Every finding on record at DFW Nursing & Rehab

Based on interview and record review the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility; the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; and failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one of five residents (Resident #1) reviewed for transfers and discharges. 1) The facility failed to ensure when Resident #1 was issued a 30-day discharge notice, on 12/12/25, citing behavioral issues, the clinical documentation contained clear evidence which documented the resident's needs could not be met in the facility and posed a danger that could not be managed through care planning or IDT intervention.2) The facility failed to ensure a safe and orderly transfer and discharge process when they sent Resident #1 to a behavioral hospital through an order of protective custody (OPC) and then refused to readmit Resident #1 following the inpatient psychiatric stabilization when he was stable.These failures could place residents at risk for inappropriate discharge, prolonged institutionalization and disruption of continuity of care. Findings include:Record review of Resident #1's Quarterly MDS Assessment, dated 12/01/25, reflected a [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 had active diagnoses which included Parkinsonism (a neurological syndrome characterized by motor symptoms like tremor, slowness, rigidity and postural instability), seizure disorder (chronic neurological condition characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical surges in the brain), anxiety (excessive fear, worry, and physical symptoms like rapid heart rate, dizziness, and restlessness that interfere with daily life), depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, fatigue, and physical pain) and schizophrenia (a chronic, severe brain disorder characterized by a detachment from reality through hallucinations, delusions, and disorganized thinking). Resident #1 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #1 had fluctuating signs and symptoms of delirium which included inattention and disorganized thinking. He had symptoms of feeling depressed and little interest noted as a mood issue. Resident #1 was noted to feel sometimes isolated around those around him. Resident #1 had no potential indicators of psychosis and no behavioral symptoms of physical or verbal aggression. Resident #1 had no rejection of care issues and no wandering behaviors. Resident #1 was ambulatory, did not use a mobility aide and had no range of motion issues. For walking 10-150 feet, Resident #1 required supervision or touching assistance. Resident #1 was administered the following high-risk medications during the assessment period: an antipsychotic, antianxiety, antidepressant, antibiotic and anticonvulsant medications. Record review of Resident #1's care plan, initiated 12/29/23 and last revised 01/12/26, reflected the following areas focus areas: 1) Signs of disorganized thinking and auditory hallucinations (initiated: 03/09/24), 2) Has a female resident that he looked at as his companion (initiated: 03/27/24). Interventions included to administer medications as ordered, allow ample time to answer questions, introduce changes slowly and monitoring by nursing every hour for his whereabouts. Resident #1 also was care planned as having a history of behaviors, refused medication at times, had a history of aggressive behavior towards other residents when he is made fun of. Care planned dates of aggression incidents were 09/16/25 when he hit another resident thinking he was making fun of him and on 01/12/26 when he pushed another resident. Additional interventions included not to argue with Resident #1 and Assist [Resident #1] to selection of appropriate coping mechanisms, ensure that other residents are safe when [Resident #1] exhibits aggressive behaviors, Illicit help from family members when [Resident #1] has aggressive behaviors, Monitor and document [Resident #1's] behaviors, Notify PCP.Refer to psych services when exhibiting behaviors, Social services to evaluate and visit with [Resident #1], Talk to him in a calm voice when behavior is disruptive.Record review of Resident #1's Physician Order Summary reflected he was prescribed the following psychotropic medications: -Lorazepam 1mg three times a day for anxiety disorder (start date: 03/13/25) -Lexapro 10 mg once a day for depression (start date 04/30/24) -Lithium Carbonate 300 mg twice a day for bipolar disorder (start date 03/14/24)-Risperdal 2 mg once in the evening for schizophrenia (start date 09/24/25)-Divalproex Sodium 250 mg twice a day for schizophrenia (start date 09/24/25)-Mirtazapine 15 mg in the evening for mood/appetite (start date 04/29/24)Record review of Resident #1's December 2025 and January 2026 MAR reflected he was administered his psychotropic medications as ordered, however, he had periodic medication refusals throughout the two months as documented by the nurses and medication aides on the MAR. Record review of Resident #1's psychological services progress note, by LPC, dated 12/11/25, reflected he had no current risk factors, which included self-injury, sexual acting out, homicidal and aggressive behavior. His appearance was neat, judgement within normal limits and he was alert and oriented to person/place/time/day/year. His attention was average and he had restless psychomotor symptoms (connection between mental states and physical movement, manifesting as either extreme agitation or severe slowing). He had tangential speech and a sad, labile, anxious and stressed affect. His mood was worried and depressed and his speech was impoverished. Short-term therapy goals were for Resident #1 to verbalize feelings about his current situation during sessions, identify and discuss at least two positive coping skills, reduce frequency of behavioral disturbances by 50% for four weeks and he will report two positive social interactions daily that improve his mood. Resident #1's response to intervention per the clinician's notes was, Engaged and interactive in session. Met in day area, where he is isolating; acknowledged insight into mood changes when isolating. Praised pt for recognizing patterns and symptoms of avoidance/disengaging. Encouraged his progress with new awareness. Record review of a 30-day Discharge Notice for Resident #1, dated 12/12/25, reflected he was formally notified that he would be discharged from the facility on 01/10/26 due to 1) The safety of other individuals is endangered, 2)The health of other individuals in the Health Care Center is endangered, and 3) Your needs cannot be met by the Health Care Center.Record review of Resident #1's Psychiatric Subsequent Assessment, dated 01/07/26, by PMHNP reflected he was being seen for medication management. The assessment reflected, Collateral Information: According to staff, the resident refuses medications at times, exhibits sx of paranoia, auditory hallucinations and anxiety. Resident is currently on hourly checks due to behavioral concerns. An increase of 0.5mg added of Risperdal daily was added with a start date of 01/12/26 with no other changes recommended. The plan was continue with care and reassess in two weeks for a follow-up visit. A follow up visit by the PMHNP on 01/14/26 reflected Resident #1 was seen for a medication management visit. The assessment reflected, Collateral Information: According to staff, the residents [sic] an improvement in sx of anxiety, agitation and psychosis. Resident recently pushed a fellow resident without any apparent provocation and is currently on 1:1 monitoring. An increase of 0.5mg added of Risperdal daily had been added on 01/12/26. No other changes were recommended. The PMHNP documented she would revisit with Resident #1 to re-assess. Record review of Resident #1's social worker progress notes from 12/01/25 through 02/04/26 reflected the facility issued a 30-day discharge notice due to behavioral concerns on . The ombudsman was notified the same day via email and fax. The RP was informed and the appeal process was explained and a copy of the discharge notice was sent to the RP. On 12/16/25, the SW documented continued communication with the RP and efforts to secure alternate placement, including exploration of nursing home and group home options. On 01/12/26, the SW documented Resident #1 continued to refuse medications, became and exhibited screaming and yelling behaviors. EMS responded and Resident #1 was subsequently approved for a transfer to a behavioral hospital via an Order of Protective Custody (OPC), with a court appearance on 01/14/26 which was approved and the RP notified regarding the transfer. The SW progress notes, dated 01/21/26 through 02/06/26, reflected ongoing communication between the facility, the behavioral hospital and an external placement coordinator regarding discharge planning to a group home. Subsequent entries reflected confusion regarding discharge timing, coordination with the behavioral hospital and whether the group home was prepared to receive the resident at the time of discharge. Notes further reflected at one point, Resident #1 was discharged from the hospital without a clear confirmation that placement arrangements were finalized. On 02/02/26, a SW progress note reflected, I received a call from the patient's [RP], who reported that both the state and the ombudsman have been contacted due to concerns of abandonment. I clarified to her that, to my knowledge, the patient was in the process of transitioning to a group home, and that I had been working closely with the group home in this regard. The [family member] stated that she is no longer able to provide care for the patient and insisted that we need to take responsibility for him. I expressed concern to her regarding the patient's recent behavior, specifically the risk associated with the patient having physically assaulted another individual. I informed her that, given the current circumstances, the risk to other patients here is considered high.Record review of Resident #1's nursing progress notes from 12/01/26 through 02/04/26 reflected periodic behavioral concerns including medication refusals, yelling, wandering into other residents' rooms, verbal altercations and two documented physical incidents. On 12/26/25, Resident #1 was documented as deliberately bumping into the maintenance director with his shoulder and was placed on 1:1 observation. On 01/12/26, Resident #1 pushed another resident and was again placed on 1:1 monitoring. The PMHNP was notified after the incident on 01/12/26 and his dose of Seroquel (antipsychotic) was increased to 0.5 mg added in the morning. Resident #1 was subsequently transferred for inpatient psychiatric evaluation on 01/14/26. The nursing progress notes did not reflect the evaluation of increased anti-psychotic medication's effectiveness on Resident #1's behaviors or that identified behavioral interventions had been exhausted or determined ineffective.Review of TULIP database reflected no facility reported incidents related to Resident #1 and resident to resident abuse for the 01/12/26 incident pf physical aggression.An interview with Resident #1's RP on 02/04/26 at 10:05 AM revealed Resident #1 was currently at the behavioral hospital and had been there since 01/14/26. The RP stated the facility's SW would not accept Resident #1 back because he got into an altercation with another patient at the behavioral hospital, but that was before he got his medication in him. The RP stated the behavioral hospital confirmed he hit a patient but did not jump on him (meaning he did not physically attack him). The RP stated she did not know why Resident #2 was sent to the behavioral hospital and only found out when someone from the hospital called her. She stated the facility did not tell her they were sending him there but stated her voice mail had been full. The RP stated she did not know what Resident #1 had done that warranted him having to be sent out but was told the resident was hearing things and needed to be evaluated. She stated while at the facility, there had been times when Resident #1 did not want to take his medication and she felt maybe he had become immune to his medications and was acting out. The RP stated she did not know anything about a group home placement. She stated, All I know is [nursing facility] referred him; you have to talk to [nursing facility] about that. The nursing home makes the decisions for [Resident #1] and they get paid to take care of him. She did not know that the behavioral hospital had tried to arrange transportation to take Resident #1 to a group home. She said she thought the behavioral hospital tried to take Resident #1 back to the facility and they refused him. The RP stated she could not take care of Resident #1 as she worked full time. She stated she felt like the facility had abandoned him by dropping him off at a behavioral hospital and telling him he was not allowed to come back. She stated Resident #1 was not cognitively able to agree to anything and she herself did not sign any documentation agreeing to any transfers or discharged . She stated she did not know anything about the facility's acquisition of an Order of Protective Custody for Resident #1. An interview with the SW on 02/03/26 at 12:50 PM revealed she had been employed at the facility for about two months and Resident #1 was already living at the facility when she started and was not initially identified as a concern. According to the SW, the resident did not immediately stand out to her, but concerns developed approximately a month later as she began interacting with him more directly. She described her early interactions with Resident #1 as troubling and stated she felt afraid of him from the beginning of those encounters. The SW stated Resident #1's demeanor alone felt threatening, even in the absence of overt verbal aggression. She stated he did not need to speak or act out physically to cause concern and said his presence, posture and eye contact was intimidating. She stated he spent much of his time in bed and was often withdrawn but when he became active, staff were immediately aware. The SW stated Resident #1 began walking the halls and entering other residents' rooms, sometimes standing over them while they were in bed. She stated this behavior caused fear among residents and staff and concerns were raised about the safety of other residents, particularly those who were vulnerable or cognitively impaired. The SW stated staff reported feeling uneasy and residents expressed fear when Resident #1 was mobile and roaming the halls. She stated the behaviors escalated to the point that 911 was called. She reported Resident #1 initially agreed to go to the hospital, but once outside the facility with EMS, he refused transport and EMS did not take him. The SW described the concerns prompting the call to 911 as behavioral rather than medical. Following these events, the SW stated she was instructed to seek alternate placement for Resident #1 due to the ongoing behaviors and safety concerns. She stated she made extensive efforts to secure a placement for him, contacting at least 15 nursing facilities, all of which declined and consistently indicated to her Resident #1's behaviors and refusal to take medications as reasons for denial. The SW stated she also attempted to pursue group home placement and worked with a group home contact. The SW said she kept Resident #1's RP informed throughout the process. The SW stated the RP acknowledged she could not care for the Resident #1 herself and did not mind the SW looking for alternate placements. The SW stated after discussions with the ADM, a 30-day discharge notice was issued on 12/12/25 while placement efforts continued. She reported due to escalating behaviors, an Order of Protective Custody (OPC) was obtained and Resident #1 was transferred to a behavioral health facility. Following the transfer, the SW stated there were significant communication problems with the behavioral hospital. She stated she attempted repeatedly to contact hospital staff for updates regarding Resident #1's condition, medications and discharge planning but did not receive return calls. She said she was initially told Resident #1 was stable but later informed that he had allegedly assaulted another resident described as an elderly male. She stated details of the incident were unclear. The SW also stated she received conflicting information regarding whether Resident #1 had been transferred to a group home, returned to the behavioral hospital or discharged to his family member. She described the situation as confusing and difficult to track. The SW reported Resident #1's RP later contacted her and accused the facility of abandoning the resident and believed the facility should accept Resident #1 back. The SW stated the final decision not to accept Resident #1 back was made by the ADM. The SW stated there were ongoing safety concerns with Resident #1's behaviors, refusal to take medications and there was a lack of clinical documentation from the behavioral hospital regarding medication changes and condition at discharge or readiness to return. She stated no discharge paperwork or medication information was received from the behavioral hospital. An interview with ADON A on 02/03/26 at 2:06 PM revealed Resident #1 had behavioral issues related to mental illness such as paranoia, verbal outbursts, misinterpreting conversations as being about him, standing in residents' doorways and causing fear among some of the residents. ADON A stated she was aware of reports that Resident #1 attempted to strike another resident, though she did not personally witness any physical contact. ADON A stated the facility managed residents with serious mental illness through psychology and psychiatry services, including regular visits and medication management. She reported one-to-one supervision was implemented when a resident exhibited aggression or posed a safety risk. ADON A stated she was not involved in discussions regarding Resident #1's transfer to a behavioral hospital, the Order of Protective Custody or decisions regarding readmission or discharge. She stated those decisions were primarily handled by the DON and ADM and her involvement was limited. An interview with LVN D on 02/03/26 at 2:35 PM revealed she was familiar with Resident #1's baseline behavioral patterns and described him as cyclical with long periods of stability followed by periodic behaviors but occurring months apart. According to LVN D, early indicators of behavioral decline for Resident #1 included refusal of medications and increased verbal fixation on perceived accusations related to his sexual orientation. LVN D reported during these cycles, Resident #1 appeared to experience auditory hallucinations, often triggered by male voices, leading to defensive verbal outbursts. She stated while she could not speak for other shifts, she was personally able to redirect him and consistently get him to take his medication by giving one on one time and patience. LVN D stated she had not personally observed Resident #1 physically strike other residents or hit walls but was aware of reports he had attempted to hit another resident. She recalled personally observing him shoulder-bump a maintenance staff member without clear provocation. LVN D stated while Resident #1 was generally redirectable during her shift, she heard reports he stood in residents' doorways on other shifts, which caused fear among residents. LVN D if staff were unfamiliar with Resident #1 and did not understand his behaviors and de-escalation techniques that worked for him and his triggers, they might feel hesitant to intervene during those episodes. LVN D stated, If staff are afraid to step in, that's when things can escalate. She stated patience was the only thing that worked for him. LVN D stated she was not involved in management-level decisions regarding Resident #1's transfer, Order of Protective Custody or readmission decisions and was unaware of the criteria used to determine whether a resident could return to the facility. She stated those decisions were handled by management staff.An interview with CNA C on 02/04/26 at 11:30 AM revealed Resident #1 was generally quiet and tended to remain in his room for much of the day. She stated for the majority of the time, Resident #1 was not highly social and did not regularly interact with other residents. When he did leave his room, it was typically to request coffee or to shower. She stated Resident #1 exhibited intermittent behavioral issues that were not constant or daily but occurred approximately once or twice per week. She described his primary behavioral concern as verbal outbursts related to paranoia, particularly believing that others were calling him derogatory names. CNA C stated these beliefs appeared to be internal to the resident and were not typically triggered by other residents or staff. CNA C stated when Resident #1 became agitated, he would sometimes verbalize his beliefs loudly, stating others were calling him names, even when staff attempted to reassure him no such comments had been made. She stated Resident #1 often could not be redirected once he became fixed on these beliefs. CNA C stated she had not heard of or seen Resident #1 entering other residents' rooms, standing over residents or intentionally frightening other residents during her shifts. She was not aware of any residents reporting fear of Resident #1 and indicated most concerns among staff related to unpredictability rather than ongoing aggression. She stated Resident #1 sometimes refused medications, particularly during periods of agitation. She stated certain staff members were more successful than others in encouraging compliance and de-escalation was commonly used. These strategies included offering coffee and redirecting Resident #1 or involving staff members with whom he was more familiar. CNA D stated that approaches to managing Resident #1's behaviors were not always consistent among facility staff and responses to him varied depending on the situation and staff working at the time. CNA D stated frontline staff were not always informed in advance of significant changes related to residents with behavioral concerns. She stated she was aware Resident #1 would be moved out of the facility but did not recall being provided advance details regarding the timing or destination. She indicated staff often learned residents had been transferred only after returning to work. CNA D stated she was not present on the day Resident #1 was transferred under an Order of Protective Custody and was not aware it had occurred until she came to work. She stated she did not receive detailed information regarding Resident #1's circumstances or subsequent discharge planning.An interview with the COO and C-RN on 02/03/26 at 3:10 PM revealed inpatient psychiatric hospitalizations were a stabilization attempt, not necessarily a permanent removal. The COO stated even when the behavioral hospital determined a resident was at baseline, that baseline may still be unsafe within the long-term care environment. The COO and C-RN stated decisions not to accept a resident back should involve facility leadership. If the facility determined a resident could not return, they stated the facility would then be responsible for assisting with alternate placement. The COO and C-RN stated their understanding was that group home placement had been arranged for Resident #1 from the behavioral hospital. An interview with the ADM on 02/04/26 at 12:15 PM revealed the concern that led to Resident #1 being issued a discharge notice on 12/12/25 was the ADM had heard some of the female residents had woken up and noticed Resident #2 was standing in their doorways saying he was not gay and to get off him, but he never touched any of them. The ADM stated, He [Resident #1] would say that he would never hit a woman and when I was there, he didn't. But residents became scared because he started changing and pacing the halls, which was normal, but he started saying he was not gay and he was no faggot. The ADM stated he knew Resident #1 had a stay in the penitentiary, so he did not know if maybe that contributed to his behavior. He stated everything with Resident #1 was manageable at first, the facility knew how to deal with him, did the right interventions psyche services. The ADM stated everything was good until Resident #1 started getting more into the staff's faces. The ADM felt it got to the point where he felt Resident #1 was acting more threatening and would was getting closer to hitting someone. The ADM stated he had been an administrator for over ten years and I know eventually he was going to go over the top and we could not afford another resident-to-resident altercation again, so he had to go to a facility that could suit his needs. So we sent him to [behavioral hospital]. The ADM said he heard from the SW, Resident #1 had assaulted a staff member at the psyche hospital and they changed his medications, but they were not working. The ADM stated, He assaulted someone there and I said I would not let him stay at the facility because he was noncompliant with his meds at the psyche hospital. The ADM further stated, So I said we can't take him back. He didn't get the help he needed. They (behavioral hospital staff) wanted him to come back to the facility, they were telling us the time was up and they couldn't do anything with him. The ADM stated the facility SW talked to Resident #1's RP and found a group home that would accept him. Then the behavioral hospital dropped him off at the group home, but no one was there and neither the facility nor behavioral hospital coordinated with the group home about him coming. The ADM stated he heard the behavioral hospital said they were going to call in a complaint to HHSC because the facility was not taking Resident #1 back. The ADM stated, We said no need because we are actively working with you to get placement. We did everything we were supposed to do. He stated the SW found the group home and he thought Resident #1's RP knew the group home and wanted to be involved in the process, but when the time came for him to discharge from the psyche hospital, the RP did not want to take him there and took him home instead. The ADM stated, I may be confused, but I am pretty sure she said she would take him with her. The ADM stated he was under the impression Resident #1 was at home with his RP and We did not hear anything else about it. The ADM stated the first priority was to make sure residents felt safe and he did not feel the facility was equipped to take care of residents like Resident #1. The ADM stated, When you take a person who at any time could be a danger to any resident or staff member, they are going to cause you issues and headaches from day one and they will hurt someone and I can't afford that. The ADM stated the Order of Protective Custody was obtained by the facility because, We needed him out as soon as possible, any minute he was going to do something. The ADM said Resident #1 would not agree to go to a psyche hospital on his own and his RP did not want him to go either and wanted him to stay at the facility. The ADM did not know if the facility obtained updated clinicals for Resident #1 since his admission to the behavioral hospital for evaluation. He stated the facility typically did not send residents for inpatient psychiatric hospitalization that they were not planning on re-admitting. The ADM stated, We will not throw them away or walk away, we will help them find a placement. We are good with that due to the connections we have of knowing people all over. We are not going to make an unsafe discharge. He said Resident #1 needed psychiatric help.because we can't help him if [psyche hospital] cannot settle him down.An interview with the Director of Clinical Services/LCSW from the inpatient psychiatric hospital on [DATE] at 11:47 AM revealed Resident #1 was admitted on [DATE] due to hearing voices and becoming agitated when the voices would call him gay. The DCS stated the facility told her due to Resident #1's aggression at their facility, they had issued him a 30-day discharge notice and on the date of the discharge, they found a group home that would take him but when the group home placement agency came to the inpatient behavioral hospital to take Resident #1 to the group home, it was not in existence. Since Resident #1 was at the inpatient hospital, he became aggressive on 01/16/26 and 01/22/26. He was treated and an attempted discharge was attempted on 01/29/26, which the DCS stated was seven days without incident, which was standard for an inpatient stabilization. The DCS stated Resident #1 had not been violent since 01/22/26, But due to this placement issue, the patient started being inconsistent with his medications as he was upset the nursing home still has all of his belongings and is not allowing him back. This has been very triggering for the patient and has caused setbacks in his treatment. As a facility, we would require at least 72 hours of medication compliance prior to discharge to assure stabilization. She stated Resident #1 had been stable and had not had any additional outbursts and a discharge location was still pending. The DCS stated it was her understanding their social worker had spoken with the facility's SW and it was understood the facility would be accepting Resident #1 back until the facility could locate a placement, as his 30-day discharge notice was not up until 02/10/26 per her understanding. The DCS stated, In the case of the nursing home, since the patient was still legally their resident, they should be responsible for locating placement as we (nursing facility) were not a long-term facility and the patient's 30 day was not up. It appears they started this process, sent him to us, then stopped assisting the patient's family member once he was in our (nursing facility) care. Although the group home placement agency stated they were working with [facility SW], [facility SW] informed me on 1/29/2026 that she 'had not set up a group home for the patient', indicating they did not attempt to locate safe placement for their patient from 1/10/2026 when the 30 day was issued until his admission here on 1/14/2026. The DCS stated the facility told the inpatient behavioral hospital staff they would not accept him back. She said her social worker was in contact with the facility and if she would have known, she would have been attempting to locate placement had she been told he was not accepted back. She said per the group home placement agency, who showed up to the behavioral hospital, on Resident #1's date of discharge, the group home was ready. The DCS stated, Then when we sent the patient there, the group home was a vacant home. The patient was brought back to my facility, [behavioral hospital SW] could not explain why the group home she came to divert the patient to was empty, and [facility SW] reports she didn't set up a group home. The patient's [family member] then called us (She had not responded to any contacts prior to this) and said the group home would be ready Saturday, 1/30, and agreed to pick the patient up. On Saturday, she refused and stated the group home won't be ready until March. The DCS stated similar situations had occurred with the facility where they would send residents and then decline to take them back. She stated there was no discharge planning assistance provided by the nursing home despite issuing 30-day notices. The DCS stated she felt the facility issued a 30-day notice to Resident #1 and did not do any discharge planning for him and sent him to an inpatient behavioral hospital for them to take on responsibility for him. She stated there was currently no clear plan for Resident #1's discharge, but

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be free from abuse for two (Resident #1 and #2) of 3 residents reviewed for abuse, in that: On 11/01/25 the facility failed to ensure that Resident #2 was not hit by Resident #1 causing Resident #2 to defend himself with his cane resulting in a laceration to Resident #1's left eyebrow. This failure could affect residents and result in abuse and injuries. Findings include: Record Review of Resident #1's Face sheet reflected she is a [AGE] year-old female admitted to the facility on [DATE]. Record Review of Resident #1's Quarterly MDS dated [DATE] reflected in part diagnoses including bipolar disorder (a mental condition marked by alternating periods of elation and depression), anxiety disorder, dementia, and mood affective disorder (affects your emotional state). A BIMS score of 11 indicated moderate cognitive impairment. Record Review of Resident #1's Care Plan dated 11/13/25 reflected Resident #1 was at risk for bleeding and bruising due to taking Aspirin. Resident #1 was at risk of hitting another resident in the back on 03/29/25. Intervention included residents were separated and assessed for injuries-no injuries noted. Repeatedly hit another resident and then made threatening and intimidating remarks about her to another resident on 04/05/25. Intervention included residents, were separated and assessed for injuries-no injuries noted. Called another resident the N word on 04/26/25. Interventions included Resident #1 was redirected and told that that her words were inappropriate. The 2 residents were separated. Received physical aggression from another resident and then retaliated back and hit a resident on 05/19/25. Interventions included residents separated, Resident #1 assessed for injury. Full skin assessment completed. Physician and Fort Worth police were notified. Identify causes for behavior and reduce factors that may provoke the resident. Resident to be redirected. Record Review of Resident #2's Face sheet reflected he is a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #2's Quarterly MDS dated [DATE] reflected in part diagnosis including schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A BIMS score of 11 indicated moderate cognitive impairment. Record Review of Resident #2's Care Plan dated 11/06/25 reflected #2 was at risk for bleeding and bruising due to taking Aspirin. Resident #2 was also at risk for displaying socially inappropriate/disruptive behavior, cursing, provoking other residents, Psych diagnosis, and deliberately rammed his wheelchair into another resident, provoking an altercation on 09/16/25. Interventions in part included psychiatric services as needed. Record Review of Resident #1's hospital record dated 11/01/25, indicated Resident #1 was treated for a facial laceration and wound irrigation was performed. In an interview on 11/19/25 at 4:41 PM, Receptionist A stated on 11/01/25 Resident #1 had just come in the building to take her medicine then she went to smoke break, she sated Resident #1 already seemed flustered. Receptionist A stated that Resident #2 was walking outside to go to smoke break and both residents exchanged words at the door. Receptionist A stated Resident #2 sat down outside and Resident #1 stood over Resident #2 fussing at him and grabbing on his pants to provoke a fight. Receptionist A stated they decided to hold off on smoke break and her and Housekeeper B separated the residents. Receptionist A stated that Housekeeper B and Resident #1 went back into the building and Resident #1 was taken to her room. Receptionists A stated Resident #1 was in her room still fussing and yelling. Receptionist A stated that she was at her desk, and she heard a loud commotion, and she ran outside to the smoking area. Receptionists A stated she did not see what happened when Resident #2 went back outside but before she was able to get out the door, she observed blood on Resident #1. Receptionist A stated that Resident #2 was trying to get away from Resident #1, but Resident #2 was pulling on Resident #1's pants still trying to fight. Receptionist A stated LVN C called 911 immediately. Receptionist A stated she tried her best to calm down Resident #2 until the police came, but she was still trying to fight Resident #1. Receptionist A stated that Resident #1 was in shock, and he was observed shaking. In an interview on 11/20/25 10:27 AM, LVN D stated he did not see the whole altercation, but what he observed was Resident #1 and #2 were arguing in the smoking area. LVN D stated that Resident #1 was standing over Resident #2 and hit him and that's when Resident #2 put his cane up to keep Resident #1 from hitting him. LVN D stated that he then told Resident #2 to go to her room so that he could assess her. LVN D stated 5 minutes later Resident #1 was back outside in the smoking area, but he didn't see anything else from that point. LVN D stated that he heard Resident #1 calling Resident #2 the ( N word) and calling him cripple. LVN D stated that someone called 911, and he assessed Resident #1 he said she had a cut on her forearm, and she was bleeding. In an interview on 11/20/25 at 12:19 PM, Housekeeper B stated from what she observed Resident #1 was coming out of the cafeteria door and she was walking through the courtyard to go back into the building. Housekeeper B stated when Resident #1 was going in the building and Resident #2 was coming out of the building, but Resident #1 was standing in the doorway and Resident #2 asked Resident #1, are you coming in or out? Housekeeper B stated Resident #1 told Resident #2, oh, you could have said that better. Housekeeper B stated LVN C told her to go and get LVN D since they were his patients. Housekeeper B stated that she observed Resident #1 calling Resident #2 the N word and the B word. Housekeeper B stated that she did not witness the physical fight, but she witnessed Resident #1 walk into the building with blood all over her face. In an observation and interview on 11/20/25 at 1:24 PM, Resident #2 was noted sitting on his bed and ending a phone call. When asked about the fight with Resident #1 he stated he was outside on a cigarette break and Resident #1 called him the N word and the B word and told him that she was going to kick his ass. Resident #2 stated that Resident #1 hit him, and he fell into the chair. Resident #2 stated he hit Resident #1 on the head with his cane because she was trying to give him a black eye. Resident #2 stated a caregiver ended up getting in between them and he was taken to jail. In an interview on 11/20/25 at 2:08 PM, LVN C stated that Resident #1 was coming from the smoking patio and Resident #2 was going out to the smoking patio and Resident #1 was standing in the doorway. LVN C stated Resident #2 asked Resident #1 are you coming in or out. LVN C stated Resident #1 then called Resident #2 a stupid black man and in return Resident #2 called Resident #1 a stupid B word. LVN C stated that's when Resident #1 turned around and went outside and walked up to Resident #2 and told him that she was not a B word. LVN C stated Resident #1 proceeded to grip Resident #1's cane and repeated she wasn't a B word. LVN C stated that she told Resident #1 to let go of Resident #2's cane and that's when the recoil on the cane hit Resident #1 in the nose. LVN C stated that Resident #2 did not hit Resident #1 with the cane but as they tussled back and forth with the cane when Resident #1 snatched the cane back and the recoil on the cane hit Resident #1 in the nose and Resident #1 let go of the cane immediately. LVN C stated that's when she told Resident #1 to go into the building because her nose was bleeding. LVN C stated Resident #1 then stated, look what he (F word) did, LVN C stated she told Resident #1 that Resident #2 did not do that, and she was hit in the nose due to recoil on the cane when she grabbed it. LVN C stated Resident #2 was still outside sitting down and his back was turned, and Resident #1 went back outside and swiped Resident # 2 on his head. LVN C stated that's when Resident #2 hit her with the cane causing Resident #1 to stumble off. LVN C stated that she was trying to calm Resident #2 down because he was shaking. LVN C stated she told LVN D that he needed to do something because Resident #1 was really looking for a fight with Resident #2. In an interview on 11/20/25 at 5:11 PM, DON stated she was not at the facility during the day Residents #1 and #2 got into a fight due to it happening on the weekend. The DON stated that she was told the recoil on the cane hit in the eye. The DON stated that LVN D said he took the cane. The DON stated that Resident #1 was taken to [Hospital Name] and Resident #2 was taken to jail. The DON stated Resident #1 had to get stitches above her eye. The DON stated Resident #1 was placed 1 on 1 with a caregiver until she was discharged from the facility. The DON stated that all the fighting couldn't be tolerated. The DON stated Resident #2 was referred for psych services, and Resident #2 was taken to jail. The DON stated they reeducated staff on resident-to-resident altercations and being proactive in separating residents. The DON stated that she expects staff to intervene, deescalate, separate the residents, report the incident, assess the residents, make sure all residents are safe, and do not argue with the residents. She stated the risk is that a resident could end up hurt or injured. In an interview on 11/20/25 at 6:36 PM, The ADM stated staff are expected to separate the residents as soon as possible, de-escalate the situation, and report to him and the DON. The ADM stated he encourages the staff to find out what's going on and try and solve the situation. The ADM stated it's a lot of situations he has de-escalated just by talking to the residents. The ADM stated the risk of residents getting into a fight is that someone can get hurt or staff could get hurt, or medical emergencies could happen that's why it's important to break it up as soon as you can. Record Review of the facility's Abuse Policy in part indicated - All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation -2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.3. Immediately is defined as a. within two hours of an allegation involving abuse or result in serious bodily injury.

Based on interviews and record review the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further potential abuse and mistreatment while the investigation was in process, and report the results of all investigations to the administrator or his or her designated representative and other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #4) of 3 reviewed for abuse. The facility failed to immediately investigate, protect the residents, and report allegations of abuse on 08/29/25 when Resident #4 reported a nurse hit her while in the shower, and the facility did not investigate or implement measures to protect the residents from further abuse. This failure could place residents residing in the facility at risk of abuse. Findings included: Record review of Resident #4's face sheet dated 11/21/25 reflected [AGE] year-old woman admitted to the facility on [DATE] with an initial admission date of 08/20/24 with a primary diagnosis of major depressive order, anxiety disorder, mood disorder and schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Record Review of Resident #4's care plan dated 10/14/25 reflected on 08/29/25 Resident #4 has a habit of calling 911 and stating, I am on drugs Resident #4 was observed on the floor and crawling to the hallway refusing to allow staff to help her up, insisting on going to the hospital. Interventions included instruct resident when behavior is inappropriate or unacceptable in a calm manner, Access Resident #4 for injuries when putting herself in unsafe situations and carefully explain procedures to resident, do not argue with the resident, drug test as needed, Psych services as needed. Record Review of Resident #4's MDS dated [DATE] reflected a BIMS score of 7, indicating severely impaired cognition. PIR was requested from the DON on 11/19/25 at 10:15 AM, and the wrong PIR was given to surveyor from the DON. Record Review of a progress note dated 08/29/25 reflected Resident #4 requested a shower even though she normally gets her shower on the 2-10 shift. Staff went on to assist resident #4 with her shower. Resident started calling staff names and throwing things at staff as they were assisting her with her shower. Staff assisted Resident #4 back to her room and wanted to assist her dressing, but resident would not let staff assist her and she laid down on the floor naked, saying I want to go to [Hospital Name 2], I want to go to [Hospital Name 2], don't touch me. Record Review of another progress note dated 08/29/25 reflected Incident Description- Resident #4 requested a shower even though she normally gets her shower on the 2-10 shift. Staff went on to assist resident #4 with her shower. Resident started calling staff names and throwing things at staff as they were assisting her with her shower. Staff assisted resident back to her room and wanted to assist her with her dressing, but resident would not let staff assist her and she laid down on the floor naked, saying, I want to go to [Hospital Name 2], I want to go to [Hospital Name 2], don't touch me. Nurse informed medical director who ordered resident to be sent out to the hospital. Resident #4 was transported out to [Hospital Name 2] for further evaluation. Resident #4 unable to give description. Immediate Action Taken - Nurse couldn't examine resident for injuries or get vital signs because resident would not let staff members touch her. Nurse informed medical director who ordered resident #4 be sent to the hospital. Nurse called the ambulance to get resident to the hospital. Residents were transported out to [Hospital Name 2] for further evaluation. Resident #4 is her own responsible party. Record Review of intake 1034343 dated 09/03/25 indicated the allegation of the incident was abuse. On 11/20/25 at 10:15 AM, surveyor requested PIR for intake 1034343. At 11:17 AM, the DON stated that she was looking for the PIR. Surveyor requested all information that was done for the investigation. At 11:45 AM, the DON presented a progress note from the incident and stated that's all she could find from the investigation. Resident #4 was unable to be interviewed due to being in the hospital at the time of the visit. In an interview on 11/20/25 at 11:46 AM, Med Tech F stated Resident #4 was given a shower and Resident #4 seemed agitated already and the aid that assisted Resident #4 could not get her dressed in the showers, so the aid brought her back to the resident's room to get her dressed. Med Tech F stated she couldn't remember the name of the aid that was assisting Resident #4 at the time. Med Tech F stated when the aid went to try and get Resident #4 dressed Resident #4 laid down on the floor and kept stating she did not want to get dressed and she just wanted to go to [Hospital Name 2]. Med Tech F stated [Hospital Name 2] is Resident #4's hospital of choice whenever she wants to be sent out to the hospital. Med Tech F stated Resident #4 did not fall and she willingly got on the floor. Med Tech F stated Resident #4 was not injured at all. Med Tech F stated Resident #4 always gets on the floor when she doesn't get her way. In an interview on 11/20/25 at 5:11 PM, the DON stated she could not find the PIR for intake 1034343. The DON stated the previous administrator would have had the missing PIR due to the incident happening when he was the active administrator, the DON stated that they couldn't find any information the old administrator had but she does remember what happened. The DON stated that during the incident with Resident #4 that the resident got on the floor while she was naked and kept saying she wanted to go to the hospital. The DON stated that they couldn't pick the resident up off the floor and the resident wouldn't get up by herself, and they couldn't drag her, so they called 911 to pick up the resident. The DON stated that Resident #4 was not hit by any of the staff. The DON stated that they are expected to keep all PIR's to have them for future references. She stated the risk of not having the PIR's can cause investigations to not be thoroughly done, poor patient care, and fines. In an interview on 11/20/25 at 6:36 PM, the ADM stated that the old administrator was disgruntled when he was fired. The ADM stated that the old administrator told him that he was going to make sure he gave him all the paperwork from the previous incidents, but he didn't leave any paperwork at all. The ADM stated that typically it's the administrator's job to keep up with PIR's. The ADM stated that due to him not being the administrator at the time of the incident and with no PIR to reference he can't speak about what happened during the incident. The ADM stated the risk of not having the PIR's is that the facility can be fined for not having that information for surveyors to reference. Record Review of the facility's Abuse Policy in part indicated - All reports of resident abuse (including injuries of unknown origin).are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation -2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.Investigating Allegations- 1. All allegations are thoroughly investigated. The administrator initiates investigations.Follow-Up Report 1. Within 5 business days of the incident, the administrator will provide a follow-up investigation report.2. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The follow-up investigation report will provide as much information as possible at the time of submission of the report.

Based on interview and record review, the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #3) for accuracy of records. The facility failed to accurately transcribe the admitting diagnoses for Resident #3. This failure can affect residents by putting them at risk for inaccurate and incomplete records. Findings include:Record review of Resident #3's face sheet dated 11/19/25 reflected a [AGE] year-old man admitted to the facility on [DATE] with a primary diagnosis of HIV (a virus that attacks cells that help the body fight infection), severe protein-calorie malnutrition (inadequate intake of protein and calories), seizures, hypertension (pressure in your blood vessels is too high), atrial fibrillation (irregular and often very rapid heart rhythm), congestive heart failure (heart can't pump enough blood), cerebral infarction (reduces blood flow to a region of the brain), end stage renal disease (kidneys no longer work as they should to meet your body's needs), and anemia. Record Review of Resident #3's face sheet reflected a diagnosis of Dementia. Record review of Resident #3's MDS dated [DATE] reflected a BIMS score of 11, indicating moderately impaired. In an interview on 11/19/25 at 12:32 PM, an Anonymous family member stated the day of the incident with Resident #3 they received a call from a nurse at [Hospital Name 1]. They stated they hung up the phone because they thought someone had the wrong number and they didn't have any children at [Hospital Name 1]. Anonymous family member stated that he received another phone call from a nurse and police from [Hospital Name 1] and informed them that Resident #3 had been at [Hospital Name 1] for two hours and he couldn't find his way back to [Facility Name]. Anonymous family member stated that he immediately called [Facility Name] and asked the receptionist how Resident #3 was doing today, and the receptionist replied that Resident #3 was doing fine. Anonymous family member stated he then asked the receptionist how he is fine, and he is not in the building. Anonymous family member stated the receptionist left the phone and never came back. Anonymous family member stated when they arrived at the facility later that day, he kept asking the staff how does someone with dementia sign themselves out, they said no one was able to answer that question. Surveyor informed Anonymous family member that they were unable to find a diagnosis of Dementia for Resident #3 in the medical records the [Facility Name] has for Resident #3. Anonymous family member stated that they would send an email of a document from Resident #3's doctor with evidence Resident #3 had Dementia. In an email on 11/19/25 at 3:34 PM, Anonymous family member sent a clinical record from [Hospital/Clinic Name] that reflected a diagnosis of HIV/AIDS with HIV Dementia and Vascular Dementia with alcoholic neurological disease component. In an interview on 11/19/25 3:51 PM with the DON, she stated that diagnosis for the residents is transcribed in the database by charge nurses, the MDS coordinators, the ADON, and her. Record Review of Resident # 3's clinical record dated 09/03/25 from [Hospital Name 2] reflected a diagnosis of Dementia. Record Review of the list of Residents Who cannot leave the building or Must be supervised reflected resident #3, resident #5, resident 6, resident #7, resident #8, resident #9, resident #10 and resident #11. Record Review of Resident #3's Wander Assessment, not dated indicated a score of 9. A score of 0-8 indicates low risk, a score of 9-10 indicates a risk to wander, and 11 and above indicates high risk to wander. In an interview on 11/20/25 at 12:45 PM, the ADON stated she wouldn't say Resident #3 has Dementia, but his cognitive status can be deceiving because when he is asked his name, he knows it, but if you continue to talk to him, you can tell he is not aware and he doesn't always know where he is at. The ADON stated Resident #3 doesn't wander but he will walk up to the front of the building and say he wants to sign out and go somewhere and he would usually come back. The ADON stated she recommends that he can sign out but only with supervision. There is a book at the receptionist's desk titled Residents Who cannot leave the building or Must be supervised, receptionists will look in the book before letting a resident sign out to determine if the resident is listed in the binder. The ADON stated that she was not at work the day of the incident, but she stated Resident #3 asked to sign out the very next day on Sunday and Resident #3 asked to sign out again and she informed him that it's not safe for him to go out on his own. The ADON stated when Resident #3 was admitted and she did his assessment his BIMS score was okay for him to sign out, but when she reassessed him on 11/15/25, she stated that's when she noticed he was not safe to go out on his own any longer[JM4] . The ADON stated since the incident Resident #3 has been placed in the Residents Who cannot leave the building or Must be supervised list, and a wander guard has been placed on the resident. In an interview on 11/20/25 at 1:16 PM, with the Medical Director he stated that he did not see a diagnosis of a mental deficiency from the facility's database. The Medical Director stated that all he saw from the facility's database for Resident #3 is that he had moderate cognitive deficiency. The Medical Director stated since Resident #3 was his own responsible party he could sign out by himself but from what we know now he shouldn't be able to sign out by himself moving forward. The Medical Director stated he was going to make some changes to Resident #3's orders to be placed on the list of residents who cannot sign out. In an interview on 11/20/25 at 3:28 PM, the MDS coordinator stated that diagnosis for residents is put in the database by the charge nurses but sometimes he may take out some diagnosis if they have been discontinued. The MDS coordinator stated that when residents are admitted it's usually a team effort when transcribing all diagnosis into the database, but he stated that if he was not given a resident's clinical paperwork or if the facility was not given that information it is possible that the information was not entered. The MDS coordinator stated that he was looking into Resident #3 and that it is correct that Dementia is not listed in Resident #3's diagnosis. The MDS coordinator stated that it is possible that Resident #3 may have had paperwork showing he had a diagnosis of Dementia and that information was not entered. The MDS coordinator stated that he noticed when he looked in the Miscellaneous tab that there was a clinical record that was uploaded on 11/19/25 that indicated Resident #3 had Dementia. According to the EHR the medical record was uploaded by Staff E. The MDS coordinator admitted that the information was not in there before 11/19/25. The MDS coordinator stated that he would have loved to have had that information before. On 11/20/25 at 3:45 PM, Surveyor requested all clinical records for Resident #3 from DON. In an interview on 11/20/25 at 5:11 PM, the DON stated Resident #3 has signed out a few other times, but he usually just stands in the front of the building and then comes back in. The DON stated residents who are listed on the Residents Who cannot leave the building or Must be supervised list is determined by their BIMS score, talking to them, and are given a wander assessment. The DON said if they score high on the wander assessment then they are given a wander guard and placed on the Residents Who cannot Leave the building or must be supervised list. When asked why the diagnosis of Dementia was not transcribed into the database for Resident #3 the DON said if he has a true diagnosis of Dementia then that information should have been uploaded. She stated the risk of them not accurately transcribing the admitting diagnoses for Resident #3 is not properly care planning him or properly knowing how to care for him. The DON stated they have 48-72 hours to complete the residents baseline care plan at admission, she said it is important to make sure that information is properly uploaded in the system so they can properly know how to take care of residents. In an interview on 11/20/25 at 6:36 PM, the ADM stated just because a resident has a diagnosis of Dementia doesn't mean they can't sign themselves out. The ADM stated they assess the residents and decide by their Wander assessments. The ADM stated when residents are admitted he expects staff to transfer all information from medical records into the system right away that day, he said he was unsure of the timeframe in which that information should be transcribed. The ADM stated they shouldn't be waiting 2-3 days to put in admitting diagnoses information he said because they need to know how to be properly care planned. The ADM stated that he fired the social worker they had because she wasn't putting in important information in the system and he has since then been looking to hire a new social worker. The ADM stated the risk of not accurately transcribing records into the database is that it could cause staff to miss something important. Record Review of the facility's Charting and Documentation Policy indicated in part- All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interviews and record reviews, the facility failed to ensure the QA committee developed and implemented appropriate plans of action to correct identified quality deficiencies. The facility failed to provide the plan of correction (POC) for a deficiency of F610 cited at D and F842 cited at D on 11/20/2025. This failure could place residents at risk of abuse and not having abuse allegations investigated and inaccurate [NAME] records. Findings included:Record review of the 2567 Provider's POC exit date 11/20/2025 for F610 revealed the following: Resident #4 was sent to hospital on 8/9/2025 and returned with no injury. Resident was assessed for injury on 12/10/2025 no injury. DON/designee attempted an investigation incident on 12/10/2025 resident does not remember episode and gives incoherent rambling answers.All residents have the potential to be affected. Education with all staff was completed by DON/designee on 12/11/2025 for reporting abuse/neglect timely. The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Date of compliance is 12/11/2025.Record review of the 2567 Provider's POC exit date 11/20/2025 for F842 revealed the following: Resident #3 diagnosis of dementia added on 12/10/2025 per hospital paperwork by MDS.All residents have the potential to be affected. Inservice's were completed by Corporate consultant on 12/11/2025 for accurate transcription of medical records. The DON/designee will monitor 3 residents weekly for 4 weeks to ensure diagnosis are entered into resident charts. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.Date of compliance is 12/11/2025.On 12/30/2025 at 8:49 am, Surveyor requested all evidence including inservices, policies, and monitoring for POC from the Administrator and DON. Review of the POC binder provided by the DON did not include any monitoring and had a blank audit form titled F-610 Investigate/Prevent/Correct Alleged Violations.Interview on 12/30/2025 at 11:29 am, Surveyor requested the full POC and the DON stated she would have to find the monitoring parts of the POC. Interview on 12/30/2025 at 12:51 pm, Surveyor requested the full POC and the DON stated she has gotten with the Administrator for the monitoring. Interview on 12/30/2025 at 1:58 pm, the DON stated she was responsible for completing the POC. She stated she in-serviced staff on abuse. No answer was given when Surveyor asked why the POC monitoring was not completed. The DON stated the Administrator was responsible to investigate allegations of abuse and she had been learning how to do the self-reports. She said she has been reporting and keeps the records in her office. The DON stated the risk of not completing the POC was more of the same behaviors and resident needs not being met. Interview on 12/30/2025 at 2:19 pm, the Administrator stated the DON in-serviced staff on abuse. He stated he was responsible for abuse investigations and because the DON had not done them before, she had been completing the reports and keeping copies of the investigations in her office. He stated he was responsible to ensure the POC was completed, and no answer was given when asked why the monitoring was not done. He stated the risk of the POC being completed was monetary and could be a risk to residents by not monitoring the things they said they were going to do.

