Resident #1 threatened to cut CNA D with his shank and CNA A saw the shank in Resident #1's hand. The report indicated CNA A said Resident #1 threatened to harm Resident #2 and sat in front of Resident #2's room waiting for Resident #2 to come out. CNA A said Resident #1 said he was going to also get others. CNA A said she did not immediately report the incident because she was scared Resident #1 would have known she was the one that reported him, and she did not want Resident #1 retaliating against her. The report indicated CNA A said she watched out for CNA D because she worked in the front of the facility away from Resident #1 and she did not want CNA D to get hurt. CNA A said Resident #2 was safe because he stayed in his room for the rest of the night. The report indicated CNA D was contacted and not allowed to work the floor and Resident #1 and #2 were in their rooms and kept apart. Resident #1 was placed on one to one monitoring until he was transferred out of the facility. The administrator and physician were notified. A detention warrant was obtained for Resident #1 and Resident #1 was transferred to a local hospital for a psychiatric evaluation. Safe surveys were conducted with residents and revealed residents were scared, threatened, uncomfortable, and uneasy with Resident #1 residing in the facility. The report indicated a homemade weapon was found in Resident #1's room. Resident #1 returned to the facility and was discharged to a homeless shelter per Resident #1's request. Resident #1 was unwilling to transfer to another nursing facility, assisted living, or inpatient psychiatric hospital. Resident #1 was denied by several apartments due to his criminal background. The ombudsman was notified of Resident #1's discharge. Staff were addressed regarding immediately reporting abuse allegations and staff were in-serviced on abuse, abuse coordinator, neglect, exploitation, resident to resident abuse, and reporting any allegation immediately to the administrator or DON. A local inpatient behavior hospital was scheduled to come to the facility and in-service staff about behaviors and how to deal with behaviors, but the in-service was rescheduled due to COVID-19. The facility investigation findings were confirmed. A witness statement dated 03/21/20 by RN G indicated Resident #5 told her she was glad Resident #1 was gone from the facility. Resident #5 said Resident #1 came to her room all the time and did things that made her mad and scared her, but she never said anything because she feared what Resident #1 might have done to her. RN G asked Resident #5 to elaborate and Resident #5 said Resident #1 would come to her room and put his hand on her knee and called her mom, which she hated. Resident #5 said Resident #1 always talked about hurting people or killing people who crossed him, and she did not want to cross Resident #1 or have him mad at her. During an interview on 04/28/20 at 6:08 p.m., RN G said Resident #1 had a history of [REDACTED]. She said she had not heard Resident #1 threaten anyone or witness him with a weapon. She said was not aware of any history of altercations between Resident #1 and Resident #2. She said she was in Resident #5's room on 03/21/20 and Resident #5 said, I hate to say this, but I'm glad Resident #1 is gone. RN G said Resident #5 continued to tell her that she was scared of Resident #1 but was too afraid to report it to staff. She said Resident #5 said Resident #1 would talk about hurting people that crossed him and she said she was not going to cross him. During an interview on 04/29/20 at 1:35 p.m., CNA F said she worked for a staffing agency and worked on 03/18/20 from 10:00 p.m. to 6:00 a.m. at the facility. She said she was told Resident #1 and Resident #2 were arguing on the evening shift but was not notified about Resident #1 threatening other residents and staff or about Resident #1 having a weapon. She said Resident #1 came to the nursing station a few times during the shift and was rude to staff. CNA F said she worked with Resident #1 a few times and it was normal for him to interact rudely with staff. CNA F said she did not witness Resident #1 cuss or yell at residents. She said Resident #1 did not make any threats towards residents or staff and did not mention any residents or staff. She said Resident #1 went back to his room and did not go down the hall where Resident #2 resided. She said Resident #2 stayed in his room during the entire shift. CNA F said if she was notified about Resident #1 making threats towards other residents and staff or if she saw Resident #1 with a weapon, she would have immediately notified the nurse, DON, and administrator. During an interview on 04/28/20 at 6:20 p.m., CNA D said she worked on 03/18/20 from 2:00 p.m. to 10:00 p.m. She said she worked in the front wing of the facility and did not work with Resident #1. She said she heard the commotion from the front of the facility when Resident #1 was outside of Resident #2's room because they were loud. She