Based on observation, interviews and record reviews, the facility failed to ensure the residents had the right to be free from abuse for 1 of 5 residents (Resident #2) reviewed for abuse, neglect, and or exploitation. The facility failed to ensure Resident #2 was free from repeated resident-to-resident abuse by Resident #3, which occurred on 05/24/2025, 08/17/2025, and 10/03/2025. A past Immediate Jeopardy (IJ) was found on 08/17/25 and the immediacy was removed on 10/05/25. While the IJ was removed on 10/025/25, the facility remained out of compliance at a severity of actual harm due to the facility's need to monitor the effectiveness of their corrective systems. These failures could place residents at risk for continued abuse, decreased quality of life, decreased self-esteem and increased anxiety.Findings included:Record review of an undated admission Record revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had the admitting diagnoses of Alzheimer's Disease, Unspecified (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), Type 2 Diabetes Mellitus without Complications (chronic condition where persistently high blood sugar levels are caused by the pancreas not being able to make enough insulin), Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (dementia where the specific cause is unknown and the person does not exhibit behavioral issues like agitation or aggression), Major Depressive Disorder, Recurrent, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Chronic Obstructive Pulmonary Disease, Unspecified (a group of lung diseases that cause airflow obstruction and breathlessness), Chronic Respiratory Failure, Unspecified (condition where there is not enough oxygen or too much carbon dioxide is in the body), and Presence of Cerebrospinal Fluid Drainage Device (long term device, or shunt, that allows excess fluid from the brain to drain to another part of the body relieving pressure).Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 03 indicating Severe Cognitive Impairment. Resident #2 was documented as having no (zero) behavioral symptoms. Resident #2 showed to be independently ambulatory with no functional limitations in range of motion.Record Review of Resident #2's Care Plan, dated 08/30/2025, revealed a focus added on 03/15/2023 of resident having a history of intruding on others privacy with interventions and tasks of place in area where frequent observation was possible, redirect when wandering into other resident rooms, and monitor and document behavior. Focus added on 01/14/2024 of displays socially inappropriate/ disruptive behavior due to known for taking personal items from her roommate and other peers that do not belong to her. When she is called out on this disruptive behavior, she curses at staff and peers, calls everyone names and refuses to listen to staff due to her cognitive status, Psych. diagnosis with interventions and tasks of administer medication as ordered, discuss options for appropriate channeling of anger, talk in calm voice when behavior is disruptive, Social Services to evaluate and visit routinely, and monitor and document behavior. Focus of at risk of being taken advantage of r/t impaired cognition updated on 10/03/2025 when Resident #3 slapped Resident #2 after she took his cup with interventions and tasks of allow Resident #2 to express concerns about safety, anticipate Resident #2's needs, encourage Resident #2 to sit in common areas that are well populated, observe Resident #2 frequently throughout the day, psych services are available as needed, and on 10/03/2025 added intervention of place Resident #2 on 1:1 monitoring until alternate placement is found.Record Review of Resident #3's undated admission Record revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had the admitting diagnoses of Bipolar Disorder, Unspecified (psychological condition that causes dramatic changes in a person's mood, ability to think clearly, and energy; involves periods of mania and depression; unspecified is diagnosed when symptoms do not meet the criteria for other types), Depression, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Anxiety Disorder, Unspecified (repeated episodes of sudden feelings of intense anxiety, and fear or terror that reach a peak within minutes), Impulse Disorder, Unspecified (group of behavioral conditions that make it difficult to control your actions or reactions), Mild Intellectual Disabilities (neurodevelopment disorder characterized by significant limitations in intellectual and adaptive functioning), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Other Specified Disorders Of Brain (group of conditions that do not fall into specific diagnostic categories that can affect various aspects of brain function including cognitive abilities, movement, and consciousness) and Epileptic Seizures Related to External Causes, not Intractable, without Status Epilepticus (epileptic seizures caused by external factors, such as head trauma or substance abuse, that are not difficult to treat and are considered provoked by a single external factor meaning there are clear, identifiable causes).Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS score of 03 indicating severe cognitive impairment. Signs and Symptoms of Delerium was ranked at 2 for both Inattention (difficulty focusing attention, being easily distracted, or having difficulty keeping track of what was said) and Disorganized Thinking (thinking was disorganized or incoherent, rambling or irrelevant conversation, unclear or illogical flow of ideas, startled easily to any sound or touch). Behavioral Symptoms for Resident #3 were listed at zero (Behavior not exhibited) for Physical Behavioral Symptoms directed towards others (e.g. hitting, pushing, kicking, scratching, grabbing other than sexually and zero for Verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others). Resident #3 was documented to have had no functional limitation in range of motion and did not utilize any assistive devices for mobility.Record review of Resident #3's care plan, dated 09/05/2025, revealed a focus area of at risk for behaviors due to impulse control disorder listing the following incidents: 05/24/2025-- resident noted with aggressive behavior, hit another resident (Resident #2), swung chair at nurse, swung chair at meal cart tipping it over, 06/15/2025 Resident increased behaviors, and 10/03/2025-- slapped a resident (Resident #2), after she took his cup. Interventions and tasks included contact to transfer resident to hospital (Geri-Psych) when explosive psychosis is exhibited, Discuss options for appropriate channeling of anger, give all meds as ordered, Give PRN anti-anxiety medication, Notify Psych NP whenever such behaviors are exhibited, psych services as needed, and Seek alternate placement that has less stimuli which could contribute to aggressive, impulsive behavior. Focus area of Potential for complications/side effects r/t use of psychotropic medications, use of antipsychotic medications added on 01/07/2024, with interventions and tasks of Administer medication as ordered observing for effectiveness &/or side effects. Notify physician as needed; Monitor mood and behaviors every shift; Observe for s/s side effects/adverse reactions from use of antipsychotic medication: dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Notify physician if noted. On 01/12/2024 the focus area of has signs of disorganized thinking was added for Resident #3 with interventions and tasks of Administer medications as ordered, Allow ample time to answer questions, introduce changes slowly, and Reality orientation daily during routine care. Resident #3 had the focus area of the potential for injury r/t side effects of antipsychotic medication use related to Medical dx Mental Disorder added on 05/08/2024 with interventions and tasks of Assess/record/report to physician gait disturbances, poor balance, dizziness, vertigo, unsteady gait, Consultant pharmacist to monitor drug regimen monthly and prn and contact physician for drug reduction as needed, Monitor for drug related cognitive/behavioral impairment of ADL functioning and report to physician if noted, Monitor for s/s changes in mood/behavior and report to physician if noted &/or as needed, and Monitor for side effects q shift. Notify physician if noted. On 01/21/2025 the focus area of Resident #3 has a h/o wandering into unsafe situations, Resident packs all belongings and states I'm moving as well as on 10/01/2025 Resident #3 removed his wander guard, and refuses to allow it to be put back on with interventions and tasks of alert staff to wandering behavior, Approach positively and in a calm manner, Check that wander guard is properly working every shift by taking to the door if not properly working notify DON and replace the wander guard, Resident on hourly safety checks, and Monitor and document behavior.Record Review of resident-to-resident assault on 05/24/2025 revealed that when Resident #2 passed Resident #3 in the hallway, Resident #3 hit her on the back of the head with his fist. Resident #2 expressed pain and was sent to the local hospital for evaluation and later returned with no injury diagnosis. Resident #3 was placed on 1:1 monitoring by staff for the remainder of that weekend and both residents were to be kept in eyesight when the other resident was around.Record review of resident-to-resident assault on 8/17/2025 revealed that as Resident #2 walked down a hallway, Resident #3 hit her. Resident #2 was reported to hit Resident #3 back and Resident #2 then fell to the ground after being hit a second time by Resident #3 where he then kicked Resident #3 before staff were able to intervene. Resident #2 did not indicate she was in pain, neither resident was sent to the hospital for evaluation. Resident #3 was placed on 1:1 monitoring for that weekend and referrals began for discharge to new facility for Resident #3.Record review of resident-to-resident assault on 10/03/2025 revealed that Resident #3 quickly charged through the door onto the smoking patio and hit Resident #3 with an open fist. Resident #2 was noted to have bruising, redness, and swelling around her left eye in facility photograph documentation. The facility ordered a facial x-ray which was unremarkable for any fracture. Both Resident #2 and #3 were placed on 1:1 monitoring from staff. Local law enforcement was contacted twice about the assault before arriving to the facility to remove from the facility and transfer Resident #3 to the local hospital for evaluation for his behaviors. Resident #2 remained on 1:1 monitoring for safety.Record review showed a SW letter Re: Discharge in Resident #3's miscellaneous area of the electronic health record. The discharge letter, dated 10/03/2025, was to a Payee and next of kin for Resident #3 to advise that an immediate discharge notice was given to the resident on 10/01/2025 and that another incident with Resident #3 had occurred. The payee and next of kin was advised that Resident #3 had been escorted to the hospital for treatment after the altercation with another resident and he would not be allowed to return to the facility. The Payee and next of kin was informed of Resident #3's placement desires and the financial responsibilities as the Payee.Record review of the facility Investigation Follow-Up, dated effective 10/05/2025, revealed that the incident on 10/03/2025 happened at approximately 11:15am when Resident #3 came out the door like a ranging [sic] bull and hit Resident #2 upside her head. When asked why, Resident #3 stated because she (Resident #2) took my cup. Resident #3 was put on 1:1 with staff, then checked every hour. The facility also placed Resident #2 on 1:1 with staff for safety. Notification was made to the QA committee, Medical Director, Resident #2's responsible party, DON, and police. Follow-up with Resident #2's family on revisions to the Care Plan included information that the police has taken Resident #3 to the hospital and he will not be returning to the facility, the medical director had ordered facial bone x-ray to left eye, and that Resident #2 was also put on 1:1 with staff for safety.Observation and interview with Resident #2 on 10/14/2025 at 11:22 AM revealed the resident was still on 1:1 monitoring by staff. Resident #2 was seen in the dining room after observing her during the 11:00 smoke break on the patio. Resident #2 stated that was doing fine and that her face was doing better now. Resident #2 could not be engaged in a detailed conversation. Observation of Resident #2 revealed any bruising or redness to her face from being hit by Resident #3 on 10/03/2025 had resolved.Interview on 10/14/2025 at 11:30 AM with CNA A revealed that she began 1:1 with Resident #2 at the start of that shift however the 1:1 was ongoing since the incident with another resident (Resident #3) on 10/03/2025. CNA A stated that Resident #2 seemed to be at her baseline and appeared to be doing fine. CNA A stated that she did not witness the incidents of assault by Resident #3 against Resident #2 on 05/24/2025, 08/17/2025, and 10/03/2025 however was informed of them during beginning of shift huddles by the charge nurses.Interview on 10/14/2025 at 2:35 PM with SW revealed that the incident on 10/03/2025 between Residents #2 and #3 was the third altercation between the two, with Resident #3 being the aggressor in all three instances. SW stated she had not noticed any effects from the resident-to-resident assaults as Resident #2 has no real short-term memory from the dementia and that when EMT came in to assess she acted like she did not know what happened but was able to tell a family member in detail a few hours later when she called her.Interview on 10/14/2025 at 4:26 PM with the DON revealed that Resident #2 was immediately placed on 1:1 after the assault on 10/03/2025 with a staff member so that someone was always with her. The DON shared that even though Resident #3 was the aggressor on all three instances, the facility felt this should be done as Resident #2 walks the building constantly. The DON indicated that even though Resident #2 may have been targeted by Resident #3, they wanted to keep eyes on her for her safety since she has had history of taking things from other residents however has not seen or heard of any negative response from Resident #2 with having the 1:1 monitoring by staff. The DON stated that staff had been informed if Resident #2 asked why she was being followed around they were to inform her it was to keep her company. The DON stated that on 10/01/2025 an immediate discharge notice was given to Resident #3 and that a group home was going to take him then his family member called and stopped the transfer. Resident #3 was on hourly checks at that time related to the incident that happened on 08/17/2025 and between the checks he acted impulsively and attacked Resident #2 again hitting her as she walked past in the hallway; Resident #2 had no injury from this assault. The DON confirmed Resident #3 was being seen by psychiatry and psychology services, and he was not having issues with any other residents; the DON reported he had said I didn't want to marry you anyway in reference to Resident #2 and may have confused her with someone else.Interview on 10/14/2025 at 5:05PM with the Administrator revealed he had been at the facility since 9/10/2025. The Administrator stated when the resident-to-resident altercation between Residents #2 and #3 happened on 10/03/2025, he determined that Resident #3 would be placed on 1:1 monitoring and had SW begin looking for a safe discharge location; he reports he had to contact local police and had to have them come out twice before the police would take Resident #3 to the local hospital for evaluation and remove him from the property. The Administrator stated that he felt Resident #2 did not remember the altercation, however, a few hours later she was able to call a family member and give details.Confidential interview with family member #1 revealed Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The resident was confused and the family member was frustrated and concerned for Resident #2's safety in the facility. Family member #1 stated they were focused on finding a suitable facility for the resident to relocate to.Review of facility policy Abuse Prevention Program, revised December 2016, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation revealed as part of the resident abuse prevention, the administration will:l. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, otherresidents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends,visitors, or any other individual.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, ormistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification andreporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of facility policy Resident Rights, revised December 2016 revealed; Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to;C. be free from abuse, neglect, misappropriation of property, and exploitation. A past Immediate Jeopardy (IJ) was found on 08/17/25 and the immediacy was removed on 10/05/25. While the IJ was removed on 10/025/25, the facility remained out of compliance at a severity of actual harm due to the facility's need to monitor the effectiveness of their corrective systems.

Based on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #2) of five residents reviewed for behavioral health services. The facility failed to ensure Resident #2 received a psychology consultation or assessment after three incidents (5/24/2025, 08/17/2025, 10/03/2025) of resident-to-resident abuse where Resident #2 was the victim. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings included:Record review of an undated admission Record revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had the admitting diagnoses of Alzheimer's Disease, Unspecified (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), Type 2 Diabetes Mellitus without Complications (chronic condition where persistently high blood sugar levels are caused by the pancreas not being able to make enough insulin), Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (dementia where the specific cause is unknown and the person does not exhibit behavioral issues like agitation or aggression), Major Depressive Disorder, Recurrent, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Chronic Obstructive Pulmonary Disease, Unspecified (a group of lung diseases that cause airflow obstruction and breathlessness), Chronic Respiratory Failure, Unspecified (condition where there is not enough oxygen or too much carbon dioxide is in the body), and Presence of Cerebrospinal Fluid Drainage Device (long term device, or shunt, that allows excess fluid from the brain to drain to another part of the body relieving pressure). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 03 indicating Severe Cognitive Impairment. Resident #2 was documented as having no (zero) behavioral symptoms. Resident #2 showed to be independently ambulatory with no functional limitations in range of motion. Record Review of Resident #2's Care Plan, dated 08/30/2025, revealed a focus added on 03/15/2023 of resident having a history of intruding on others privacy with interventions and tasks of place in area where frequent observation was possible, redirect when wandering into other resident rooms, and monitor and document behavior. Focus added on 01/14/2024 of displays socially inappropriate/ disruptive behavior due to known for taking personal items from her roommate and other peers that do not belong to her. When she is called out on this disruptive behavior, she curses at staff and peers, calls everyone names and refuses to listen to staff due to her cognitive status, Psych. diagnosis with interventions and tasks of administer medication as ordered, discuss options for appropriate channeling of anger, talk in calm voice when behavior is disruptive, Social Services to evaluate and visit routinely, and monitor and document behavior. Focus of at risk of being taken advantage of r/t impaired cognition updated on 10/03/2025 when Resident #3 slapped Resident #2 after she took his cup with interventions and tasks of allow Resident #2 to express concerns about safety, anticipate Resident #2's needs, encourage Resident #2 to sit in common areas that are well populated, observe Resident #2 frequently throughout the day, psych services are available as needed, and on 10/03/2025 added intervention of place Resident #2 on 1:1 monitoring until alternate placement is found. Record Review of Resident #3's undated admission Record revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had the admitting diagnoses of Bipolar Disorder, Unspecified (psychological condition that causes dramatic changes in a person's mood, ability to think clearly, and energy; involves periods of mania and depression; unspecified is diagnosed when symptoms do not meet the criteria for other types), Depression, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Anxiety Disorder, Unspecified (repeated episodes of sudden feelings of intense anxiety, and fear or terror that reach a peak within minutes), Impulse Disorder, Unspecified (group of behavioral conditions that make it difficult to control your actions or reactions), Mild Intellectual Disabilities (neurodevelopment disorder characterized by significant limitations in intellectual and adaptive functioning), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Other Specified Disorders Of Brain (group of conditions that do not fall into specific diagnostic categories that can affect various aspects of brain function including cognitive abilities, movement, and consciousness) and Epileptic Seizures Related to External Causes, not Intractable, without Status Epilepticus (epileptic seizures caused by external factors, such as head trauma or substance abuse, that are not difficult to treat and are considered provoked by a single external factor meaning there are clear, identifiable causes). Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS score of 03 indicating severe cognitive impairment. Signs and Symptoms of Delerium was ranked at a 2 for both Inattention (difficulty focusing attention, being easily distracted, or having difficulty keeping track of what was said) and Disorganized Thinking (thinking was disorganized or incoherent, rambling or irrelevant conversation, unclear or illogical flow of ideas, startled easily to any sound or touch). Behavioral Symptoms for Resident #3 were listed at zero (Behavior not exhibited) for Physical Behavioral Symptoms directed towards others (e.g. hitting, pushing, kicking, scratching, grabbing other than sexually and zero for Verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others). Resident #3 was documented to have had no functional limitation in range of motion and did not utilize any assistive devices for mobility. Record review of Resident #3's care plan, dated 09/05/2025, revealed a focus area of at risk for behaviors due to impulse control disorder listing the following incidents: 05/24/2025-- resident noted with aggressive behavior, hit another resident (Resident #2), swung chair at nurse, swung chair at meal cart tipping it over, 06/15/2025 Resident increased behaviors, and 10/03/2025-- slapped a resident (Resident #2), after she took his cup. Interventions and tasks included contact to transfer resident to hospital (Geri-Psych) when explosive psychosis is exhibited, Discuss options for appropriate channeling of anger, give all meds as ordered, Give PRN anti-anxiety medication, Notify Psych NP whenever such behaviors are exhibited, psych services as needed, and Seek alternate placement that has less stimuli which could contribute to aggressive, impulsive behavior. On 01/21/2025 the focus area of Resident #3 has a h/o wandering into unsafe situations, Resident packs all belongings and states I'm moving as well as on 10/01/2025 Resident #3 removed his wander guard, and refuses to allow it to be put back on with interventions and tasks of alert staff to wandering behavior, Approach positively and in a calm manner, Check that wander guard is properly working every shift by taking to the door if not properly working notify DON and replace the wander guard, Resident on hourly safety checks, and Monitor and document behavior.Record Review of resident-to-resident assault on 05/24/2025 revealed that when Resident #2 passed Resident #3 in the hallway, Resident #3 hit her on the back of the head with his fist. Resident #2 expressed pain and was sent to the local hospital for evaluation and later returned with no injury diagnosis. Resident #3 was placed on 1:1 monitoring by staff for the remainder of that weekend and both residents were to be kept in eyesight when the other resident was around. Record review of resident-to-resident assault on 8/17/2025 revealed that as Resident #2 walked down a hallway, Resident #3 hit her. Resident #2 was reported to hit Resident #3 back and Resident #2 then fell to the ground after being hit a second time by Resident #3 where he then kicked Resident #3 before staff were able to intervene. Resident #2 did not indicate she was in pain, neither resident was sent to the hospital for evaluation. Resident #3 was placed on 1:1 monitoring for that weekend and referrals began for discharge to new facility for Resident #3. Record review of resident-to-resident assault on 10/03/2025 revealed that Resident #3 quickly charged through the door onto the smoking patio and hit Resident #3 with an open fist. Resident #2 was noted to have bruising, redness, and swelling around her left eye in facility photograph documentation. The facility ordered a facial x-ray which was unremarkable for any fracture. Both Resident #2 and #3 were placed on 1:1 monitoring from staff. Local law enforcement was contacted twice about the assault before arriving to the facility to remove from the facility and transfer Resident #3 to the local hospital for evaluation for his behaviors. Resident #2 remained on 1:1 monitoring for safety.Record review of the facility Investigation Follow-Up, dated effective 10/05/2025, revealed that the incident on 10/03/2025 happened at approximately 11:15am when Resident #3 came out the door like a ranging (raging [sic]) bull and hit Resident #2 upside her head as witnessed by a CNA. When asked why, Resident #3 stated because she (Resident #2) took my cup. Resident #3 was put on 1:1 with staff, then checked every hour. The facility also placed Resident #2 on 1:1 with staff for safety. Notification was made to the QA committee, Medical Director, Resident #2's responsible party, DON, and police. Follow-up with Resident #2's family on revisions to the Care Plan included information that the police has taken Resident #3 to the hospital and he will not be returning to the facility, the medical director had ordered facial bone x-ray to left eye, and that Resident #2 was also put on 1:1 with staff for safety. Record review of Resident #2's Trauma Informed Screening Tool, administered by SW dated 09/09/2025, that the resident, family, and staff participated in revealed positive (yes) responses on questions: Have you ever experienced this kind of event (assault by another resident)? In the past month have you had nightmares about the event when you did not want to? In the past month, have you tried hard not to think about the event or went out of your way to avoid situations that remind you of event? In the past month, have you been constantly guarded, watchful, or easily startled? Record review of Resident #2's Trauma Informed Screening Tool, administered by SW and dated 08/13/2025 and 10/06/2025, indicated that the resident and staff participated; a positive (yes) response on question Have you ever experienced this kind of event? only was given when asked about being assaulted by another resident. Interview on 10/14/2025 at 11:21 AM with LPC A revealed that Resident #2 was not currently being followed by psychological services and had never had a referral for evaluation or services. LPC A verified these findings in their system using Resident #2's name and date of birth searching for all psychology related providers. Observation and interview with Resident #2 on 10/14/2025 at 11:22 AM revealed the resident was still on 1:1 monitoring by staff. Resident #2 was seen in the dining room after observing her during the 11:00 smoke break on the patio. Resident #2 stated that was doing fine and that her face was doing better now. Resident #2 could not be engaged in a detailed conversation. Resident #2 was observed to be calm and kept to herself while smoking and in the dining room. Resident #2 was polite but reserved in her interactions with others. Interview on 10/14/2025 at 11:30 AM with CNA B revealed that she began 1: with Resident #2 at the start of that shift, however the 1:1 was ongoing since the incident with another resident on 10/03/2025. CNA B stated that Resident #2 was at her baseline and appeared to be doing fine from what she could tell. Interview on 10/14/2025 at 2:35 PM with SW revealed that the incident of physical assault on 10/03/2025 between Residents #2 and #3 was the third altercation between the two, with Resident #3 being the aggressor in all three instances. SW stated she had not noticed any effects from incidents of assault as Resident #2 has no real short-term memory from the dementia and that when EMT came in to assess she acted like she did not know what happened but was able to tell her family member in detail a few hours later when Resident #2 called her. The SW stated that the facility has conducted trauma assessments with Resident #2 but no further actions had been taken with that information. When asked about referral for psychological assessment or therapy due to the positive responses on the trauma assessments, the SW responded that she had not made any referrals as Resident #2 was known to refuse services in the past such as dental and vision however family were able to easily get Resident #2 to participate with care from outside providers. SW stated that she had not noticed any change in Resident #2's behaviors since Resident #3 was discharged .Interview on 10/14/2025 at 4:26 PM with the DON revealed that psychology services were offered in facility multiple times a week, however due to Resident #2's advanced dementia they had not referred for an evaluation or services. The DON stated that the SW has done trauma screenings, but no referrals were sent as Resident #2 was difficult to assess. The DON stated that Resident #2 was placed on 1:1 with a staff member so that someone was always with her. The DON indicated that even though Resident #2 may have been targeted by Resident #3, they wanted to keep eye on her for her safety since she has had history of taking things from other residents however has not seen or heard of any negative response from Resident #2 with having the 1:1 monitoring by staff. The DON stated that staff had been informed if Resident #2 asked why she was being followed around they were to inform her it was to keep her company. Interview on 10/14/2025 at 5:05PM with the Administrator revealed he had been employed at the facility since 9/10/2025. The Administrator stated that he felt Resident #2 did not remember the altercation on 10/03/2025, however, a few hours later she was able to call her family member and give details. The Administrator stated he would expect behavioral health services to be offered to residents after they were assaulted by another resident and for staff to follow what was recommended by the mental health providers as they are in the building on Wednesdays every week. The Administrator stated he also expected staff to call on these contracted mental health providers as needed, to alert them to situations that had happened in the facility since their last visit, and to do what was needed or recommended by those providers. Confidential interview with family member #1 revealed Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The resident was confused and the family member was frustrated and concerned for Resident #2's safety in the facility. Family member #1 stated they were focused on finding a suitable facility for the resident to relocate to. Resident #2 did not receive any behavioral services after each incident and Resident #3 continued to abuse Resident #2.Review of facility policy Unmanageable Residents, revised April 2010 revealed; Each resident will be provided I. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately:a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.);b. Notify the resident's Attending Physician for instructions; Review of facility policy Resident Rights, revised December 2016 revealed; Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;f. communication with and access to people and services, both inside and outside the facility;h. be supported by the facility in exercising his or her rights;

Based on interviews and record review, the facility failed to notify the ombudsman of the transfer or discharge before transferring or discharging the resident for 1 of 1 resident (Resident #1) reviewed for Discharge Rights.The facility failed to notify the ombudsman in writing of the transfer/ discharge of Resident #1 to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet dated 10/14/2025 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was discharged to hospital for a behavioral evaluation on 09/28/2025. Resident's diagnosis included Schizophrenia, Unspecified (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania ); Unspecified Psychosis Not Due to a Substance or Known Psychological Condition (used when psychotic symptoms are present but a specific cause, like drugs, other mental disorders, or a medical condition hasn't been identified or confirmed yet); and Major Depressive Disorder, Recurrent, Unspecified (used when a person has significant symptoms of depression that cause distress or impairment, but they do not meet the full diagnostic criteria for a more specific depressive disorder, or there is not enough information to provide one).Record review of Resident #1's MDS assessment dated [DATE], noted his BIMS Score to be 12 which reflected moderate cognitive impairment. Resident #1 Review of Resident #1's progress notes reflected that on 09/28/2025, the facility initiated a referral to transfer the resident to the hospital for a psychological evaluation due to the resident having an increase in his verbal, physical, and violent behavior towards the staff. Family member notified by phone concerning Resident #1's transfer. Resident #1 was his own responsible party. Record review on 09/29/2025 of social services notes revealed that SW spoke with Resident #1's family member about how his behavior had not gotten better since giving him the 30-day notice before. SW informed family member about Resident #1 threatening staff. Family member stated she has never known Resident #1 threaten to kill anyone and that the staff are triggering him. DSS said this was done after staff redirected him while breaking rules. Resident #1 was contacted by SW that he was being provided an immediate discharge from the facility r/t his violent behavior towards the staff and other residents in the facility. Resident #1 refused to give verbal consent by phone. SW planned for Resident #1 to move to a residential group home in the community upon discharge from hospital. Resident #1 was transferred to a group home and has adjusted well to the move. On 10/13/2025 at 1:12 p.m., an interview with the family member revealed that Resident #1 had not been at the facility for some time. Family member could not give the specific time he was discharged to hospital for a psychological evaluation. Family member stated that Resident #1 is now in another place but cannot remember the name of the group home he moved to. Resident #1 has his own room, is stable, and happy. Family member stated Resident #1 had schizophrenia and did not understand he could not smoke anytime he wanted when he was at the facility. When he acted up at the facility, the staff would contact the family member to come to the facility to calm him down. Family member stated she told the staff it was their job to take care of him. Family member stated that Resident #1 is glad he is no longer at that facility because the staff stated he was threatening to kill others and kill himself. Family member did not believe what they told her. Family member did not state if she was aware of the 30-day notice. On 10/14/2025 at 2:32 p.m., an interview with SW revealed that she contacted the Ombudsman (person who acts as an independent and neutral intermediary to help resolve complaints and disputes fairly between individuals and an organization or government agency) and left a message concerning Resident #1's immediate discharge. SW did not document that a message was left on Ombudsman's voicemail and could not provide a date when she left the message. SW could not provide a copy of the first 30-day notice that was given to Resident #1 and could not provide the date. SW provided a copy of the immediate discharge notice given to Resident #1. Record review of an email conversation with the Ombudsman on 10/14/2025 at 4:33 p.m. revealed she did not receive a phone call or email r/t a notification before or after Resident #1's discharge on [DATE]. On 10/14/2025 at 4:17 p.m., an interview with DON revealed that Resident #1 exhibited behaviors that placed residents' and staff's safety at risk. He was non-compliant with facility smoking rules, would go out to the laundry, take staff's food from the employee breakroom, and verbally threaten to harm the employees. Resident #1 threatened to kill other staff and himself. Resident #1's family member was informed of his behavior, but she thought the staff were not telling the truth. The family member was verbally aggressive towards staff when she was informed by phone of Resident #1's behaviors. DON stated she was not aware the Ombudsman was not notified of Resident #1's discharge. On 10/14/2025 at 4:55 p.m., an interview with the ADM revealed that Resident #1 had to be given an immediate discharge for the safety of the other residents and staff. Resident #1 was non-compliant with the smoking rules and verbally aggressive towards other residents and staff. Resident #1 was discharged to the hospital for a psychiatric evaluation and SW planned for transfer to a group home. Resident #1's family member came into the facility to pick up his belongings and began cursing staff. The ADM was not aware that the Ombudsman had not been notified by SW r/t Resident #1's immediate discharge. The ADM expectations are for the SW to contact the Ombudsman concerning all discharges from the building and document in SS notes of notification.Record review of the facility's admission and Discharge including AMA, Against Medical Advice Policy dated March 2017, reflected, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.

Based on observation, interview, and record review the facility to protect the resident's right to be free of sexual abuse by a resident for one (Resident #2) of twelve residents reviewed for abuse. The facility failed to protect Resident #2 from sexual abuse by another resident when Resident #1 led Resident #2 into his room on 09/07/2025 and sexually assaulted her. An IJ was identified on 09/08/2025. The IJ template was provided to the facility on [DATE] at 1:54 PM. While the IJ was removed on 09/10/2025, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. This failure placed residents at risk of subsequent abuse resulting in potential mental anguish, emotional distress, and physical harm. Findings included: Review of Resident #1's admission Record, dated 09/08/25, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body), depression, anxiety, cerebral infarction (stroke), and traumatic brain injury (sudden injury to the brain usually caused by a blow or jolt to the head.) Resident #1 was his own responsible party. Review of Resident #1's MDS, dated [DATE], reflected Resident #1 was able to understand others, and be understood by others, and had a BIMS score of 14, indicating he was cognitively intact. He exhibited no signs of delirium or psychosis, and was not depressed, but did sometimes feel socially isolated. He had no behaviors during the assessment period. Resident #1 used a wheelchair for locomotion, and needed little assistance with his ADLs. Resident #1 required partial to moderate (helper does less than half the effort) assistance with toileting, showering, and lower body dressing. He required only supervision or touching assistance with personal hygiene and upper body dressing. Resident #1 was able to move himself around in bed, and sit and lie down with no assistance. Review of Resident #1's care plans reflected the following care plans:- 07/24/25 for impaired comprehension related to his history of traumatic brain injury- 08/22/25 for potential for disruption of continuity of care related to signing himself out of the facility to gather off the facility property with other residents to smoke and socialize-08/25/25 for a psychosocial well-being problem related to a history of drug and alcohol use- 09/07/25 for sexually inappropriate behavior with another resident. This careplan had a goal of the resident not displaying any sexually inappropriate behavior through the target date of 10/23/25, and had interventions which included trauma assessment, not arguing with resident, monitoring and documenting behavior, notifying psych services when inappropriate behavior is noted, notifying Medical Director when inappropriate sexual behaviors occurred, and speaking in a calm voice when behavior was disruptive. The care plans did not include any other care plan for sexual behavior, or care plan for drug use which had occurred while he was a resident in the facility. Review of Resident #1's psychological services note, dated 09/05/25 reflected he was seen for hallucinations and delusions. The document noted that Resident #1 told the counselor that he had been served with a 30-day discharge notice due to alleged drug use, but denied using drugs. The document also noted that he provided inconsistent information and had difficulty articulating or focusing. Under Risk Factors the note included Sexual Acting Out: None. Review of Resident #1's progress notes reflected the following:- A note on 09/05/25 at 11:30 PM by LVN C reflected Resident was in A hall knocking at a female resident's room (female resident not identified). Resident was informed that the female resident was asleep. This resident was insisting that the female resident needs to come out, but the female resident told this writer with the A hall nurse and a female CNA that she does not want to be disturbed. When this resident was told what the female resident said, he did not want to move away from the hallway to his hall. He then came to the front lobby and sad [sic] he was waiting for a female visitor. Resident was informed that visitation time ends at 8 pm. He then said, I am a [AGE] year-old man, I can go out whenever I want. He then went to the patio. - A note on 09/06/25 at 12:35 PM by LVN B reflected Resident in room door closed, staff member open door togive lunch tray to resident strong drug order [sic] in room. DON and Ad min [sic] notified - A note on 09/06/25 at 2:59 AM by LVN C reflected (.) Resident noncompliant to instructions. Earlier on the shift, resident was knocking at the female residents rooms (identities of female residents unknown) and refused being redirected to his room. - A note on 09/06/25 at 10:26 PM by LVN C reflected, Resident outside (female resident #13's) knocking at the door. Resident redirected back to his room but non-compliant with instructions, refused to go and started talking to a female resident (identity unknown) inquiring her room number. - A note on 09/07/25 at 4:30 AM by RN A reflected This writer and another nurse were at A hall nurses' stationand saw resident trying to get into (male resident's room). We redirected him to go to his room and stop going into other residents' rooms because they are still sleeping. - A note on 09/07/25 at 7:00 AM by LVN B, reflected Resident refused to answer question on how resident (#2) was in the room. Resident refused skin observation - A note on 09/07/25 at 7:07 AM by LVN B reflected Notified DON and ADMIN (Administrator's name) for possible sexual abuse from resident - A note on 09/07/25 at 11:45 AM by the DON reflected This nurse spoke with (name of worker) from (name of group home) which is part of a home community based service for adult mental health, a placement agency; she will come out tomorrow to evaluate him for placement. Resident currently on 1 :1 observation, will continue until placement is found. - A note on 09/07/25 at 12:44 PM by the DON reflected the PCP and Psych Nurse were made aware of the incident. Review of Resident #2's admission Record, dated 09/07/25 reflected she was a [AGE] year-old female, with diagnoses of Alzheimer's disease, dementia in other disease (dementia caused by another health condition), stroke, major depressive disorder, and presence of a cerebrospinal fluid drainage device (stent for draining excess fluid from around the brain). A family member (Resident #2's POA) was her responsible party. Review of Resident #2's MDS, dated [DATE], reflected she was only sometimes able to be understood, and to understand others. She had a BIMS score of three, indicating severely impaired cognition. Resident #2 had fluctuating inattention and disorganized thinking, and the staff mood assessment reflected she had little interest or pleasure in doing things and felt tired from two to six days of a fourteen-day lookback period, and that she had trouble concentrating every day or nearly every day. She exhibited no behavioral symptoms during the assessment period. Review of Resident #2's care plans reflected the following:- 08/19/22 has difficulty making decisions- 03/15/23 Intrudes on other residents' privacy with a goal of not intruding on resident privacy during the quarter, and interventions (all dated 03/15/23) of monitoring and documenting behavior, placing her in an area where frequent observation is possible, and redirecting her when wandering into other resident rooms.- 07/01/23 h/o physically aggressive behavior with staff and other residents, which included 07/01/23 - was physically aggressive with a staff and resident and on 08/17/25 - physically aggressive with another resident, who hit her and caused her to fall- 01/14/24 displays socially inappropriate/ disruptive of taking items not belonging to her, and when confronted curses, calls people names, and refuses to listen, due to her cognitive diagnosis- 07/12/24 refuses to shower or change clothing for 2-3 days and goes home with family member to shower- 08/12/24 has periods of forgetfulness The care plans did not include any care plan for sexual behavior, or drug use. Review of Resident #2's psych services note, dated 08/13/25, reflected the staff reported signs of cognitive impairment (confusion, word-finding difficulties and difficulties with ADLs) but no behavioral concerns. Resident #2 had no history of alcohol or drug use. Resident #2's thought process was impoverished (resident was unable to think well, leading to minimal speech, lack of detail in conversations, and difficulty sustaining topics), flat (unexpressive) affect, poor eye contact, no risk of aggression, poor attention span, fair judgment, and severely impaired long and short term memory. The document reflected the resident had been in several group homes prior to her admission, but wandered away. Review of Resident #2's progress notes reflected the following: - A note on 09/07/25 at 4:40 AM by RN A Resident resting in bed, door open and lights on. No c/o pain and nos/s of acute distress noted. ADLs provided, safety precautions maintained, will continue to monitor. - A note on 09/07/25 at 6:45 AM by LVN B Resident not in room, this writer went to check blood sugar, resident not in room. This writer then being [sic] to search the B hall area, outside patio, dining area and was unable to find resident - A note on 09/07/25 at 6:55 AM by LVN B Resident notified by over head page to staff missing resident location, (Resident #2's name and room location). Staff member went room to room. Resident was found by (LVN C) in (Resident #1's room number). - A note on 09/07/25 at 7:01 AM by LVN B Resident was in (Resident #1's room number) wear and [sic] black top with no underwear facing the wall and the back toward the door. her under [sic] and pants in the bed with her. This writer assist with sup. (supervisor ADON) to room gait unsteady she was confused and could not walk. This writer went to get wheelchair and resident was taken to her room - A note on 09/07/25 at 7:01 AM by LVN B Resident in room very unsteady bp 122/76 heart rate 112 temp 96.8.Resident refused head to toe assessment from this writer. No signs of bleeding or bruising to arms or legs andface. - A note on 09/07/25 at 7:01 AM by LVN B This writer stay with resident and staff until EMT arrived. Residentasked several times what's happening to me. This writer told help is on the way. Resident in bed some what alert calm no signs or symptom of pain - A note on 09/07/25 at 7:07 AM by LVN B Notified PCP - A note on 09/07/25 at 7:07 AM by LVN B Notified DON and Admin of situation - A note on 09/07/25 at 7:10 AM by LVN B Notified the police and requested EMT - A note on 09/07/25 at 7:15 AM by LVN B Police on the scene. This writer inform the police that resident wasin another resident room undress and resident has Alzheimer's and Dementia confusion sometime can't make decisionon her on [sic]. - A note on 09/07/25 at 7:17 AM by LVN B EMT on the scene to take resident to hospital for evaluation. Resident refused to go. - A note on 09/07/25 at 7:27 AM by LVN B Notified (Resident #2's family member's name) of the situation and (Resident #2's family member's name) (Resident #2's (Resident #2's family member's name) spoke to resident and resident was sent to (name of hospital). - A note on 09/07/25 at 8:26 AM by LVN B sent to ER - A note on 09/07/25 at 9:00 AM by LVN B (Resident #2's family membe4) and (Resident #2's POA) arrived asking what happened and how did I let this happen. This writer explained the event between 6:45 and 7:00 am. (Resident #2's family member) crying asking why did you let this happen. This writer listen to family member and assured her that Admin (Administrator's name) and DON (DON's name) was working on the situation as we speak - A note on 09/07/25 at 9:30 AM by ADON This nurse was at A-hall nurse's station after huddle (a meeting at shift change, for communication) this morning, when I heard overhead page by B-hall charge nurse that she cannot locate one of her residents and she need help to look for her. Other staff members started looking, while this nurse headstraight [sic] to Shall [sic]. Charge nurse reported to this nurse that (Resident #2) was observed lying in bed in room (Resident #1's room number). This nurse entered room (Resident #1's room number) and saw the male resident in room (Resident #1's room number) sitting across his bed facing the door and (Resident #2) was lying on the bed facing the wall and her back to the door. I asked the male resident what's going on? Why is she lying on your bed? He did not respond. He just looked down. I saw his pants and underwear were down to his thighs, and he tried pulling his pants up to cover his pubic area from being exposed. I turned to (Resident #2) and asked her what are you doing on the male resident's bed?. She replied, nothing. I asked her to get out of bed and let me take her back to her room. She tried to get up but couldn't. I noticed when she moved that she didn't have any underwear or pants on. She had a blouse, and sweater on. She also appeared weak and unstable. I asked the male resident to transfer to his w/c x3 while I try to get the female resident out of the bed, but he didn't move. I pulled the bed away from the wall, with both residents sitting on it, then I assisted the female resident to get out of bed and hold her hand while leading her to her room . She stopped and leaned against the wall outside the door because she was staggering. We finally made it to her room with my assistance. Male resident finally got out of bed to his w/c. Charge nurse had notified the DON, Administrator, and police. DON came into the building to start investigation. Marketing director also notified and came into the building to assist. This nurse took resident's vital signs: BP=122/76, P=112, Resp=28-30. Temp=96.8. She denied pain/discomfort from her vagina. She refused to have this nurse do a complete assessment of virginal [sic] area, stating I'm ok, I don't need that. Ambulance with EMT arrived and took over. Police also arrived and spoke with the male resident, charge nurse, and this nurse. Resident was transferred to [name] hosp for further eval and treatment if indicated. - A note on 09/07/25 at 12:56 PM by LVN B Notified resident [sic] of possible abuse by another resident - A note on 09/07/25 at 7:37 PM by LVN B Resident return from hospital alert bruising to rt eye swollen [sic] to top lip. voiced no to pain, gait unsteady some confusion noted - A note on 09/08/25 at 6:47 AM by LVN C Resident's upper lip remains swollen, denies pain or discomfort. - A note on 09/08/25 at 7:21 AM by LVN I resident awake and alert sitting on side of bed at this time. (.) Resident denies any pain/discomfort at this time. Upper lip remains slightly swollen, no c/o pain or discomfort. No signs ofdifficulty swallowing or chewing. Resident eating snack in room at this time. (.) - A note on 09/08/25 at 9:32 AM by the ADON This nurse saw resident being escorted by cna to smoke patio. CNA was holding her arm to assist her while ambulating from her room on B-hall to smoke patio. CNA reported to this nurse that resident is unstable on her feet on that's why she's holding on [NAME] [sic] arm while walking. Noted upper lip swollen. Resident denied pain at this time. Resident unable to verbalized what happen to her upper lip d/t dx of dementia/alzheimers. Charge nurse notified. DON aware. - A note on 09/08/25 at 10:22 AM by LVN I vitals assessed by this writer at 9:53am. 108/77 p97, 98% RA, 97.1 . Resident c/o pain to upper lip at this time. No order [sic] pain. Requested prn pain med at this time. - A note on 09/08/25 at 11:35 AM by LVN I resident oof to hospital with EMT per (Resident #2's family member) phone call to EMT for resident to get CT Scan. Resident sent with face sheet and med list. (Medical Director's name) and admin staff notified - A note on 09/08/25 at 5:43 PM by Agency LVN K the writer of this note made aware that resident was going to pend [sic] the night at her family home - A note on 09/08/25 at 6:00 PM by Agency LVN K Resident during the AM shift for a hospital appointment at (5:00 PM) family member came to the facility and informed the writer of this note that resident was going to pend [sic] the night at home. Evening and HS meds prepped and given to (Resident #2's family member). - A note on 09/09/25 at 11:35 AM by LVN I resident returned back to facility with (Resident #2's family member) and (Resident #2's family member CC) . (Nurse Practitioner's name) in facility and will assess resident per (Resident #2's family member's) request. Will continue with plan of care. Hospital records for Resident #2 were not reviewed. An observation on 09/07/25 at 12:22 PM revealed that Resident #2 was not in her room but a name plate with her first initial and last name was on the door. An interview and observation on 09/07/25 at 12:24 PM revealed Resident #1 outside his room, wheeling back and forth a short distance, and turning around in a circle and ranting. The ADON was standing next to his door, watching him. Resident #1 agreed to speak privately with the surveyor in his room, and the ADON said she would be right outside the door. Resident #1's speech was hard to understand at times, somewhat slurred, and he jumped from one unfinished sentence to another at times. He was speaking without stopping unless the surveyor interrupted him to ask questions. He said they (the facility staff) were talking this stuff about him, for no reason, and they didn't know anything. He said she (Resident #2) had autism and he didn't know that but they were friends and he talked to her all the time and she made decisions as well as him. He said she thinks good thoughts. When the surveyor asked the name of the lady he was talking about, he gave an incorrect first name starting with the same initial as Resident #2's, and the correct last name. He said They are saying a whole lot of whatever it is. They don't know that me and her have whole, decent conversations. He said he had not talked to her about sex, but he went into her room and told her he was going to his room, and she said she was coming over to get weed. When asked if he normally kept drugs in his room, he said no but when the surveyor asked about Resident #2 saying she was coming over to get marijuana, he said that he just kept a little weed in his room. He said that when they were in his room she I'm ready and he said no because them people are going to come in here but she pulled her clothes off. He said the door to his room just opened, he could not lock it, and people came in all the time. He said they both fit in his (twin) bed, and they watched TV first, then she wanted to have sex. He repeated that she was his friend, and just a friend, and that they (facility staff) know better than I am fixin' to rape. He said it was just like 10 minutes and he didn't even finish and he repeated this, and that the staff were makin' a big deal about it, and that they did not understand, repeatedly throughout this conversation. He said Resident #2's shoe was on the floor, and his money fell in her shoe. When the surveyor tried to talk about the allegation again, he continued to talk about the money, which was over $300, but when asked what kind of decisions he had ever seen Resident #2 make, he denied that she had any problem making her mind up about anything including sex or anything else. He said she was able to say yes or no and that she was happy while they were together, not upset. He said someone came in and saw them sitting there, and looked all over and got upset. He said a nurse came in and he was sitting upright in the bed. He then backtracked to how Resident #2 was his friend, and said she said naw then she said yes. When the surveyor asked if she said no to sex before she said yes, he said no, she never said no and that she wanted to get together with him. He said that when they were looking at the TV she told him to put on this song she liked, and he started looking for a song on his phone, and humming. He said when she said that he wasn't even thinkin' like that but he did it because she wanted to. He talked more about his money, the amount, and that she (pointed at the door) took the money and counted it and he wanted his money back. Several times during this interview the surveyor had to ask him to re-state things, and when he did, his speech was noticeably more clear and easy to understand. In his demeanor he seemed to be more emotional about his money and did not express any concern for Resident #2. Constantly throughout the interview he put his hands on his head and shook his head, while he denied there was any problem with his actions toward Resident #2. An interview on 09/07/25 at 12:36 PM with the ADON revealed she was the person designated to watch Resident #2 at this time. She said there was some question about who the money belonged to, because it was found in another resident's room, and it was being held until they were certain of who it belonged to. The resident was inside his room and loudly said they knew it was his money and he wanted it back. A telephone interview on 09/07/25 at 12:44 PM with Resident #2's Family Member said the facility called at about 7:30 that morning (09/07/25) to tell her they needed the resident to go to the hospital, and she would not go, because she did not understand why. She talked to Resident #2 so she would go, and when she was at the facility she saw the man who did it. She said there was nothing wrong with him, except his was in a wheelchair, and he said the night nurse knew they had been doing it (he and Resident #2 having sexual contact) for a while, and told them it was OK. During the conversation, Resident #2's family member was crying and said that earlier another man had jumped on Resident #2 and hit her on the head. She said the resident had a stent in her head and they sent her to the hospital because she was worried that the man might have done something to her stent. She said Resident #2 had dementia and she was very concerned, because she thought the staff were supposed to protect Resident #2, and check her at least every two hours, and she wanted to know how nobody noticed she was in a man's room. She said her dementia was getting worse, and she was not able to decide to go to a man's bed. She said she did not believe there was any way Resident #2 would be thinking to look for that (sex) and she would not be looking for drugs. She was worried the facility would lie about it and say Resident #2 meant to be in the man's room. She did not know how the resident was doing, because she was still at the hospital. Once she was released her family meant to take her home for a while. A telephone interview on 09/07/25 at 12:59 PM with Resident #2's POA said he had been told that Resident #2 had been found in a man's room with no clothes on, around 6:50-7:00AM that morning, and she appeared to have no recollection that anything happened. He said she did not seem agitated or upset because she was completely unaware of what happened. He said he was at the hospital during this conversation and they were waiting for them to do a rape kit on the resident. He said she had never talked about being involved with a man at the facility and no staff had ever told them she showed any interest in that, and he would not expect her to, because she could not remember anything from one minute to the next. Resident #2's POA said they were feeling very bad about the facility after another man assaulted her by hitting her, twice, for no reason and he wanted to find a better place for her because of that. He said the other assaults had been in the last couple of months, he thought. He said that on top of that, now this has happened and they (her family) were very, very upset. An interview on 09/07/25 at 2:10 PM with LVN B revealed the staff were having huddle at about 6:30 or 6:40 and she noticed Resident #2's door was open and she was not in there. She said she made a round to look for her, and she was not in any of her normal places. She said she went from room to room on her hall and checked the rooms again, in case they had missed each other in passing. When she was not able to find Resident #2 she asked another nurse if they had seen her, and did a page overhead to call for help. RN A and LVN C found Resident #2 in Resident #1's room and told her. The ADON was also searching and she went into Resident #2's room with her. She said Resident #2 was in the bed, facing the wall, and her underwear and pants were off, and her shirt was pulled part-way up her back. She said the ADON asked Resident #1 to pull his clothes up and get in the wheelchair so they could get Resident #2 off the bed. LVN B said she called the Administrator and the DON because this was abuse, and she called 911 for police and EMTs. She said Resident #2 seemed loopy and could not get out of the bed, so they helped her to a chair. She said normally Resident #2 was able to walk very well, and she walked all the time, but she was having trouble walking. She said Resident #2 was hugging herself and shaking when the ADON got her back into her own bed, and the ADON stayed with her. She said the DON stayed on her cell phone with her while she called the police, and that Resident #1 would not allow them into his room or talk to them. The police came and spoke with Resident #1, then with her, and she gave them her version of what happened. LVN B said Resident #2 was not able to make decisions about things like that for herself, but she was very passive, and easily influenced, and if she needed her to be somewhere she just said Come on (Resident #2's name), let's go and she would go right along with her. She did not believe Resident #2 would ever be seeking out drugs or sex, and she had never shown any idea of those things, in the time she had known her. She had never had any sort of sexually related behaviors. She said Resident #1 had a history of going on pass and doing drugs and Resident #2 never left the building except with her family, and never went out to the tree to be with other residents. She mostly just kept to herself. She said that Resident #1 was a sick person and on the night of 09/06/25 he was hanging his entire torso out his window, and smoking something that made his room and the hall smell terrible. When she told him to stop, he swore at her. She said he did that a lot, and was very threatening. She reported it to the Administrator and the night staff. The Administrator told her to call the police. She had been told that Resident #1 had earlier gone into a men's room, looking for a female friend and when RN A and LVN C told him no, it was a men's room, he said it was her (identity of her unknown) room. RN A and LVN C redirected him back to his room after that, and they watched him go all the way to his room. She reiterated that she felt Resident #1 was a sick person and that something was very wrong with him, and he was very perverted. She said when she notified Resident #2's family member, because she was able to get her to do things, she talked to her and got her to go to the hospital. Later Resident #2's family member and Resident #2's POA came to the facility and they had Resident #1's phone with them, and wanted to know where Resident #2's phone and wallet was. Resident #1 was there and told Resident #2's POA Give me my phone and the POA asked Resident #1 how Resident #2 even had his phone. Resident #1's response when Resident #2's POA asked him if he did that (sex) to Resident #1 was it lasted maybe 10 minutes and it's not a big deal and everyone is making a big deal about it. LVN B said Resident #1 said they (he and Resident #2) went in the room and it didn't last long and that everyone was acting like they didn't know what a man and woman being together was. She said Resident #2's POA called the police and her family member was in tears. She said she explained to Resident #1 that Resident #2 was not mentally equal to him, and he responded that she was older than him, and she explained it was not about age, it was about her mind. She said she did not know why someone did not go watch Resident #1 after he tried to go into rooms in the middle of the night. She said she had been so stressed over Resident #1's behavior that she had to take some time off. She said Resident #1 had talked about a lot of things that made her uncomfortable, and been very threatening toward her. She had asked him to turn his loud music down once, and close his door, because it was night, and people were sleeping, and he said he was going to get somebody's cousin to fuck her up. She said she talked to the Administrator about it, but he just said they could call the police but they probably would not do anything. She told the DON she did not feel safe there, and took some time off. She said they moved her to a different nurses station, but it did not help. She said Resident #2's only real behavior problem was that she was a little bit of a klepto and would go into rooms and pick up other people's things, and she collected the water pitchers, and things like that. The only time she ever heard of her going into a man's room was because she wanted to take something she saw, not because it was a man's room. She said the resident probably had no idea whose room it even was. She said Resident #2 probably did not even know Resident #1's name. She said she felt like Resident #1 was really bad, and the Administrative staff should have taken him more seriously before this. An interview on 09/07/25 at 4:58 PM with the Hospital SANE revealed she had just seen Resident #2, and examined her for possible sexual assault. She said the resident could not remember what happened or answer any questions about it, so the information she got came mostly from her family. She said she did a full head-to-toe assessment, taking pictures of anything she found, and swabbed her for DNA. She said the only injury she found was some redness on her face , which her family said was not normal for her, but that lack of injury did not necessarily mean lack of assault. She said Resident #2 did not remember at all what happened, and did not seem particularly upset. An interview on 09/07/25 at 6:38 PM with RN A revealed Resident #1 was trying to go into a man's room on the night of 09/06/25, and he and the other nurse (LVN C) told him to stop trying to go into rooms because it was late and people wanted to rest. He said he was aware of Resident #1 and another resident who had recently been discharged having a consensual sexual relationship, and he had reported it to the DON and Administrator. He said both residents were fully alert and oriented and able to consent. He said he was not aware of Resident #1 trying to have sex with any other resident. He said they were near the nurses station at the front door (at the opposite of a hall from Resident #1 and Resident #2's rooms) at the time, and watched Resident #1 go all the way down the hall, and into his room. He said it was about 4:00 AM on 09/07/25 when that happened. He said around 4:45 AM Resident #2 was in bed, with the light on, which was normal for her. He said at that time, Resident #1 was in his room, sitting in his wheelchair, watching TV. He said Resident #2 had never had any sexual behaviors, or shown any interest in drugs, that he was aware of. He said they had done training on abuse and neglect, including sexual abuse, and what consent meant, and he did not know if Resident #2 would be able to give consent, but Resident #1 was able to consent. He said Resident #2 could remember bits and pieces of things that happened years ago, but was not able to remember recent things because her short-term memory was very poor. He said he did not think someone with poor short-term memory would be able to give informed consent, which meant a person was able to understand the implications of their decisions. An interview on 09/07/25 at 7:03 PM with LVN C revealed he was working at the station by the front door, on admitting a resident, when he heard the call on the intercom that there was a missing resident, so he went to the other nurses station. He said he checked in Resident #2's room, and she was not there so he went room to room and found Res[TRUNCATED]

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for five (Residents #1, #8, #9, #11, and #12) of eight residents reviewed for care plans related to sexual activity with other residents. The facility failed to create care plans addressing known sexual relationships between residents for Residents #1, #8, #9, #11, and #12. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Review of Resident #1's admission Record, dated 09/08/25, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body), depression, anxiety, cerebral infarction (stroke), and traumatic brain injury (sudden injury to the brain usually caused by a blow or jolt to the head.) Resident #1 was his own responsible party. Review of Resident #1's MDS, dated [DATE], reflected Resident #1 was able to understand others, and be understood by others, and had a BIMS score of 14, indicating he was cognitively intact. He exhibited no signs of delirium or psychosis, and was not depressed, but did sometimes feel socially isolated. He had no behaviors during the assessment period. Resident #1 used a wheelchair for locomotion, and needed little assistance with his ADLs. Resident #1 required partial to moderate (helper does less than half the effort) assistance with toileting, showering, and lower body dressing. He required only supervision or touching assistance with personal hygiene and upper body dressing. Resident #1 was able to move himself around in bed, and sit and lie down with no assistance. Review of Resident #1's Careplans reflected the following care plans:- 09/07/25 for sexually inappropriate behavior with another resident.- The care plans did not include any other care plan related to sexual behavior or relationships. Review of Resident #8's admission Record, dated 09/10/25, reflected the resident was a [AGE] year-old male admitted on [DATE], with diagnoses of epilepsy, depression, and mild cognitive impairment. Resident #8's family member was listed as his responsible party. Review of Resident #8's quarterly MDS assessment, dated 09/01/25, reflected the resident had a BIMS score of 11, which indicated moderate cognitive impairment. He was usually understood by others, and usually understood others. Resident #8 exhibited no signs of delirium or psychosis during the assessment period, and had no behavioral problems. Review of Resident #8's care plans, dated 09/03/25, reflected the following:- Resident was at risk for altered status due to a traumatic life experience, due to being raped as a young child.- Resident was a registered sex offender and must be supervised when he goes out on pass in a child safety zone.- The care plans did not include any other care plan related to sexual behavior or relationships. Review of Resident #9's admission Record, dated 09/10/25, reflected the resident was a [AGE] year-old male admitted on [DATE], with diagnoses of schizoaffective disorder (a mental health condition having symptoms of schizophrenia and a mood disorder), major depressive disorder, and generalized anxiety disorder. Resident #9 was listed as his own Responsible Party. Review of Resident #9's quarterly MDS assessment, dated 08/29/25, reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #9 was usually understood by others, and usually able to understand others. Resident #9 had fluctuating inattention and disorganized thinking during the assessment period, and no behavioral problems. Review of Resident #9's care plan, dated 09/04/25, reflected the following:- Resident has a history of frequently accusing other male residents that he is fixated on and (who he doesn't like) of raping his female companion, even though his female companion clearly states that I never told him that. That has never happened to me.- (Resident #9) experiences disorganized thinking due to Schizophrenia. He frequently makes false accusations againstothers. If he does not get his way he becomes angry and curses at others. He tries to manipulate staff into getting hisway. He recently has begun to say that people are beating the crap out of my girlfriend.- The care plans did not include any plan related to sexual behavior or relationships. Review of Resident #11's face sheet, dated 09/10/25, reflected the resident was a [AGE] year-old male, admitted on [DATE], with diagnoses of diffuse traumatic brain injury with loss of consciousness of unspecified duration (a type of traumatic brain injury that results from blunt injury to the brain which can lead to loss of consciousness), major depressive disorder, and bipolar disorder. Resident #11 was listed as his own Responsible Party. Review of Resident #11's quarterly MDS assessment, dated 07/01/25, reflected the resident had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #11 was usually able to be understood by others, and usually able to understand others. Resident #11 had fluctuating disorganized thinking and no behavioral problems during the assessment period. Review of Resident #11's care plans reflected no care plans related to sexual behavior or relationships. Review of Resident #12's face sheet, dated 09/10/25, reflected the resident was an [AGE] year-old female admitted on [DATE], with diagnoses of chronic kidney disease, mood disorder, and bipolar disorder. She was listed as her own Responsible Party. Review of Resident #12's quarterly MDS assessment, dated 08/07/25, reflected the resident had a BIMS score of 08, which indicated moderate cognitive impairment. Resident #12 was usually able to understand others, and usually able to be understood by others. Resident #12 exhibited no indicators of psychosis or delirium and had no behavioral problems during the assessment period. Review of Resident #12's care plans reflected no care plans related to sexual behavior or relationships. An interview on 09/07/25 at 6:38 PM with RN A revealed Resident #1, and Resident #3 (a resident who was discharged on 09/03/25) had a consensual sexual relationship, and that both of them were alert and oriented, and able to give or refuse consent. An interview on 09/07/25 at 7:03 PM with LVN C revealed he witnessed Resident #1 and Resident #3 in Resident #1's room, having sex, and that he believed they had a consensual relationship. An interview on 09/08/25 at 10:14 AM with Resident #7 revealed she had a boyfriend in the facility who had moved out of town, and now Resident #8 was her boyfriend. She said they were sexually active together, and the nurses talked to them about condoms and how to be safe and all that. An interview and observation on 09/08/25 at 10:20 AM revealed Resident #9 and Resident #10 seated next to each other. Resident #9 said This is my lady, my girlfriend. This alerted Resident #10 to wake up from her apparent nap, and say Yes, this is my boyfriend. An interview on 09/08/25 at 11:10 AM with the DON revealed she was aware of Resident #1 and Resident #3 having a consensual sexual relationship before Resident #3 discharged . She said if residents were both in their right minds, and consenting, the staff provided privacy. She said she thought it was careplanned, and she knew it was for Resident #7, who had a boyfriend who was transferred to another facility, before she was with Resident #8. She said they provided condoms for those residents, and when they had a younger female resident having sex, they talked about sexual health and safety (birth control, diseases, etc.) She said their residents were adults, and did not ask permission to do it, they just decided in the privacy of their rooms to do it, and they did it. She said when staff learned they were sexually involved with each other, and if they were both consenting adults, they offered them condoms, and privacy. An interview on 09/08/25 at 11:25 AM with the Administrator revealed he was aware of Resident #1 and Resident #3 having a sexual relationship. He said it was consensual, and they both had private rooms, and he talked with both of them. He said he thought the staff talked to residents about consent and safe sex. A telephone interview on 09/09/25 at 9:43 AM with Resident #3 revealed she denied having any relationship with Resident #1, and when asked about the staff witnessing them having sexual contact, she said the staff were lying. When asked if the staff talked to them about consent and safe sex, she said they did not, because they were not having sex. An interview on 09/09/25 at 1:17 PM with the ADON revealed she was aware of some of the residents having sexual relations with each other. She said aside from Resident #1 and Resident #3, they had Residents #9 and #10 who had originally asked to be in a room together, but at some time were moved to separate rooms, but she did not know if they requested that, or it was some other reason. She said Resident #11 actually brought Resident #12 from another facility because she was his girlfriend, and they used to room together, and are still a couple, though they do not room together any more. She said Resident #7 and Resident #8 were a recent couple. She said she heard about it from staff who told her they go out on dates, and sometimes come back drunk. She said Residents #7 and #8 were signing out once for overnight, and she asked when they expected to return, and Resident #8 said in the morning, when the room they had arranged closed. She told them she did not feel it was a good idea for them to be gone overnight, because of his health condition, but he just asked What are you going to do when we get married? She notified his responsible party, and the responsible party said she hoped they did get married so they could take her name off the contact list. She did not know of any official assessment, but she thought the management team was aware of all of the relationships. She thought there were probably care plans in place for them, but she was not sure. An interview on 09/09/25 at 2:45 PM with the MDS Coordinator revealed he had been told to do acute careplans about resident relationships, but it had been a long time ago. He said the ADON and DON did most of the acute careplans about things like sexual activity. He said that even though he had not done careplans for all of them, he had been requested to do a quick BIMS assessment on residents before, as part of an assessment of them to decide if they were competent to make the decision to be in a sexual relationship. An interview on 09/09/25 at 4:01 PM with the DON revealed she had done careplans on residents for relationships before. She said the careplans for relationships, if she knew about them, would probably fall to her, and the Social Worker could also do them, but she never thought to care plan the couples having sex. She said she would have to take a look at the individual careplans, and that the careplans were important because the staff would know how to care for residents, and what the interventions were for helping them reach their goals. Review of the policy Care Planning - Interdisciplinary Team, revised September 2013, reflected Policy StatementOur facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team (.) 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. (.) The policy did not directly address acute careplans for issues not covered by the resident's comprehensive assessment.

Based on interview and record review, the facility failed to ensure that an allegation of abuse was reported immediately but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse to Health and Human Services for one (Resident #3) of twelve residents reviewed for abuse and neglect. The facility failed to report an allegation by Resident #3 (a discharged resident) that Resident #1 put drugs in a beer he gave her on 08/31/25 or 09/01/25. This failure could place residents at risk of being abused and lack of oversight by a state agency. Findings included: Review of Resident #1's admission Record, dated 09/08/25, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body), depression, anxiety, cerebral infarction (stroke), and traumatic brain injury (sudden injury to the brain usually caused by a blow or jolt to the head.) Resident #1 was his own responsible party. Review of Resident #1's MDS, dated [DATE], reflected Resident #1 was able to understand others, and be understood by others, and had a BIMS score of 14, indicating he was cognitively intact. He exhibited no signs of delirium or psychosis, and was not depressed, but did sometimes felt socially isolated. He had no behaviors during the assessment period. Resident #1 used a wheelchair for locomotion, and needed little assistance with his ADLs. Resident #1 required partial to moderate (helper does less than half the effort) assistance with toileting, showering, and lower body dressing. He required only supervision or touching assistance with personal hygiene and upper body dressing. Resident #1 was able to move himself around in bed, and sit and lie down with no assistance. Review of Resident #1's Careplans reflected the following care plans:- 07/24/25 for impaired comprehension related to his history of traumatic brain injury- 08/22/25 for potential for disruption of continuity of care related to signing himself out of the facility to gather off the facility property with other residents to smoke and socialize-08/25/25 for a psychosocial well-being problem related to a history of drug and alcohol use Review of Resident #1's psychological services note, dated 09/05/25 reflected he was seen for hallucinations and delusions. The document noted that Resident #1 told the counselor that he had been served with a 30-day discharge notice due to alleged drug use, but denied using drugs. The document also noted that he provided inconsistent information and had difficulty articulating or focusing. Review of a note on 08/31/25 at 1:10 AM by RN A reflected At about 12am, this writer and another nurse were doing nurse's rounds and observed that resident was in his room with another female resident with door slightly opened. Resident stated that we are just watching a movie. Shortly after, his door was closed and this writer and another nurse went to check on patient. When we knocked on patient's door, he answered and stated that i am enjoying myself. We observed both residents lying in bed having sex. We provided privacy. (Medical Director), Administrator and DON notified. Review of Resident #3's admission Record, dated 09/10/25 , reflected the resident was a [AGE] year-old female with diagnoses of bipolar disorder, anxiety disorder, COPD (a condition which makes it difficult to breathe) and post-traumatic stress disorder. Review of Resident #3's MDS assessment, dated 09/01/25, reflected Resident #3 was usually understood, and usually able to understand others. She had diagnoses of depression, mild cognitive impairment, and personal history of suicidal behavior. She had a BIMS score of 11, which indicated moderate cognitive impairment. During the assessment period she showed no signs of delirium, psychosis, or behavioral problems. She had one-sided impairment of her upper extremity, and was able to use her wheelchair with only supervision or touching assistance. Review of Resident #3's careplans reflected the following:- 03/15/25 a history of suicidal ideation (thoughts of killing oneself)- 03/15/25 impaired cognitive function- 03/17/25 impaired comprehension- 05/12/25 a history of verbal aggression with staff, residents and transport drivers, and socially in appropriate/ disruptive behavior, sexually inappropriate behavior, cursing, and throwing things.- 05/21/25 puts herself in dangerous situations, and rolling walker inside and outside, and wandering into unsafe situations re: cognitive status- 05/21/25 After discovering (Resident #3) was sexually [sic] she disclosed her triggers were men, and aggressive people. She also said that constant stares triggers her. An 08/31/25 note added to this careplan that on that date she was observed by a nurse having sexual relations with another resident. - 08/21/25 potential for disrupting continuity of care due to signing out and sitting outside socializing with other residents.08/25/25 history of alcohol and drug used, and goes out on pass regularly. A note added to this careplan on 09/01/25 reflected the resident called 911 and requested to go to the hospital as a result of another resident putting drugs in her beer when they were outside. Review of Resident #3's progress notes reflected the following: - A note on 08/31/25 at 3:10 AM by LVN C This resident was in room (Resident #1's room number) saying that she waswatching a movie with the resident who stays in room (Resident #1's room number). Shortly after, the door closed and when this writer and another nurse went there and knocked at the door, the two residents were in bed having sex. Then the resident who lives in room (Resident #1's room number) said, I am enjoying myself'. The residents were accorded [sic] privacy. (Medical Director's name), administrator and DoN notified. - A nurses note on 08/31/25 at 11:50 PM, writer unknown, reflected Resident returns from hospital for chest pain of uncertain cause. Patient is in stable condition BP: 118/76, HR: 65, SATS: 96% on room air, Temp: 98.1, no c/o pain and no s/s of acute distress (Medical Director's name) notified, will continue to monitor. - A note on 09/01/25 at 3:10 AM by RN A At about 2:00am, this writer and the nurse on C. hall knocked on resident's door. She stated go away (Resident #1) is here. The door was barricaded with their wheelchairs and trash can. (Medical Director's name), DON, and Administrator notified. Male resident finally cameout [sic] of her (Resident #3's room number) at about 2:30am. - A note on 09/01/25 at 6:29 AM, writer unknown, reflected CNA answered this resident's call light at this time andresident asked for a refill of Ice and stated to CNA I have the ambulance coming. The CNA notified this nurse and at that time a police officer walked into the facility. The officer stated So l'mhere [sic] for a (Resident #3's name). The officer went to speak with resident in her room. This nurse notified the Administrator and DON. The officer came outof the room stating to this nurse So she is saying the resident in room (Resident #1's room number) gave her a steel reserve last night and it didn't taste like normal beer. She said it tasted like some other chemicals were in it as wellmaking her chest hurt. The Administrator and DON notified of this information at this time. 0637am At this time (name of ambulance company) personnel walked into facility setting resident up for transport. (.) - A note on 09/01/25 at 1:18 PM by LVN E This nurse called (name of hospital) ER and spoke to (name of hospital nurse) who stated All of the patient's labs were normal, so she was given tramadol and ASA , and discharged back to (name of facility). - A note on 09/02/25 at 12:29 AM by LVN D resident remains awake up in w/c sitting in room. states I filed a police report against male in (Resident #1's room number) for putting drugs in my drink the hospital did a urine screen and said i could get my records for the police tomorrow. im pressing charges and i want him arrested resident stated it all happened over the weekend i felt funny after I drank the drink but the hospital said i was ok and sent me back denies pain or distress at this time denies sob or discomfort im fine now this was yesterday nad [sic] noted tolerating snacks and po fluids well prn for pain effective. cont poc - A note on 09/08/25 at 7:00 AM by LVN E This former resident called at this time stating Y'all think it's a joke I'm filing a lawsuit against y'all nursing home. I was drugged by (Resident #1's name) and every since I been feeling like I was dying. I been in the hospital ever since I discharged . Tell the administrator and DON to give me a call please. The administrator and DON notified of this information. Review of change in condition documentation for Resident #3, dated 08/31/25 at 4:01 PM, reflected the resident had sharp musculoskeletal pain at a level 5 and tightness in her chest, with no shortness of breath, which started on the afternoon of 08/31/25, but resident was otherwise normal. Her blood pressure was 147/92, pulse 97, respirations 20, temperature 98.1, oxygen 96% on room air. It was noted that the symptoms stayed the same since the change in condition occurred. Resident #3 was sent to the ER. An interview on 09/09/25 at 1:17 PM with the ADON revealed she was aware that Resident #1 and Resident #3 had a consensual sexual relationship, and the staff had notified her that they observed them in bed having sex. She said she was also aware of the allegation that Resident #1 drugged her, and she was sent to the hospital for stomach pain and her body did not feel right since he put something in her drink. She did not know any more details, and was not aware of whether it had been reported to the state or not. She said whenever a staff member reported something to her that should also be reported to the DON and Administrator, she asked them if they reported it to the DON and Administrator, and the answer they gave was always Yes. An interview on 09/09/25 at 4:01 PM with the DON revealed she was aware that Resident #3 had made an allegation that Resident #1 put something in her drink. She said Resident #3 went to the hospital, and came back shortly after. She said her nurse called the hospital to find out results, and was told that they found nothing, and everything was clear, so they sent her back with some tramadol (a narcotic pain reliever.) She thinks that she and the Administrator did not report it, because there were no drugs in her system, and it did not happen. She said that Resident #3 called her on 09/08/25, and she could tell by the way she sounded that she was recording the call, and she said that they put her out and she was mad about Resident #1. The DON said she reminded Resident #3 that she wanted the discharge and they tested her at the hospital and she had no drugs in her system, and the resident hung up on her. An interview on 09/12/25 (post-exit) at 9:53 AM with the Administrator revealed he heard about Resident #3 making an allegation that Resident #1 drugged her third party . He did not say who told him, or when he heard about it. He said he heard that it happened off-site, when both residents had signed out of the facility. He did not know if it was under the tree where the residents hung out, or somewhere else. He did not report it, because it happened off-site, and there was no proof. He said that whether he reported something that happened off-site would depend on the situation. He gave an example of an incident from a previous building he worked in, where a resident returned and said that their family member had left them in the car by themselves. He said something like that, they would probably look at reporting. He said if the resident had spoken to him directly, he would have talked to his advisors and found out whether it needed to be reported. He said he attempted to talk to her about it, and she swore at him, flipped him off, and told him he was no kind of manager and come the third (of September) she would be gone, and that was going to be it. He did not document that he attempted to speak with her. He said some days she would be pleasant and speak to him, but most of the time she made it well known that one of her big triggers was talking to men in authority, and she did not like talking to them. He said the police came, and wanted to talk to someone named (name not belonging to any residents or staff at the facility) , and he told them there was nobody there by that name. He said somehow it was determined it was Resident #3, and they went out under the tree and spoke to her, and left. The police did not ask him anything, or speak with him about anything, so he did not know what the conversation was about. He said he was not notified of her call on 09/08/25. Review of the policy Abuse Prevention Program, revised December 2016, reflected Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: (.) 7. (.) and report any allegations of abuse within timeframes as required by federal requirements;(.)

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for4 (Res#1, Res#2, Res#3 and Res#4) of 5 residents reviewed for updated care plans. The facility failed to provide Resident#1,2,3,4 with updated care plans to reflected concerns for health and safety when leaving the facility unsupervised. An IJ was identified on 08/21/25. The IJ template was provided to the facility on [DATE] at 5:53 pm While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern because all staff had not been trained on 08/22/25. This failure can affect residents health, safety and possible death.Findings included:Record review of Resident#1's face sheet dated 08/20/25 reflected, he was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Paraplegia (symptom of paralysis that mainly affects your legs (though it can sometimes affect your lower body and some of your arm abilities, too), Anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Hyperlipidemia (have high lipid levels), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations), Cerebral infarction ( an ischemic stroke, it is the most common form of stroke) personal history of traumatic brain injury (a brain injury that is caused by an outside force), chronic pain( lasts months or years and can affect any part of your body), essential hypertension (abnormally high blood pressure), pressure ulcer (forms on an area of the skin with prolonged pressure due to immobility) of right buttock, stage 4 (Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle)-onset 07/23/25, and Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) -unspecified organism-08/08/25 onset. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#1 care plan, dated 07/14/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#2's face sheet, dated 08/22/25 reflected, he was a [AGE] year-old male who or was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Epilepsy (neurological disorder characterized by recurrent, unprovoked seizures), depression, mid cognitive impairment of uncertain unknown etiology (cognitive issues like memory and thinking problems are present but the specific underlying cause hasn't been identified), depression, unspecified convulsions, hyperlipidemia (a condition characterized by high levels of lipids (fats) in the blood, including cholesterol and triglycerides), hypothyroidism (happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs), and tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an airway and facilitate breathing.) Record review of Resident#2's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#2 care plan, dated 08/18/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#3 s face sheet, 08/21/25 reflected, she was a [AGE] year-old female who was originally admitted on [DATE] and diagnosed with unspecified Dementia (a condition where cognitive decline is present, but the specific underlying cause cannot be identified), bipolar disorder, anxiety disorder and cerebral infraction (occurs when blood flow to the brain is interrupted, leading to cell death and brain damage), unspecified. Record review of Resident#3's MDS, date reflected her BIMS score was 13 which indicated cognitive intact. Record review of Resident#3 care plan, dated 07/14/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#4 face sheet, dated 08/22/25 reflected, he was a [AGE] year-old male who was originally admitted [DATE] and readmitted [DATE] and diagnosed with major depressive disorder, diffuse traumatic brain injury (a type of brain injury that occurs when the brain experiences rapid acceleration or deceleration forces, causing widespread damage to the white matter tracts) with loss of consciousness of unspecified, conversion disorders with seizures or convulsions (involves real physical symptoms that resemble epileptic seizures but result from psychological factors),Epileptic seizures related to external causes not intractable (seizures triggered by an external factor that are not the chronic, difficult-to-manage form of epilepsy). Record review of Resident#4's MDS, date reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#4 care plan, dated 08/01/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. In an interview on 08/20/25 at 10:45 am Resident#1 stated he did not want to talk about why he left the facility, where he went, who he was with and about his hospital stay. Resident#1 stated he was ok and did not have any concerns. Resident#1 stated that he signs himself in and out when he left the facility. In an interview on 08/20/25 at 10:52 am Resident# 4 stated he signed himself in and out. Resident#4 stated that he comes back to the facility every day. Resident#4 stated he did not have any concerns. In an interview on 08/21/24 at 12:48 pm resident#3 stated he signed himself in and out. Resident#3 stated he came back the same day that he left. Resident#3 stated he did not have any concerns. In an interview on 08/22/25 at 11:30 am the DON stated she was responsible for updating the care plans. The DON stated she was not sure why those residents care plans were not updated to reflect that they did not follow the facility policy on signing in and out. Those residents care plans do not mention they can leave unsupervised. The DON stated she has been working the floor a lot. The DON stated not updating the care plan could leave residents needs not being met. Record review od facility policy dated, revised 12/2016, titled Care plans, comprehensive person centered reflected in part: C. Describe services that would otherwise be provided for the above, but are not provided due to residents exercising his or her right, including the right to refuse treatment.G, incorporate identified problem areas.13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents condition changes. On 08/21/25 at 5:53 PM the IJ was called. The template was provided to the Admin and DON, POR was approved on 08/22/25. 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 8/21/2025 [Residnet#1] returned to the facility on 8/8/2025 [Resident#1] care plan was updated by don/designee on 8/21/2025 2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/21/2025) Care plans will be reviewed for all residents that sign themselves out. The IDT team will be in-serviced on revising the care plans for each resident that signs out by the corporate nurse/DON by 8/22/2025. The administrator/director of nursing were in-serviced by corporate team on 8/21/2025 at 6:54 on updating care plans A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. QAPI will be completed by corporate nurse by 8/21/25. New staff will be educated and trained on resident signing in and out, with timely returning Agency staff will be educated and trained on residents signing in and out, with timely returning prior to starting shift. Care plan, drugs, and signing out policies always made available for review.Record review of Resident#1 revised 08/22/25, care plan initiated on 08/21/25 reflected Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, Attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. Record review of Resident#2 revised care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, Referral to psyche services as needed. The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. Record review of Resident#3 revised care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign herself out of the facility and sits outside with a group of other s . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. In an interview on 08/22/25 at 2:53 pm with the corporate consulting nurse at 11:00 am she was able to verbalize everything that the facility had implemented. In an interview on 08/23/25 between 1:00 pm to 3:30 pm, the ADON, DON, RN J, LVN G, LVN H, LVN I stated the care plans needed to be updated as needed and acute changes . The DON stated after QAPI meetings and morning minutes Residents care plans needed to be updated so that concerns or issues that need to have interventions could be addressed. RN J stated the care plans needed to reflect the Residents current conditions and concerns. RN J stated measurable interventions and goals need to be put in place to address corns for residents' health and safety. All residents care plans were audit who signed themselves out. The DON was responsible for updating care plans daily after IDT meetings if needed and monthly after QAA meetings and as needed. In an interview on 08/22/25 at 3:30 pm the DON and Admin verbalized everything the facility had implemented. An IJ was identified on 08/21/25. The IJ template was provided to the facility on [DATE] at 5:53 pm While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern because all staff had not been trained on 08/22/25.

Based on interview, observations and record review, the facility failed to ensure 1 (Resident#1) out of 4 received adequate supervision when reviewed for accidents. The facility failed to provide Resident#1 with adequate supervision on 08/01/25 when Resident#1 left the unsupervised for 3 day's The facility was not made aware until 08/04/25 that Resident#1 had been admitted the hospital. An IJ was identified on 08/21/15. The IJ template was provided to the facility on [DATE] at 4:45 pm. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of isolated because all staff had not been trained on 08/22/25. Thia failure could affect all resident's health, safety and possible death. Findings included:Record review of Resident#1's face sheet, dated 08/30/25 reflected, he was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Paraplegia (symptom of paralysis that mainly affects your legs (though it can sometimes affect your lower body and some of your arm abilities, too), Anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Hyperlipidemia (have high lipid levels), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations), Cerebral infarction ( an ischemic stroke, it is the most common form of stroke) personal history of traumatic brain injury (a brain injury that is caused by an outside force), chronic pain( lasts months or years and can affect any part of your body), essential hypertension (abnormally high blood pressure), pressure ulcer (forms on an area of the skin with prolonged pressure due to immobility) of right buttock, stage 4 (Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle)-onset 07/23/25, and Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) -unspecified organism-08/08/25 onset. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review reflected no behaviors noted on the MDS. Record review of Resident#1 care plan, dated 07/14/25 reflected, no documentation of resident leaving the facility unsupervised. Record review of Resident#1's progress notes dated, 07/25/25 to 08/20/25 reflected in part:On 08/01/25 Nurse noted reflected. Resident signed out on pass at 2145. Still out of the facility. Completed by LVN A. On 08/02/25 Nurse notes reflected, Resident still out on pass. Completed by LVN G On 08/03/25 Nurse note reflected, out on pass. Completed by LVN I On 08/04/25 Administration notes reflected, Resident on leave. Completed by LVN G On 08/07/25 communication with physician noted reflected, Spoke with nurse he is doing fine. Vitals are fine he is still on IV antibiotics for an infection once he has completed his antibiotics, he should be ready to discharge. Completed by nursing. Record review on 08/20/25 of sign out/in sheet from sign out/in booklet from the receptionist desk reflected, Resident#1 did not sign out on 08/01/25.Record review of hospital records dated 08/21/25 reflected Resident#1 arrived at the hospital on [DATE] at 12:35 pm. Resident#1 chief complaint reflected Resident#1 checked himself out, been sitting out in the rain and heat for 3 days. Record review of hospital record did not detail how Resident#1 arrived at the hospital.Diagnosed reflected:*Sepsis (serious condition in which the body responds improperly to an infection) due to Pseudomonas aeruginosa (severe infections, particularly in immunocompromised individuals) and Beta hemolytic streptococci group C infected decubitus ulcer (Bedsores are injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time)* Fever 101.2 (fever is defined as a temperature above 100.4 F )*Tachycardia (heart rate over 100 beats a minute)*Leukocytosis (high white blood cell count, can indicate a range of conditions, including infections, inflammation, injury and immune system disorders.)*Foul drainage from woundPolysubstance use disorder reflected, a history of methamphetamine ( a potent central nervous system (CNS) stimulant that is mainly used as a recreational), cannabis (which can also be called marijuana, weed, pot, or bud, refers to the dried flowers, leaves, stems, and seeds of the cannabis plant) and opiate (are natural or synthetic chemicals that bind to receptors in your brain or body to reduce the intensity of pain signals reaching the brain) abuse.*Repeated drug toxic screened positive for amphetamines, benzodiazepines (benzos, are a class of central nervous system (CNS) depressant drugs), cannabinoids and cocaine (Central nervous system stimulant and tropane alkaloid derived primarily from the leaves of two coca species.Requested EMS report online from city on 08/22/25 and have not received at this time. Record review of progress notes dated 08/01/25 to 08/04/25 reflected no documentation of emergency contact was called before 08/04/25. No documentation of active search for Resident#1 before 08/04/25. Record review of Resident#1 sign out and in sheet reflected, sign out and sign in sheet not completed. Review reflected dates, times, signatures and destination information missing. In an interview on 08/20/25 at 10:00 am the Admin and the DON stated the incident with Resident#1 would not be considered an elopement because Resident#1 signed out before he left the facility. The Admin stated the Representative adds a new sheet to the sign out sheet when the page was full and he kept the completed sign in/out sheets in his office in a separate binder. Admin stated Resident#1 signed out on his own and would sign himself back in. In an interview on 08/20/25 at 10:45 am Resident#1 stated he did not want to talk about why he left the facility, where he went, who he was with and about his hospital stay. Resident#1 stated he was ok and did not have any concerns. Resident#1 stated that he signs himself in and out when he left the facility. In an interview on 08/20/25 at 11:00 am the Front desk Representative stated she was told to encourage the residents to sign in/ sign out but do not complete the sign out sheet for them. Front desk Representative stated Resident#1 was one of the residents did not sign out every time he left and would get upset when staff asked him to sign out. In an interview on 08/20/25 at 11:45 am the admission Director stated Resident#1 called her on 08/02 cussing her out and saying he saw her having sex with another man and that she stole his money. The admission Director stated she knew he had to be on an unknown substance because he was not acting that way the day before. The admission Director stated Resident#1 was found down [name of street] Street and transported to the hospital. In an interview on 08/21/25 at 4:30 am over the phone with LVN A who stated Resident#1 was already gone when he arrived at the facility at 10pm. LVN A stated he was told that Resident#1 had signed out and went to [NAME] and the box. LVN A did not recall who told him about Resident# 1 leaving. In an interview on 08/21/25 at 12:30 pm with the Marketer stated he started calling around to the local hospitals for Resident#1 after he was gone for 24 hours. The marketer stated he was not able to find Resident#1. The Marketer stated a discharge planner informed him that Resident#1 was in the hospital. The Marketer stated the discharge planner stated Resident #1 was denied admission to other facilities. The Marketer stated the facility did not want to get in trouble for dumping Resident#1 and he returned to the facility on [DATE]. In an interview on 08/21/25 at 1:50 pm LVN G stated she was Resident#1 day nurse, and the resident leaves the facility throughout the day. Resident#1 knows that he needs to sign in and out in the front before he leaves. In an interview on 08/21/25 at 2:20 pm LVN H stated she was Resident#1's night nurse and he left the facility often out on pass and returns the same day. LVN H stated he goes out by the tree with the other residents for 30 minutes or so and returned. In an interview on 08/22/25 at 8:00am with Resident#1 emergency contact stated she was notified on Monday 08/04/25 that Resident#1 had signed himself out and was in the hospital. Resident#1 emergency contact stated he was not able to stay with her and the facility had asked her about Resident#1 being discharged to her home and she said no. Resident#1 emergency contact stated she could not remember who called her. On 08/21/25 at 4:45PM the IJ was called. The template was provided to the Admin and DON, POR was approved on 08/22/25. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: ____8/22/2025__________) The Administrator and DON were in-serviced at 6:45pm on 8/22/25 by the Corporate Consulting Nurse on residents signing out and what to do if they do not return within the expected timeframe. The Administrator/DON provided education to staff on resident's signing out of facility on 8/21/2025. Resident # 1 returned to facility on 8/8/2025. Nurse assessed head to toe. Medical director and family notified of resident return on 8/8/25 Census checks to be completed on 8/21/2025 by DON/designee The Care Plan Coordinator/designee ensured all residents who sign out of facility have their care plan updated to reflect the education provided on returning to the facility, the dangers of using illegal substances, and providing an estimated return time. The DON/designee checked for any residents that have signed out at the current time to determine if any have been out on pass for over 24 hours, no other residents were identified as being out of the facility without the staff aware. 1. The facility took the following actions to prevent an adverse outcome from reoccurring.(Completion Date: 8/22/2025) The charge nurses will conduct census checks twice a shift for two weeks and then they system will be re-evaluated. A resident council meeting was held on 8/22/25 to discuss drug usage, signing in and out of facility. Each resident was notified they will be provided to give an anticipated return time. The residents will be notified that if they do not return within the anticipated return timeframe the police will be notified, and the facility will start an investigation of their whereabouts. The DON or designee educated all staff that any resident that does not return within 2 hours of time frame we will notify MD and family and start to look for residents, The Corporate Nurse/Consultant Nurse In-serviced the administrator/don on the updated policy for residents signing out on 8/21/2025. All new staff and agency staff will be in-serviced upon hire or before working the shift. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Record review of the facility's policy titled Wandering and Elopements revised 03/2019 reflected: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure:b. If the resident was not authorized to leave, initiate a search of the building(s) and premises.c. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the attending physician, law enforcement officials.4. When the resident returns to the facility, the Director of Nursing services or charge Nurse shall:A. Examine the resident for injuries.E. Complete and file an incident reportF. Document relevant information in the resident's medical records. Record review of the facility policy titled signing Residents out revised 08/2006 reflected: Policy statement: All residents leaving the premises must be signed out.1. Each resident leaving the premises (excluding transfers/discharges) must be signed out 9. Resident must be signed in upon return to the facility. Record review of sign in and sign out sheet provided by the admin after the IJ was identified reflected, different handwriting, printed signature, missing dates, times and no destination information. Review of the sign out and in sheet reflected, Resident#1 signed out at 9:45pm on 08/01/25 and showed Resident#1 signed back in on 08/08/25 at 3:55 pm. Review of dates from 07/24 to 08/01/25 reflected Resident#1 did not stay gone more then then 3 hours at a time on the slots that were filled out. Review of sign out sheet reflected cted the sheet was not completely full. In an interview on 08/22/25 at 2:53 pm with the corporate consulting nurse at 11:00 am she was able to verbalize everything that the facility had implemented. In an interview on 08/22/25 between 1:00 pm to 3:30 pm, the ADON, DON, Admin, LVN B, CNA C, CNA D, CNA E, CNA F, LVN G, LVN H, LVN I, RN J, Front desk representative, over the phone interviews RN A, stated they had been in-serviced on when a resident refused to sign out let the charge nurse know, and residents need to document the approximate time they plan on being back. If a resident stays out longer than 2 hours of the approximate time they will be back the facility will start calling around for the resident and then report to the police. If a resident returns to the facility and they appear to be under a substance the police will be called. The facility will complete census check twice a shift to ensure residents are accounted for. In an interview on 08/22/25 at 3:30 pm the DON and Admin verbalized everything the facility had implemented. Record review of Resident#1 revised, care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe,Attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass. The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. During an observation on 08/22/25 at 3:45pm, residents were gathered for a special resident council meeting. The DON talking to residents about signing in and out of the facility log. The DON stated residents must put an approximate time they will return to the facility and if they did not return in 2 hours, the facility would start a search for them. Record review of revised sign in/out sheet reflected, a return time was added to the sign out section and the destination/phone number information was deleted. An IJ was identified on 08/21/15. The IT template was provided to the facility on [DATE] at 4:45 pm. While the IT was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Threat and a severity level of isolated because all staff had not been trained on 08/22/25.