said she was not aware of Resident #1's threats towards her until the next day. CNA D said she did not know why Resident #1 targeted her because her and Resident #1 got along well. She said Resident #1's threats made her feel uneasy. CNA D said Resident #1 could be nice and quickly become upset, but she had not heard him threaten other residents or staff. She said she was not aware of Resident #1 yelling or cussing at Resident #2. She said she would immediately report any threats towards residents or if she saw a resident with a weapon to the administrator or DON. During an interview on 04/28/20 at 11:20 a.m., the ADON said she was working as the charge nurse on 03/19/20 from 6:00 a.m. to 2:00 p.m. She said sometime before 1:45 p.m., Resident #1 approached her and asked if he was in trouble. The ADON said she asked Resident #1 why he would be in trouble. She said Resident #1 said he and Resident #2 argued the previous evening after Resident #2 almost ran over him. The ADON said Resident #1 did not say anything about sitting in front of Resident #2's room, threatening residents, or having a homemade weapon. She said she went to notify the administrator and DON of what Resident #1 said but they were at lunch. She said she began investigating, made sure Resident #1 and Resident #2 were separated, and spoke to Resident #2. She said Resident #2 had a belt in his wheelchair and he said he would use it if Resident #1 kept threatening him. The ADON said by that time, CNA A had called the DON and they were aware of the allegations. She said staff should have reported the allegations immediately and not waited until the next day. She said Resident #1 had a history of [REDACTED].#1 being verbally aggressive with Resident #2. During an interview on 04/28/20 at 9:08 a.m., the administrator and DON said Resident #1 had a history of [REDACTED]. She said Resident #1 had no history of threatening Resident #2. The DON said on 03/19/20 at 1:45 p.m., she received a call from CNA A indicating she was concerned for the residents and staff because Resident #1 threatened to hurt CNA D, Resident #2, and several other residents on 3/18/19 around 7:30 p.m. The DON said CNA A said she saw Resident #1 holding a shank in his hand and the way he was gripping it, things got real. The DON said CNA A said Resident #1 and Resident #2 were arguing and Resident #1 sat in front of Resident #2's door and threatened to harm him. The DON said CNA A said she did not immediately report the allegations because she was scared Resident #1 would know she reported him. The DON said CNA A said she had to work with Resident #1 and she did not want him retaliating against her. The DON said CNA A said she watched out for CNA D and Resident #2 stayed in his room the rest of the shift. The DON said CNA D was scheduled to come in to work at 2:00 p.m. and they got in touch with her and made sure she did not work the floor. She said they placed Resident #1 on one to one monitoring and ensured Resident #2 stayed in his room. The administrator said they gathered statements from staff who worked the evening shift on 3/18/20. The administrator said the police were contacted and they obtained permission from Resident #1 to check his room for possible weapons. The administrator said Resident #1 told the police officer and staff if he had a shank, they would never find it. The administrator said a homemade weapon, scissors and metal utensils were found in the resident's drawer. She said she removed all potential weapons from Resident #1's room. She said she verbally in-serviced CNA A, CNA B (agency staff), and LVN C (agency staff) one on one about immediately reporting and went over the abuse guidelines. She said all staff were in-serviced on the facility's abuse policy, the abuse coordinator, definitions of abuse, neglect, exploitation, resident to resident abuse, and the administrator and DON should immediately be notified of any abuse or neglect allegations. The DON said an inpatient behavioral hospital was scheduled to come to the facility to in-service staff about resident behaviors and how to deal with behaviors but due to COVID-19, the in-service would be rescheduled when visiting restrictions were lifted. The DON said emergency medical services (EMS) arrived to transport Resident #1 to the local hospital and Resident #1 said he was ready to leave the facility and wanted to get his own apartment. The DON said she reported the incident to the state and called Resident #1's insurance case manager and they began working on finding alternative placement for Resident #1. The DON said Resident #1 said he wanted to return to the community, but several apartments denied him due to his criminal history. She said Resident #1 refused to go to another nursing facility or assisted living. The DON said on 03/20/20 she was in contact with the case manager at the hospital and they wanted to send Resident #1 back to the facility because they felt he was not a danger. The DON said she tried to exp(TRUNCATED)