Based on interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in this facility (one of one) reviewed for water management. The facility failed to implement a water management program/plan including: 1.) An assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; and2.) to implement measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. This failure could place all residents at risk of water borne illness.Findings included: In an interview on 7/31/25 at 12:00 pm, RN C stated that the facility had a legionella policy and plan, but that there was no documentation of the implementation of the water management program. She stated a water management binder had been started but that the plan was never designed or implemented . She stated she had spoken with the maintenance director today (7/31/25) and he had reported to her that he had done some water monitoring activities such as temperature checks, but that he did not have any documentation. In an interview on 7/31/25 at 1:12 pm, the Operations Manager reported that he was not aware of any water management plan at the facility. Regarding the responsibility for the water management plan he stated, I thought it was an administration thing. I know they just started it a couple of years ago. I've never been asked about this before. Regarding the assessment of the facility to identify areas of potential concern for Legionella he stated, You want to make sure the showers are clean and standing water areas. He denied any knowledge or involvement or documentation of a water management plan or control measures at this facility. He reported the risk of Legionella is, it is a very dangerous flesh-eating bacteria. In an interview on 8/01/25 at 9:10 am, the DON stated she was not aware that there was not a water management plan at the facility but that she was aware that monthly water temperatures are checked by maintenance. She reported the risk of not having a water management plan would be the risk of Legionnaires disease. She reported she had assumed that the plan would be implemented by maintenance and any issues would be reported to the Administrator. The DON stated no residents had been identified with Legionella's disease at the facility. In an interview on 7/31/25 at 1:05 pm, the ADM stated when he was previously the administrator at this facility in 2023, they had just begun initiating a water management plan. He stated that he had not followed up on this since he was rehired to the facility in January 2025, and he was not sure if the plan had ever been implemented. He reported the maintenance director was responsible for this. He stated the risk to residents of not having a water management plan it could risk a lot of people getting sick of waterborne illness. He denied any residents had been identified with Legionella's disease. The facility water management binder was reviewed and contained only the Health and Human Services publication titled, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated June 24, 2021. There was no facility assessment, developed plan, or implementation of prevention measures present. The facility policy titled, Legionella Surveillance and Detection dated 2001 and revised July 2017 stated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaire's disease will be included as part of our infection surveillance activities.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure the stand-by refrigerator were dated and labeled.The facility failed to ensure the refrigerator food items were dated, labeled and securely stored.The facility failed to ensure the dry storage food items were dated and labeled.The facility failed to ensure that the steam tray table was cleaned daily.The facility failed to ensure that canned good food items were free of dents.The facility failed to ensure that dishwashing protocol was followed.The facility failed to ensure pureed food temperatures were logged.The facility failed to ensure dietary staff had an adequate amount of safe and functional essential kitchen equipment, including cutting boards, stock pots, and metal sheet pans. These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included: Observation on 07/29/2025 beginning at 8:43AM of 1 of 2 refrigerators revealed:- A metal pan of a pasta dish, covered with saran wrap, with no label or use by date.- Hamburger patties wrapped in foil, and labeled, in a metal pan of gravy. The wrapped hamburger patties were separated from the gravy by a layer of saran wrap that was not sealing the gravy.- A metal pan of food with no date or label of the food item.- An unsealed bag of fully cooked pork sausage patties, in the manufacturer's box dated 7-25-25, with no use by date.- An unsealed bag of fully cooked chicken breast chunks, in the manufacturers box dated 7-25-25, with no use by date. Observation on 07/29/2025 at 8:49AM of 2 of 2 refrigerators revealed:- 4 deli sandwiches in a large Ziploc bag, with no label or use by date.- A Styrofoam plate with a deli sandwich and potato chips, covered with saran wrap, and with no label or use by date.At that time, an interview with the dietary assistant revealed the pasta dish was turkey tetrazzini and made the day before, and the metal pan of food with no date or label was chicken sausage gumbo made a few days before. The dietary assistant stated that the procedure for dating items was to label the boxes when delivered to the facility. She explained the boxes of fully cooked pork sausage patties and fully cooked chicken breast chunks had been delivered on 07/26/2025 and the date was written incorrectly but would be corrected to match the date of the delivery. She further stated the importance of labeling and dating was to not give resident's something that the kitchen had for over extended (period of) time and the risk of not properly sealing food items can cause bacteria to get in it and it's harmful to residents. The dietary assistant stated that refrigerated foods items were kept 7 days after opening. When asked why there were multiple boxes of fully cooked pork sausage patties in the refrigerator and not kept in the freezer, she explained the residents liked the pork sausage patties and they would be eaten before they were no longer appropriate for the residents to consume. Observation on 07/29/2025 at 8:52AM of the standby refrigerator revealed- An open carton of Med Plus 2.0, with no use by date. Observation on 07/29/2025 at 8:58AM of the 3-compartment sink revealed large metal pans in the 1st compartment, a serving spoon in the 2nd compartment, and a large stockpot and metal pan lids in the 3rd compartment, and a drying rack with various kitchen utensils and metal pan lids next to the 3rd compartment. No water, soap, or sanitizing solutions were in the sink. There were no sanitizing solution test strips by the sink. An interview on 07/29/2025 at that time with the dietary assistant revealed that degreaser and a bottle of soap are used on the dishes to wash them. When this surveyor asked where the sanitizer solution test strip and log were kept, the dietary assistant showed test strips by the automatic dishwashing machine and no test strip log was provided. This surveyor asked the dietary assistant what the test strip should read when the sanitizing solution was tested, she stated 32, this surveyor asked what color the test strip should read, she stated purple, light purple. The dietary assistant did not know what sanitizer was used for the 3-compartment sink. This surveyor asked the dietary assistant the importance of testing the sanitizing solution, she stated too much, or too little sanitizer can result in residents getting sick. Observation on 07/29/2025 at 9:07AM of the steam tray table revealed a brown like substance built up on the heating elements, food particles including rice in the water used to steam foods. Interview on 07/29/2025 at that time with the dietary assistant revealed that steam tray table was supposed to be cleaned daily by dietary staff, and the rice seen in the water was from the lunch meal served the day before. An observation on 07/29/2025 at 9:08AM revealed 4 large cooking sheet pans with carbonized grease (black substance that forms on cookware when oils, fats, and food particles are repeatedly exposed to high heat) build-up.At that time, an interview with the dietary assistant and the diet aide revealed that they would not want to eat foods that are cooked on sheet pans with carbonized grease build up. The dietary assistant stated that the kitchen needs new sheet pans. Observation on 07/29/2025 at 9:19AM of the dry storage closet revealed - A dented caned good of diced pears dated 7/18- 2 dented cans of tomato soup dated 7/15/25- A dented can diced tropical fruit salad dated 7/18 - A saran wrapped package of dry pasta noodles, with no date or label. An interview on 07/29/2025 at that time with the dietary assistant revealed dented canned good items were a risk because they can have hole that compromises the seal. She said there is a separate spot for dented cans and they can be returned to the food vendor. An observation on 07/30/2025 11:38AM revealed the kitchen's one cutting board had deep scratching and scoring; the cutting board was had gray discoloration on the outer edges and was light yellow/white in the middle. During an observation on 07/30/2025 at 11:45AM, this surveyor intervened when the diet aide began to pour hot steaming water onto frozen plastic juice cups. An interview at that time revealed the diet aide stated that she knew cool running water should be used when thawing frozen food items, but due to the short time frame before serving the juice cups at lunch, she was going to use hot water to melt the frozen juice. Record reviews on 07/30/2025 at 11:47AM of the Daily Food Temperature Log dated July 29, 2025 and July 30, 2025, reflected temperature recorded for food items on the regular menu. No record of temperature checks for pureed food items. An observation on 07/30/2025 at 11:50AM of the facility's kitchen revealed a large cooking stock pot with tan and brown build-up on the inner sides of the pot.At that time, an interview with [NAME] F revealed she only used the large stock pot for cooking scrambled eggs; she explained liquid eggs come in a bag that can be put into water for cooking and the eggs were not exposed to the pot. She further stated the pot had been in it's condition since she began working at the facility 3 months ago. [NAME] F further stated there was only one cutting board in the kitchen. She stated she had worked in other kitchens that had different coloring cutting boards for different food items. An interview on 07/30/2025 at 1:53PM with the dietary assistant revealed the kitchen only had one cutting board. When asked the importance of having appropriate kitchen equipment, she stated for the health and safety of staff and residents, maintain proper food policy, and prevent food contamination. An interview on 07/31/2025 at 1:53PM with [NAME] F revealed that she utilizes the 3-compartment sink to pre-wash cookware she used but will then wash all cookware in the automatic dishware. She does not know if the 3-compartment sink was being used to wash dishes thoroughly; she explained incorrect water temperatures and sanitizer solutions results in unclean dishes and can lead to residents getting sick. She explained she temperature checks all food items before serving to residents but does not keep record of temperatures for pureed food items because she did not have a temperature log sheet to record the pureed foods temperatures on. She only had a temperature log sheet for regular food items. When asked what can be done until she had a separate temperature log sheet for pureed foods, she stated she could create a separate row on the regular food temperature log for the pureed foods and showed the surveyor a separate row for the pureed foods temperatures. An observation on 07/31/2025 at 1:57PM of 1 of 2 refrigerators revealed:- Boxes of fully cooked pork sausage, dated 7-25-25 were still in the refrigerator, and the dates had not been updated to reflect the delivery date of 7-26-25- A box of frozen ground beef tubes on top of a box of frozen chickenAn interview at that time with the dietary assistant revealed that updating the delivery dates was being worked on. When asked what can be done to make sure food items were being dated correctly, she stated she constantly had to tell the dietary staff to make sure they date and label all food items. When asked why the frozen ground beef stacked on top of the frozen chicken was an issue, she stated the ground beef could leak onto the chicken while thawing. She proceeded to place the box of frozen ground beef tubes into a large pan to prevent dripping. On 07/31/2025 at 2:45PM, this surveyor intervened and asked the dietary assistant to discard all the boxes of fully cooked pork sausage patties, dated 7-25-25. The dietary assistant proceeded to discard all the boxes. When asked why it had to be thrown away, she stated it was because the food was out of the timeframe of what would be safe to eat. She further stated the timeframe (food can be kept after opening) was 3-5 days. An interview on 08/01/2025 at 9:19AM with the facility's registered dietitian revealed she somewhat works with the dietary staff and checks the kitchen every time she's at the facility and notified the food service manager of any issues. She explained the food service managers over the kitchen but had been out of the facility recently. The registered dietitian had done in-services with the dietary staff in the past, but the food service manager would do in-services and sometimes they would do them together. When asked if dietary staff used the 3-compartment sink, she said staff used it for pot washing and other dishware was washed using the automatic dishwasher. The registered dietitian she stated the kitchen should have 2 cutting boards for vegetables and 2 cutting boards for meats, and 1 cutting board was a problem because of cross contamination of food items. When asked the expectations of dating and labeling food items, the registered dietitian stated it depends on the food item. For items in boxes, staff were encouraged to leave items like dry pasta in the manufacturer boxes and to date them when they were delivered. Once food items were opened, staff should take the food item out of the box and write an opened on date. She further stated food items only stay in the refrigerator for 3 days after opening. This surveyor asked why the dietary assistant had to throw away the fully cooked sausage patties on 07/31/2025, she explained keeping the patties in the refrigerator past the 3 days could result in bacteria growth and make resident extremely ill if they consumed the patties. The registered dietitian discussed dented canned good items can lead to a broken seal, and further lead to botulism (illness caused by toxin produced by the bacteria Clostridium botulinum, which grows when exposed to oxygen). An interview on 08/01/2025 at 10:55AM with the food service manager revealed dietary staff had been using the 3-compartment sink but then began to pre-wash dishes in the sink and fully wash all dishes in the automatic dishwasher. The food service manager thinks this was done because dietary staff do not think dishes were sanitized in the 3-compartmen sink. The food service manager plans to start having dietary staff use the 3-comaprtment sink for pot washing. She further discussed she had planned to order new sheet pans and cutting boards prior to being out of the facility. The food service manager stated she expected staff to temperatures for regular and pureed food items. She expected staff to date and label all boxed food items, for items to be in first in and first out order. She said prior to being out of the facility, she checked the refrigerator every morning to see how long food items had been in the refrigerator. She explained if food items were not dated or labeled, they were not considered good (safe for consumption). She expected staff to seal all opened food items and explained rolling up (a bag) was not enough to seal food items. The food server manger discussed how long food items can stay in the refrigerator depends on the food item; left over food items can be kept in the refrigerator for 24-48 hours. She stated keeping the fully cooked sausage patties longer than 3 days can make residents sick if they were consumed. She stated dented canned food items were expected to be taken off shelves because they can cause residents to get sick. The food service manager stated she always expected frozen meats to be placed in a pan when thawing in a refrigerator, and she expected the steam tray table to be cleaned daily. The food service manager stated she had done in-services with her staff in the past but needs to do more. Record review of a letter of a kitchen equipment order, dated Jul-29-2025, reflected 5 full size sheet pans ordered. The order stated the items would arrive no later than 8-7-25. Record review of the facility's Food Receiving and Storage policy, revised October 2017, reflected: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation.2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted.8. All foods stored in the refrigerator or freezer will be covered, label and dated ( use by date).13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. Record review of the facility's Sanitation policy, revised October 2008, reflected: Policy Statement The food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and Implementation.1. All kitchens, kitchen areas and dining areas shall be kept clean.2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning.3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing. 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the U.S. FDA Food Code 2022 reflected: 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated .3-501.13 Thawing. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed. (B) Completely submerged under running water: (1) At a water temperature of 21 C (70 F) or below.3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above. (2) At 5 C (41 F) or less .3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .4-501.12 Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced.4-501.19 Manual Warewashing Equipment, Wash Solution Temperature - The temperature of the wash solution in manual WAREWASHING EQUIPMENT shall be maintained at not less than 43 C (110 F) or the temperature specified on the cleaning agent manufacturer's label instructions.4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness .A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and pH of the solution as listed in the following chart.(B) An iodine solution shall have a: (1) Minimum temperature of 20 C (68 F), (2) pH of 5.0 or less or a pH no higher than the level for which the manufacturer specifies the solution is effective, and (3) Concentration between 12.5 MG/L and 25 MG/L; (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24 F C (75 F), P (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. Record review of the U.S Department of Agriculture's publication Leftovers and Food Safety, last updated July 31, 2020, reflected: Store Leftovers Safely - Leftovers can be kept in the refrigerator for 3 to 4 days.

Based on interview and record review, the facility failed to ensure the facility's only registered dietitian carried out the functions of food and nutrition services dietitian, according to the facility's Consultant Dietitian: Retainer Agreement. The facility failed to ensure that the registered dietitian worked a minimum of 16 hours a month and/or adjusted hours based on the facility's census. This failure could result in residents not maintaining or achieving optimal nutrition status. Findings included: An interview on 08/01/2025 at 9:19AM with the registered dietitian revealed that she had been working at the facility for 22 years and worked 12 hours a month. She explained it always had been 12 hours a month; if the census was around 60 residents, she would be expected to work at least 8 hours, if the census is 61-90 residents, she'd work 12 hours. She further stated she usually does more than 12 hours a month. Record review of the Consultant Dietitian: Retainer Agreement, dated 1/1/2026 reflected: This agreement is being entered on the 1ST day of [DATE]. Consultant ResponsibilitiesCoordinate the overall functions of the facility's consultant services in that the dietitian shall: .10. Provide a minimum of 16 hours in the facility, based on census.(Approx. 8 hours (+/- based on resident acuity) for every 30 patients) .Financial Arrangements1. The consultant agrees that he/she shall devote a sufficient number of hours based upon the census of the facility, to carry out the responsibilities outlined in this agreement.The agreement was signed by the owner of the consultant group and the facility administrator on 1/1/2016. Record review of the facility's census on 08/01/2025 was 75 residents, with a licensed capacity for 98 residents. An interview on 08/01/2025 at 10:47AM with the ADM, he had thought the agreement was for the registered dietitian to work a minimum of 12 hours a month. He said the contract between the facility and the consultant group the registered dietitian worked for was signed by the consultant group owner.

Based on observation, interview, and record review, the facility failed to maintain safe and functional essential kitchen equipment in the facility's only kitchen. The facility failed to ensure the gas stove top oven had all turn knobs, did not leak grease, and was safe to touch when operating.The facility failed to assure the wall plug sockets were free of food and grease particles, and in safe operating condition. The facility failed to ensure the toaster oven was in safe operating condition. These failures could place residents at a risk for facility essential equipment not being maintained in working order. Findings included: An observation on 07/29/2025 at 8:52AM of the gas stove top oven revealed a small pile of white cloth towels with grease on them under the left front corner of the oven.An observation on 07/30/2025 beginning at 11:50AM of the facility's kitchen revealed:- A toaster over with electrical tape around its power cord- 2 wall sockets with black burn-like appearance- 2 wall sockets covered with food particles and grease- Food particles and grease build up on the wall behind the 3-compartment sink - Power strip on the counter next to the 3-compartment sink, covered with food particles and grease- [NAME] grease like stains lining the top of the left oven door on the gas stove top oven.- 2 turn knobs missing from the stove topAt that time, an interview with [NAME] F revealed the toaster oven had electrical tape on the power cord since she began working at the facility 3 months ago. [NAME] F further discussed issues with the kitchen's stove top oven. She stated the oven had a problem with dripping grease and it had been like this since she began working at the facility. [NAME] F said the kitchen staff drain the grease from the grease tray after using the grill top on the stove, but it continued to leak. The towels were placed under the oven to catch the grease drips. She stated the turn knobs were hot to the touch and turn knob to turn on the oven does not have labeling to indicate the temperature the ovens turned onto. This surveyor touched the oven's turn knobs and was able to confirm the cook's concern of the hot turn knobs on the oven. During an interview on 07/30/2025 at 1:53PM with the dietary assistant she stated the kitchen staff had tried to have maintenance work on the oven due to the leaking grease and hot turn knobs. An interview on 07/31/2025 at 1:20PM with the maintenance director revealed that he had been planning to paint and repair imperfections in the kitchen. He further discussed that the gas stove top oven must be worked on by the vendor, and that it had been recalibrated earlier in the year. During an interview on 8/01/2025 at 9:19AM with facility's registered dietitian, she stated kitchen equipment like the steam tray table had to be fixed. The registered dietitian stated condition of the kitchen equipment matters because its good practice to have not well used equipment that's going to be serviceable. She further discussed that when the food service manager was at the facility, the kitchens operating, but it had been a challenge since the food service manager had been out. She explained the kitchen was old and the problems were ongoing. During an interview on 08/01/2025 at 10:55AM with the food service manager, she stated after discussing the oven issues with the maintenance manager, the vendor came and recalibrated the oven. She further discussed that she needed to order new turn knob, but she did not know why grease leaked from the oven. The food service manager stated she was not sure why electrical tape was on the toaster oven power cord because the toaster oven was purchased about a year ago. Record review of the U.S. FDA Food Code 2022 reflected: 4-1 Materials for Construction and Repair.4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.4-2 Design and Construction 4-201 Durability and Strength 4-201.11 Equipment and Utensils. EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. 4-201.12 Food Temperature Measuring Devices. FOOD TEMPERATURE MEASURING DEVICES may not have sensors or stems constructed of glass, except that thermometers with glass sensors or stems that are encased in a shatterproof coating such as candy thermometers may be used.4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of the three hallways reviewed for pest control and the facility's only kitchen. The facility failed to ensure Resident #36 and Resident #28's room was free of flies on 7/29/25 and 7/30/25.The facility failed to ensure Resident #56 and Resident #28's room was free of flies on 7/30/25. This failure could lead to pest infestation and place residents at risk of insect transmitted diseases.Findings included: Review of Resident #36's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #28s face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #56's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #29's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #36's Quarterly MDS dated [DATE] reflected a BIMs score was not done as resident was rarely/never understood. Review of Resident #28's Quarterly MDS dated [DATE] reflected a BIMs score of 4 indicating severely impaired cognition. Review of Resident #56's Quarterly MDS dated [DATE] reflected a BIMs score of 10 indicating moderately impaired cognition. Review of Resident #29's Annual MDS dated [DATE] reflected a BIMs score of 3 indicating severely impaired cognition. In an observation and interview on 7/29/2025 at 11:00 a.m., Resident #36 was observed asleep in his bed in his room. Two flies were observed on the resident's window. A third fly was observed on the resident's upper lip walking towards his nostril. Resident eventually aroused and waved the fly away. Resident # 36 was not interviewable. In an observation and interview on 7/29/25 at 11:00 a.m., Resident #29, the roommate of Resident #36, was observed laying in his bed. There were three flies observed in his bedroom, including two on the window and one on his roommate. Resident # 29 reported that flies had been in his room for months and that, they bother me. In an observation on 7/30/25 at 2:35 two flies were observed landing on the bedspread covering Resident #36 in his room. In an observation and interview on 7/31/25 at 8:30 a.m., Resident #56 was sitting at his bedside, and a fly was observed landing on his bedside table next to the coffee cup he had been drinking from. Resident #56 stated that there had been some flies in his room for about a week. He stated he had not discussed the flies with staff and was not aware if anything was being done about them. He stated the flies make him feel, bad. In an observation and interview on 7/31/25 at 8:35 a.m., Resident #28 was noted sitting on the side of his bed and a fly was sitting on the top of his bald head. Resident #28 stated flies have been a problem in his room, forever and they are, always bothering me. He stated he eats in his room and the flies are, always getting in your food and pestering you. He stated he had not notified staff of the flies indicating they were obvious. He reported the flies made him feel, not good. In an interview on 07/30/25 at 4:30 p.m., LVN A reported that she had worked at the facility for one year and four months, and that the facility had a problem with flies, since summer began this year (2025). She stated that flies were, everywhere. She reported that, the flies are terrible in the dining room at dinner time. She stated that the facility had placed electronic fly traps in the hallway but that it had not been helpful. She stated that she was aware that maintenance had been notified of the fly problem, and they were responsible for contacting pest control. She denied having received any complaints from residents about the flies. She stated that she would have expected residents to have been, aggravated and annoyed by the flies and that the flies were a risk to residents related to, germs. In an interview on 07/31/25 at 9:50, CNA B stated she had seen flies in residents' rooms, sometimes. She stated she had noted that the facility had pest control out in the past (dates unknown). She reported that when staff noted insects, they were to report it to maintenance or tell the nurses. She stated she had previously told a nurse about flies in a resident's room, months before but not lately. In an interview on 7/31/25 at 1:05 pm, the ADM stated that flies at the facility were a problem that had occurred in the last week or less. He reported that, We need to get the pest control company back out here. He stated that the facility had installed some electronic fly traps. He reported there was a pest control log at the nurse's station for staff to report any pest sightings. He stated he believed the pest control program was working, he didn't get a lot of complaints, and it was an old building. He reported that pest control was scheduled and came every month and that he notified them as needed in addition to the scheduled visits. He reported that the last time he requested an additional visit was for bed bugs several months ago. He reported he had not had any complaints related to the flies from residents or staff. He reported that if flies were on residents' food or faces that, that is not good but did not identify a specific risk. In an interview on 8/01/25 at 9:10 am, the DON stated that a pest control company came to the facility perhaps twice a month, and the facility had a pest log, and in addition they let maintenance know when there was an excessive problem. She stated that the current pest control program worked but that the flies were very bad everywhere right now and the pest control company must continue to come out. She stated the risk to residents would be spreading infections that flies carry. She stated that the maintenance director was responsible for pest control and that this was monitored by the ADM.In an interview on 7/31/25 at 1:12 pm, the Operations Manager (maintenance director) stated that the pest control company came to the facility every month but that it is summertime, and he can't control the arrival of the flies. He reported they do have the zappers out for flies but that the frequencies of the doors being opened contributed to flies getting in. In a review of the facility pest control log from April 2025 through June 2025, invoices reflected a pest control company provided pest treatment at the facility on 4/08/25, 5/10/25, 5/29/25, and 6/06/25. The invoices dated 4/08/25 and 6/06/25 noted a target pest of flies. The facility policy titled, Pest Control dated 2001 and revised May 2008 was reviewed and stated, Our facility shall maintain an effective pest control program and This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to develop, prepare, and periodically update menu items to meet residents needs and preferences. The facility failed to utilize and follow dietitian approved recipes for pureed food items.The facility failed to prepare an alternate menu in advance. The facility failed to ensure alternate menus were reviewed and approved to ensure it met the residents nutritional needs by the facility's dietitian.The facility failed to make reasonable efforts to develop a menu based on resident complaints about the lack of variety in food options. These failures could result in an adverse effect to resident's physical and psychosocial well-being.Findings included: During an observation on 07/29/2025 at 9:30AM, this surveyor asked the dietary assistant for a regular and alternate menu for the next 3 days. The dietary assistant was able to provide a regular menu of the meal being served that day, but not an alternate menu. She explained the alternate menu item was chosen the day of and there was not an official alternate menu. An interview on 07/29/25 at 11:58 AM with Resident #41 revealed he thought the food sucked. He said they had chicken 4-5 times a week, and it was overkill on the chicken. He said he had things listed on his slip that he could not eat, and they continually brought them to him. He said sandwiches were always their go-to alternative; if you were allergic, or did not like the main meal, you were stuck with a sandwich. He said the sandwiches were not good, either. He said their grilled cheese sandwich was so dry it was hard. He said when the residents made suggestions, the dietary staff would tell them there were set guidelines about what they could serve and they could not change it. He said they served terrible chicken patties often, and one time they had a different kind that was really good, and they never saw it again after the single time they served it. An observation on 07/30/2025 at 12:27PM revealed [NAME] F preparing pureed shrimp. [NAME] F added bread slices as thickener. [NAME] F asked the dietary assistant to get hot water to add into the pureed shrimp. At that time, this surveyor intervened before hot water was added in as the liquid ingredient. [NAME] F revealed that she was told to use bread slices as thickener and water for the liquid consistency. She stated she had seen broth and food thickener used in other kitchens outside of the facility, but that she had been doing what she was told to, and that the facility did not have food thickener or broth. When asked what the recipe instructs, the cook discussed that she used her knowledge when determining pureed food consistency. [NAME] F proceeded to pour the pureed shrimp onto pre-divided plates. When asked why she didn't use a scoop, she stated doesn't use a scoop to fill a portion of the plate. She said she was told to fill a portion of the plate with the pureed food. At that time, the dietary assistant asked if milk was acceptable to use in place of the water. This surveyor responded by asking what the recipe for pureed shrimp instructed, the dietary assistant looked for the pureed shrimp recipe in the kitchen's recipe book and was not able to provide one. The dietary assistant and [NAME] F decided to use the liquid the cooked shrimp were in. An interview on 07/29/25 at 12:57 PM with Resident #11 revealed he was unhappy with the food in the facility. He said he had not eaten pork since he was very small (young), but the facility kept serving him pork. He said some days the lunch meal, and the dinner meal would be pork, and if the alternate was also something he did not eat, they would give him a sandwich. He said he had lost weight in the facility because the food was so bad. He said pork was listed on his meal ticket as a dislike and they were not supposed to bring it to him, but they had it on the menu all the time, and they brought it to him a lot. He said he knew of a few other residents who did not eat pork in the facility, and they also continued to be served pork. He said they also just made-up names for things that did not describe what the food was. He said they served something they called turkey tetrazzini, but it was just a pasta dish with hot dogs cut up in it, and it was disgusting. An interview on 07/31/2025 at 12:42PM with Resident #80 revealed that she had resided at the facility for a few years and had issues with meal variety. Resident #80 stated that she sometimes received food items that she does not want. She explained that CNAs inform her of the alternative menu item of the day about an hour before the meal being served, and residents could only choose the regular or alternative menu item for each meal. She stated she wished she knew of the alternative options sooner than an hour before the meal was served. She further discussed sometimes they (the kitchen) don't have enough of what residents want, the menus need more variety, and the menus were too repetitive. When asked what alternative options were, she stated it may be a sandwich and chips or soup, it maybe last nights dinner as next day alternative meal item. As an example, the resident stated Salisbury steak will be given for lunch as the regular menu item and then as the alternate menu option the same day. Resident #80 said there was a lot of repetition of same old food items. She explained the turkey tetrazzini was on the regular menu item and had been used over the previous years and it was an item she did not enjoy. Resident #80 stated she had expressed these issues with the food service manager, but had been told someone else makes the menu, not the dietary staff. She stated the food service manager does not follow up with the resident regarding her concerns. During an interview on 8/01/2025 at 9:19AM with facility's registered dietitian, she explained that cycle menus (menu changes every day but eventually repeats itself in the same order) were utilized at the facility and she signs off on recipes and menus that come from a food vendor. If there was an issue, a substitution would be made to the menu, and she would approve of it. She further discussed the alternate menu option was chosen the day of, and that had always been done the day of. She stated that an official alternate menu would be beneficial for the dietary staff. The registered dietitian stated she did not sign off on the alternate menu items. She stated anything on the regular menu was okay, the alternates typically a balanced meal. When asked if a deli sandwich with chips was a balanced alternate meal, she stated residents should get a salad or vegetable and would offer fruit with it. When asked if the regular menu item for lunch was acceptable for the dinner's alternate menu item, she stated that the dietary staff try to do different meats for regular and alternate menus. The registered dietitian explained the dietary staff had pureed recipes from the vendor. She further discussed bread was being used as thickener and milk was typically used as the liquid for the pureed foods, to add calories. She expected staff to not pour pureed foods onto plates and use scoops to have correct portion size. During an interview with the food service manager on 08/01/2025 at 10:55AM, she stated that alternate menus were not planned ahead of time. Dietary staff plan the alternate menu the day of, and sandwiches or leftovers were the alternate most of the time. She further explained leftovers would be the alternate for the next day or next evening depending on what the kitchen had in stock. The food service manager stated she normally did not serve the same meats for the regular and alternate menu items, if pork was on the regular menu, she would try to serve beef or chicken as the alternate option. She said she had told her staff to do that during in-services. The food service manager stated residents occasionally complained of meals being repetitive and if residents continue to complain about a specific meal, they dietary staff try to address the complaints by doing an alternate for that meal. The food service manager stated the alternate menu was something she needed to work on. She explained that in the past, she had hot dogs and burgers as an alternate all the time, but the residents were wanting the alternate instead of the regular menu item. The food service manager did not find it to be a concern that the residents preferred the hot dogs and hamburgers over the regular menu items. The food service manager said she expected staff to use scoops when serving food items and did not know why a scoop was not used for pureed food items. She expected staff to utilize recipes that had been signed off by the dietitian and can be found in the recipe book in the kitchen. She stated there were recipes for pureed foods. The food service manager stated she would put milk in pureed food instead of hot water, and broth could be an option. She stated that using recipes make the cooking process easier. Record review of the facility's regular menu Sysco Acadiana 2025 Spring Summer Menus revealed the menus were approved by the facility's registered dietitian. The menus were shown to have a start date of April 6 and end date of October 25 (29 weeks), and to be cycled every 4 weeks. Week 1's menu was shown to be repetitively used for 8 weeks, Week 2's, 3's, and 4's menu were shown to be repetitively used for 7 weeks each. The breakfast menu item for every day of every week reflected: Egg Choice, Juice, Cereal of Choice, Breakfast Meat of Choice, Breakfast Bread, Coffee, Milk/Water. Record review of the facility's Menus policy revised October 2017 reflected: Policy - Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.Policy and Interpretation and Implementation1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences).2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance.3. Menu items and available snacks reflect the religious, cultural and ethnic preferences of the residents, whenever reasonable.4. The Dietitian reviews and approves all menus.5. Input from the resident is considered in menu planning.8. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal.9. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified non-dairy alternatives). 10. Menus are updated periodically.

Based on observations, interviews, and record reviews, the facility failed to provide a clean, safe, and functional environment for 6 of 10 rooms (Rooms 1, 2, 3, 4, 6, and 8) reviewed for environment. 1. The facility failed to repair the window in room [ROOM NUMBER].2. The facility failed to have baseboards, holes in the wall, and tile repaired in shared resident restrooms. 3. The facility failed to have soap and paper towels available in resident shared restrooms.4. The facility failed to repair the window, and repair holes in the wall and baseboards in room [ROOM NUMBER]. These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life. Findings included: Observation on 07/29/2025 at 10:22 am, revealed dirt, grime and peeling paint on the windowsill in room [ROOM NUMBER]. A disposable under pad was stuffed between a small gap between the window and window seal. Observation on 07/29/2025 at 10:33 am, revealed all baseboards loose in the restroom, 3 wall tiles were missing, and no paper or towels were available in the shared restroom for rooms [ROOM NUMBERS]. Observation on 07/29/2025 at 10:39 am, revealed all baseboards loose in restroom, a hole in the wall near the sink, cracked caulk around the sink, no soap dispenser and no soap or paper towels in the shared restroom for rooms [ROOM NUMBERS]. Observation on 07/29/2025 at 10:43 am, revealed a cracked window with a small piece of glass missing and peeling paint on the windowsill in room [ROOM NUMBER]. There were no baseboards on the wall near the window, exposing holes in the wall. The walls appeared dirty and stained. Observation on 07/29/2025 at 11:07 am, revealed no soap or paper towels available in the shared restroom for rooms [ROOM NUMBERS]. Interview on 07/29/2025 at 11:08 am, Housekeeper R stated she cleaned and stocked every room and will make a round after cleaning and before leaving to stock supplies before the next person comes in. She stated she was waiting on supplies to be delivered and was waiting on soap. She stated she was not out and had a jar that she was using to fill up soap in the restrooms. Housekeeper R stated if there was no soap or paper towels available it could spread germs and make residents sick. Interview on 07/31/2025 at 12:33 pm, the Administrator stated there was a maintenance book at each nurse's station and the Operations Manager checks them daily. He stated they did angel rounds every morning and each department head was assigned rooms where they look for environmental concerns. He stated if there were issues on floor or repairs were needed and not done, infections could spread and would not be homelike for residents. Interview on 07/31/2025 at 1:12 pm, the Operations Manager stated he was not aware windows in room [ROOM NUMBER] & 4 needed repair. He stated he knows the condition of the bathrooms and not making excuses . He stated if repairs were needed, staff were supposed to write it in the book. He stated a lot of times staff should report something, but they do not. He stated it was not homelike, but there was no risk to residents if rooms, windows and bathrooms were not repaired. Interview on 07/31/2025 at 2:27 pm, CNA D stated before providing care she washes her hands in the bathroom or uses hand sanitizer. She stated sometimes soap and paper towels were not available and she would have to ask. She stated sometimes she brings her own soap. CNA D said resident restrooms should have soap and paper towels so the residents could use it and for infection control. CNA D stated sometimes residents hoard supplies and that was part of the reason some people do not have them. She stated in other areas staff have access to have soap and paper towels. Interview on 08/01/2025 at 8:33 am, CNA E stated if repairs were needed for a resident room, she would write down the repair and time in the book at the nurse's station. She stated if repairs were needed and not done residents could get hurt. CNA E stated she did notice no soap or paper towels in resident restrooms, and it had been like that for months. She stated there were other bathrooms like the staff bathroom where she could wash her hands. She stated the risk to residents would be infection control if soap and paper towels were not available. Interview on 08/01/2025 at 9:17 am, LVN P stated there was a maintenance book at the nurse's station to write down repairs. He stated if repairs were not done the residents would not be comfortable or safe. LVN P stated not having soap or paper towels available would be infection risk and could be failing to provide proper care. Interview on 08/01/2025 at 10:12 am, the Housekeeping Manager stated if any repairs were needed in rooms, staff were supposed to put it in the maintenance book. She said there was no risk to residents if rooms were not repaired. She stated housekeeping was responsible to clean and fill soap and paper towels in resident rooms. She said she makes 3 rounds in the facility and staff or residents would tell her if they needed some and she would take care of it. She said there was soap and paper towels available for staff in everyone's office, the break room and multiple restrooms. She said there was no risk to residents not having soap and paper towels in their restrooms. Interview on 08/01/2025 at 1:37 pm, the DON stated her expectation for staff was they report to maintenance or housekeeping any repairs or cleaning that needed to be done. She said it was not homelike, the building was old, and they were working on repairs. She said the risk for not having soap or paper towels was infection, illness, feeling not clean and could be embarrassing. Record review of the facility policy titled, Resident Rights, Revised December 2016, revealed in part, the following: Employees shall treat all residents with kindness, respect and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.

Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to ensure Resident #1 was free from deprivation of services and goods abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and prevent him from sexually abusing others, which could lead to harm to himself and others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk for abuse or neglect that could lead to serious harm. Findings include: Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission. Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following: HPI: LTC on therapy Today: . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following: [SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt. Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following: [DON] was notified by [Activity Director] that [Resident #1] has 'inappropriately touched' a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware. Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following: [Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities. Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following: -Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services. In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation, report it to the state agency, or notify law enforcement. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. In an interview on 5/19/25 at 9:26 AM, the Activity Director stated students from the local high school would come to the facility twice a month to do activities with the residents. The Activity Director stated on 4/23/25, the students were at the facility doing an activity with the residents in the dining area. He stated a student came up to him visibly upset then pointed at Resident #1 and stated he grabbed one of the student's thighs. The Activity Director stated he saw the student run out of the area but did not know her name and the other students refused to identify her. The Activity Director stated he immediately removed Resident #1 from the area until the students left the facility. He stated he reported the incident to the Administrator and the DON. The Activity Director stated Resident #1 was placed on 1 to 1 supervision for some time, but he was not sure what else was done. He stated the Administrator did not ban the students from the facility because he was still expecting them to show up; however, they never returned. The Activity Director stated he heard Resident #1 was sexually inappropriate with the aides, but he never heard of Resident #1 doing anything to other residents. Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated after the incident she did not in-service the staff on abuse/neglect and sexually inappropriate behaviors. The DON stated the staff received routine trainings and in-services as needed on abuse and neglect, but she did not know if they received trainings specifically regarding sexual behaviors other than upon hire. The DON stated staff knew to document daily on Resident #1 and the staff who were assigned to do Q 15-miute checks were informed about the incident and knew what to monitor for; however, this was not documented as an in-service. The Administrator stated he had a meeting with management regarding the incident, but it was not documented. The Administrator stated he had a memo typed up that had not been sent out yet because he was waiting to see if the students would return to the facility. He did not state what information was included in the memo . The DON stated not having effective interventions in place, placed residents and visitors at risk of being sexually abused. She stated this also placed Resident #1 at risk of being harmed because he could be sexually inappropriate towards someone who could hurt him. In an interview on 5/19/25 at 4:36 PM, Resident #1's RP stated the facility notified her sometime last month to inform her the resident was being discharged to a group home for being sexually inappropriate with a student that was visiting the facility. The RP stated she was aware Resident #1 exhibited sexually inappropriate behaviors from his previous facility; however, he could not help it due to his dementia. The RP stated the last thing she heard from the facility was Resident #1 was placed on 1 to 1 supervision and was told she would have to pay for it to continue. The RP stated she was informed she could not afford to pay, and she also could not bring Resident #1 home with her, and that was the last time she heard from them. In an observation and interview on 5/19/25 at 4:52 PM, revealed Resident #1 was sitting in a wheelchair in his room. He was dressed and well-groomed . Resident #1 stated he had just returned to the facility from dialysis and was tired. Resident #1 stated he was fine then refused to answer any other questions. This state surveyor was unable to obtain any information from Resident #1 regarding the incident. In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 5. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation. b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 8. Protect residents during abuse investigations; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and 10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program . This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the template on 05/19/25 at 3:25 PM. The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM: [Nursing Facility] 1. F600 | Free from Neglect - The facility failed to ensure Resident #1 was free from neglect when he was not provided appropriate good or services to prevent his sexually inappropriate behaviors to potentially cause harm to himself and to others. 2. Identification of Residents Affected or Likely to be Affected: The DON, Social Services Director, and designee(s) interviewed/assessed residents all residents for potential abuse by conducting safe surveys on each resident. Concerns were identified. Concerns identified were resident keeps staring at them and touching his privates-3 residents). (Completion Date: 4/23/2025): The following actions were taken to prevent Resident # 1 from perpetrating additional abusive behaviors. Resident evaluated by primary care provider on 5/14/25 and provided a medication update. Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted on 5/20/2025. Psych consult provided (5/23/2025). Resident will not be seated near female resident(s) at activities, dining, etc . when at all possible. IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident. 3. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/20/2025) Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident. Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes. Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies. Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting. Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect, by 5/20/2025. Started 5/19/2025. DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Started 5/19/2025 Process will be on going. In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Started 5/19/2025. Process will be on going . The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. Started 5/19/2025 In-service will be on going. QAPI meeting will be held monthly, and findings discussed. The DON will monitor the effectiveness of interventions will be ongoing. A pre/posttest on abuse and neglect will be on going starting 5/20/2025. Started 5/20/2025. The facility is still looking for proper placement of resident . Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training. Review the following: Regulation: F-600 S483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Intent S483.12(a)(1) Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Highlight the deficient practice and specifics of the citation. Facility Policy and Practice Facility's Action Plan regarding the deficiency. Facility's Policies and Procedures related to the deficiency. Facility's Checklists and Monitoring tools used to verify compliance. Facility's Abuse investigation procedure and documentation process. Record of Training Complete Record of In-service Training and Attendance Form. Be sure that all participants sign in. Monitoring of the POR included the following: Interviews on 5/08/25at 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, MDS Nurse, nurses, CMAs, and CNAs : LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's policy on abuse/sexual abuse, neglect, and exploitation starting on 5/19/25-5/20/25. All staff were able to identify abuse/sexual abuse, neglect, and exploitation, state when to report it, and who to report it to. All staff were able to state the updated procedure for sexual abuse which included removing any residents who exhibited inappropriate sexual behaviors from the area, placing them on 1 to 1 supervision until further advised, immediately reporting the behaviors to the MD, DON, and family, and following any new orders. The nurses were able to state all behaviors had to be documented and reported to the DON. The SSD was able to state she was responsible for monitoring documentation for any changes in residents' behaviors and ensure the care plans were updated and assist in the discharge process as necessary. The Administrator and DON were able to state it was the facility's expectation to identify, report, and investigate any suspected or alleged abuse/sexual abuse, neglect, and exploitation. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of interventions put in place. Observation, interview and record review on 5/20/25 at 3:00 PM-4:00 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11, who were all at risk for abuse, neglect, and exploitation , revealed no further concerns. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or a lack in necessary goods and services. Observation of the residents revealed no signs of abuse or neglect. Interviews with residents and/or RPs revealed no concerns for abuse, neglect, or exploitation. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected the Administrator, DON, and SSD were educated on implementing the facility's policy to assess, investigate, and report any alleged abuse and neglect. Record review of an in-service titled Sexual Assault, dated 5/20/25, reflected all staff were educated on recognizing and reporting any signs of sexual abuse and inappropriate sexual behaviors. Record review of documents provided by the Regional Nurse Consultant titled Abuse, Neglect, and Exploitation-Pre/Post Test, dated 5/20/25, reflected the DON tested all staff over their knowledge on recognizing and reporting abuse, neglect, and exploitation. Record review of a progress note, dated 5/20/25 at 11:25 AM, reflected Resident #1 was connected to psychiatric services to address sexual behaviors . Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Pla Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in neglect. The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to implement policies and procedures to ensure Resident #1 was free from deprivation of goods and services abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and in-service staff on measures to properly handle the behaviors to prevent Resident #1 from sexually abusing others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems . These failures could place residents at an increased risk for abuse and neglect. Findings include: Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels, chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission. Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following: HPI: LTC on therapy Today: . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors. . Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following: [SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt. Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following: [DON] was notified by [Activity Director] that [Resident #1] has 'inappropriately touched' a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware. Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following: [Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities. Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following: -Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services. In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and the DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation, report it to the state agency, or notify law enforcement. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. In an interview on 5/19/25 at 9:26 AM, the Activity Director stated students from the local high school would come to the facility twice a month to do activities with the residents. The Activity Director stated on 4/23/25, the students were at the facility doing an activity with the residents in the dining area. He stated a student came up to him visibly upset then pointed at Resident #1 and stated he grabbed one of the student's thighs. The Activity Director stated he saw the student run out of the area but did not know her name and the other students refused to identify her. The Activity Director stated he immediately removed Resident #1 from the area until the students left the facility. He stated he reported the incident to the Administrator and the DON. The Activity Director stated Resident #1 was placed on 1 to 1 supervision for some time, but he was not sure what else was done. He stated the Administrator did not ban the students from the facility because he was still expecting them to show up; however, they never returned. The Activity Director stated he heard Resident #1 was sexually inappropriate with the aides, but he never heard of Resident #1 doing anything to other residents. Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated after the incident she did not in-service the staff on abuse/neglect and sexually inappropriate behaviors. The DON stated the staff received routine trainings and in-services as needed on abuse and neglect, but she did not know if they received trainings specifically regarding sexual behaviors other than upon hire. The DON stated staff knew to document daily on Resident #1 and the staff who were assigned to do Q 15-miute checks were informed about the incident and knew what to monitor for; however, this was not documented as an in-service. The Administrator stated he had a meeting with management regarding the incident, but it was not documented. The Administrator stated he had a memo typed up that had not been sent out yet because he was waiting to see if the students would return to the facility. He did not state what information was included in the memo . The DON stated not having effective interventions in place, placed residents and visitors at risk of being sexually abused. She stated this also placed Resident #1 at risk of being harmed because he could be sexually inappropriate towards someone who could hurt him. In an interview on 5/19/25 at 4:36 PM, Resident #1's RP stated the facility notified her sometime last month to inform her the resident was being discharged to a group home for being sexually inappropriate with a student that was visiting the facility. The RP stated she was aware Resident #1 exhibited sexually inappropriate behaviors from his previous facility; however, he could not help it due to his dementia. The RP stated the last thing she heard from the facility was Resident #1 was placed on 1 to 1 supervision and was told she would have to pay for it to continue. The RP stated she was informed she could not afford to pay, and she also could not bring Resident #1 home with her, and that was the last time she heard from them. In an observation and interview on 5/19/25 at 4:52 PM, revealed Resident #1 was sitting in a wheelchair in his room. He was dressed and well-groomed . Resident #1 stated he had just returned to the facility from dialysis and was tired. Resident #1 stated he was fine then refused to answer any other questions. This state surveyor was unable to obtain any information from Resident #1 regarding the incident. In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 5. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation. b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 8. Protect residents during abuse investigations; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and 10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 05/19/25 at 3:25 PM The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM: [Nursing Facility] 1. F600 (F607)| Free from Neglect - The facility failed to ensure Resident #1 was free from neglect when he was not provided appropriate good or services to prevent his sexually inappropriate behaviors to potentially cause harm to himself and to others. 2. Identification of Residents Affected or Likely to be Affected: The DON, Social Services Director, and designee(s) interviewed/assessed residents all residents for potential abuse by conducting safe surveys on each resident. Concerns were identified. Concerns identified were resident keeps staring at them and touching his privates-3 residents). (Completion Date: 4/23/2025): The following actions were taken to prevent Resident # 1 from perpetrating additional abusive behaviors. Resident evaluated by primary care provider on 5/14/25 and provided a medication update. Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted on 5/20/2025. Psyche consult provided (5/23/2025). Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible. IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident. 3. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/20/2025) Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident. Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes. Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies. Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting. Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect, by 5/20/2025. Started 5/19/2025. DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Started 5/19/2025 Process will be on going. In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Started 5/19/2025 Process will be on going. The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect Started 5/19/2025 In-service will be on going. QAPI meeting will be held monthly, and findings discussed. The DON will monitor the effectiveness of interventions will be ongoing. A pre/posttest on abuse and neglect will be on going starting 5/20/2025. Started 5/20/2025. The facility is still looking for proper placement of resident. Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training. Review the following: Regulation: F-600 (F607) S483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Intent S483.12(a)(1) Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Highlight the deficient practice and specifics of the citation. Facility Policy and Practice Facility's Action Plan regarding the deficiency. Facility's Policies and Procedures related to the deficiency. Facility's Checklists and Monitoring tools used to verify compliance. Facility's Abuse investigation procedure and documentation process. Record of Training Complete Record of In-service Training and Attendance Form. Be sure that all participants sign in. Monitoring of the POR included the following: Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, MDS Nurse, nurses, CMAs, and CNAs: LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's policy on abuse/sexual abuse, neglect, and exploitation starting on 5/19/25-5/20/25. All staff were able to identify abuse/sexual abuse, neglect, and exploitation, state when to report it, and who to report it to. All staff were able to state the updated procedure for sexual abuse which included removing any residents who exhibited inappropriate sexual behaviors from the area, placing them on 1 to 1 supervision until further advised, immediately reporting the behaviors to the MD, DON, and family, and following any new orders. The nurses were able to state that all behaviors had to be documented and reported to the DON. The SSD was able to state that she was responsible for monitoring documentation for any changes in residents' behaviors and ensure the care plans were updated and assist in the discharge process as necessary. The Administrator and DON were able to state it was the facility's expectation to identify, report, and investigation any suspected or alleged abuse/sexual abuse, neglect, and exploitation. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of interventions put in place. Observation, interview, and record review on 5/20/25, 3:00 PM-4:00 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, who were all at risk for abuse, neglect, and exploitation, revealed no further concerns. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or a lack in necessary goods and services. Observation of the residents revealed no signs of abuse or neglect. Interviews with residents and/or RPs revealed no concerns for abuse, neglect, or exploitation. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected the Administrator, DON, and SSD were educated on implementing the facility's policy to assess, investigate, and report any alleged abuse and neglect. Record review of an in-service titled Sexual Assault, dated 5/20/25, reflected all staff were educated on recognizing and reporting any signs of sexual abuse and inappropriate sexual behaviors. Record review of documents provided by the Regional Nurse Consultant titled Abuse, Neglect, and Exploitation-Pre/Post Test dated 5/20/25, reflected the DON tested all staff over their knowledge on recognizing and reporting abuse, neglect, and exploitation. Record review of a progress note, dated 5/20/25 at 11:25 AM, reflected Resident #1 was connected to psychiatric services to address sexual behaviors. Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Pla Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in neglect. Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #2) reviewed for accidents. -The facility failed to ensure Resident #2 was provided with adequate supervision to prevent the resident from using nonprescription drugs at the facility. On 2/15/25 Resident #2 was found exhibiting signs of an overdose and was transported to the local hospital where he tested positive for marijuana. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for accidents that could lead to serious injury or harm. Findings include: Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: COPD (lung disease), multiple sclerosis (nerve disorder), bipolar disorder (mood disorder) and legal blindness. Record review of Resident #2's Quarterly MDS assessment, dated 5/02/25, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication under the high-risk drug class which included an antidepressant, diuretic, and anticonvulsant. Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD, reflected the following: [Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents. Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following: [Resident #2] 30-day discharge notice was issued and signed due to lack of facility compliance. Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD reflected the following: [SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help him look for housing. Record review of Resident #2's progress notes, dated 2/15/25 at 8:00 AM by LVN A, reflected the following: [LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware. Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following: Today's Visit (continued) Reason for Visit: Drug / Alcohol Assessment Diagnosis: Bladder infection . Labs: Marijuana (Cannabinoid)- Positive . Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD, reflected the following: [SSD] reached out to [Resident #2's] [PO] to inform her of his resent [sic] drug overdose hospital visit. Record review of Resident #2's care plan, dated 2/20/25 , did not reflect a care plan for the resident's behavior related to substance abuse. Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following: -Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25. -Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25. -Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain. Further review of this document reflected Resident #2 did not have an order for medical marijuana. Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility. He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem. In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to the facility. He could not state why he did not investigate or report these incidents. In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else. She stated she would not order THC to the facility again. In an interview on 5/16/25 at 2:09 PM, the SSD stated to her knowledge, the DON addressed the drug issue that was brought to their attention by other residents. The SSD stated there were residents in the facility who were on parole and must complete drug screenings. She stated Resident #2 was on parole for a sex offense and drug use. The SSD stated the parole officers informed the facility of any failed drug screenings. The SSD stated Resident #2 failed a drug screening on 2/11/25 and his PO was informed he would be discharged from the facility for bringing drugs into the facility. She stated Resident #2 had already failed a drug screening that was positive for marijuana on 2/06/25. The SSD stated the facility was trying to find a facility for Resident #2 to transfer to, but it was difficult due to his background. In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go. Attempted interview on 5/16/25 at 4:32 PM with LVN A, who worked with Resident #2 when he was sent out to the hospital on 2/15/25, was unsuccessful due to no response to call. Callback information was left on the voicemail. In an observation and interview on 5/19/25 at 9:14 AM, Resident #2 was well-groomed, alert and oriented, and showed no s/sx of drug use or intoxication. Resident #2 stated he ended up at the local hospital on 2/15/25 due to his stupid ways of using drugs. Resident #2 admitted to using marijuana. Resident #2 stated he had a long history of heavy drug use but stopped and had only been using marijuana sometimes. Resident #2 stated he had been clean since because his PO found out about the incident, and it risked him going back to prison and it caused the MD to take him off his pain medication temporarily. Resident #2 stated residents were always bringing drugs into the facility, but he did not state who. He stated the staff were also aware drugs were being brought into the facility. Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm . Record review of the facility's, undated, policy titled Illegal Drug Use, reflected in part the following: Policy: This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession or distribution of any substance which is unlawful under the Controlled Substances Act. This facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. Policy Explanation and Compliance Guidelines: 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. 2. No one is allowed to sell, buy, transfer, distribute or use said illegal drugs on the premises of this facility. 3. No one is allowed to sell, buy, transfer, distribute or use any drug paraphernalia on the premises of this facility. 4. Anyone that is under a physician's care and requires the use of prescription or over-the-counter drugs must follow these rules: a. Use prescription drugs only if a licensed health care provider has prescribed them within the last year. b. Directions must be followed as written by the physician. c. Prescribed drugs must be in the original container. 5. The facility reserves the right to consult with said physician if prescription or over-the counter drugs create risk. 6. All facility staff that enter the facility may be subject to an investigation of substance abuse to include tests that detect the use of alcohol or any substance which is unlawful under the Controlled Substance Act . This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 05/19/25 at 3:25 PM The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM: [Nursing Facility] F689 IJ plan of removal The facility failed to ensure Resident #2 received adequate supervision to prevent a serious accident when the resident went to the hospital on 2/15/25 and was found to have marijuana in his system, after the facility was made aware that he was bringing nonprescription drugs into the facility. 1. Resident #2 was assessed and found to not have any signs or symptoms of current drug use. Date completed 5/19/25. MD was notified of the use of illegal drugs related to the past incident. Resident was drug tested on [DATE]. Drug test was negative. 2. All residents have the potential to be affected although no other residents have been affected. 3. All residents will be in-serviced on the facility policy regarding illegal drug use. (5/20/2025). All residents will be assessed upon return from any leave from the facility to look for signs and symptoms of illegal drug use to include limpness on both sides of body, pinpoint pupils, confusion, and difficulty talking. All nursing staff will be in-serviced to perform and document the assessment upon return and if any signs and symptoms are noted the Administrator and DON will be notified, and the facility will follow the illegal drug use policy. 5/20/2025 4. The DON/designee will monitor the documentation for each resident return to ensure the assessments are complete. This will be completed on 5/20/25. 5. Resident is still being discharged pending acceptance. 6. The DON/designee will monitor the effectiveness of assessments completed of residents . 7. QAPI meeting will be held monthly, and findings will be discussed. 8. A pre/posttest will be completed by staff on signs/symptoms of drug use Completion 5/20/2025 and ongoing. 9. Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training. Monitoring of the POR included the following: Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, nurses, CMAs, and CNAs : LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's drug policy and recognizing and reporting any s/sx of drug use in residents and staff starting on 5/19/25-5/20/25. All staff were able to state drugs were not tolerated at the facility by staff or residents, and residents could only have drugs and alcohol if ordered by the MD and administered by a nurse. All staff were able to state residents would be monitored for s/sx of drug use in general and when they went out into the community and returned to the facility. All staff were able to provide s/sx of drug use and stated if residents exhibited any of the s/sx it would be reported to the charge nurse and administration immediately. The nurses were able to state s/sx of drug use and residents who exhibited any s/sx would be assessed and the MD, DON, Administrator, and family would be notified, and any new orders followed. The nurses were able to state all assessments and incidents would be documented . The DON stated there was a town hall meeting held with the residents to educate them on the facility's drug policy. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of all interventions put in place. Observation, interview and record review on 5/20/25 from 3:00 PM-4:00 PM, of Residents #2, #3, #4, #6, and #7, who were all at risk for accidents due to inadequate supervision. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or concerns for the potential of accidents that could cause serious injury. Observation of the residents revealed no s/sx of drug use, intoxication, or harm from inadequate supervision. Interviews with residents and/or RPs revealed no concerns for inadequate supervision or harm. Further interview with the residents revealed they were aware of the facility's drug policy and understood illegal and nonprescription drugs were not allowed at the facility. Record review of an in-service titled Illegal Drug Use, dated 5/19/25, reflected all staff were educated on the facility's drug policy and on recognizing and reporting any s/sx of drug use in residents and staff. Record review of an in-service titled Assessment of signs and symptoms of drugs, dated 5/20/25, reflected the DON, ADON, and all nurses were educated on recognizing, assessing for, and reporting any s/sx of drug use. Record review of documents provided by the Regional Nurse Consultant, titled F689-Pre/Post Test, dated 5/20/25, reflected all staff were tested over their knowledge on recognizing and reporting s/sx of drug use. Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Plan Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in quality of care. Record review of document provided by the Regional Nurse Consultant, dated 5/20/25, reflected Resident #2 had a negative drug screening. The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems . This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder. Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation] . Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. Record review revealed no incident/accident report was completed about the incident on 01/22/25. Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25. Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25. Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found, An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell . The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident. An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1. An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back. An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell . CNA J stated he grabbed Resident#1 and took him outside to smoke. An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one . The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: Plan of Removal: 1. Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services. The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm. In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test. TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas: Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse. Conducting Education and Training with all Departments Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication Five day follow up with the State Office 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. Findings of this audit will be reviewed in the Resident Council meetings. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. Record review of Director of Nursing in-services by the Nurse on ANE Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25. An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift). Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M. An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility. An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. Attempted to call PCP on 02/13/24 at 9:27 AM Attempted to call Psy services on 02/13/24 at 9:52 AM An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns. Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

Based on interview, observations and record review, the facility failed to ensure 1 (Resident#3) of 4 residents received adequate supervision and assistance devices to prevent accidents. The facility failed to provide Resident#3 with adequate supervision on 01/20/25 when he eloped from the facility. The non-compliance was identified as past non-compliance (PNC). The IJ began on 01/20/25 and ended on 01/20/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect all residents at risk of elopement. Findings included: Record review of Resident #3's face sheet dated 01/23/25 reflected Resident #3 was a [AGE] year-old male and was originally admitted to the facility on [DATE]. Resident #3 was readmitted to the facility on [DATE]. Resident #3 was diagnosed with Hyperlipidemia (high levels of lipoproteins in the blood), Schizophrenia (Serious mental health condition that affects how people think, feel and behave) -unspecified, Depression (mood disorder that cause persistent feeling of sadness and loss of interest) -unspecified, anxiety disorder(Repeat episodes of sudden feelings of intense anxiety and fear) (-unspecified, Parkinsonism-unspecified, Epilepsy (A neurological disorder that causes seizures or unusual sensations )and behaviors unspecified. Record review of Resident #3's quarterly MDS assessment, dated 01/03/25, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Record review of Resident #3's care plan, dated 05/09/24, reflected no wandering behaviors. Record review of Resident#3 incident report dated 01/20/25 reflected: night [CNA A] noticed the resident is not in building, notify the nurse. The nurse called code yellow and all staffs in the building looking for resident inside the building and in the smoke patio. Unable to locate resident. Notify Administrator, DON, and all management directors. Call 911 and notify PD of missing resident. Notify [Family Member] of resident. Instructed some of the staff to go outside and look in the surrounding area. Police came to the building to talk to the staff. One of the [CNA A] found resident and brought him back to the building. Resident was shivering and skin very cold to touch .Police immediately called 911 .transfer resident to ER. Record review of Hospital records dated, 01/20/25, reflected: Resident#3 was coughing, sneezing, shivering and had an oral temperature of 99.7 [Resident #3] blood pressure was elevated. [Resident#3] was diagnosed with a viral upper respiratory infection. In an interview on 01/24/25 at 12:55 PM ADON stated she had clocked in 5 minutes to 6:00 AM. She overheard the overnight [CNA A] state he could not find a resident. ADON asked who? and when was the last time he was seen? [CNA A] stated to ADON that Resident#3 was coming in and out of his room and the last time he saw him was at 5:10 AM. The ADON stated she called a yellow code. Staff started looking everywhere inside and around the building and he could not be located. The ADON sent out a text to management team, she called 911, called the Resident#1 family members. The ADON talked with DON over the phone. [CNA A] found Resident#1 outside not too far from the facility. The ADON stated Resident#3 looked very cold, was shivering and he would not talk. ADON Instructed staff to put blankets on him. The DON was in the facility and was on the phone with the Administrator. The police arrived at the facility and called 911. The EMT transported Resident#3 to the ER. The ADON stated when she came in, she did not hear any alarms going off. Record review of temperatures on January 20, 2025, reflected: Temperatures at 6:00 AM range from 23 to 21 degrees. In an interview over the phone on 01/25/24 at 3:50 AM CNA A and CNA B stated Resident#3 was up walking around at 4:30 AM. Resident#3 tried to urinate in the trash at the nursing station and they walked him back to his room to use the bathroom. He did not want to go and continued to walk around. CNA's started last rounds at 5:10 AM. CNA B stated she could not find Resident#3. CNA A and CNA B searched the building for Resident#3. CNA A stated about 5:45 AM the ADON was made aware that Resident#3 was missing. CNA B stated staff searched outside and got in their cars to look for Resident#3. CNA A stated he was concerned for Resident#3 because he was barefoot, did not have a jacket on and it was cold. CNA A had to leave the facility at 6:45 AM. CNA A found Resident#3 three blocks from the facility. CNA A stated Resident#3 did not have any aggressive behaviors when he was asked to come back to the facility. CNA A transported Resident#3 to the facility. In an observation on 01/24/25 at 4:30 PM all exits doors were checked to ensure they were working properly. Three random residents with wander guards and Resident#3 wander guard was checked to ensure they worked properly. The non-compliance was identified as past non-compliance (PNC). The IJ began on 01/24/25 and ended on 01/25/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of incident/accident reports, from 11/01/24-01/23/25, reflected no other elopements. Record review of in-service titled Elopement, dated 01/20/25, reflected all staff were educated by the DON on elopement protocol and code yellow. Record review of Residents #3, EHR revealed his care plans and TAR were updated and had interventions to address all care needs. Record review of service invoice dated, 01/20/25 reflected: both side exits, and back exit was operating fine and egressing a timely manner. The front door, however, would stop annunciating after the egress had been activated .adjusted the dip switches in lock and tested to verify that it was annunciating after egressed. All systems are normal. Record review of Resident #1's care plan, revised 01/20/25, reflected Resident#3 had an elopement on 01/20/25. Interventions included: alert staff to wandering behaviors, check wander guard was properly working every shift by taking to the door if not properly working notify DON and replace the wander guard, in-service staff elopement risk, monitor and document behavior, send to ER for evaluation, skin check every shift to area wander guard is in place and wander guard in place when [Resident#3] returns from ER (wander guard to right ankle). Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O (2nd shift). Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M. All staff were able to provide competency regarding in-service over elopement. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report elopements to. All staff were to provide an example on what to do if a resident eloped. Record review of the facility's policy titled Wandering and Elopements revised 03/2019 reflected: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: b. If the resident was not authorized to leave, initiate a search of the building(s) and premises. c. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the attending physician, law enforcement officials. 4. When the resident returns to the facility, the Director of Nursing services or charge Nurse shall: A. Examine the resident for injuries. E. Complete and file an incident report F. Document relevant information in the resident's medical records.

Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of five residents reviewed for change of condition. -The facility failed to notify Resident #1's physician and responsible party when the resident had a fall on 3/27/24 and when the resident showed signs of increased lethargy and altered mental status as the week progressed. An Immediate Jeopardy (IJ) was identified on 04/22/24. An IJ Template was provided to the facility on [DATE] at 1:28 PM. While the Immediate Jeopardy was removed on 04/23/24 at 02:02 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not receiving immediate medical attention when there is a change in their condition. Findings included : Record review of Resident #1's face sheet, dated, 04/02/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: encephalopathy (change in brain function), sickle cell (blood disorder), type II diabetes, cerebral infarction (stroke), and cirrhosis of liver (chronic liver damage). Record review of Resident #1's EHR revealed she did not have a completed admission MDS assessment. Further review revealed Resident #1 had a BIMs of 11 which indicated moderate cognitive impairment. Record review of Resident #1's baseline care plan, dated, 03/27/24, revealed the resident's level of consciousness was lethargic and she was cognitively impaired. Record review of Resident #1's consolidated admitting orders, dated 3/25/24, reflected an order to make the family/resident/responsible party aware of the resident's conditions. Further review reflected a lack of documentation of an order to make the MD aware of Resident #1's conditions, besides new onset symptoms of COVID-19. Record review of Resident #1's discharge hospital records (prior to admitting to [nursing facility]), dated 3/11/24-3/25/24, reflected the following: Progress note at 3/14/24 1:30 PM: . Assessment/Plan: . -Place NGT if [Resident #1] is lethargic and is unable to take PO. . Discharge Summary at 03/25/24 7:06 PM: Principle Final Diagnosis: Acute hepatic encephalopathy . Test results pending at discharge: none. Follow-up appointments: none Summary of hospital course: Hepatic encephalopathy Known history of cirrhosis secondary to alcohol abuse . Physical therapy and occupational therapy consulted, recommending SNF. [Resident #1] was improving but 03/19/24 worsening in mental status; oriented to person only. Repeat ammonia on 03/20/24 up to 178. . Mental status has now returned to [Resident #1] baseline. . Therapeutic diet, encourage PO intake. . Further review of discharge hospital records reflected no documentation that ammonia levels were rechecked on 03/20/24 or prior to discharge. Record review of Resident #1's hospital records, dated 3/31/24, reflected the following: [Resident #1 is a [AGE] year-old female with history of CKD, cirrhosis (liver damage), encephalopathy (change in brain function), CVA (stroke), diabetes, hypertension (high blood pressure), who presents via EMS from nursing home due to altered mental status and facial droop. Per EMS, [Resident #1] is GCS (scale that assesses consciousness) 15 (mild brain injury) at baseline and able to speak and follow commands. Last known normal was 2 days ago per EMS until noticing change in neurological status today. [Resident #1] was recently admitted on [DATE] for hepatic encephalopathy (loss of brain function due to liver damage). . Laboratory Results: . Ammonia, plasma-205 umol/L (severely elevated) . Imaging results (CT head): 1. No acute intracranial abnormality. Chronic atrophic and chronic ischemic changes (brain damage), similar to the prior. In an interview on 04/02/24 at 9:48 AM, Resident #1's family member stated Resident #1 admitted to the facility after being in the hospital for about two weeks where she was being treated for complications related to her diabetes to her knowledge. The family member stated Resident #1 was visited at the facility on 03/30/24 by another family member and they were upset because Resident #1 did not look good, and staff reported she had been sleeping a lot more. The family member stated she had not been informed of a change in Resident #1's condition by the facility. The family member stated Resident #1 had a fall on 03/27/24 and they were informed of that by the roommate. In an interview on 04/02/24 at 10:48 AM, RN A, who worked at the local hospital, stated Resident #1 was previously admitted to the hospital from 3/11/24-3/25/24 for altered mental status and hyperglycemia (high blood sugar), and returned to the hospital on 03/31/24 with similar symptoms. RN A stated Resident #1 returned with altered mental status, encephalopathy (change in brain function), and critically high levels of ammonia from liver failure. RN A stated Resident #1 has been sleeping and nonverbal since admitting and had to get a nasogastric tube placed to receive nutrition and medication. RN A stated Resident #1's CT scans only showed evidence of past stroke with no new changes. In an interview on 04/02/24 at 10:48 AM, LVN B stated she worked at the facility since 02/2024. She stated she worked weekdays, 6am-2pm, and worked with Resident #1. LVN B stated she worked with Resident #1 on the day she was admitted , and Resident #1 was alert x 2 (only aware of person and place) and could respond to her name and answer yes/no questions. LVN B stated Resident #1 was confused and required assistance with eating as she would not initiate eating or drinking on her own. LVN B stated Resident #1 always seemed to have low energy and did not speak most of the time, but one morning during rounds she heard Resident #1 saying she was hungry and wanted a hotdog. LVN B stated she was the nurse who received report from the hospital before Resident #1 admitted to the facility, and they reported that Resident #1 had an altered mental status, hyperglycemia, and encephalopathy (change in brain function). LVN B stated she last worked with Resident #1 on the morning of 03/29/24 and the resident seemed to be less responsive than she had been and now required touch for response; however, before she would respond to her name. LVN B denied that Resident #1 showed signs of a stroke. LVN B stated she was responsible for checking Resident #1's blood sugar every morning and she was a little more responsive during previous mornings. LVN B stated a resident being less responsive was something that would be reported to the MD. LVN B stated she did not notify the MD of the change because she thought Resident #1 could have been sleepy due to it being early in the morning. In an interview on 04/02/24 at 10:48 AM, CNA C stated she worked at the facility for 3 years. CNA C stated she worked 6am-2pm on different halls, but she worked with Resident #1 on 03/28/24 and 03/31/24. CNA C stated on 03/28/24, Resident #1 was alert and eating but was not talking. CNA C stated she worked with Resident #1 again on 03/31/24 and there was a significant change. CNA C stated Resident #1 would not eat and required total assistance with care. CNA C stated before, Resident #1 could help move herself slightly during incontinent care. CNA C stated Resident #1 was weaker and less responsive. She stated she reported it to LVN F on 3/31/24. In an interview on 04/02/24 at 10:48 AM, CNA D stated she worked at the facility for 4 weeks. She stated she worked 6am-2pm on weekdays and worked with Resident #1 on 03/26/24, 03/27/24, and 03/28/24. CNA D stated earlier in the week, Resident #1 was talkative and very feisty. CNA D stated as the week went on, Resident #1 started talking less and was sleeping more. CNA D stated on the last day she worked with Resident #1 she was still sleeping more and had to be woken up for meals. She stated she was able to get Resident #1 to eat some of her food, but she was eating less. CNA D stated this was reported to the nurse; however, staff were still learning Resident #1's baseline and she was not sure what to think about the change. In an interview on 04/02/24 at 01:19 PM, the DON stated she was not at the facility when Resident #1 admitted ; however, she was there the next day and poked her head in to speak to Resident #1 and she responded. The DON stated there were no reports of a significant change in Resident #1 until 03/26/24 when LVN E reported the resident being nonresponsive with a blood glucose level of 50. The DON stated the MD was notified on 03/26/24 regarding the resident's low blood glucose, and after giving Resident #1 emergency Glucagon (medication to regulate blood glucose) and juice, her blood glucose stabilized. The DON stated EMS had already been called out to the facility, but the DON and MD decided not to transport Resident #1 to the hospital since her vitals were stable. The DON stated she did not receive any other report of a significant change in Resident #1 until 03/31/24 when it was reported that the resident was not waking up, eating, or responding. The DON stated staff reported Resident #1 had not eaten a lot in a day or so. The DON stated she went to assess Resident #1 and she was sleeping. The DON stated she pinched Resident #1's skin and she appeared to be dehydrated. The DON stated she told LVN G to call the MD and he gave an order to send Resident #1 to the hospital. The DON stated Resident #1 admitted to the hospital with hyperglycemia and was always lethargic with little response from the beginning. The DON stated the staff were still getting familiar with Resident #1's baseline as she had only been at the facility for a week; however, if there was any change from the day she admitted , the expectation was for the staff to report it to the DON and MD. In an interview on 04/02/24 at 02:05 PM, LVN E stated she admitted Resident #1 to the facility on [DATE]. LVN E stated Resident #1 was unarousable and would not speak or open her eyes when she admitted . LVN E stated Resident #1's baseline remained the same throughout the week and she never saw the resident feisty or very alert. LVN E stated on 03/26/24 she had to call the MD after Resident #1's blood glucose dropped, and she received an order to give the resident Glucagon (medication to regulate blood glucose). LVN E stated Resident #1 then had a fall on 03/27/24 with no injuries and she did not notify the MD although it was protocol. LVN E stated she would normally notify the MD of falls; however, she just forgot to do so for this incident. In an interview on 04/02/24 at 02:53 PM, the MD stated he visited the facility every Wednesday; however, he did not see Resident #1 when he visited on 03/27/24. The MD stated he had been notified of Resident #1's low blood sugar the day prior (3/26/24), but no one reported any other significant change or brought it to his attention that Resident #1 needed to be seen that day. The MD stated he was also not notified that Resident #1 had a fall on 03/27/24. The MD stated it was the expectation for staff to notify him of falls, but if it was late at night with no injury or change of condition, they could report it the following morning. The MD stated with Resident #1 being a new resident and due to her condition, he would have expected staff to notify him of her fall and any other changes. In an interview on 04/02/24 at 03:30 PM, LVN F stated she worked at the facility for 2 weeks. She stated she worked with Resident #1 on 03/30/24 and 03/31/24. LVN F stated Resident #1 was sleeping most of the time and not eating much during both shifts. LVN F stated on 03/31/24 the aide reported Resident #1 did not look like she was going to make it. LVN F stated she went to assess Resident #1 and she was very weak and lethargic, but the resident would open her eyes when spoken to, respond to sternum rub, and her vitals were normal. LVN F stated Resident #1's face was not drooping, and she did not have any other signs of a stroke. LVN F stated she notified the MD on 3/31/24 that Resident #1 had been sleeping more the past two days, was unarousable, and eating less, and the MD ordered Resident #1 to be sent out to the hospital. In an interview on 04/02/24 at 04:00PM, Resident #2 stated Resident #1 was her roommate for about a week. Resident #2 stated Resident #1 would sleep most of the time and only wake up for medication and to eat. Resident #2 stated Resident #1 was not able to converse with her but would sometimes pick up words from the television and repeat them over and over. In an interview on 04/02/24 at 05:05 PM with the DON and the Administrator, the DON stated she expected staff to notify her and the MD of any significant change in a resident's condition. The DON stated the MD wanted to make it clear to Investigator that the facility received a resident who was not stable enough to leave the hospital. The Administrator stated reporting a change of condition was easier said than done, especially with a new resident when staff were not familiar with their baseline. In an attempt to further interview about expectations and risks to the resident, the Administrator stated, no comment. In an interview on 04/23/24 at 10:08 AM with the Regional Nurse revealed she understood the facility failed to notify the physician of significant changes in Resident #1 after multiple opportunities presented, including a fall and other changes in mental and physical status that indicated a decline in health. The Regional Nurse stated her expectation and the facility's policy for any significant incidents and change in condition to be reported immediately. The Regional Nurse stated the risk of not notifying the MD of significant incidents and change of condition could result in a resident having serious harm or death. Review of the facility's policy titled Notification of Change, undated, revealed in part the following: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health mental. Or psychosocial status [sic]. This may include: a. Life-threatening conditions, or b. Clinical complications An Immediate Jeopardy (IJ) was identified on 04/22/24 at 11:45 AM. On 04/22/24 at 12:35 PM, the Administrator and the DON were notified of the IJ. The IJ template was provided to the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 04/23/24 at 10:11 AM. The POR reflected the following: Issue Cited: Failure to Notify the Physician of a Significant Change of Condition Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 4/22/24) o The DON or designee notified the facility Medical Director of the incident. o Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were/were not identified. (Provide details if concerns were identified from the physical assessments). 2. Actions to Prevent Occurrence/Recurrence: The facility took, the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 4/23/24) o All licensed nurses will be educated by the DON/designee on change of condition and physician notification regulations, as well as facility policy and procedure. o Nurse aides will be educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. o Staff members are not permitted to work a shift until education was completed. o New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. o The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on physician notification of significant changes. o The PIP resulted in implementation of daily DON/designee audits of the 24-hour report to monitor for change in resident condition. o The DON/designee will also complete chart audits/health document assessment as follows: o Three residents weekly for four weeks then; o Two residents weekly for two weeks then; o Two residents a month for two months. o The regional/corporate/consultant nurse will visit the facility monthly to provide general oversight and monitoring of the PIP. Monitoring 04/23/24 (10:15 AM-1:45 PM): Record review of Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10's, who were all at risk of having a physical, mental, or psychosocial change in condition based on diagnoses, electronic health records reflected no documented incidents or change of condition. Record review of in-service on 04/22/24, conducted by the Regional Nurse, reflected the DON and ADON were trained on their responsibility to monitor resident charting for any changes in resident status and follow up accordingly. Record review of in-services on 04/22/24-04/23/24, conducted by the DON, reflected all staff were trained during or prior to their shift on guidelines for notifying the physician of clinical problems, incidents, and change of condition. Record review of a document provided by the DON reflected a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented for the DON and/or designees to audit 24-hour reports to monitor for change of condition of residents and audit resident charts. Record review of a document provided by the DON reflected a fax form for non-emergent notification to ensure the physician is aware of all incidents and residents' conditions. Interview on 4/22/24 at 3:00 PM with the Administrator and the DON revealed the MD was notified of the facility's failure to report a resident's change of condition. Interviews on 4/22/24-4/23/24 (various times) with Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10's, who were all at risk of having a physical, mental, or psychosocial change in condition, revealed they had not experienced any signs or symptoms of a change in their condition. Interviews on 04/23/24 (10:08 AM-1:43 PM) were conducted with DON, ADON, LVN B (1st shift), LVN E (2nd shift), LVN G (1st shift), LVN H (1st shift), CNA I (1st shift), MA J (1st shift), CNA K (1st shift), CNA L (2nd shift), LVN M (2nd shift), CNA N (3rd shift), LVN O (3rd shift), LVN P (double weekends). All interviewed aides were able to provide competency regarding in-services over monitoring for and reporting change of condition to the charge nurse. The aides stated they knew to monitor residents for any changes to skin, behavior, mental/physical status while performing care and to immediately report it to the charge nurse and/or DON. All interviewed licensed staff were able to provide competency regarding monitoring for and acknowledging reports of change of condition and reporting to the physician. The licensed staff stated they were responsible for monitoring resident for any signs of change in condition, assessing a resident after receiving reports of change in condition from the aides, and immediately reporting any concerns to the DON/MD/family. An Immediate Jeopardy (IJ) was identified on 04/22/24. An IJ Template was provided to the facility on [DATE] at 1:28 PM. While the Immediate Jeopardy was removed on 04/23/24 at 02:02 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #1) residents reviewed for supervision. The facility failed to adequately supervise Resident #1 and to ensure the back door by the kitchen was secured or monitored while getting groceries delivered. Resident #1, who had dementia and a history of wandering, eloped from the facility through the propped open door at unknown time on 10/10/23. The facility was unaware of Resident #1's elopement until another facility notified them Resident was at their facility. The facility failed to ensure adequate interventions were implemented to prevent residents with a high risk of wandering/elopement from eloping through the same door. An IJ was identified on 11/09/2023. The IJ template was provided to the facility on [DATE] at 2:45pm. While the IJ was removed on 11/10/23 the facility remained out of compliance at a scope of potential for more than minimal harm and severity level of isolated due to the need for the facility to monitor it corrective action for effectiveness. This failure could place residents at risk of not being properly supervised resulting in injury or death. Findings included : Record Review of Resident #1's face sheet dated 11/10/2023 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia, hypertension (high blood pressure), bipolar disorder, and metabolic encephalopathy (brain imbalance). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, indicating he was severely cognitive impaired . Record review of Resident #1's admission wandering risk scale assessment dated [DATE] revealed he was high risk. Resident #1 didn't have a wander guard placed at this time of assessment. Observation/interview on 11/09/2023 at 12:30PM revealed Resident #1 sitting in the dining area. Unable to interview resident. Attempted to interview and Resident #1 wasn't able to answer questions. Resident #1 was observed wearing a wander guard on his right foot. Record review of Resident #1's Care Plan dated 09/24/23 revealed he wandered into unsafe situations, cognitive status: dementia. The care plan was updated the day of the incident (elopement) on 10/10/23 to reflect the resident was noted on the porch of a neighbor facility. Interventions included: alert staff to wandering behavior, approach positively and in a calm manner, monitor and document behavior, observe wander guard placement and function every shift and provide diversional activities. Wander Guard placed on right foot. Record review of Resident #1's incident report dated 10/10/2023 revealed at approximately 9:31 AM the administrator was notified by telephone of Resident #1 being at the nursing home behind the facility. Resident #1 was last seen on 10/10/2023 at 9:00 AM walking the halls as normal. Resident #1 was not exit seeking when last observed in the building. Record review of the nursing schedule and staff timecards for 10/10/23 revealed 4 CNAs, 1 LVNs, 2 med-aides, and 2 RNs were working the 6 AM-2 PM shift. Interview at 11/09/2023 at 8:50 AM with the DON revealed on the date of the incident on 10/10/23 groceries were being delivered to the kitchen and the door was left open when Resident #1 eloped from the facility. The nursing home across the street called and stated Resident #1 was at their facility. The DON stated she and the Administrator looked back at the cameras during the investigation and saw Resident #1 going through the delivery doors that lead to outside. Staff were told to put a wander guard on Resident #1 after his return and to complete skin assessments every 15 min and then to move to hourly assessments. Resident #1 had never attempted to go to doors or exit seek at the facility and he was very redirectable but also hads bad dementia. Resident #1 usually would sit at the nursing station with the staff. Thatis was the first time an incident like this has occurred. Interview at 11/09/2023 AM at 10:20 AM with the DON revealed wander guards were not placed on every wanderer until they actually saw the resident trying to elope or saw residents constantly going close to doors all the time. The DON then stated they were now making sure the door was secure and hadve changed the code on the keypad. In-services hadve been done to educate staff on residents who wandered. The biggest thing was making sure the door wasn't propped open, but she stated she couldn't guarantee someone was supervising the door at all times. Interview on 11/09/2023 at 10:35 AM with the Dietary Manager stated most of the time the grocery truck would be gone by the time she comes came to work in the morning during the days grocery delivery came. She also stated she and the kitchen staff triedy to have someone watch the door and the delivery staff usually closed it when they wereget done with delivery. The Dietary Manager stated she and the Administrator have told staff and the delivery staff not to leave the door open. Usually, the kitchen staff triedy to have someone supervise the door, but it was hard since the delivery truck would come at different times. Interview on 11/09/2023 at 12:00 PM with CMA P revealed staff have been in-serviced on elopement and wanderers. The DON and Admin have told staff what signs to look for regarding residents with elopement risks and what to do when it happens. The signs included: resident wandered towards the door and if they were to go in and out of rooms; There is a book at every nursing station to identify the wanderers in the building and where the wander guard was placed on the resident. Interview on 11/09/2023 at 12:20 PM with the DON revealed her definition of a wanderer was a resident who would walk around aimlessly with no direction. She stated elopement is defined as when a resident is actively seeking direction or getting out of the facility. She stated elopement means they left the facility. She stated PCC didn't have an elopement assessment. If the resident had a history of elopement at their last facility or where they were coming from prior to admission, then the facility would place a wander guard on them when they arrived. She stated if a resident scored high on the wander guard scale, then staff knew to monitor those residents to make sure they weren't exhibiting elopement behavior or try to open doors to exit. The DON stated they currently don't have anyone posted at the door because the dietary staff were aware of the wanderers by knowing each resident. Even though the door wasn't supervised, the DON stated they have staff in the hallway. The DON stated she and the Admin were trying to get the delivery truck company to deliver the groceries to the front door, but theis process hadn't been put in place. She then revealed stated that all the residents with wander guards were an elopement risk. She also stated elopement drills have been done for staff so they were aware of what to do when if an elopement ever occurred. Interview on 11/09/2023 at 1:56 PM with the Admin revealed he received a phone call around 9:20 AM that Resident #1 was found at a facility behind the facility. As soon he was aware, he walked over to get Resident #1 and returned around 9:30 AM, approximately. The Admin stated he told the grocery delivery staff they had to close the door and that it couldn't be propped opened or left opened. The door must stay closed at all times. There was a laundry room near where staff were, and they could see the back door (door where Resident #1 eloped) and the staff were there from 6 AM-8 PMpm. The Administrator stated he had educated staff . He stated he had tried to get the groceries delivered to the front door, but the delivery company hadn't been following the instructions. The Admin then revealed the back door should only be used for emergencies. The Admin then stated usually the kitchen was notified via a computer the time the delivery truck would show up. The truck used to come early and the dietary staff would help bring the groceries in but after the situation he talked with staff and educated them that the groceries had to be delivered to the front door. Interview on 11/09/2023 at 2:12 PM with Cook K revealed the staff had been educated on not letting groceries come through the back door but the grocery provider was still delivering at the back door. He stated he wasn't sure why they still allowed them to come through the back door. He revealed the risk factors of allowing them to use the back door could cause another elopement that occur red . Interview on 11/09/2023 at 2:20 PM with Dietary Aide Q revealed she has been working at the facility since February 2023 and she had been educated on groceries coming through the back door. She then stated the dietary staff try to have someone watch the door or switch out if they were busy, but they also try to tell the grocery provider to deliver through the front door if possible . Record review of the Elopement and Wandering Residents policy dated March 2019 revealed, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as a risk for wandering, elopement, or other safety issues, the resident care plan will include strategies and interventions to maintain the resident's safety. The administrator was informed on 11/109/2023 at 3:45 PM that an Immediate Jeopardy (IJ) existed on 10/10/2023, and a copy of the IJ Template was provided and requested a POR at this time. The following Plan of Removal was accepted on 11/10/2023 at 3:20pm: F689 Plan of Removal 1) The identified failure was due to an exit not being supervised by staff and a resident eloped from the building 2) The action that has been taken to remove the immediacy of this issue was 1) all deliveries must come through the front door as this entrance has been monitored and supervised during all hours. This was implemented on 11/09/2023 2) The back door will remain locked with a secure code. 3) The laundry room will have a sign posted Employees only. 3) The in-service that was provided was done by both the [DON] and the [Dietary Manager]. The date that all the in-service will be completed will be by 11/10/2023. This in-service will include all current staff, and the team from the food delivery group. The back door will be used as an exit only. 4) The Policy and Procedures will have an addendum added to them that will state that all deliveries must come through the front door at all times. Policy reviewed on 11/10/2023 and verified of addendum. 5) The way that this will be monitored is the delivery driver will have to sign in and out upon the delivery of what is being delivered. This will be implemented 11/10/23. The DON/designee will monitor the sign in sheet to ensure all signing in and out of the facility and that no delivery is entered through the back door 3 times a week for one week, then weekly for one month and then monthly for 3 months. All findings will be reported to the QAPI team monthly. 2. The back door will be monitored for usage. A sign out sheet will be placed by the back door for employees to sign out when using. This will be monitored by the don/designee 3 times a week for one week, then weekly for one month, and then monthly for three months. 6) Fire Safety will come out today (11/10/23) to secure the laundry room door so that it's not assessable accessible to any residents 7) Maintenance Director, [Maintenance Director], will continue to do weekly audit/checks on alarmed doors and security keypads to ensure proper functioning 8) Dietary and laundry staff will monitor laundry door in 30-minute increments until laundry door is secured with latch or locking mechanism, nursing will monitor on off shifts 9) Once the laundry doors are secured/ locked, all staff will have access to security key pad codes. Monitoring of the POR included: A 100% elopement audit was conducted by the DON; starting 11/09/2023 and was completed by 11/10/2023. - In-service dated 11/09/2023 topic: delivery effective immediately will be made through the front door. If not and the side door is used a dietary staff will stay at the door until they are finished with the delivery. This was confirmed with an observations on 11/10/2023 at 9:25AM of the grocery staff being redirected to go through the front door instead of the back door for grocery delivery. Interview with Receptionist R on 11/10/2023 10:17AM revealed the receptionist was able to verbalize that they now used a sign-in book as well as the computer check in for all guests and vendors. Review of in-services dated 11/09/2023 revealed they were completed on deliveries coming through the front door was also confirmed with observation of deliveries being brought through the front door on 11/10/2023 at 9:20 AM and interviews with staff confirmed by verbalizing expectations. Interviews on 11/10/2023 from 10:14 AM to 3:00 PM with ( Nurse A id A, Nurse Aid B, Dietary G, Cook F, Cook K, Housekeeper E, Housekeeper O, the Receptionist R, Dietary Manager , RN C, LVN D, MA H, MA I, MA N, MA P, Dietary Aid Q, and Laundry Aid L revealed they were in-serviced on using the front door for deliveries for the facility as well and expressed understanding on the new delivery policies and procedures as well as elopement education from the in-service. Interview and observation on 11/10/2023 at 2:00 PM with the DON revealed until the facility was able to get the door locked properly leading to the outside door, they will have staff switch off to supervise the door. Interview on 11/10/2023 at 2:00 PM the DON stated all staff had been in-serviced on the new delivery process and completed by 11/10/2023. Interview on 11/10/2023 at 3:34 PM with the DON revealed the incident was an IJ because of what could have happened to Resident #1 when he eloped. She also stated the risk factors of not making sure all the doors are secure could lead to death or injury to a resident. The DON stated her expectations of staff are to make sure all doors are secured at all times as well as know who the wandering residents are as well as identify them upon admission An IJ was identified on 11/09/2023. The IJ template was provided to the facility on [DATE] at 2:45pm. While the IJ was removed on 11/10/23 the facility remained out of compliance at a scope of potential for more than minimal harm and severity level of isolated due to the need for the facility to monitor it corrective action for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 (Resident #2) residents reviewed for quality of care, in that: The facility failed to provide wound care services for Resident #2 on the dates of 05/04, 05/07, 05/08 and 05/09 as ordered by the resident's wound care physician. This failure could lead to an increased and unnecessary risk of complications including worsening of existing wounds, development of new wounds, and infection. Findings Included: A review of Resident #2's electronic face sheet revealed a [AGE] year-old male, was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #2 was discharged from the facility on 05/21/23. Resident#2's diagnoses included Diabetes, Schizophrenia, and Chronic viral Hepatitis C. Resident #2 was his responsible party. A review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 09, indicating moderate cognitive impairment. The MDS for Resident#2 revealed no rejection of care. Resident#2 had no behaviors noted on the MDS. Resident #2 required supervision with setup help only with ADLs. The MDS revealed Resident #2 had no ulcers, wounds, or skin problems noted. The MDS noted Resident#2 received skin and ulcer/injury treatment that included, the application of nonsurgical dressings and the application of ointments/medications. A review of Resident #2's care plan dated 04/22/23 revealed Resident was at risk for skin breakdown due to incontinence and poor mobility later revised on 04/07/23. Resident #2 had an alteration in skin integrity due to a diabetic ulcer to the posterior neck last revised on 09/11/22. Resident #2 was at risk for infection to a neck wound due to refusing wound care initiated on 04/15/23. The interventions included attempting wound care as ordered, psyche services as needed, and when Resident #2 refuses wound care attempt again at a later time. An interview and observation with Resident #2 on 05/23/23 beginning at 9:17 am while at the local hospital, revealed he had called emergency services while at the facility on 05/21/23 because he was not receiving wound care treatment at the nursing facility. He had not refused wound care at the facility. Resident #2 believed the wound had gotten worse at the nursing facility. A review of the local hospital record dated 05/23/23 for Resident #2 revealed the resident was admitted to the facility for a wound check, his Chronic wound to his neck/upper back, reports recently got worse with a foul odor. A review of Resident #2 skin revealed an assessment of a Significant open wound to the posterior neck and upper thoracic spine concerning a possible active versus chronic cellulitis process, there is also some ulceration concerning for possible malignant process. A review of the Treatment Administration Record (TAR) for Resident #2 for May 2023, revealed he did not receive wound care treatment on the dates of 05/04, 05/07, 05/08, and 05/09 as ordered. A review of the physician order for Resident #2 for May 2023, revealed an order of Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply gentamicin then Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn, with the start date of 04/19/23 and discharge date [DATE]. A review of the physician order for Resident #2 for May 2023, revealed an active order of Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn, with the start date of 05/10/23. A review of the progress notes for Resident #2 for May 2023, revealed no evidence of Resident #2 receiving wound care treatment for 05/04, 05/07, 05/08, and 05/09 as ordered. Review of Resident #2 weekly wound evaluation completed by the wound care physician on the following dates reflected: 04/25/23-Current Treatment plan: Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply gentamicin then Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn. Wound progress: continue current tx as ordered 05/04/23- Current Treatment plan: gentamicin, Santyl, calcium alginate, cover with a dry dressing Wound progress: Unchanged Continue with gentamicin, Santyl, and calcium alginate, and cover with a dry dressing. 05/09/23- Current Treatment plan: Cleanse posterior neck, wound with NS or wound cleanser, pat dry, apply Santyl, then Calcium Alginate to fit wound, and then cover with dry dressing daily and prn. Wound progress: Unchanged, DC gentamicin, Continue with Santyl, and calcium alginate, and cover with dry dressing. 05/16/23- Current Treatment plan: Santyl, calcium, alginate, and dry dressing daily and prn. Wound progress: worsening, continue with current tx as ordered. An interview with the wound care physician on 05/23/23 at 10:05 am revealed he completed wound care treatment rounds weekly on Resident #2. The most recent evaluation on 05/16/23 reflected the neck wound has worsen. He had not been made aware Resident #2 had not received wound care on the dates of 05/04, 05/07, 05/08, and 05/09 as ordered. He was also not informed Resident #2 TAR reflected he refused wound care on 05/10, 05/11, 05/15, and 05/17. Resident #2 was noncompliant with his diabetic food options. Resident #2 would often it unhealthy snacks and juices, which could have affected the wound from healing properly. An interview with the DON on 05/23/23 at 11:41 am revealed she was not aware the TAR for May 2023 reflected Resident #2 had not received wound care on the dates of 05/04, 05/07, 05/08, and 05/09 as ordered. The DON did not know why the resident had called 9-1-1 to be taken to the hospital on 05/21/23. The nurses were required to notify her when the resident did not get wound care at the scheduled times. The DON stated the wound care was to be completed by each floor (hallway) nurse, before the end of the first shift. A review of the facility's Wound care policy dated 10/10 revealed Documentiation:8. Any problems or complaints made by the resident related to the procedure.9. If the resident refused the treatment and the reason why. 10. The signature and titles of the person recording the data. Reporting. 1. Notify the supervisor if the resident refuses the wound care.

Based on interview and record review the facility failed to immediately inform the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for 1 of 6 Residents (Resident #1) whose records were reviewed for change in condition LVN B failed to contact the Attending Physician when Resident #1 had a change of condition of chest pain and low blood pressure on [DATE] and the resident expired on [DATE]. This failure resulted in the identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of their corrective actions. This deficient practice could result in the residents not receiving urgent medical care and could result in death. The findings were: Record review of Resident #1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a female, age 62. The resident was her own responsible party. The resident expired at the facility on [DATE]. Record review of Resident #1's care plan, dated [DATE], revealed she was a full code. Resident #1 required assistance with Activity of daily living. Review of Resident #1's MDS assessment, dated [DATE], revealed the resident had a brief interview mental status score of 03, indicating severely impaired cognition Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was administered on [DATE] at 6:17 pm. Resident #1 had not recieived the medication prior to [DATE]. Review of Resident #1's progress note, dated [DATE] at 3:36 pm, revealed a blood pressure of ,d+[DATE]. At 6:17 pm revealed Resident #1 was administered [MEDICATION(S)] tablet sublingual 0.4mg. At 8:04pm revealed the blood pressure of ,d+[DATE] No notes reflected the complaint of chest pain. Review of Resident #1 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's progress note dated [DATE] at 8:28 am completed by LVN A Resident in bed resting this morning while making rounds with the outgoing nurse. Prior to breakfast, resident was still in bed. At 7.50am while making another round and med pass, went into the room to do her wound care, resident who is full code was found unresponsive in her bedroom. At this point CPR was initiated by this nurse while another nurse was delegated to call 911 and resuscitation measures was still in progress by this nurse and other nurses. Shortly, the paramedics and firefighters arrived and took over at the scene and continued CPR. Resident was pronounced dead at 8:22 am. Notified the physician, DON, and Administrator, Family was notified through her daughter, no further issues noted. An interview with Resident #1's family member on [DATE] on 8:07 am revealed she visited the facility on [DATE], while visiting Resident #1, the resident complained of chest pain around 6pm. She stated she pressed the call light and LVN B responded to Resident #1 that evening. She told LVN B that Resident #1 had chest pain and she wanted the resident sent to the hospital. She stated LVN B ignored her request and only provided the resident with a pill ([MEDICATION(S)]). She stated Resident #1 passed away because of an [CONDITION(S)]. An interview with LVN A on [DATE] at 10:15 am (6am -2pm shift) revealed she worked on [DATE] and found Resident #1 unresponsive when attempting to do wound care. She stated the resident was unconscious, so she started CPR and called a code blue for others to respond. She stated she was not made aware Resident #1 had chest pain and a low blood pressure. An interview with LVN B on [DATE] at 1:47 pm revealed he began working at the faciltiy in 2018. He administered [MEDICATION(S)] on [DATE] to Resident #1. He stated while working the 2:00 pm- 10:00 pm shift on [DATE], he responded to Resident #1 after a family member informed him Resident #1 had chest pain. He stated he provided the resident the medication and did not inform the physician. He did not inform the physician because there was an existing order for [MEDICATION(S)], so he did not. He stated the resident's chest pain was a change in condition. He assessd Resident #1 for chest pain and the effectiveness of the medication, the resident informed him the chest pain had went away. He did not follow up regarding the low blood pressure he stated. An interview with the ADM on [DATE] at 2:27 pm revealed she was not aware LVN B did not contact the physician when Resident #1 had a change in condition. The expectation for the nurses were to inform the physician when there is a change in condition. An interview with the Attending physician on [DATE] at 8:38 am revealed if Resident #1 had chest pain, it was change in condition, and he expected to have been notified. He stated he was not informed of Resident #1's chest pain and low blood pressure. He was only informed the resident expired on [DATE], by LVN B . He stated because the resident had an unusually low blood pressure, coupled with chest pain, he likely would have sent Resident #1 to the hospital for further evaluation. He stated the blood pressure of ,d+[DATE] is extremely low, even though Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was not made aware of the medication given for the leg pain. An interview with the DON on [DATE] at 9:45 am revealed she was not aware LVN B did not contact the attending physician when Resident #1 had a change in condition of chest pain and low blood pressure. The expectation was to notify the physician when the residents have a change in condition and follow the recommendation of the doctor. Record review of the facility's Change in a Resident's Condition or Status policy revised May, 2017 revealed Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and or status. The nurse will notify the residents Attending Physician or physician on call when there has been a: d. significant change in the resident's physical/emotional condition. A significant change is a major decline or improvement in the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. On [DATE] at 11:55 am , the Administrator was informed these failures resulted in an Immediate Jeopardy. The IJ template was provided to the Administrator. A plan of removal to remove the immediacy was requested at that time. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date:([DATE]) The DON or designee notified Medical Director of the incident (Completed [DATE] Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were/were not identified. The Administrator suspended the licensed nurse who was aware of significant change, but did not report it to the physician, pending investigation completed [DATE]. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: ([DATE]) The DON implemented disciplinary action with licensed nurse who was aware of significant change but did not report it to the physician (Administrator suspended Nurse immediately; additional discipline up to termination pending investigation). All licensed nurses were educated by the DON/designee on change of condition and physician notification regulations, as well as facility policy and procedure started [DATE]. Nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurse started [DATE]. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. The DON/ designee implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on physician notification of significant changes. The PIP resulted in implementation of daily DON/designee audits of the 24-hour report (or insert name of facility specific report here) to monitor for change in resident condition. The DON/designee will also complete chart audits as follows: Three residents weekly for four weeks then. Two residents weekly for two weeks then. Two residents a month for two months. The regional/corporate/consultant nurse will visit the facility monthly to provide general oversight and monitoring of the PIP. Monitoring: Review of the In-service education started on [DATE] revealed staff were educated regarding change in condition, notification of the physician anytime the resident's physical or mental condition changed. Review of the form Change of condition dated [DATE] reflected all residents of the facility were assessed for change in condition. No residents had change of conditions that were not reported to the physician. An interview with RN C on [DATE] at 9:41 am revealed she was in-serviced on change in condition and interventions - who to notify, would include physician, DON, Adm., family. She stated notifications should be done immediately. She revealed some examples of change in condition as weakness, facial droop, chest pain, arm pain, vital signs out of normal parameters, falls with or without injury, and altered mental status. She stated any complaint of chest pain would prompt physician notification. An interview with LVN D on [DATE] at 10:04 am revealed he had been in-serviced on change in condition. LVN D was asked what change in condition meant to him. He stated anything different from resident's base line. Stated any complaints of pain in head, chest or abdomen would prompt physician notification and also to notify the family. Stated he would notify the DON and administrator after he notified the doctor. Stated if any aide report of resident seeming different would prompt further checks. Stated he used a skill form to document assessment findings. He stated he would notify the physician of any changes in conditions to the resident. An interview with LVN E on [DATE] at 12:40 pm revealed he had been in-serviced on change in condition. He stated a change in condition was anything out of normal for a resident. He stated it could be vital signs, a scratch, or anything. Stated he would notify physician ,family, and the DON of any change in condition. Stated all information would be documented . Stated all falls were documented. All facility staff were interviewed between [DATE] and [DATE] had all been in-serviced on Change of Condition, and reporting. Staff verbalized examples of various changes and who to notify regarding change. All nursing staff stated physician,DON,Administrator would be notified of the change and documented. An interview with LVN B on [DATE] at 10:30 am revealed he had been suspended pending the results of the investigation. He received training regarding change in condition. He stated, going forward, when a resident had a change in condition, he would promptly notify the physician. An interview with the ADM on [DATE] at 10:53 am revealed all residents had been assessed for change in condition and none was noted. All staff working at the facility had been educated regarding identifying change or condition to whom to report. All nurses are required to report change of condition to the physician and follow the instructions of the physician. An interview with the DON on [DATE] at 11:15 am revealed all staff, including nursing staff, were educated regarding change in condition and the reporting requirements. The residents were assessed and no changes were noted. The nurses were responsible for reporting changes to the physician. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:55 a.m. While the IJ was removed on [DATE] 11:38am, the facility remained out of compliance at a severity level of actual harm that is not an immediate threat and a scope of isolated, due to the facility's need to monitor effectiveness of their Plan of Removal.

Based on observation, interview, and record review the facility failed to, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #1 ) of six residents reviewed for quality of care. The facility failed to provide treatment and care when Resident #1 had chest pain and an unusually low blood pressure (according to the doctor). LVN B failed to notify the doctor of the chest and low blood pressure. LVN B failed monitor and report the chest pain and low pressure. There was no evidence the nurse followed up regarding the low blood pressure. The resident expired the next day. This failure resulted in the identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of their corrective actions. This deficient practice could result in the residents not receiving urgent medical care and could result in death. The findings were: Record review of Resident #1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a female, age 62. The resident was her own responsible party. The resident expired at the facility on [DATE]. Record review of Resident #1's care plan, dated [DATE], revealed she was a full code. Resident #1 required assistance with Activity of daily living. Review of Resident #1's MDS assessment, dated [DATE], revealed the resident had a brief interview mental status score of 03, indicating severely impaired cognition Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was administered on [DATE] at 6:17 pm. Resident #1 had not recieved the medication any other time. Review of Resident #1's progress note, dated [DATE] at 3:36 pm, revealed a blood pressure of ,d+[DATE]. At 6:17 pm revealed Resident #1 was administered [MEDICATION(S)] tablet sublingual 0.4mg. At 8:04pm revealed the blood pressure of ,d+[DATE] No notes reflected the complaint of chest pain. There was no evidence LVN A followed up regareding the low blood pressure. The notes reflect LVN A assessed the resident five minutes later, and the medication was effective. There were no addiotional notes regarding monitor the blood pressure, chest pain or leg pain. Review of Resident #1 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's progress note dated [DATE] at 8:28 am completed by LVN A Resident in bed resting this morning while making rounds with the outgoing nurse. Prior to breakfast, resident was still in bed. At 7.50am while making another round and med pass, went into the room to do her wound care, resident who is full code was found unresponsive in her bedroom. At this point CPR was initiated by this nurse while another nurse was delegated to call 911 and resuscitation measures was still in progress by this nurse and other nurses. Shortly, the paramedics and firefighters arrived and took over at the scene and continued CPR. Resident was pronounced dead at 8:22 am. Notified the physician, DON, and Administrator, Family was notified through her daughter, no further issues noted. An interview with Resident #1's family member on [DATE] on 8:07 am revealed she visited the facility on [DATE], while visiting Resident #1, the resident complained of chest pain around 6pm. She stated she pressed the call light and LVN B responded to Resident #1 that evening. She told LVN B that Resident #1 had chest pain and she wanted the resident sent to the hospital. She stated LVN B ignored her request and only provided the resident with a pill ([MEDICATION(S)]). She was informed the resident passed away because of a [CONDITION(S)]. An interview with LVN A on [DATE] at 10:15 am (6am -2pm shift) revealed she worked on [DATE] and found Resident #1 unresponsive when attempting to do wound care. She stated the resident was unconscious, so she started CPR and called a code blue for others to respond. She stated she was not made aware Resident #1 had chest pain and a low blood pressure. An interview with LVN B on [DATE] at 1:47 pm revealed he administered [MEDICATION(S)] on [DATE] to Resident #1. He stated while working the 2:00 pm- 10:00 pm shift on [DATE], he responded to Resident #1 after a family member informed him Resident #1 had chest pain. The resident also complained of having leg pain. The resident was given pain medication for the leg pain. He stated he provided the resident the medication and did not inform the physician. He did not inform the physician because there was an existing order for [MEDICATION(S)], so he did not. He stated the resident's chest pain was a change in condition. The resident low blood pressure was not identified because the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the ADM on [DATE] at 2:27 pm revealed she was not aware LVN B did not contact the physician when Resident #1 had a change in condition. The expectation for the nurses were to inform the physician when there is a change in condition. An interview with the Attending physician on [DATE] at 8:38 am revealed if Resident #1 had chest pain, it was change in condition, and he expected to have been notified. He stated he was not informed of Resident #1's chest pain and low blood pressure. He was only informed the resident expired on [DATE], by LVN B . He stated because the resident had an unusually low blood pressure, coupled with chest pain, he likely would have sent Resident #1 to the hospital for further evaluation. He stated the blood pressure of ,d+[DATE] is extremely low, even though Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was not aware the resident had also experienced leg pain, and had also recieved medication for leg pain. An interview with the DON on [DATE] at 9:45 am revealed she was not aware LVN B did not contact the attending physician when Resident #1 had a change in condition of chest pain and low blood pressure. The expectation was to notify the physician when the residents have a change in condition and follow the recommendation of the doctor. Record review of the facility's Change in a Resident's Condition or Status policy revised May, 2017 revealed Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and or status. The nurse will notify the residents Attending Physician or physician on call when there has been a: d. significant change in the resident's physical/emotional condition. A significant change is a major decline or improvement in the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. On [DATE] at 11:55 am , the Administrator was informed these failures resulted in an Immediate Jeopardy. The IJ template was provided to the Administrator. A plan of removal to remove the immediacy was requested at that time. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date:([DATE]) The DON or designee notified Medical Director of the incident (Completed [DATE] Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were/were not identified. The Administrator suspended the licensed nurse who was aware of significant change, but did not report it to the physician, pending investigation completed [DATE]. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: ([DATE]) The DON implemented disciplinary action with licensed nurse who was aware of significant change but did not report it to the physician (Administrator suspended Nurse immediately; additional discipline up to termination pending investigation). All licensed nurses were educated by the DON/designee on change of condition and physician notification regulations, as well as facility policy and procedure started [DATE]. Nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurse started [DATE]. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. The DON/ designee implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on physician notification of significant changes. The PIP resulted in implementation of daily DON/designee audits of the 24-hour report (or insert name of facility specific report here) to monitor for change in resident condition. The DON/designee will also complete chart audits as follows: Three residents weekly for four weeks then. Two residents weekly for two weeks then. Two residents a month for two months. The regional/corporate/consultant nurse will visit the facility monthly to provide general oversight and monitoring of the PIP. Monitoring: Review of the In-service education started on [DATE] revealed staff were educated regarding change in condition, notification of the physician anytime the resident's physical or mental condition changed. Review of the form Change of condition dated [DATE] reflected all residents of the facility were assessed for change in condition. No residents had change of conditions that were not reported to the physician. An interview with RN C on [DATE] at 9:41 am revealed she was in-serviced on change in condition and interventions - who to notify, would include physician, DON, Adm., family. She stated notifications should be done immediately. She revealed some examples of change in condition as weakness, facial droop, chest pain, arm pain, vital signs out of normal parameters, falls with or without injury, and altered mental status. She stated any complaint of chest pain would prompt physician notification. An interview with LVN D on [DATE] at 10:04 am revealed he had been in-serviced on change in condition. LVN D was asked what change in condition meant to him. He stated anything different from resident's base line. Stated any complaints of pain in head, chest or abdomen would prompt physician notification and also to notify the family. Stated he would notify the DON and administrator after he notified the doctor. Stated if any aide report of resident seeming different would prompt further checks. Stated he used a skill form to document assessment findings. He stated he would notify the physician of any changes in conditions to the resident. An interview with LVN E on [DATE] at 12:40 pm revealed he had been in-serviced on change in condition. He stated a change in condition was anything out of normal for a resident. He stated it could be vital signs, a scratch, or anything. Stated he would notify physician ,family, and the DON of any change in condition. Stated all information would be documented . Stated all falls were documented. All facility staff were interviewed between [DATE] and [DATE] had all been in-serviced on Change of Condition, and reporting. Staff verbalized examples of various changes and who to notify regarding change. All nursing staff stated physician,DON,Administrator would be notified of the change and documented. An interview with LVN B on [DATE] at 10:30 am revealed he had been suspended pending the results of the investigation. He received training regarding change in condition. He stated, going forward, when a resident had a change in condition, he would promptly notify the physician. An interview with the ADM on [DATE] at 10:53 am revealed all residents had been assessed for change in condition and none was noted. All staff working at the facility had been educated regarding identifying change or condition to whom to report. All nurses are required to report change of condition to the physician and follow the instructions of the physician. An interview with the DON on [DATE] at 11:15 am revealed all staff, including nursing staff, were educated regarding change in condition and the reporting requirements. The residents were assessed and no changes were noted. The nurses were responsible for reporting changes to the physician. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:55 a.m. While the IJ was removed on [DATE] 11:38am, the facility remained out of compliance at a severity level of actual harm that is not an immediate threat and a scope of isolated, due to the facility's need to monitor effectiveness of their Plan of Removal.

Based on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of four residents reviewed for elopement. The facility failed to ensure Resident #1, who had a history of [REDACTED]. Resident #1 was found sitting on the curb near the street by a nurse leaving the facility. It was determined Resident #1 exited the building via his window. An Immediate Jeopardy (IJ) was identified to have occurred from 07/17/20 to 07/18/20. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. This failure placed residents at risk of serious injury, harm, or death. Findings Included: Review of Resident #1's face sheet, dated 11/17/20, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set assessment, dated 07/25/20, revealed he admitted to the facility with a brief interview for mental status score (BIMS) of 3 indicating severe cognitive impairment and displayed wandering behavior placing himself at significant risk of getting to a potentially dangerous place. Review of Resident #1's hospital admission records, dated 7/10/20, revealed during his hospital stay he had a sitter for elopement concerns. A recommendation had been made that elopement precautions be continued, and he would benefit from being discharged to a setting with monitoring and supervision. Review of Resident #1's facility admission wandering risk assessment, dated 07/16/20, revealed he scored an 18 placing him in a high-risk category to wander. Review of Resident #1's facility progress note, dated 07/17/20 at 2:42 AM, revealed, Resident observed out of his room with a walker and said he wants to get out of here. Resident was informed that it is night time but did not follow instructions, he said I got a wife. Call the police to kick this door open or I go inside the room and kick the window out. Resident was placed on 1-on-1 since he portrayed signs of elopement. In an interview on 11/17/20 at 2:25 PM LVN A stated Resident #1 was placed with a one to one sitter because the resident was verbal about not wanting to be in the facility, needing his wife, and because the resident looked like he wanted to elope. LVN A stated the sitter remained in place for Resident #1 until 6:00 AM the morning of 7/17/20. LVN A stated he briefed RN B that Resident #1 was a flight risk, and while providing report to RN B the resident came out of his room. LVN A stated he was not certain if Resident #1's one to one sitter was continued beyond 6:00 AM on 07/17/20. LVN A stated he left the facility about 7:06 AM on 7/17/20 and on his way to his car he saw Resident #1 sitting behind the building and he notified the facility the resident was outside. LVN A stated when he placed a one to one sitter on Resident #1 he did not notify the Administrator or DON as he should have. He stated he had since been in-serviced on who to notify should a resident show exit seeking behavior, precautions to put in place, and received disciplinary action as result of the incident. In an interview on 11/17/20 at 11:24 AM RN B stated he was working the morning of 07/17/20 when Resident #1 left the facility. He stated he took over Resident #1's care from LVN A who reported the resident was placed on one to one observation because the resident exhibited exit seeking behaviors. RN B stated when he arrived to begin his shift at 6:00 AM there was no sitter providing one to one supervision for Resident #1. RN B stated he made observations of Resident #1 leaving his room on two occasions during shift change between 6:00 AM and 6:45 AM and being verbally redirected by LVN A to return to his room. He stated he was told by LVN A the one to one sitter for Resident #1 would not be continued for his (RN B) 6:00 AM-2:00 PM morning shift. RN B stated on 07/17/20 between 6:45 AM and 7:15 AM Resident #1 kicked out his screen from his room window and exited the building. Resident #1 was found on facility property by staff. RN B stated what should have happened was a one to one sitter should have remained in place for Resident #1 due to his elopement risk. He stated usually when a resident was an elopement risk the physician and DON were notified and other precautions were discussed to mitigate a resident's exit seeking behavior. RN B stated he was uncertain why LVN A made the determination a one to one sitter was no longer needed for Resident #1. In an interview on 11/17/20 at 2:30 PM the DON stated Resident #1 admitted to the facility during the early morning hours of 07/17/20. She stated upon admission, LVN A placed Resident #1 on one to one sitter elopement precautions because the resident was exit seeking. She stated at the time elopement precautions were initiated by LVN A, neither the administrator or she were notified Resident #1 was an elopement risk and required one to one observation. She stated Resident #1 remained on one to one elopement observations from 10:00 PM to 6:00 AM 07/17/20 and the precautions were discontinued by the nursing staff at 6:00 AM on 07/17/20 because nursing felt Resident #1 was no longer exit seeking. She stated the procedure when a resident was placed on one to one observation for elopement was for the physician, Administrator, and herself to be notified, included in the decision-making process and provide additional guidance on what other elopement precautions might need to be taken. In an interview on 11/17/20 at 2:53 PM the ADMN stated when a resident was an elopement risk, the staff member should alert the DON and her. She stated LVN A did not notify her Resident #1 was an elopement risk, even though he took the appropriate action of providing the resident a one to one sitter. She stated Resident #1's one to one sitter elopement precaution was discontinued by the staff nurses at 6:00 AM on 07/17/20 because LVN A believed the resident had calmed down and was capable of being redirected to his room verbally when being observed to leave his room twice the morning of 07/17/20. The ADMN stated she provided LVN A written disciplinary action concerning the event because the nurse did not communicate to the DON or her of Resident #1's elopement risk. She stated if she was notified of the elopement risk arrangements would have been made to continue Resident #1's one to one sitter the morning the resident left the facility. She stated Resident #1 was found by facility staff outside of the facility on facility property without injury. Review of the facility's interview with LVN A, dated 07/27/20, revealed, On this day (ADMN) spoke to (LVN A) and explained that in the future when there is a resident that is (in) need of being placed on 1 on 1 supervision please be sure to inform the DON and the ADMN Review of the facility's policy Wandering and Elopements, revised March 2019, revealed, Policy Interpretation and Implementation 2. If an employee observes a resident leaving the premises, he/she should: Attempt to prevent the resident from leaving in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing services that a resident is attempting to leave or has left the premises. Review of the facility's policy Resident Monitoring Procedures, revised 11/19/20, revealed, A designated employee will be assigned to a resident while exhibiting signs of aggression, exit seeking, etc. or any form of behavior that could potentially cause harm and or inflect danger to themselves or others. The attending Charge Nurse will inform the Director of Nursing, and the Administrator of the need of one on one monitoring. At that time a designated staff person will document where the resident is or what the resident is doing while being monitored. When the resident is no longer a risk for the specific behavior the monitoring will be lifted. The ADMN was informed on 11/19/20 at 12:11 PM that past non-compliance IJ was identified to have existed from 07/17/20-07/18/20. The facility took the following actions to correct the deficient practice prior to the investigation: Review of a facility in-service training on elopement, dated 7/18/20, revealed summary of training: Any resident at risk of elopement must be placed on a safety precaution immediately and the administrator/director of nursing notified for further strategies/interventions to be put in place. In an interview on 11/17/20 at 2:53 PM the ADMN stated in response to the incident, the facility took immediate corrective action by in servicing all staff on policy and actions to take for residents with exit-seeking behavior on 07/18/20. The ADMN stated the resident was placed on increased one to one sitter supervision with 15-minute checks to document his location in the facility, a wander guard was implemented, and an alarm was placed on his window until Resident #1 was discharged from the facility home with his family. The ADMN stated the facility continued to monitor staff compliance with facility policy by performing ongoing in-service training, performing elopement procedure drills, performing ongoing resident assessments for elopement risk behaviors and implementing appropriate security measures to keep them safe. The ADMN stated LVN A received written disciplinary action and retraining regarding the incident. On 11/17/20 between 6:00 AM and 4:30 PM and 11/19/20 between 9:00 AM and 12:00 PM separate interviews were conducted with LVN A,LVN G, LVN H, LVN L,LVN N, LVN R, RN B, RN P, ADON, DON, CNA C, CNA D, CNA E, CNA F, CNA G, CNA J, CNA K, CNA M, CNA O and CNA Q across all three shifts 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM, and weekend staff. Each member was able to demonstrate competency in identifying residents with exit seeking behaviors, the procedures to take to ensure resident safety, and who should be notified.

Based on observation, interview, and record review, the facility failed to ensure sinks used by residents were within a safe temperature range to prevent burns on three (Halls A, B and C) of three halls, in both resident rooms and a shower room, reviewed for water temperatures. The facility failed to properly monitor and document water temperatures in December 2016. Water temperatures in sinks used by residents ranged from 120 degrees Fahrenheit (F) to 168 F. An Immediate Jeopardy (IJ) was identified on 12/20/16. While the IJ was removed on 12/21/16, 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 widespread because the facility was still in-servicing staff, the water heaters had not been repaired and the facility was monitoring the implementation of the Plan of Removal. This failure placed the facility's 71 residents, including nine residents identified by the facility as those who wandered, at risk for burns, pain and the need for hospitalization . Findings included: Interview on 12/20/16 at 10:49 a.m. with the Maintenance Director revealed an order had been placed the previous week for a new thermostat for one of the facility's water heaters that controlled two (Hall B shower and Hall C shower next to resident room 47) of the facility's three shower rooms. Observation on 12/20/16 at 10:53 a.m. revealed the following water temperatures were taken by the Maintenance Director: Hall C shower next to resident room 47 registered 63 F; Hall C shower room sink next to resident room 38 registered 168 F (Note: The surveyor observed steam coming from the water while the temperature was being taken.); and Hall B shower registered 66 F. Observation on 12/20/16 at 4:10 p.m. revealed the following water temperatures were taken by the Maintenance Director: Hall C shower room sink next to resident room 38 registered 154 F; resident room 38 (Hall C) sink registered 154 F; resident room 39 (Hall C) sink registered 156 F; resident room 1 (Hall A) sink registered 120 F; resident room 4 (Hall A) sink registered 125 F; resident room 25 (Hall B) sink registered 158 F; resident room 24 (Hall B) sink registered 153 F; and resident room 32 (Hall B) sink registered 154 F. (Note: All resident rooms checked for temperatures were occupied by residents on 12/20/16.) The American Burn Association's online resource Scald Injury Prevention Educator's Guide (no date), at <http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf>, reflected that at 155 F a third degree burn could result in one second, at 148 F a third degree burn could result in two seconds, at 140 F a third degree burn could result in five seconds, at 133 F a third degree burn could result in 15 seconds, at 127 F a third degree burn could result in one minute, at 124 F a third degree burn could result in three minutes and at 120 F a third degree burn could result in five minutes. (Note: This information was accessed on 12/28/16.) Review of the facility's water temperature logs, dated August 2016 to December 2016, revealed there were no temperatures documented for December 2016. Interview on 12/20/16 at 5:56 p.m. with the Maintenance Director revealed he was busy the first two weeks of December 2016 with other maintenance concerns and the water temperatures for that month were not documented. He stated he noticed the water temperatures were fluctuating on 12/16/16 and did not document those water temperatures because they did not appear to be accurate. Review of the facility's maintenance request logs, dated December 2016, did not reveal concerns regarding water temperatures. Interview on 12/20/16 at 6:50 p.m. with the Maintenance Director revealed no concerns had been brought to his attention regarding high water temperatures prior to 12/20/16. He stated the high water temperature reading on 12/20/16 for Hall C shower room sink next to resident room 38 had triggered the concern with the second water heater. Interview on 12/21/16 at 5:21 p.m. with the Administrator revealed the facility had no policy or procedure regarding required water temperature ranges. The Administrator stated the facility followed the state and federal regulations regarding required water temperatures. Interview on 12/21/16 at 10:07 a.m. with an employee from a plumbing service and repair company, hired by the facility, revealed two thermostats (one for each water heater) had to be replaced and a third water heater was being inspected to determine if it also needed a new thermostat. The employee stated the needed parts were being ordered at that moment and he was unable to give an estimated time of arrival. The employee stated there was no way to regulate temperatures in a water heater without a working thermostat. Interview on 12/21/16 at 5:52 p.m. with two employees from a plumbing service and repair company, hired by the facility, revealed they were currently working on the facility's water heaters. The employees stated the needed parts had been ordered and they anticipated the repairs to be completed on 12/23/16. Interview on 12/20/16 at 11:32 a.m. with the DON revealed there had been a problem with the shower water temperatures for at least a week. She stated there was one working shower room (with hot water) that staff members had been directed to use for residents. The DON stated the maintenance staff were currently working on the water temperatures in the shower rooms. Observation on 12/20/16 at 3:16 p.m. revealed water was trailing from Resident #1 ' s wheelchair as he was coming out of Hall C shower room next to resident room 47. LVN J was informed the resident had come out of the shower room alone. The surveyor and LVN J located the resident going back to his room and LVN J stated the resident wandered the facility and collected items. During Confidential Resident Interview #1, it was revealed the hot water in the resident's room was mighty hot. The resident stated he/she barely turned on the hot water and mixed it with cold water. He/She stated the hot water had been too hot for at least a week. The resident stated no injury had occurred. During Confidential Resident Interview #2, it was revealed the hot water in the resident's room was hot enough to cause a third degree burn. The resident stated no injury had occurred. Interview on 12/21/16 at 11:24 a.m. with Resident #2 revealed the resident had hollered out during a bed bath the day before (12/20/16) when CNA D poured hot water, obtained from the sink in her room, over her legs. The resident stated CNA D was wearing gloves at the time and could not tell how hot the water was. The resident stated CNA D then worked directly from the basin after the incident and no longer poured the water directly on her. The resident stated no injury had occurred. During Confidential Resident Interview #3, it was revealed the water in the resident's room had been really hot for about a week. The resident stated he/she used more cold water as a result. The resident stated he/she did not notify anyone at the facility regarding the water being too hot in his/her room. The resident stated no injury had occurred. In an interview on 12/20/16 at 12:32 p.m., LVN A stated the maintenance staff members had been working on the hot water in the shower rooms for at least a week. LVN A stated not all shower rooms were affected and residents were taken to the Hall C shower that currently had warm water. In an interview on 12/20/16 at 1:15 p.m., CNA B stated one shower room always had warm water and another shower room had fluctuating hot and cold water. He stated the problem with the shower room water temperatures had gone on for about two weeks. In an interview on 12/20/16 at 5:15 p.m., CNA C stated there had been no problems with the water temperatures being too hot. She stated she had no knowledge of new blisters or burns with residents during December 2016. In an interview on 12/20/16 at 5:18 p.m., CNA D stated she had given a resident a bed bath the other day. She stated the water could be too hot for a resident if she was not careful. She stated she was informed by other staff members that the water was hot and checked it before it was used on residents. In an interview on 12/20/16 at 7:50 p.m., LVN E stated she was unaware of high water temperatures at the facility. She stated there had been no new blisters or burns with residents during December 2016. In an interview on 12/20/16 at 7:54 p.m., CNA F stated he was unaware of high water temperatures at the facility. He stated there had been no new blisters or burns with residents during December 2016. In an interview on 12/21/16 at 11:10 a.m., LVN G stated no concerns had been brought to his attention regarding high water temperatures at the facility. He stated there had been no new blisters or burns with residents during December 2016. In an interview on 12/21/16 at 11:16 a.m., CNA C stated no concerns had been brought to her attention regarding high water temperatures at the facility prior to 12/20/16. She stated she noticed the water temperatures were high in a resident's room at the beginning of her shift (2:00 p.m. to 10:00 p.m.) on 12/20/16 and she notified the nurse who informed her she was already aware of the concern. She stated there had been no new blisters or burns with residents during December 2016. In an interview on 12/21/16 at 1:43 p.m., CNA H stated she noticed three days ago that the water in resident room 22 was too hot while washing her hands. She stated no one had reported the water being too hot to her. She stated she notified the Maintenance Director and LVN A regarding the water temperature being too hot and they both stated they would look into it. She stated there had been no new blisters or burns with residents during December 2016. In an interview on 12/21/16 at 1:58 p.m., MA I stated she did not notice high water temperatures prior to 12/21/16. She stated there had been no new blisters or burns with residents during December 2016. In an interview on 12/21/16 at 2:53 p.m., CNA D stated she first noticed the water was too hot on 12/19/16. She stated the water being too hot had been brought up in general conversation at the facility. She stated she made sure the hot water was mixed with cold water before using it on residents. She stated Resident #2 had mentioned the water was a little hot during a bed bath on 12/19/16. On 12/20/16 at 6:35 p.m. the Administrator and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 12/21/16, was accepted on 12/21/16 at 7:00 p.m. and reflected the following: PLAN OF REMOVAL The resident (sic) in all rooms were assessed by the DON. The residents were not negatively affected by the alleged practice. This failure has the potential to affect all residents. The hot water to all resident rooms was turned off on 12/20/16. Shower Room C which is located at the end of Hall C, between rooms 18 and 54; and the Shower Room B which is located at the end of Hall B across from the therapy office were left on for resident (sic) who needed or wanted an evening shower. Shower C is being manually locked by staff in-between showers to prevent resident's (sic) from entering the shower unattended. The maintenance director will continue to check the water temperatures daily in all rooms. The Administrator will monitor the maintenance logs daily until the hot water problems have been resolved. A local plumber came to the facility and assessed the problems. As of 12/21/16 all parts needed to repair the water heaters have been ordered. The new parts will be placed on the hot water heaters as soon as the parts arrive. The time the plumber said the parts would be delivered would be by the end of the week. Direct Care staff which consist of RN, LVN, CNA and (MA) who worked last evening and overnight were educated by the DON to use Shower Rooms B & C for the residents who needed or required showers. Direct Care Staff was also educated to test the water prior to giving showers by gently and cautiously running their hand under the water when the water is turned on. Direct Care Staff which consist of RN, LVN, CNA, and (MA) education will continue for staff prior to their returning to work (Staff will not be able to work until they have had training from the DON. DON will monitor training of staff.) Direct Care Staff was educated by the DON to immediately notify Maintenance or a supervisor when the water seems too hot for comfort and not to give the resident a shower if that occurs. Direct Care Staff will be educated to use the shower schedule to control the admission to the shower rooms To verify the facility implemented their Plan of Removal the following observations and interviews were obtained and the following records were reviewed. Observation on 12/20/16 at 7:02 p.m. revealed the hot water was turned off in resident rooms throughout the facility. All three shower rooms were locked and could not be accessed without staff assistance. An interview was conducted on 12/21/16 at 12:28 p.m. with the Administrator and DON. The DON stated head to toe assessments were done on 12/20/16 with all residents and the alert and oriented residents were interviewed as well regarding possible injuries from hot water. The DON stated the shower rooms were to remain locked to restrict resident access. The DON stated she had gone around the facility to inform staff members regarding the facility's corrective actions related to the hot water. The Administrator stated there was no written policy or procedure regarding water temperature checks. The Administrator stated it was standard for the water temperatures to be checked weekly. The Administrator and DON both stated the facility's hot water in resident use areas was to remain off until the plumber had cleared everything and the water heaters were working properly. Review of the facility's in-service training, provided on 12/21/16 by the DON, revealed LVNs, CNAs, MAs and housekeeping were in-serviced on room water temperatures, use of shower rooms, locking shower room doors, cutting off hot water in rooms, use of Halls B and C shower rooms for showers, and notifying the supervisor if water is too hot in the shower rooms or resident rooms. Interviews were conducted with LVN G, CNA B, CNA H, MA I, CNA D, LVN J, CNA F and MA L on 12/21/16 from 1:22 p.m. to 5:32 p.m. The staff members knew to keep the shower rooms locked and how to test the water temperature prior to resident use. The staff members also knew that the Maintenance Director had to be notified when water temperatures were too high. Review of a work order, dated 12/21/16, from a plumbing service and repair company, hired by the facility, revealed . Estimate to replace the gas control valve and burner Assembly on the Rheen - Ruud Commercial Gas water heater . We will also purchase an additional gas control valve for the nursing home to have on hand when needed. This estimate also includes same parts and installation for the AO Smith Commercial Gas heater . We will also purchase another gas control valve for the AO Smith unit so that will be on hand when needed. We will remove both units burner assembly's and gas controls valves and thoroughly clean each units combustions chambers and then install the new Gas control valves and burner assembly's. After these parts have been properly installed we will bring them on line and run them a series of test (sic) to ensure that (sic) are operating properly. (Plumbing service and repair company) will set these commercial gas water heaters to the manufacturers (sic) suggested temperatures. Should the (facility) management team require a higher temperature a member of their team will have to make the adjustment On 12/21/16 at 7:00 p.m., the Administrator was informed the IJ was removed. While the IJ was removed on 12/21/16, 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 widespread because the facility was still in-servicing staff, the water heaters had not been repaired and the facility was monitoring the implementation of the Plan of Removal. Review of the facility's daily census, dated 12/20/16, revealed a total census of 71 residents. Review of a list of residents who wandered at the facility, provided by the facility and dated 12/20/16, reflected the nine residents which respresented all three halls, including Resident #1.

Based on observation, interview, and record review, the facility failed to ensure sinks used by residents were within a safe temperature range to [MEDICAL CONDITION] three (Halls A, B and C) of three halls, in both resident rooms and a shower room, reviewed for water temperatures. The facility failed to properly monitor and document water temperatures in December 2016. Water temperatures in sinks used by residents ranged from 120 degrees Fahrenheit (F) to 168 F. An Immediate Jeopardy (IJ) was identified on 12/20/16. While the IJ was removed on 12/21/16, 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 widespread because the facility was still in-servicing staff, the water heaters had not been repaired and the facility was monitoring the implementation of the Plan of Removal. This failure placed the facility's 71 residents, including nine residents identified by the facility as those who wandered, at risk for burns, pain and the need for hospitalization . Findings included: Interview on 12/20/16 at 10:49 a.m. with the Maintenance Director revealed an order had been placed the previous week for a new thermostat for one of the facility's water heaters that controlled two (Hall B shower and Hall C shower next to resident room 47) of the facility's three shower rooms. Observation on 12/20/16 at 10:53 a.m. revealed the following water temperatures were taken by the Maintenance Director: Hall C shower next to resident room 47 registered 63 F; Hall C shower room sink next to resident room 38 registered 168 F (Note: The surveyor observed steam coming from the water while the temperature was being taken.); and Hall B shower registered 66 F. Observation on 12/20/16 at 4:10 p.m. revealed the following water temperatures were taken by the Maintenance Director: Hall C shower room sink next to resident room 38 registered 154 F; resident room 38 (Hall C) sink registered 154 F; resident room 39 (Hall C) sink registered 156 F; resident room 1 (Hall A) sink registered 120 F; resident room 4 (Hall A) sink registered 125 F; resident room 25 (Hall B) sink registered 158 F; resident room 24 (Hall B) sink registered 153 F; and resident room 32 (Hall B) sink registered 154 F. (Note: All resident rooms checked for temperatures were occupied by residents on 12/20/16.) The American Burn Association's online resource Scald Injury Prevention Educator's Guide (no date), at <http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf>, reflected that at 155 F a third degree burn could result in one second, at 148 F a third degree burn could result in two seconds, at 140 F a third degree burn could result in five seconds, at 133 F a third degree burn could result in 15 seconds, at 127 F a third degree burn could result in one minute, at 124 F a third degree burn could result in three minutes and at 120 F a third degree burn could result in five minutes. (Note: This information was accessed on 12/28/16.) Review of the facility's water temperature logs, dated August 2016 to December 2016, revealed there were no temperatures documented for December 2016. Interview on 12/20/16 at 5:56 p.m. with the Maintenance Director revealed he was busy the first two weeks of December 2016 with other maintenance concerns and the water temperatures for that month were not documented. He stated he noticed the water temperatures were fluctuating on 12/16/16 and did not document those water temperatures because they did not appear to be accurate. Review of the facility's maintenance request logs, dated December 2016, did not reveal concerns regarding water temperatures. Interview on 12/20/16 at 6:50 p.m. with the Maintenance Director revealed no concerns had been brought to his attention regarding high water temperatures prior to 12/20/16. He stated the high water temperature reading on 12/20/16 for Hall C shower room sink next to resident room 38 had triggered the concern with the second water heater. Interview on 12/21/16 at 5:21 p.m. with the Administrator revealed the facility had no policy or procedure regarding required water temperature ranges. The Administrator stated the facility followed the state and federal regulations regarding required water temperatures. Interview on 12/21/16 at 10:07 a.m. with an employee from a plumbing service and repair company, hired by the facility, revealed two thermostats (one for each water heater) had to be replaced and a third water heater was being inspected to determine if it also needed a new thermostat. The employee stated the needed parts were being ordered at that moment and he was unable to give an estimated time of arrival. The employee stated there was no way to regulate temperatures in a water heater without a working thermostat. Interview on 12/21/16 at 5:52 p.m. with two employees from a plumbing service and repair company, hired by the facility, revealed they were currently working on the facility's water heaters. The employees stated the needed parts had been ordered and they anticipated the repairs to be completed on 12/23/16. Interview on 12/20/16 at 11:32 a.m. with the DON revealed there had been a problem with the shower water temperatures for at least a week. She stated there was one working shower room (with hot water) that staff members had been directed to use for residents. The DON stated the maintenance staff were currently working on the water temperatures in the shower rooms. Observation on 12/20/16 at 3:16 p.m. revealed water was trailing from Resident #1 ' s wheelchair as he was coming out of Hall C shower room next to resident room 47. LVN J was informed the resident had come out of the shower room alone. The surveyor and LVN J located the resident going back to his room and LVN J stated the resident wandered the facility and collected items. During Confidential Resident Interview #1, it was revealed the hot water in the resident's room was mighty hot. The resident stated he/she barely turned on the hot water and mixed it with cold water. He/She stated the hot water had been too hot for at least a week. The resident stated no injury had occurred. During Confidential Resident Interview #2, it was revealed the hot water in the resident's room was hot enough to cause a third degree burn. The resident stated no injury had occurred. Interview on 12/21/16 at 11:24 a.m. with Resident #2 revealed the resident had hollered out during a bed bath the day before (12/20/16) when CNA D poured hot water, obtained from the sink in her room, over her legs. The resident stated CNA D was wearing gloves at the time and could not tell how hot the water was. The resident stated CNA D then worked directly from the basin after the incident and no longer poured the water directly on her. The resident stated no injury had occurred. During Confidential Resident Interview #3, it was revealed the water in the resident's room had been really hot for about a week. The resident stated he/she used more cold water as a result. The resident stated he/she did not notify anyone at the facility regarding the water being too hot in his/her room. The resident stated no injury had occurred. In an interview on 12/20/16 at 12:32 p.m., LVN A stated the maintenance staff members had been working on the hot water in the shower rooms for at least a week. LVN A stated not all shower rooms were affected and residents were taken to the Hall C shower that currently had warm water. In an interview on 12/20/16 at 1:15 p.m., CNA B stated one shower room always had warm water and another shower room had fluctuating hot and cold water. He stated the problem with the shower room water temperatures had gone on for about two weeks. In an interview on 12/20/16 at 5:15 p.m., CNA C stated there had been no problems with the water temperatures being too hot. She stated she had no knowledge of new blisters [MEDICAL CONDITION] residents during December 2016. In an interview on 12/20/16 at 5:18 p.m., CNA D stated she had given a resident a bed bath the other day. She stated the water could be too hot for a resident if she was not careful. She stated she was informed by other staff members that the water was hot and checked it before it was used on residents. In an interview on 12/20/16 at 7:50 p.m., LVN E stated she was unaware of high water temperatures at the facility. She stated there had been no new blisters [MEDICAL CONDITION] residents during December 2016. In an interview on 12/20/16 at 7:54 p.m., CNA F stated he was unaware of high water temperatures at the facility. He stated there had been no new blisters [MEDICAL CONDITION] residents during December 2016. In an interview on 12/21/16 at 11:10 a.m., LVN G stated no concerns had been brought to his attention regarding high water temperatures at the facility. He stated there had been no new blisters [MEDICAL CONDITION] residents during December 2016. In an interview on 12/21/16 at 11:16 a.m., CNA C stated no concerns had been brought to her attention regarding high water temperatures at the facility prior to 12/20/16. She stated she noticed the water temperatures were high in a resident's room at the beginning of her shift (2:00 p.m. to 10:00 p.m.) on 12/20/16 and she notified the nurse who informed her she was already aware of the concern. She stated there had been no new blisters [MEDICAL CONDITION] residents during December 2016. In an interview on 12/21/16 at 1:43 p.m., CNA H stated she noticed three days ago that the water in resident room 22 was too hot while washing her hands. She stated no one had reported the water being too hot to her. She stated she notified the Maintenance Director and LVN A regarding the water temperature being too hot and they both stated they would look into it. She stated there had been no new blisters [MEDICAL CONDITION] residents during December 2016. In an interview on 12/21/16 at 1:58 p.m., MA I stated she did not notice high water temperatures prior to 12/21/16. She stated there had been no new blisters [MEDICAL CONDITION] residents during December 2016. In an interview on 12/21/16 at 2:53 p.m., CNA D stated she first noticed the water was too hot on 12/19/16. She stated the water being too hot had been brought up in general conversation at the facility. She stated she made sure the hot water was mixed with cold water before using it on residents. She stated Resident #2 had mentioned the water was a little hot during a bed bath on 12/19/16. On 12/20/16 at 6:35 p.m. the Administrator and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 12/21/16, was accepted on 12/21/16 at 7:00 p.m. and reflected the following: PLAN OF REMOVAL The resident (sic) in all rooms were assessed by the DON. The residents were not negatively affected by the alleged practice. This failure has the potential to affect all residents. The hot water to all resident rooms was turned off on 12/20/16. Shower Room C which is located at the end of Hall C, between rooms 18 and 54; and the Shower Room B which is located at the end of Hall B across from the therapy office were left on for resident (sic) who needed or wanted an evening shower. Shower C is being manually locked by staff in-between showers to prevent resident's (sic) from entering the shower unattended. The maintenance director will continue to check the water temperatures daily in all rooms. The Administrator will monitor the maintenance logs daily until the hot water problems have been resolved. A local plumber came to the facility and assessed the problems. As of 12/21/16 all parts needed to repair the water heaters have been ordered. The new parts will be placed on the hot water heaters as soon as the parts arrive. The time the plumber said the parts would be delivered would be by the end of the week. Direct Care staff which consist of RN, LVN, CNA and (MA) who worked last evening and overnight were educated by the DON to use Shower Rooms B & C for the residents who needed or required showers. Direct Care Staff was also educated to test the water prior to giving showers by gently and cautiously running their hand under the water when the water is turned on. Direct Care Staff which consist of RN, LVN, CNA, and (MA) education will continue for staff prior to their returning to work (Staff will not be able to work until they have had training from the DON. DON will monitor training of staff.) Direct Care Staff was educated by the DON to immediately notify Maintenance or a supervisor when the water seems too hot for comfort and not to give the resident a shower if that occurs. Direct Care Staff will be educated to use the shower schedule to control the admission to the shower rooms To verify the facility implemented their Plan of Removal the following observations and interviews were obtained and the following records were reviewed. Observation on 12/20/16 at 7:02 p.m. revealed the hot water was turned off in resident rooms throughout the facility. All three shower rooms were locked and could not be accessed without staff assistance. An interview was conducted on 12/21/16 at 12:28 p.m. with the Administrator and DON. The DON stated head to toe assessments were done on 12/20/16 with all residents and the alert and oriented residents were interviewed as well regarding possible injuries from hot water. The DON stated the shower rooms were to remain locked to restrict resident access. The DON stated she had gone around the facility to inform staff members regarding the facility's corrective actions related to the hot water. The Administrator stated there was no written policy or procedure regarding water temperature checks. The Administrator stated it was standard for the water temperatures to be checked weekly. The Administrator and DON both stated the facility's hot water in resident use areas was to remain off until the plumber had cleared everything and the water heaters were working properly. Review of the facility's in-service training, provided on 12/21/16 by the DON, revealed LVNs, CNAs, MAs and housekeeping were in-serviced on room water temperatures, use of shower rooms, locking shower room doors, cutting off hot water in rooms, use of Halls B and C shower rooms for showers, and notifying the supervisor if water is too hot in the shower rooms or resident rooms. Interviews were conducted with LVN G, CNA B, CNA H, MA I, CNA D, LVN J, CNA F and MA L on 12/21/16 from 1:22 p.m. to 5:32 p.m. The staff members knew to keep the shower rooms locked and how to test the water temperature prior to resident use. The staff members also knew that the Maintenance Director had to be notified when water temperatures were too high. Review of a work order, dated 12/21/16, from a plumbing service and repair company, hired by the facility, revealed . Estimate to replace the gas control valve and burner Assembly on the Rheen - Ruud Commercial Gas water heater . We will also purchase an additional gas control valve for the nursing home to have on hand when needed. This estimate also includes same parts and installation for the AO Smith Commercial Gas heater . We will also purchase another gas control valve for the AO Smith unit so that will be on hand when needed. We will remove both units burner assembly's and gas controls valves and thoroughly clean each units combustions chambers and then install the new Gas control valves and burner assembly's. After these parts have been properly installed we will bring them on line and run them a series of test (sic) to ensure that (sic) are operating properly. (Plumbing service and repair company) will set these commercial gas water heaters to the manufacturers (sic) suggested temperatures. Should the (facility) management team require a higher temperature a member of their team will have to make the adjustment On 12/21/16 at 7:00 p.m., the Administrator was informed the IJ was removed. While the IJ was removed on 12/21/16, 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 widespread because the facility was still in-servicing staff, the water heaters had not been repaired and the facility was monitoring the implementation of the Plan of Removal. Review of the facility's daily census, dated 12/20/16, revealed a total census of 71 residents. Review of a list of residents who wandered at the facility, provided by the facility and dated 12/20/16, reflected the nine residents which respresented all three halls, including Resident #1.

Based on observation, interview and record review, the facility failed to ensure a reasonable accommodation of individual needs for one (Resident #6) of 15 residents who were reviewed for accommodation of needs. The facility failed to provide Resident #6 with a functioning wheelchair, which provided her left leg with a stable support and did not cause her pain. These failures resulted in Resident #6 refusing to get up in the wheelchair, no longer attending facility ativities, staying in bed, social withdrawal, and symptoms of Depression. These failures could affect the 41 residents, who used wheelchairs most of the time, and placed them at risk for social withdrawal, depression, and decreased self-worth. Findings included: Resident #6 was observed during the initial tour on 01/26/14 at 3:30 p.m., lying in her bed. She was alert and oriented, responded appropriately to questions and was dressed appropriately. The resident was tall and above average weight. At that time, Resident #6 stated she was paralyzed on the left side of her body. A slight hand contracture in her left hand was observed. The resident stated she was able to move her left arm with her right hand. Resident #6's Face sheet, dated 11/04/13, reflected she was an [AGE] year-old female, who was admitted into the facility on [DATE]. According to Resident #6's MDS assessment, dated 05/09/13, the resident's [DIAGNOSES REDACTED]. The resident's assessment reflected she had moderate cognitive impairment, with no behavioral symptoms present. The MDS assessment reflected it was important to Resident #6 to keep up with the news, to participate in her favorite activities and religious services or practices. At the time of admission, Resident #6 required limited assistance with bed mobility and personal hygiene; extensive assistance with transfers, dressing and toilet use; and was independent with eating and used a wheelchair for locomotion. Resident #6's Care Plan, dated 05/14/13, reviewed on 08/23/13, and 11/13/13, reflected a problem with Depression, Anxiety, Constipation, [MEDICAL CONDITION], and potential for skin breakdown. The approaches for these concerns included: encourage Resident #6 to be out of bed, encourage exercise, socialization, and activity attendance as tolerated. Resident #6's January 2014 physician's orders [REDACTED]. The psychologist's diagnostic assessment, dated 06/17/13, reflected the referral was due to verbal aggression and hostility, and a primary [DIAGNOSES REDACTED]. Resident #6's Psychological Services progress Note dated 01/15/14 reflected the new Presenting Behavior/Target Symptoms, which were not on the Treatment Plan dated 06/17/13: Appetite Disturbance, Hopelessness, Pain, Paranoia/Suspiciousness and Withdrawl. Resident #6's activities progress notes reflected the following: 08/22/13 - high level of participation in activities; 11/07/13 - participating in activities; 12/16/13 - has stopped wanting to come out of room so as of today she will begin in-room visits three times a week. An activity progress note from 01/27/14 reflected: "The resident had made a dramatic change in her activity participation. She used to attend 90% and now she will not come out of her room. Made several attempts to get her up and out of room and she makes an excuse why she can't. Still on 1:1 activities." Review of nursing notes from November 2013 through January 2014, did not reveal any issues with the resident's wheelchair, leg brace or ankle-foot orthotic. Nurse's notes dated 11/25/13 reflected the resident was up in her wheelchair. It was the last time it was documented by nursing the resident was up in her wheelchair. Documentation of Resident #1's participation in 1:1 activities was available for January 2014 only, and reflected the AD visited the resident twice a week for "socialization, conversation, television and movies." An interview with Resident #6 on 01/27/14 at 9:45 a.m. revealed, "There is no living here. There is only existing." The resident stated she used to have a custom electric wheelchair, but it was in storage. She stated the wheelchair the facility had provided for her did not fit as she was too tall, and it was a generic wheelchair. The resident stated she was paralyzed on her left side and had to use the left leg rest for the wheelchair; however, she could not lock it. Resident #6 stated the locking mechanism was broken on the wheelchair footrest and in order to attempt to secure it, she had to use her right arm, which could not reach that far. As a result, she said the leg rest would swing while she was sitting in the wheelchair, causing her significant pain. The resident also thought the unsecured leg rest caused her left knee to become misaligned. The resident stated even when the left leg rest lock was manually pushed into place by staff, the leg rest would still wobble. She said maintenance would fix the wheelchair periodically, but it was temporary. Resident #6 said the facility replaced her wheelchair sometime in the early fall, but it did not have leg rests. As a result, they put the old leg rests on her new wheelchair, which did not correct the problem she was having. She stated she did not watch a lot of television because her room was too bright, and there were no mini-blinds, so there was a glare on the television. When asked about attending activities, Resident #6 stated she did not participate in activities anymore. When asked about activities in her room, she stated she did not want any in-room activities, but would not mind if another resident wanted to come in and play cards. She stated she went to activities for a while, but the pain from sitting in the wheelchair had gotten "too bad." Resident #6 stated when she first came to the facility, she was able to walk with a hemi-walker and used her left side to propel, but the hemi-walker broke, and she was no longer able to use it in therapy. The resident stated she did not like taking pain medications because they caused constipation. She said her pain was on her left side from the hip down, and she had [MEDICAL CONDITION] in her left leg, which felt like pin pricks. She stated she needed staff assistance with transfers and with showering (such as cleaning her back and right arm and below the knees). Interview with the COTA, Director of Rehab, on 01/27/14 at 11:45 a.m., regarding Resident #6's history with physical therapy and occupational therapy at the facility, revealed it was his first day, and he was not aware of the resident or her needs. He was unable to locate a discharge plan for the resident when services were stopped several months prior. He was not aware of the resident's wheelchair and leg rest needing repair or replacement. Observation of the therapy room at that time did not reveal a hemi-walker. The COTA stated they did not have one, but he was in the process of compiling a list of items he needed the facility to order. An interview with the SW on 01/28/14 at 9:45 a.m. regarding Resident #6's lack of activity participation, revealed the resident was involved in activities previously in the facility. She said a new wheelchair had been ordered for the resident through maintenance and they were waiting on it. The SW did not know specifically what was wrong with Resident #6's wheelchair, except it may have been "crooked." The SW stated the resident's family member told the previous Administrator there was no storage facility and no custom electric wheelchair. The SW said she never observed the resident walking, and she always used a wheelchair, except maybe in therapy. An interview with the AD on 01/28/14 at 10:00 a.m. regarding Resident #6's activities over the past few months, revealed the resident had made references to her wheelchair being broken. When Resident #6's family member was called about the broken wheelchair, the family member told the AD the custom wheelchair was gone. This upset the resident, according to the AD. Resident #6 then started telling the AD her wheelchair was misaligned, and he told maintenance about it. The AD said the resident told him the wheelchair was twisting something on her leg or foot. Resident #6 also told him the leg brace did not fit well. The AD stated the resident liked Bingo; teaching other residents and staff new card games; wearing makeup and making jewelry; and she even "chased some younger men around the facility." The AD said Resident #6 used to go on group outings to a retail store and would also go by herself to a couple of grocery stores with the bus driver. He stated the resident typically drove her wheelchair backwards with her right foot. The AD stated Resident #6 missed one activity, then two, then more. He said the resident stopped activities in early December 2013 because she was in too much pain and her wheelchair was uncomfortable. He said maintenance had a wheelchair on order, but he did not know the status of it. The AD stated he changed her to one-on-one in-room activities in December 2013. He said he visited Resident #6 about three times a week for 30 minutes and he normally watched TV with her or just sat and talked with her. In an interview with the Maintenance Director on 01/28/14 at 10:45 a.m., he stated Resident #6 came to the facility with a wheelchair from a nursing facility across the street. He ordered her another one, but the wheel broke. He stated he replaced the wheel and had to periodically fix her wheelchair and leg rests. He said the current leg rests were hard to latch. Observation of Resident #6's wheelchair and leg/foot rests at that time revealed the Maintenance Director put the left leg rest on the chair, and it would not automatically lock into place. He had to push the lever with some force to keep the leg rest fixed. The surveyor also tried to lock the leg rest, and it would not lock. The Maintenance Director stated even when the leg rest was manually locked into place, it could still move. At that time, Resident #6 confirmed this was what occurred. She stated the leg rest would unlock after a while, which made her left leg pull out to the left of her body, causing her a lot of pain. The Maintenance Director provided a receipt for a wheelchair he had ordered for the resident a few days prior. He stated the new wheelchair would be able to be adjusted to her height and had longer leg rests. Review of the Maintenance Logs from 10/25/13 through 01/27/14 revealed no requests or repairs were completed on Resident #6's wheelchair. On 01/28/14 at 11:00 a.m., an interview with the Direct Supply representative revealed a wheelchair was ordered that morning by the facility, not several days prior. The order was for a Panacea heavy-duty wide wheelchair with detachable arms and elevating leg rests. The representative stated it should arrive at the facility within a week. The DON and Administrator were interviewed together on 01/29/14 at 5:10 p.m. The DON stated Resident #6 had never complained to her about her wheelchair or adaptive aids being an issue. The ADM stated he was in contact with a mobility company regarding the possibility of getting the resident a new electric wheelchair. The DON stated the resident used to be active in activities. An interview on 01/29/14 at 5:25 p.m. with the Psychologist, regarding Resident #6, revealed she was down and depressed and was a "chronic complainer." He stated sometimes she was able to see the bright side of life, and then the next visit she would be depressed. He revealed the resident told him she was depressed because she was in pain. He thought that might be due to her left side weakness and bladder spasms. He recalled she discussed having leg pain from using her wheelchair, but he thought she just really did not want to get out of bed, and she just wanted to be taken care of. The Psychologist revealed he initially saw her in June or July 2013 and then stated, "She blew me off for a while." The resident then saw one of his assistants for a couple of months for psychotherapy, and recently he started seeing her for a couple of sessions. An interview on 01/29/14 at 6:05 p.m. with the SW revealed when a resident was exhibiting signs of isolation, it was her role to check and see if there was a concern with Depression, and refer the resident to psychiatric services, which the resident was already receiving. The SW stated she would complete a BIMS and mood score if the resident was on the schedule to have one done, but Resident #6 was not. She also stated her role was to go and talk to the resident about the depression. The SW was queried about when she noticed Resident #6 was isolating herself. She responded she had noticed Resident #6's self-isolation about two to three weeks ago. The SW revealed the resident was talking at that time about her wheelchair and being unable to use it. The SW stated she brought it to the attention of staff at the morning meeting and maintenance was going to look at the wheelchair and possibly order a new one. The SW stated, "I can say I haven't seen her as much as I should. I have seen her a couple of times, but not for anything in particular except that one time about her wheelchair." Interview with LVN I on 01/30/14 at 9:45 a.m., revealed she thought Resident #6 was depressed. She stated the resident refused to get out of bed, wore a brief, and did not use staff assistance to go to the bathroom. LVN I said the last time she saw Resident #6 was up in her wheelchair was last week. LVN I stated she was aware the resident had a leg brace, but had not been told it was broken. She said the resident had never mentioned her wheelchair was broken. She stated the resident used to be up in her wheelchair often, wearing sparkly makeup. Resident #6 was interviewed on 01/29/14 at 12:20 p.m., and a full length left leg brace was observed leaning against the wall in her room. When asked about the leg brace, she stated she was supposed to wear the leg brace whenever she was up in her wheelchair, and it was supposed to keep her leg from hyper-extending, but it did not. She also stated she was supposed to wear an ankle-foot-orthotic, but it did not work either because the Velcro fasteners were worn out, so she threw it away. Resident #6 said the previous therapist was notified of the issues she was having with her adaptive aids. When asked about receiving assistance with toileting, the resident stated toileting was scary because the floor was slick, but the aides helped her transfer. She stated when she came to the facility, her leg was not turning out, and it only happened once she received a wheelchair the facility provided after admission. Resident #6 was asked when she was last able to walk without assistance, and she responded only in therapy with the use of the bars and in the hall using the rails. She stated she had the use of a hemi-walker during therapy (for balance on left leg), but one of the rubber [MEDICATION NAME] came off, and it could no longer be used. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the MDS Coordinator on 01/27/14, reflected 41 residents used a wheelchair most of the time.

Based on observation, interview, and record review, the ADM and the DON failed to administer the facility in a manner, which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for six (Residents #7, #12, #13, #17, #18 and #19) of six residents reviewed for quality of care. The Administrator failed to ensure the facility's Infection Control p/p were implemented. The Administrator failed to supervise and monitor the DON: to ensure nursing services were provided in a manner to promote the overall well-being of six (Residents #7, #12, #13, #17, #18 and #19) of six residents reviewed for quality of care. to ensure IV therapy services were provided by qualified nurses. to ensure implementation of the facility's Infection Control p/p. The DON failed to supervise and monitor staff for implementation of the facility's Infection Control program. The DON failed to train, supervise, apprise and monitor staff for their technique used to handle PICC lines. The DON failed to supervise, apprise and monitor staff when it was learned Residents #17 and #7 had [DIAGNOSES REDACTED]. The following failures were identified: 1) Facility staff were unaware Resident #17 had a [DIAGNOSES REDACTED]. When orders were received for contact isolation, they were not immediately implemented as LVN D provided care for Resident #17 without sanitizing/washing her hands, wearing a mask, a cap, a gown and shoe covers. 2) During the provision of care for Residents #17, #19, #18, and #13, LVN C failed to wash/sanitize her hands, wear gloves, a gown, a cap, a mask or shoe covers; she carelessly allowed PICC line ports to become contaminated; and contaminated supplies. 3) LVN D did not wash/sanitize her hands, wear a mask, cap, gown or foot covers when providing care for Resident #17, she contaminated supplies, and carelessly allowed PICC line ports to become contaminated. 4) Staff was unaware Resident #7 [MEDICAL CONDITION] until surveyor intervention and was not included on the facility's Infection Control Log. 5) Resident #12 was [MEDICATION NAME](antibiotic) for an infection, but it was not effective against either organism identified as causing the infection. 6) The facility failed to ensure the Infection Control Program included a review of antibiotics to monitor and identify the infection/causative agent being treated and the appropriate use of antibiotics. An Immediate Jeopardy was identified on 02/22/13. While the Immediate Jeopardy (IJ) was removed on 02/25/13, the facility remained out of compliance at a scope of "widespread" and at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" due to the facility continuing to inservice staff and monitor the implementation of the plan of removal. These failures could affect the facility's 78 residents and placed them at risk for contamination of wounds, contamination of PICC lines, cross-contamination between residents and staff and other residents, resulting in the spread or development of infections, requiring contact isolation resulting in decreased socialization, causing a delay in the healing process, requiring hospitalization for further treatment, onset of depression, and even death. Findings included: Per Administrative Review on 03/07/13, it was determined the surveyors needed to return to the facility for further investigation. 1) Resident #17's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE]. The MDS assessment reflected Resident #17 was cognitively intact. The MDS assessment reflected current diagnoses, which included: Hypertension, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION], Depression, [MEDICAL CONDITIONS] and Abscess, [MEDICAL CONDITION] Reflux and Anxiety. Further review of the MDS assessment revealed Resident #17 was independently mobile in the facility, but required assistance with dressing. The MDS assessment also reflected Resident #17 had a Stage III pressure ulcer with slough, which was present upon admission. On 02/22/13 at 1:15 p.m., the surveyor spoke with the resident. The surveyor found the resident to be alert and oriented and responded to questions appropriately and intelligently. When asked about activities, Resident #17 told the surveyor he enjoyed reading and did not like to attend group activities, but preferred activities in his room. Review of a transfer form, dated 02/06/13, revealed Resident #17 was transferred to the hospital for evaluation of his pressure ulcer located on the outside of his right foot. On 02/25/13 at 9:40 a.m., LVN E was observed providing treatment to the pressure ulcer on Resident #17's right foot. The surveor observed brown exchar covering approximately half of the wound bed of the resident's pressure ulcer. The pressure ulcer was approximately 1.5 cm by 1.5 cm with redness and swelling of the skin surrounding the pressure ulcer. The pressure ulcer had purulent drainage. The rest of the foot had very dry, scaly skin. An admission order dated 02/20/13 reflected Resident #17 was re-admitted to the facility on [DATE]. The admission orders [REDACTED]. A peripherally inserted central catheter (PICC) line is a long, slender, small, flexible tube inserted into a peripheral vein, typically in the upper arm. The PICC line is advanced up the vein until the catheter tip (end of the PICC line) reaches a large vessel near the heart to gain central venous access. The PICC line may have a single or multiple lumens for different purposes. Retrieved on 03/21/13 from http://picclinenursing.com/pic_why.html. Resident #17's telephone order dated 02/21/13 reflected the physician's standing orders to: 1) Flush PICC line with 10 cc normal saline before and after medication. 2) Flush PICC line with 3 cc [MEDICATION NAME] after medication administration. 3) Change PICC line dressing every three days. Another telephone order written by the DON, dated 02/21/13, reflected a contradictory order to flush the PICC line with 10 cc normal saline and 5 cc [MEDICATION NAME] following a blood draw. On 02/22/13 at 1:00 p.m., the surveyor asked ADON A what the facility protocol was for using [MEDICATION NAME] flushes. ADON A stated the facility protocol called for 3 ml of [MEDICATION NAME] for flushes. The DON was interviewed on 02/22/13 at 3:40 p.m. regarding the facility's procedures for flushing PICC lines. At that time, the DON stated she used 10 cc of NaCl and 5 ml of [MEDICATION NAME] to flush the red port on the PICC line to unclog it. The surveyor asked the DON if she had written the telephone order to use 5 cc to flush the PICC line. The DON stated she did. The surveyor inquired if 5 cc of [MEDICATION NAME] was the normal facility policy for flushing PICC lines. The DON stated the facility policy was for 3 cc of [MEDICATION NAME], and she was going to change the order immediately to use 3 cc of [MEDICATION NAME] for flushes. On 02/21/13 at 1:15 p.m., the surveyor observed LVN C enter Resident #17's room without washing/sanitizing her hands, putting on gloves, wearing a mask, gown, cap or shoe covers. Observation of Resident #17's room revealed there was no stand outside of the resident's room, which contained gloves, masks, gowns, caps or shoe covers. There were no containers inside the resident's room for contaminated linen or trash. LVN C checked the bag of IV [MEDICATION NAME] hanging on a pole and stated it had finished infusing. LVN C came back to the nurse medication cart by the door in the hallway and obtained two alcohol pads, one 6 cc syringe of [MEDICATION NAME] and two 10 cc syringes of normal saline and then reentered the resident's room. LVN C opened the two syringes of normal saline and the syringe with [MEDICATION NAME]. The LVN also removed the caps from the syringes. LVN C placed the syringes on Resident #17's overbed table at the bed side, which she had not cleaned or covered with a clean barrier. LVN C then tried to disconnect the IV tubing from the PICC line, but was unsuccessful. LVN C then wiped both of her (bare) hands on her uniform pants and continued to attempt to disconnect the tubing from the PICC line's purple port (used for administration of the [MEDICATION NAME]). After finally disconnecting the IV tubing from the purple port, LVN C cleaned the purple port with an alcohol pad. LVN C had not washed or sanitized her hands and was not wearing gloves. LVN C then picked up the uncapped syringe with the normal saline from the overbed table, and without priming the syringe to remove the air, she flushed the purple port. LVN C dropped the PICC purple port allowing it to dangle. The tip was observed coming in contact with the resident's skin. LVN C then picked up the uncapped [MEDICATION NAME] syringe from the overbed table and again, without priming it to remove the air, LVN C flushed the line with five cc of [MEDICATION NAME] (instead of only three cc). LVN C left Resident #17's room without washing or sanitizing her hands and returned to the nurse's station. LVN D was observed on 02/22/13 at 10:00 a.m. to pull the nurse medication cart close to Resident #17's room. LVN D took from the cart one bag of [MEDICATION NAME], IV tubing, dial-a-flow tubing, alcohol wipes, gloves, two syringes with normal saline and one syringe containing [MEDICATION NAME]. LVN D entered the room and set her supplies on Resident #17's overbed table. LVN D had not cleaned the overbed table or covered it with a clean barrier. Without washing/sanitizing her hands, LVN D donned gloves but did not put on a gown, cap, mask or shoe covers. The LVN rolled the resident's sleeve up on his left upper arm. LVN D used an alcohol swab to clean the PICC line's red port (used for blood draws) first and then the purple port. She dropped both ports, allowing them to dangle, while she opened up the syringes she had brought into the resident's room. The surveyor observed both ports come in contact with the resident's sleeve. LVN D then connected the syringe with normal saline to the red port, without recleaning it and without priming the syringe to remove the air in the syringe. When the surveyor queried whether the LVN had checked the PICC line for patency (because she had not observed the LVN to do so), LVN D replied she had checked for patency, had pulled back and had obtained a blood flash in the tube. However, when LVN D tried to flush the red port, she was unable to flush the line as the PICC line's red port was clogged. LVN D then picked up the purple port she had cleaned earlier (which had then come into contact with the resident's sleeve), opened the syringe and without priming the syringe and/or re-cleaning the port, flushed the PICC line's purple port with 10 cc of normal saline. (Note: [MEDICATION NAME] was for flushing after the PICC line medication had infused.) LVN D picked up the bag of [MEDICATION NAME], which the label indicated contained [MEDICATION NAME], one gram in 250 cc of normal saline and was to be infused per IV over one hour every twelve hours. The surveyor observed LVN D open the small medication vial in the IV bag mixing the white, powdered [MEDICATION NAME] by shaking it, but bag still had clumps of the [MEDICATION NAME] undissolved in the bag when LVN D spiked the bag and hung it on the IV pole for administration. LVN D then set the medication on the dial-a-flow tubing to run at 125 cc/hr for one hour; (note: the correct setting should have been 250 cc/hr to run over one hour) the medication would infuse over an hour. After hanging the medication for administration, LVN D removed her gloves, but did not wash/sanitize her hands. She picked up six syringes: three unopened syringes (now contaminated from being in Resident #17's room), which LVN D had found in the room, and her three syringes, one of [MEDICATION NAME] and two of normal saline from Resident #17's room and returned to the nurse medication cart. After writing on Resident #17's February 2013 MAR, LVN D then placed the three unopened syringes back into the nurse medication cart, contaminating it, and pushed the cart back to the nurse's station. On 02/22/13 at approximately 10:45 a.m., during an interview with LVN D, LVN E and ADON A, when the surveyor asked why Resident #17 was being given [MEDICATION NAME], they confirmed the resident had Osteo[DIAGNOSES REDACTED]. The surveyor queried whether the facility had information from the resident's discharging hospital identifying the resident's Osteo[DIAGNOSES REDACTED]. ADON A stated she would call the hospital for further information about Resident #17. At that time, ADON A called the discharging hospital and was told Resident #17 was on contact isolation while he was in the hospital and was being treated for [REDACTED]. ADON A was observed to become angry with the person she was speaking to at the hospital, because the hospital did not provide the facility with the resident's [DIAGNOSES REDACTED].#17's right foot pressure ulcer. MRSA causes infections in different parts of the body and is tougher to treat than most strains of staph, because it's resistant to some commonly used antibiotics. [MEDICAL CONDITION] can cause serious kin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract. [MEDICAL CONDITION] infections can be life-threatening. Because it's hard to treat,[MEDICAL CONDITION] is sometimes called a "super bug." [MEDICAL CONDITION] is spread by contact with touching another person or touching objects contaminated [MEDICAL CONDITION]. Retrieved on 03/21/13 from http://www.webmd.com, "[MEDICAL CONDITION] Infection -- the Basics." Residents on contact isolation with contact precautions have an infection such [MEDICAL CONDITION] or VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]). Procedures for contact isolation include the use of PPE (personal protective equipment), which include wearing special gear, such as gloves, goggles or mask, gown, cap and/or shoe covers. A sign at the resident's room would reflect PPE was required or to see the nurse before entering the resident's room. Contact isolation also includes the proper handling and disposal of infected waste and materials. Retrieved on 03/19/13 from www.ehow.com/info_ 24_protocols-contact-precautions.html. Resident #17's hospital records included a transcription from Physician Q dated 02/20/13, which indicated the resident's right foot pressure ulcer was infected [MEDICAL CONDITION]. The bone biopsy was negative [MEDICAL CONDITION], but as the pressure ulcer was tracking to the bone, Resident #17 had been given a clinical [DIAGNOSES REDACTED]. Physician Q recommended treatment for [REDACTED]. Observation on 02/22/13 at 3:45 p.m. revealed Resident #17's IV [MEDICATION NAME] had finished infusing. Observation of the hall outside Resident #17's room revealed there was no stand containing PPE for staff and visitors to use. There was no sign directing visitors to the nurses' station. Inside the room, Resident #17's roommate was still there. There were no containers noted for disposal of contaminated linen or trash. LVN D moved the nurse medication cart to the resident's door, removed two syringes of NaCl and one syringe of [MEDICATION NAME] from the cart and entered Resident #17's room. In the room, LVN D donned gloves without washing/sanitizing her hands. The LVN did not wear any mask, cap, gown or shoe covers. LVN D disconnected the empty bag of [MEDICATION NAME]. LVN D cleaned the purple port and left it hanging. As LVN D turned around to open the syringe with NaCl, the surveyor observed the port touch Resident #17's upper arm and sleeve. Without recleaning the port, LVN D flushed the PICC line with NaCl and then tried to flush the PICC line with [MEDICATION NAME]. After several attempts, leaving the resident's room without washing her hands and returning with extra [MEDICATION NAME], LVN D flushed the port with approximately 2.5 cc of [MEDICATION NAME] (not the 3 cc orderd by the physician). LVN D then left the resident's room without washing/sanitizing her hands. (Note: the facility had already found Resident #17 was infected [MEDICAL CONDITION] at that time and he was not in contact isolation.) Resident #17's care plan dated 01/17/13 was reviewed again on 02/25/13. The care plan still had not been updated to address the resident's pressure ulcer,[MEDICAL CONDITION] infection, contact isolation, and PICC line. No other care plan was provided for Resident #17 prior to the survey team's exit from the facility on 02/25/13. 2) During initial rounds on 02/20/13 at 10:10 a.m., ADON O had described Resident #19 as ambulatory, continent and confused. Resident #19's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old male, was admitted on [DATE]. The MDS assessment indicated the resident had no difficulty expressing his wants and needs, was able to understand what was said to him and cognitively independent with decision-making. The MDS assessment reflected the resident was independent with ADLs required the assistance of one person to move in bed, to transfer, for personal hygiene, to eat and had a tube feeding, which provided 25% or less of the total calories needed throughout the day. The MDS assessment reflected Resident #19 was independent with mobility, dressing and toileting. Resident #19's comprehensive plan of care, which was updated 02/13/13, did not address the resident's [DEVICE]. LVN C was observed on 02/21/13 at 9:20 a.m. preparing to flush Resident #19's [DEVICE]. LVN C picked up a cup from the nurse medication cart and entered his room. LVN C went to the bathroom and filled the cup with water from the sink. LVN C did not wash/sanitize her hands or put on gloves. LVN C then checked for placement of the [DEVICE] and gave a 60 cc water flush through the [DEVICE]. When LVN C finished with the flush, she tugged on her uniform top to pull it down, got a paper towel, clamped the [DEVICE], dried the resident and returned the syringe and plunger to the plastic bag. LVN C then left the resident's room without washing/sanitizing her hands. 3) The Admission Record dated 10/11/11 reflected Resident #18, a [AGE] year-old male, was admitted on [DATE]. Review of Resident #18's February 2013 consolidated physician's orders [REDACTED]. FSBS were included to be conducted twice a day and orders were included for sliding scale [MEDICATION NAME] regular insulin. Resident #18's MDS assessment dated [DATE] reflected the resident was able to express his wants and needs, was able to understand others and was moderately impaired cognitively. The MDS assessment further reflected the resident was independent with all ADLs except for set-up help with eating and support during bathing. Resident #18's Comprehensive Plan of Care dated 04/12/12 reflected the resident's [DIAGNOSES REDACTED]. On 02/21/13 at 11:30 a.m., the surveyor observed LVN C enter Resident #18's room to conduct a fingerstick blood sugar check using a glucometer. LVN C did not wash her hands/conduct hand hygiene prior to starting the procedure, and she did not wear gloves. With her bare hands, she cleaned Resident #18's second finger on the right hand with an alcohol pad and lanced the finger to obtain a blood sample. After obtaining the blood sample, LVN C placed an alcohol pad directly onto the resident's bleeding finger. After a few seconds, she took the alcohol pad off and was observed rolling the blood-soiled pad between her fingers, transferring some of the blood to her fingers. LVN C left Resident #18's room, disposing of the lancet, strip and alcohol pad in the sharps container, and then returning the glucometer to a drawer inside the general-use cart. The LVN picked up two glucose testing strips (used with the glucometer), which had not been used from the top of the nurse's medication cart and replaced them in the community container of glucose testing strips. LVN C did not clean her hands, which were now soiled with Resident #18's blood, and she did not clean the glucometer. LVN C then left Resident #18's room and went directly to Resident #13's room. 4) Resident #13's Admission Record dated 03/08/13 reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE] with an original admission date of [DATE]. Resident #13's February 2013 consolidated physician orders [REDACTED]. Resident #13's MDS assessment dated [DATE] reflected he was able to make his needs and wants known, understood what was said to him, and was moderately impaired cognitively. The MDS assessment reflected the resident was independent with all ADLs. Diabetes Mellitus was identified as a current diagnosis. Resident #13's Comprehensive Plan of Care originally dated 03/22/12 and updated on 02/23/13 reflected the most current change in the resident's orders for FSBS. On 02/21/13 at 11:40 a.m., LVN C was observed leaving Resident #18's room going directly to Resident #13's room for FSBS monitoring. LVN C did not wash/sanitize her hands before removing the glucometer from the cart. LVN C was then observed to clean the glucometer with a Sani-wipe towel. (SANI-WIPE Hand Sanitizer Towels sanitizes and conditions skin, while eliminating germs and bacteria.) She removed a glucose test strip from the container and placed it in the glucometer. LVN C entered Resident #13's room and did not wash/sanitize her hands or put on gloves. LVN C cleaned and lanced Resident #13's second finger on the right hand to get a blood sample for the glucometer. The surveyor again observed LVN C, who was still not wearing gloves and again handling the alcohol pad, which was soiled with Resident #13's blood, rolling the pad with her fingers. She disposed of the lancet, strip and alcohol pad in the sharps container. LVN C then placed the glucometer in the drawer of the cart without cleaning it. The surveyor asked LVN C when she was going to clean the glucometer. LVN C stated she cleaned the glucometer before she used it, but not afterwards. Without washing and/or sanitizing her hands, LVN C was then observed to go to the nurse's station, where she sat down. She still did not wash/sanitize her hands. 5) Review of the CDC article dated 03/11/05 entitled "Transmission of [MEDICAL CONDITION] Virus Among Persons Undergoing Blood Glucose Monitoring in Long-Term-Care Facilities - Mississippi, North Carolina, and Los Angeles County, California 2003-2004," revealed the following recommendations: "...If a glucometer used for one patient must be reused for another patient, the device must be cleaned and disinfected. Glucometers and other environmental surfaces should be cleaned regularly and whenever contamination with blood or body fluids occurs or is suspected... Because of possible inadvertent contamination, unused supplies and medications taken to a patient's bedside during fingerstick monitoring or insulin administration should not be used for another patient... Perform hand hygiene (i.e. hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other patients." 6) On 02/20/13 at 9:35 a.m., the surveyor observed Resident #7 during the initial rounds in his room. His roommate was present. LVN B stated Resident #7 was alert and oriented to person, place and time, used the wheelchair for mobility in the facility, and was non-weight bearing due to having surgeries on both legs. LVN B stated Resident #7 had a non-union of the bones and would require more surgeries. The surveyor observed Resident #7 with a PICC line with a double lumen in his right upper arm. A bag of [MEDICATION NAME] 1 gm was infusing at that time. The Nursing 2012 Drug Handbook, copyright 2012 by Lippincott, Williams and Wilkins, page 1383, reflected [MEDICATION NAME] is ordered for "serious or severe infections when other antibiotics are ineffective or contraindicated, including those caused by [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA)...." Resident #7's facility admission orders [REDACTED]. Resident #7's MDS assessment dated [DATE] reflected the resident was able to express his wants and needs, was able to understand what was said to him and was moderately impaired cognitively. The MDS assessment further reflected the resident was independent with all ADLs except for receiving support when bathing. Resident #7's Comprehensive Plan of Care dated 12/14/12 reflected the resident was receiving IV antibiotic therapy. During an interview on 02/20/13 at 2:30 p.m., Resident #7 stated he was in a motor vehicle accident and hurt both legs, and they required surgery on both legs. Resident #7 stated he had two infections in his legs. He said the hospital Infectious Disease physician he saw in the hospital told him he had "MRSA and Staph" in his surgical wounds, which "got into his bones." On 02/21/13 at 1:35 p.m., the wound care nurse, LVN E, was observed providing wound care to Resident #7's right knee. LVN E was using gloves but no other PPE such as a mask, cap, gown or foot covers. The right knee incision had staples and had bloody drainage. The right shin had two incisions with staples. Resident #7's left leg also had bloody drainage from the foot, which was draining from the incision site. The left shin had an incision with a black scab on it. During the wound care, Resident #7 stated he was told by the infectious disease doctor in the hospital he [MEDICAL CONDITION] and a Staph infection. LVN E told the resident he had Osteo[DIAGNOSES REDACTED] and [MEDICAL CONDITION]. In an interview on 02/21/13 at 2:00 p.m., LVN B, LVN E and ADON A all confirmed Resident #7 was treated for [REDACTED]. They agreed the hospital did not tell them the resident had another infection. On 02/22/13 at 5:20 p.m., the surveyor interviewed the ADM about Resident #7 being administered [MEDICATION NAME] and whether the resident had a [DIAGNOSES REDACTED]. On 02/25/13 at 1:00 p.m., the ADM provided the surveyor a copy of Resident #7's hospital record, which was dated 02/08/13. Review of the Progress Notes dated 02/06/13 revealed the physician from Infectious Disease documented: "...Remains on vanc ([MEDICATION NAME]) and [MEDICATION NAME] osteo (Osteo[DIAGNOSES REDACTED]) L tibia." However, review of the facility's Infection Control Log for November, December 2012, January and February 2013 r02/21/13 revealed Resident #7 was not included on the log for infection. ADON A added his name during a discussion on 02/21/13, saying she had forgotten to add the resident to the facility's Infection Control Tracking Log. 7) Resident #12 was initially observed during rounds with ADON A on 02/20/13 at 9:25 a.m. resting in bed. ADON A stated the resident was incontinent of bowel/bladder, confused at times and required total assistance with all ADLs. The Admission Record dated 03/08/13 reflected Resident #12, an [AGE] year-old female, was originally admitted on [DATE] and readmitted on [DATE]. Resident #12's MDS assessment dated [DATE] reflected she had no difficulty communicating her wants and needs, was able to understand what was said to her and was moderately impaired cognitively. Further review revealed Resident #12 required staff assistance with all ADLs and was always incontinent of bladder and bowel. Resident #12's Comprehensive Plan of Care dated 02/18/13 reflected the resident had a UTI and was to [MEDICATION NAME](antibiotic) 250 mg by mouth for ten days. A physician's telephone order dated 02/18/13 for Resident #12 reflected an order for [REDACTED]. Review of the facility's Infection Control Logs dated 02/18/13 revealed Resident #12 was receiving the [MEDICATION NAME] treat the UTI. According to the log, the resident was not experiencing any symptoms, a urine specimen had been cultured and the results were pending. However, the organism(s) had not been identified prior to Resident #12 receiving the antibiotic. Review of Resident #12's UA dated 02/18/13 revealed a urine specimen had been collected on 02/17/13, and the lab notified the facility of the results on 02/18/13. According to the report, Resident #12's urine was cloudy, contained a small amount of Leukocytes, and bacteria were too numerous to count. The UA had a notation indicating the physician had reviewed the report on 02/19/13. The surveyor reviewed Resident #12's entire clinical record looking for the final lab results from the resident's UA with the C&S, which would identify the bacteria causing the infection, but it was not on the chart. A copy of Resident #12's UA with C&S was requested from LVN B on 02/25/13 at 9:30 a.m. The LVN was unable to locate the final results of Resident #12's UA with C&S, and said she did not know why the report was not in the resident's clinical record. At that time, LVN B checked the computer and found Resident #12's UA with C&S in the computer and printed the report. LVN B reviewed the report and stated the [MEDICATION NAME] "good" for the identified organisms. The surveyor requested a copy of the report to review. The final report for the UA with C&S was dated 02/21/13. The report reflected the organisms Escherichia coli (bacteria found in the colon) and [MEDICATION NAME] faecalis (bacteria found in the GI tract) were identified in the resident's urine, which indicated the infection was from the bowel. The report further reflected both organisms were resistant to Cipro, the antibiotic Resident #12 was currently receiving. On reviewing Resident #12's C&S with LVN B, the surveyor queried whether the resident's physician had been provided the final report for review or whether he had been informed the organisms in the resident's urine were resistant to Cipro. LVN B acknowledged the organisms were resistant [MEDICATION NAME] said Resident #12's physician had not been provided the C&S report or been informed of the organisms' resistance to Cipro. Resident #12's February 2013 MAR indicated [REDACTED]. On 02/25/13 at 10:15 a.m., LVN B stated she had notified the physician and had received new orders to [MEDICATION NAME] start the antibiotic [MEDICATION NAME] (antibiotic) 100 mg by mouth two times a day for ten days to treat Resident #12's UTI. Review of Resident #12's Comprehensive Plan of Care on 02/25/13 revealed it was updated on 02/25/13. [MEDICATION NAME] been discontinued on 02/25/13 and [MEDICATION NAME] ([MEDICATION NAME]) 100 mg had been ordered to be given twice a day for ten days. 8) During a confidential interview, when queried about reporting the results of lab reports to the physicians, he/she told the surveyor there was no working system, which ensured nursing staff and/or physicians were informed of lab results. He/she stated the staff was expected to remember which labs were collected and then follow-up to ensure the lab results were received. He/she stated following up on lab results was difficult, because the logs at the nurses stations were not updated with current information, and the 24-hour nurses report did not always include information regarding the residents' labs, whether it was the results of the lab or the need to follow-up on lab work. During an interview on 02/25/13 at 10:10 a.m., the DON stated there had been problems with the facility's contracted lab providing her with a list of the residents, who had lab specimens collected. According to the DON, lab collections and pending results should have been documented on the nurses' twenty-four hour report. The DON further stated there was a log at each nurse's station of the orders received for lab work. 9) The surveyor int

Based on observation, interview and record review, the facility failed to ensure services provided by two (LVNs C and D) of four LVNs observed providing care for one (Resident #17) of two residents reviewed with PICC lines and for four (Residents #17, #19, #18 and #13) of six residents reviewed for quality of care met professional standards of care within their scope as LVNs. 1) During the provision of care for Residents #17, #19, #18, and #13, LVN C failed to wash/sanitize her hands and wear gloves, a mask, a cap, a gown or shoe covers as needed; she carelessly allowed PICC line ports to become contaminated; she contaminated supplies used for PICC lines and FSBS; did not clean the glucometer appropriately, she did not attend facility inservices on infection control, ensure she received training for PICC lines and/or use Universal Precautions/Contact Isolation. 2) During the provision of care for Resident #17, LVN D failed to wash/sanitize her hands before wearing gloves, did not wear a mask, a cap, a gown or shoe covers as needed; failed to implement Contact Isolation for Resident #17 when it was found he [MEDICAL CONDITION]; she contaminated supplies, carelessly allowed PICC line ports to become contaminated, she did not attend facility inservices on infection control, ensure she received training for PICC lines and/or use Universal Precautions/Contact Isolation. An Immediate Jeopardy was identified on 02/22/13. While the Immediate Jeopardy (IJ) was removed on 02/25/13, the facility remained out of compliance at a scope of "widespread" and at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" due to the facility continuing to inservice staff and monitor the implementation of the plan of removal. The facility's failures to ensure LVN C and LVN D implemented Universal Precautions/Contact Isolation, and were trained to provide care for residents with PICC lines could affect the facility's 78 residents, placing them at risk for cross-contamination, infection, the potential spread [MEDICAL CONDITIONS], the need for ever stronger antibiotics, hospitalization and even death. Findings included: Per Administrative Review on 03/07/13, it was determined the surveyors needed to return to the facility for further investigation. 1) The Position Statement from the Board of Nursing, reviewed January 2013, included the following: "15.3 LVNs Engaging in Intravenuous Therapy, Venipuncture, or PICC Lines The basic educational curriculum for Licensed Vocational Nurses (LVNs) does not mandate teaching of principles and techniques of insertion for peripheral intravenous catheters, or the administration of fluids and medications via the intravenous route. Knowledge and skills relating to maintaining patency and performing dressing changes of central line intravenous catheters is also not mandated as part of basic LVN education. As such, basic competency in management of intravenous lines/intravenous therapy is not a given for any specific LVN licensee." "Position Statement 15.27, The Licensed Vocational Nurse Scope provides additional clarification of the Standards Rule as it applies to LVN Scope of Practice. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow a LVN to expand his/her scope of practice to include intravenous therapy. It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including Venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON does not define or set qualifications for an "IV Validation Course" or for "LVN IV certification." The LVN who chooses to engage in intravenous therapy must first have been instructed in the principles of intravenous therapy congruent with prevailing nursing practice standards." 2) Resident #17's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE]. The MDS assessment reflected Resident #17 was cognitively intact. The MDS assessment reflected current diagnoses, which included: Hypertension, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION], Depression, [MEDICAL CONDITIONS] and Abscess, [MEDICAL CONDITION] Reflux and Anxiety. Further review of the MDS assessment revealed Resident #17 was independently mobile in the facility, but required assistance with dressing. The MDS assessment also reflected Resident #17 had a Stage III pressure ulcer with slough, which was present upon admission. On 02/22/13 at 1:15 p.m., the surveyor spoke with the resident. The surveyor found the resident to be alert and oriented and responded to questions appropriately and intelligently. When asked about activities, Resident #17 told the surveyor he enjoyed reading and did not like to attend group activities, but preferred activities in his room. Review of a transfer form, dated 02/06/13, revealed Resident #17 was transferred to the hospital for evaluation of his pressure ulcer located on the outside of his right foot. On 02/25/13 at 9:40 a.m., LVN E was observed providing treatment to the pressure ulcer on Resident #17's right foot. The surveor observed brown exchar covering approximately half of the wound bed of the resident's pressure ulcer. The pressure ulcer was approximately 1.5 cm by 1.5 cm with redness and swelling of the skin surrounding the pressure ulcer. The pressure ulcer had purulent drainage. The rest of the foot had very dry, scaly skin. An admission order dated 02/20/13 reflected Resident #17 was re-admitted to the facility on [DATE]. The admission orders [REDACTED]. A peripherally inserted central catheter (PICC) line is a long, slender, small, flexible tube inserted into a peripheral vein, typically in the upper arm. The PICC line is advanced up the vein until the catheter tip (end of the PICC line) reaches a large vessel near the heart to gain central venous access. The PICC line may have a single or multiple lumens for different purposes. Retrieved on 03/21/13 from http://picclinenursing.com/pic_why.html. Resident #17's telephone order dated 02/21/13 reflected the physician's standing orders to: 1) Flush PICC line with 10 cc normal saline before and after medication. 2) Flush PICC line with 3 cc [MEDICATION NAME] after medication administration. 3) Change PICC line dressing every three days. Another telephone order written by the DON, dated 02/21/13, reflected a contradictory order to flush the PICC line with 10 cc normal saline and 5 cc [MEDICATION NAME] following a blood draw. On 02/22/13 at 1:00 p.m., the surveyor asked ADON A what the facility protocol was for using [MEDICATION NAME] flushes. ADON A stated the facility protocol called for 3 ml of [MEDICATION NAME] for flushes. The DON was interviewed on 02/22/13 at 3:40 p.m. regarding the facility's procedures for flushing PICC lines. At that time, the DON stated she used 10 cc of NaCl and 5 ml of [MEDICATION NAME] to flush the red port on the PICC line to unclog it. The surveyor asked the DON if she had written the telephone order to use 5 cc to flush the PICC line. The DON stated she did. The surveyor inquired if 5 cc of [MEDICATION NAME] was the normal facility policy for flushing PICC lines. The DON stated the facility policy was for 3 cc of [MEDICATION NAME], and she was going to change the order immediately to use 3 cc of [MEDICATION NAME] for flushes. On 02/21/13 at 1:15 p.m., the surveyor observed LVN C enter Resident #17's room without washing/sanitizing her hands, putting on gloves, wearing a mask, gown, cap or shoe covers. Observation of Resident #17's room revealed there was no stand outside of the resident's room, which contained gloves, masks, gowns, caps or shoe covers. There were no containers inside the resident's room for contaminated linen or trash. LVN C checked the bag of IV [MEDICATION NAME] hanging on a pole and stated it had finished infusing. LVN C came back to the nurse medication cart by the door in the hallway and obtained two alcohol pads, one 6 cc syringe of [MEDICATION NAME] and two 10 cc syringes of normal saline and then reentered the resident's room. LVN C opened the two syringes of normal saline and the syringe with [MEDICATION NAME]. The LVN also removed the caps from the syringes. LVN C placed the syringes on Resident #17's overbed table at the bed side, which she had not cleaned or covered with a clean barrier. LVN C then tried to disconnect the IV tubing from the PICC line, but was unsuccessful. LVN C then wiped both of her (bare) hands on her uniform pants and continued to attempt to disconnect the tubing from the PICC line's purple port (used for administration of the [MEDICATION NAME]). After finally disconnecting the IV tubing from the purple port, LVN C cleaned the purple port with an alcohol pad. LVN C had not washed or sanitized her hands and was not wearing gloves. LVN C then picked up the uncapped syringe with the normal saline from the overbed table, and without priming the syringe to remove the air, she flushed the purple port. LVN C dropped the PICC purple port allowing it to dangle. The tip was observed coming in contact with the resident's skin. LVN C then picked up the uncapped [MEDICATION NAME] syringe from the overbed table and again, without priming it to remove the air, LVN C flushed the line with five cc of [MEDICATION NAME] (instead of only three cc). LVN C left Resident #17's room without washing or sanitizing her hands and returned to the nurse's station. LVN D was observed on 02/22/13 at 10:00 a.m. to pull the nurse medication cart close to Resident #17's room. LVN D took from the cart one bag of [MEDICATION NAME], IV tubing, dial-a-flow tubing, alcohol wipes, gloves, two syringes with normal saline and one syringe containing [MEDICATION NAME]. LVN D entered the room and set her supplies on Resident #17's overbed table. LVN D had not cleaned the overbed table or covered it with a clean barrier. Without washing/sanitizing her hands, LVN D donned gloves but did not put on a gown, cap, mask or shoe covers. The LVN rolled the resident's sleeve up on his left upper arm. LVN D used an alcohol swab to clean the PICC line's red port (used for blood draws) first and then the purple port. She dropped both ports, allowing them to dangle, while she opened up the syringes she had brought into the resident's room. The surveyor observed both ports come in contact with the resident's sleeve. LVN D then connected the syringe with normal saline to the red port, without recleaning it and without priming the syringe to remove the air in the syringe. When the surveyor queried whether the LVN had checked the PICC line for patency (because she had not observed the LVN to do so), LVN D replied she had checked for patency, had pulled back and had obtained a blood flash in the tube. However, when LVN D tried to flush the red port, she was unable to flush the line as the PICC line's red port was clogged. LVN D then picked up the purple port she had cleaned earlier (which had then come into contact with the resident's sleeve), opened the syringe and without priming the syringe and/or re-cleaning the port, flushed the PICC line's purple port with 10 cc of normal saline. (Note: [MEDICATION NAME] was for flushing after the PICC line medication had infused.) LVN D picked up the bag of [MEDICATION NAME], which the label indicated contained [MEDICATION NAME], one gram in 250 cc of normal saline and was to be infused per IV over one hour every twelve hours. The surveyor observed LVN D open the small medication vial in the IV bag mixing the white, powdered [MEDICATION NAME] by shaking it, but bag still had clumps of the [MEDICATION NAME] undissolved in the bag when LVN D spiked the bag and hung it on the IV pole for administration. LVN D then set the medication on the dial-a-flow tubing to run at 125 cc/hr for one hour; (note: the correct setting should have been 250 cc/hr to run over one hour) the medication would infuse over an hour. After hanging the medication for administration, LVN D removed her gloves, but did not wash/sanitize her hands. She picked up six syringes: three unopened syringes (now contaminated from being in Resident #17's room), which LVN D had found in the room, and her three syringes, one of [MEDICATION NAME] and two of normal saline from Resident #17's room and returned to the nurse medication cart. After writing on Resident #17's February 2013 MAR, LVN D then placed the three unopened syringes back into the nurse medication cart, contaminating it, and pushed the cart back to the nurse's station. On 02/22/13 at approximately 10:45 a.m., during an interview with LVN D, LVN E and ADON A, when the surveyor asked why Resident #17 was being given [MEDICATION NAME], they confirmed the resident had Osteo[DIAGNOSES REDACTED]. The surveyor queried whether the facility had information from the resident's discharging hospital identifying the resident's Osteo[DIAGNOSES REDACTED]. ADON A stated she would call the hospital for further information about Resident #17. At that time, ADON A called the discharging hospital and was told Resident #17 was on contact isolation while he was in the hospital and was being treated for [REDACTED]. ADON A was observed to become angry with the person she was speaking to at the hospital, because the hospital did not provide the facility with the resident's [DIAGNOSES REDACTED].#17's right foot pressure ulcer. MRSA causes infections in different parts of the body and is tougher to treat than most strains of staph, because it's resistant to some commonly used antibiotics. [MEDICAL CONDITION] can cause serious kin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract. [MEDICAL CONDITION] infections can be life-threatening. Because it's hard to treat,[MEDICAL CONDITION] is sometimes called a "super bug." [MEDICAL CONDITION] is spread by contact with touching another person or touching objects contaminated [MEDICAL CONDITION]. Retrieved on 03/21/13 from http://www.webmd.com, "[MEDICAL CONDITION] Infection -- the Basics." Residents on contact isolation with contact precautions have an infection such [MEDICAL CONDITION] or VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]). Procedures for contact isolation include the use of PPE (personal protective equipment), which include wearing special gear, such as gloves, goggles or mask, gown, cap and/or shoe covers. A sign at the resident's room would reflect PPE was required or to see the nurse before entering the resident's room. Contact isolation also includes the proper handling and disposal of infected waste and materials. Retrieved on 03/19/13 from www.ehow.com/info_ 24_protocols-contact-precautions.html. Resident #17's hospital records included a transcription from Physician Q dated 02/20/13, which indicated the resident's right foot pressure ulcer was infected [MEDICAL CONDITION]. The bone biopsy was negative [MEDICAL CONDITION], but as the pressure ulcer was tracking to the bone, Resident #17 had been given a clinical [DIAGNOSES REDACTED]. Physician Q recommended treatment for [REDACTED]. Observation on 02/22/13 at 3:45 p.m. revealed Resident #17's IV [MEDICATION NAME] had finished infusing. Observation of the hall outside Resident #17's room revealed there was no stand containing PPE for staff and visitors to use. There was no sign directing visitors to the nurses' station. Inside the room, Resident #17's roommate was still there. There were no containers noted for disposal of contaminated linen or trash. LVN D moved the nurse medication cart to the resident's door, removed two syringes of NaCl and one syringe of [MEDICATION NAME] from the cart and entered Resident #17's room. In the room, LVN D donned gloves without washing/sanitizing her hands. The LVN did not wear any mask, cap, gown or shoe covers. LVN D disconnected the empty bag of [MEDICATION NAME]. LVN D cleaned the purple port and left it hanging. As LVN D turned around to open the syringe with NaCl, the surveyor observed the port touch Resident #17's upper arm and sleeve. Without recleaning the port, LVN D flushed the PICC line with NaCl and then tried to flush the PICC line with [MEDICATION NAME]. After several attempts, leaving the resident's room without washing her hands and returning with extra [MEDICATION NAME], LVN D flushed the port with approximately 2.5 cc of [MEDICATION NAME] (not the 3 cc orderd by the physician). LVN D then left the resident's room without washing/sanitizing her hands. (Note: the facility had already found Resident #17 was infected [MEDICAL CONDITION] at that time and he was not in contact isolation.) 3) During initial rounds on 02/20/13 at 10:10 a.m., ADON O had described Resident #19 as ambulatory, continent and confused. Resident #19's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old male, was admitted on [DATE]. The MDS assessment indicated the resident had no difficulty expressing his wants and needs, was able to understand what was said to him and cognitively independent with decision-making. The MDS assessment reflected the resident was independent with ADLs required the assistance of one person to move in bed, to transfer, for personal hygiene, to eat and had a tube feeding, which provided 25% or less of the total calories needed throughout the day. The MDS assessment reflected Resident #19 was independent with mobility, dressing and toileting. Resident #19's comprehensive plan of care, which was updated 02/13/13, did not address the resident's [DEVICE]. LVN C was observed on 02/21/13 at 9:20 a.m. preparing to flush Resident #19's [DEVICE]. LVN C picked up a cup from the nurse medication cart and entered his room. LVN C went to the bathroom and filled the cup with water from the sink. LVN C did not wash/sanitize her hands or put on gloves. LVN C then checked for placement of the [DEVICE] and gave a 60 cc water flush through the [DEVICE]. When LVN C finished with the flush, she tugged on her uniform top to pull it down, got a paper towel, clamped the [DEVICE], dried the resident and returned the syringe and plunger to the plastic bag. LVN C then left the resident's room without washing/sanitizing her hands. 4) The Admission Record dated 10/11/11 reflected Resident #18, a [AGE] year-old male, was admitted on [DATE]. Review of Resident #18's February 2013 consolidated physician's orders [REDACTED]. FSBS were included to be conducted twice a day and orders were included for sliding scale [MEDICATION NAME] regular insulin. Resident #18's MDS assessment dated [DATE] reflected the resident was able to express his wants and needs, was able to understand others and was moderately impaired cognitively. The MDS assessment further reflected the resident was independent with all ADLs except for set-up help with eating and support during bathing. Resident #18's Comprehensive Plan of Care dated 04/12/12 reflected the resident's [DIAGNOSES REDACTED]. On 02/21/13 at 11:30 a.m., the surveyor observed LVN C enter Resident #18's room to conduct a fingerstick blood sugar check using a glucometer. LVN C did not wash her hands/conduct hand hygiene prior to starting the procedure, and she did not wear gloves. With her bare hands, she cleaned Resident #18's second finger on the right hand with an alcohol pad and lanced the finger to obtain a blood sample. After obtaining the blood sample, LVN C placed an alcohol pad directly onto the resident's bleeding finger. After a few seconds, she took the alcohol pad off and was observed rolling the blood-soiled pad between her fingers, transferring some of the blood to her fingers. LVN C left Resident #18's room, disposing of the lancet, strip and alcohol pad in the sharps container, and then returning the glucometer to a drawer inside the general-use cart. The LVN picked up two glucose testing strips (used with the glucometer), which had not been used from the top of the nurse's medication cart and replaced them in the community container of glucose testing strips. LVN C did not clean her hands, which were now soiled with Resident #18's blood, and she did not clean the glucometer. LVN C then left Resident #18's room and went directly to Resident #13's room. 5) Resident #13's Admission Record dated 03/08/13 reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE] with an original admission date of [DATE]. Resident #13's February 2013 consolidated physician orders [REDACTED]. Resident #13's MDS assessment dated [DATE] reflected he was able to make his needs and wants known, understood what was said to him, and was moderately impaired cognitively. The MDS assessment reflected the resident was independent with all ADLs. Diabetes Mellitus was identified as a current diagnosis. Resident #13's Comprehensive Plan of Care originally dated 03/22/12 and updated on 02/23/13 reflected the most current change in the resident's orders for FSBS. On 02/21/13 at 11:40 a.m., LVN C was observed leaving Resident #18's room going directly to Resident #13's room for FSBS monitoring. LVN C did not wash/sanitize her hands before removing the glucometer from the cart. LVN C was then observed to clean the glucometer with a Sani-wipe towel. (SANI-WIPE Hand Sanitizer Towels sanitizes and conditions skin, while eliminating germs and bacteria.) She removed a glucose test strip from the container and placed it in the glucometer. LVN C entered Resident #13's room and did not wash/sanitize her hands or put on gloves. LVN C cleaned and lanced Resident #13's second finger on the right hand to get a blood sample for the glucometer. The surveyor again observed LVN C, who was still not wearing gloves and again handling the alcohol pad, which was soiled with Resident #13's blood, rolling the pad with her fingers. She disposed of the lancet, strip and alcohol pad in the sharps container. LVN C then placed the glucometer in the drawer of the cart without cleaning it. The surveyor asked LVN C when she was going to clean the glucometer. LVN C stated she cleaned the glucometer before she used it, but not afterwards. Without washing and/or sanitizing her hands, LVN C was then observed to go to the nurse's station, where she sat down. She still did not wash/sanitize her hands. 6) Review of the CDC article dated 03/11/05 entitled "Transmission of [MEDICAL CONDITION] Virus Among Persons Undergoing Blood Glucose Monitoring in Long-Term-Care Facilities - Mississippi, North Carolina, and Los Angeles County, California 2003-2004," revealed the following recommendations: "...If a glucometer used for one patient must be reused for another patient, the device must be cleaned and disinfected. Glucometers and other environmental surfaces should be cleaned regularly and whenever contamination with blood or body fluids occurs or is suspected... Because of possible inadvertent contamination, unused supplies and medications taken to a patient's bedside during fingerstick monitoring or insulin administration should not be used for another patient... Perform hand hygiene (i.e. hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other patients." 7) The surveyor interviewed LVN D on 02/22/13 at 1:30 p.m. regarding the training she had received in regard to PICC lines. LVN D told the surveyor she had received PICC line training on 02/15/13 (one week earlier). The facility's staff training records, which the ADM had provided to the survey team on 02/22/13, reflected the only training LVN D had participated in was on 05/01/12. There was no documentation of training conducted by the facility on 02/15/13. An Inservice Training Report dated 05/01/12 reflected the subject covered was "Nurse's Practice Act." The hand out included an advertisement from a corporation, which offered IV training. The rest of the inservice covered information from the Board of Nurse Examiners. There was no actual training in regard to IV or PICC lines. An Inservice Training Report dated 06/15/12 reflected it was for "Exposure Control/Bloodborne Pathogens" and neither LVN C nor LVN D had signed the sign-in sheets, which indicated they had not attended. An Inservice Training Report dated 12/31/12 identified the subject as Infection Control and was conducted by the facility's Administrator. Subjects covered included: Management of Infectious Waste, Body Substance Precautions, Prevention Strategies for Seasonal Influenza. Review of the sign-in sheets revealed neither LVN C nor LVN D had signed the sign-in sheets, which indicated they had not attended and no confirmation was received of their having attended training. The ADM also provided the facility's IVPB Competency Validation Checklist, Central Vascular Competency work sheets and certificates for Cenral Vascular Access and "Central Catheter Care & Maintenance. Neither LVN C nor LVN D had any evidence of having received competency with PICC lines. During an interview with the DON on 02/22/13 at 3:13 p.m., she informed the surveyor PICC line training was scheduled for 03/15/13. 8) The facility's policy on PICC lines (undated) provided to the surveyor by the Administrator on 01/22/13 and identified as current reflected the following: Procedures Peripherally Inserted Central Catheters (PICC): Care and Maintenance 1. Purpose: To safely care for, maintain and monitor PICC lines... 2. Guidelines a. Definition: A PICC line is an IV catheter, which is inserted peripherally through a vein located in the inside of the elbow using sterile technique. The tip of the catheter is threaded to the desired location... b. PICC lines ae inserted by RNs or physicians with advanced IV skills. c. An x-ray is used to confirm placement... ...e. Dressings may be changed by qualified nurses, according to a specific job description. f. PICC lines may be removed by RNs in the facility if trained in the procedure. g. The catheter insertion site should be monitored along with the upper arm for redness, swelling or tenderness... ...k. It is recommended an infusinon pump be used to deliver all therapies through the PICC line. 3. Procedure a. Use of [MEDICATION NAME] when flushing the PICC line i. PICC lines and their injection ports should be flushed as follows: --Before and after each use --At least once every 24 hours --NaCl 0.9% 5-1- cc before and after each medication --[MEDICATION NAME] flush solution 10 units/cc 1-3 cc when the line is not in use.... 11) On 02/25/13, the ADM provided the facility's complete infection control P/P and identified it as current. The P/P was entitled, "Operational Policy and Procedure Manual, Infection Control," and was dated as revised August 2001. The Manual reflected the following: Gloves - Policy Statement Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Policy Interpretation and Implementation "1. All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. 2. When gloves are indicated they shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. ...8. Hand washing is necessary when gloves are removed." Handwashing - Policy Statement "Handwashing shall be regarded by this facility as the single most important means of preventing the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow our established handwashing procedures to prevent the spread of infections and disease to other personnel, patients, and visitors. 2. Employees must perform appropriate ten (10) to fifteen (15) second hand washing procedures under the following conditions: a. When coming on duty; b. Whenever hands are obviously soiled; c. Before performing invasive procedures; d. Before preparing or handling medications; ...f. After handling used dressings, contaminated equipment, etc.; g. After contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin; h. After handling items potentially contaminated with blood, body fluids, excretions, or secretions; ...j. After removing gloves; ...m. Upon completion of duty. ...4. The use of gloves does not replace hand washing...." Infection Control Policies/Practices - Policy Statement "The primary purposes of this facility's infection control policies and practices are to establish guidelines to follow in providing a safe, snaitary and comfortable environment and to aid in preventing the development and transmission of diseases and infections." Isolation Precautions, Categories of - Policy Statement "Transmission based isolation precautions will be used for residents who are documented or suspected to have infections... that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. Transmission-based isolation precautions are to be used in addition to Standard Precautions...." MRSA - Policy Statement "When a resident is diagnosed with [REDACTED]. Standard Isolation Precautions - Policy Statement "Standard Isolation Precautions will be used in the care of all residents regardless of their diagnosed or presumed infection status. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, nonintact skin, and mucous membranes. Policy Interpretation and Implementation 1. Handwashing a. Wash hands after touching blood, blody fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. b. Was hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. c. Use a plain (nonantimicrobial) soap for routine handwashing. d. Use an antimicrobial agent or waterless antiseptic agent for specific circumstances (e.g., control of outbreaks...). 2. Gloves a. Wear gloves (clean, nonsterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on clean gloves just before touching mucous membranes and nonintact skin. c. Change gloves between tasks and procedures on te same resident after contact with material that may contain a high concentration of microorganisms. d. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other residents or environments. ...5. Resident-Care Equipment ...b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. 12) On 02/22/13 at 5:11 p.m., an IJ was identified. The ADM and DON were notified of the IJ at that time and a plan of removal for the IJ was requested. 13) The facility's Plan of Removal was accepted on 02/24/13 and reflected the following: The facility addressed and corrected areas specific to infection control, including universal precautions found to be deficient during daily blood glucose monitoring by finger stick blood sugar testing (FSBS) and PICC line procedures. LVN D and LVN C were not proficient when following universal precautions specific to hand washing, wearing gloves, and were both unaware of the resident's medical condition [MEDICAL CONDITION] re

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the potential development and transmission of disease and infection for six (Residents #7, #12, #13, #17, #18 and #19) of six residents observed for infection control. 1) Resident #17 was admitted with a PICC line (an IV line inserted into a vein and continuing until ending at a large vein near the heart), a [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED]. (MRSA causes infections, which are tougher to treat than most staph infections, are resistant to commonly used antibiotics and can be life-threatening.) 2) During the provision of care for Residents #17, #19, #18, and #13, LVN C failed to sanitize her hands and wear gloves, gown, mask, goggles and/or shoe covers; carelessly allowed PICC line ports to become contaminated; she contaminated supplies used for PICC lines and FSBS; did not clean the glucometer appropriately, and she did not attend facility inservices on infection control and/or use Universal Precautions. 3) LVN D failed to sanitize her hands and wear a gown, mask, goggles and/or shoe covers when providing care for Resident #17's PICC line, resulting in contamination of everything she touched including the PICC line; she contaminated supplies, carelessly allowed PICC line ports to become contaminated, and she did not attend facility inservices on infection control and/or use Universal Precautions. 4) Resident #7 was receiving [MEDICATION NAME] for Osteo[DIAGNOSES REDACTED], but the facility did not know what caused the infection and had not included the resident in the facility's Infection Control Log. Following surveyor intervention, the facility learned the resident had MRSA and the resident was placed on contact isolation. 5) Resident #12 had a UTI and was [MEDICATION NAME] the infection. The C&S for the resident's UA was not reviewed until surveyor intervention, and it was [MEDICATION NAME] not effective against either organism identified as causing the infection. 6) The facility failed to ensure the Infection Control Program included a review of antibiotics to monitor and identify the infection/causative agent being treated and the appropriate use of antibiotics. The current Infection Control Log did not include Resident #7. An Immediate Jeopardy was identified on 02/22/13. While the Immediate Jeopardy (IJ) was removed on 02/25/13, the facility remained out of compliance at a scope of "widespread" and at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" due to the facility continuing to inservice staff and monitor the implementation of the plan of removal. These failures could affect the facility's 78 residents and placed them at risk for contamination of wounds, contamination of PICC lines, cross-contamination between residents and staff and other residents, resulting in the spread or development of MRSA and/or infections, requiring contact isolation resulting in decreased socialization, causing a delay in the healing process, requiring hospitalization for further treatment, onset of depression, and even death. Findings included: Per Administrative Review on 03/07/13, it was determined the surveyors needed to return to the facility for further investigation. 1) Resident #17's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE]. The MDS assessment reflected Resident #17 was cognitively intact. The MDS assessment reflected current diagnoses, which included: Hypertension, Peripheral Vascular Disease, Diabetes, [DIAGNOSES REDACTED], Depression, Psychotic Disorder, Cellulitis and Abscess, Esophageal Reflux and Anxiety. Further review of the MDS assessment revealed Resident #17 was independently mobile in the facility, but required assistance with dressing. The MDS assessment also reflected Resident #17 had a Stage III pressure ulcer with slough, which was present upon admission. On 02/22/13 at 1:15 p.m., the surveyor spoke with the resident. The surveyor found the resident to be alert and oriented and responded to questions appropriately and intelligently. When asked about activities, Resident #17 told the surveyor he enjoyed reading and did not like to attend group activities, but preferred activities in his room. Review of a transfer form, dated 02/06/13, revealed Resident #17 was transferred to the hospital for evaluation of his pressure ulcer located on the outside of his right foot. On 02/25/13 at 9:40 a.m., LVN E was observed providing treatment to the pressure ulcer on Resident #17's right foot. The surveor observed brown exchar covering approximately half of the wound bed of the resident's pressure ulcer. The pressure ulcer was approximately 1.5 cm by 1.5 cm with redness and swelling of the skin surrounding the pressure ulcer. The pressure ulcer had purulent drainage. The rest of the foot had very dry, scaly skin. An admission order dated 02/20/13 reflected Resident #17 was re-admitted to the facility on [DATE]. The admission orders [REDACTED]. A peripherally inserted central catheter (PICC) line is a long, slender, small, flexible tube inserted into a peripheral vein, typically in the upper arm. The PICC line is advanced up the vein until the catheter tip (end of the PICC line) reaches a large vessel near the heart to gain central venous access. The PICC line may have a single or multiple lumens for different purposes. Retrieved on 03/21/13 from http://picclinenursing.com/pic_why.html. Resident #17's telephone order dated 02/21/13 reflected the physician's standing orders to: 1) Flush PICC line with 10 cc normal saline before and after medication. 2) Flush PICC line with 3 cc [MEDICATION NAME] after medication administration. 3) Change PICC line dressing every three days. Another telephone order written by the DON, dated 02/21/13, reflected a contradictory order to flush the PICC line with 10 cc normal saline and 5 cc [MEDICATION NAME] following a blood draw. On 02/22/13 at 1:00 p.m., the surveyor asked ADON A what the facility protocol was for using [MEDICATION NAME] flushes. ADON A stated the facility protocol called for 3 ml of [MEDICATION NAME] for flushes. The DON was interviewed on 02/22/13 at 3:40 p.m. regarding the facility's procedures for flushing PICC lines. At that time, the DON stated she used 10 cc of NaCl and 5 ml of [MEDICATION NAME] to flush the red port on the PICC line to unclog it. The surveyor asked the DON if she had written the telephone order to use 5 cc to flush the PICC line. The DON stated she did. The surveyor inquired if 5 cc of [MEDICATION NAME] was the normal facility policy for flushing PICC lines. The DON stated the facility policy was for 3 cc of [MEDICATION NAME], and she was going to change the order immediately to use 3 cc of [MEDICATION NAME] for flushes. On 02/21/13 at 1:15 p.m., the surveyor observed LVN C enter Resident #17's room without washing/sanitizing her hands, putting on gloves, wearing a mask, gown, cap or shoe covers. Observation of Resident #17's room revealed there was no stand outside of the resident's room, which contained gloves, masks, gowns, caps or shoe covers. There were no containers inside the resident's room for contaminated linen or trash. LVN C checked the bag of IV [MEDICATION NAME] hanging on a pole and stated it had finished infusing. LVN C came back to the nurse medication cart by the door in the hallway and obtained two alcohol pads, one 6 cc syringe of [MEDICATION NAME] and two 10 cc syringes of normal saline and then reentered the resident's room. LVN C opened the two syringes of normal saline and the syringe with [MEDICATION NAME]. The LVN also removed the caps from the syringes. LVN C placed the syringes on Resident #17's overbed table at the bed side, which she had not cleaned or covered with a clean barrier. LVN C then tried to disconnect the IV tubing from the PICC line, but was unsuccessful. LVN C then wiped both of her (bare) hands on her uniform pants and continued to attempt to disconnect the tubing from the PICC line's purple port (used for administration of the [MEDICATION NAME]). After finally disconnecting the IV tubing from the purple port, LVN C cleaned the purple port with an alcohol pad. LVN C had not washed or sanitized her hands and was not wearing gloves. LVN C then picked up the uncapped syringe with the normal saline from the overbed table, and without priming the syringe to remove the air, she flushed the purple port. LVN C dropped the PICC purple port allowing it to dangle. The tip was observed coming in contact with the resident's skin. LVN C then picked up the uncapped [MEDICATION NAME] syringe from the overbed table and again, without priming it to remove the air, LVN C flushed the line with five cc of [MEDICATION NAME] (instead of only three cc). LVN C left Resident #17's room without washing or sanitizing her hands and returned to the nurse's station. LVN D was observed on 02/22/13 at 10:00 a.m. to pull the nurse medication cart close to Resident #17's room. LVN D took from the cart one bag of [MEDICATION NAME], IV tubing, dial-a-flow tubing, alcohol wipes, gloves, two syringes with normal saline and one syringe containing [MEDICATION NAME]. LVN D entered the room and set her supplies on Resident #17's overbed table. LVN D had not cleaned the overbed table or covered it with a clean barrier. Without washing/sanitizing her hands, LVN D donned gloves but did not put on a gown, cap, mask or shoe covers. The LVN rolled the resident's sleeve up on his left upper arm. LVN D used an alcohol swab to clean the PICC line's red port (used for blood draws) first and then the purple port. She dropped both ports, allowing them to dangle, while she opened up the syringes she had brought into the resident's room. The surveyor observed both ports come in contact with the resident's sleeve. LVN D then connected the syringe with normal saline to the red port, without recleaning it and without priming the syringe to remove the air in the syringe. When the surveyor queried whether the LVN had checked the PICC line for patency (because she had not observed the LVN to do so), LVN D replied she had checked for patency, had pulled back and had obtained a blood flash in the tube. However, when LVN D tried to flush the red port, she was unable to flush the line as the PICC line's red port was clogged. LVN D then picked up the purple port she had cleaned earlier (which had then come into contact with the resident's sleeve), opened the syringe and without priming the syringe and/or re-cleaning the port, flushed the PICC line's purple port with 10 cc of normal saline. (Note: [MEDICATION NAME] was for flushing after the PICC line medication had infused.) LVN D picked up the bag of [MEDICATION NAME], which the label indicated contained [MEDICATION NAME], one gram in 250 cc of normal saline and was to be infused per IV over one hour every twelve hours. The surveyor observed LVN D open the small medication vial in the IV bag mixing the white, powdered [MEDICATION NAME] by shaking it, but bag still had clumps of the [MEDICATION NAME] undissolved in the bag when LVN D spiked the bag and hung it on the IV pole for administration. LVN D then set the medication on the dial-a-flow tubing to run at 125 cc/hr for one hour; (note: the correct setting should have been 250 cc/hr to run over one hour) the medication would infuse over an hour. After hanging the medication for administration, LVN D removed her gloves, but did not wash/sanitize her hands. She picked up six syringes: three unopened syringes (now contaminated from being in Resident #17's room), which LVN D had found in the room, and her three syringes, one of [MEDICATION NAME] and two of normal saline from Resident #17's room and returned to the nurse medication cart. After writing on Resident #17's February 2013 MAR, LVN D then placed the three unopened syringes back into the nurse medication cart, contaminating it, and pushed the cart back to the nurse's station. On 02/22/13 at approximately 10:45 a.m., during an interview with LVN D, LVN E and ADON A, when the surveyor asked why Resident #17 was being given [MEDICATION NAME], they confirmed the resident had Osteo[DIAGNOSES REDACTED]. The surveyor queried whether the facility had information from the resident's discharging hospital identifying the resident's Osteo[DIAGNOSES REDACTED]. ADON A stated she would call the hospital for further information about Resident #17. At that time, ADON A called the discharging hospital and was told Resident #17 was on contact isolation while he was in the hospital and was being treated for [REDACTED]. ADON A was observed to become angry with the person she was speaking to at the hospital, because the hospital did not provide the facility with the resident's [DIAGNOSES REDACTED].#17's right foot pressure ulcer. MRSA causes infections in different parts of the body and is tougher to treat than most strains of staph, because it's resistant to some commonly used antibiotics. MRSA can cause serious kin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract. Some MRSA infections can be life-threatening. Because it's hard to treat, MRSA is sometimes called a "super bug." MRSA is spread by contact with touching another person or touching objects contaminated by MRSA. Retrieved on 03/21/13 from http://www.webmd.com, "Understanding MRSA Infection -- the Basics." Residents on contact isolation with contact precautions have an infection such as MRSA or VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]). Procedures for contact isolation include the use of PPE (personal protective equipment), which include wearing special gear, such as gloves, goggles or mask, gown, cap and/or shoe covers. A sign at the resident's room would reflect PPE was required or to see the nurse before entering the resident's room. Contact isolation also includes the proper handling and disposal of infected waste and materials. Retrieved on 03/19/13 from www.ehow.com/info_ 24_protocols-contact-precautions.html. Resident #17's hospital records included a transcription from Physician Q dated 02/20/13, which indicated the resident's right foot pressure ulcer was infected by MRSA. The bone biopsy was negative for MRSA, but as the pressure ulcer was tracking to the bone, Resident #17 had been given a clinical [DIAGNOSES REDACTED]. Physician Q recommended treatment for [REDACTED]. Observation on 02/22/13 at 3:45 p.m. revealed Resident #17's IV [MEDICATION NAME] had finished infusing. Observation of the hall outside Resident #17's room revealed there was no stand containing PPE for staff and visitors to use. There was no sign directing visitors to the nurses' station. Inside the room, Resident #17's roommate was still there. There were no containers noted for disposal of contaminated linen or trash. LVN D moved the nurse medication cart to the resident's door, removed two syringes of NaCl and one syringe of [MEDICATION NAME] from the cart and entered Resident #17's room. In the room, LVN D donned gloves without washing/sanitizing her hands. The LVN did not wear any mask, cap, gown or shoe covers. LVN D disconnected the empty bag of [MEDICATION NAME]. LVN D cleaned the purple port and left it hanging. As LVN D turned around to open the syringe with NaCl, the surveyor observed the port touch Resident #17's upper arm and sleeve. Without recleaning the port, LVN D flushed the PICC line with NaCl and then tried to flush the PICC line with [MEDICATION NAME]. After several attempts, leaving the resident's room without washing her hands and returning with extra [MEDICATION NAME], LVN D flushed the port with approximately 2.5 cc of [MEDICATION NAME] (not the 3 cc orderd by the physician). LVN D then left the resident's room without washing/sanitizing her hands. (Note: the facility had already found Resident #17 was infected with MRSA at that time and he was not in contact isolation.) Resident #17's care plan dated 01/17/13 was reviewed again on 02/25/13. The care plan still had not been updated to address the resident's pressure ulcer, MRSA infection, contact isolation, and PICC line. No other care plan was provided for Resident #17 prior to the survey team's exit from the facility on 02/25/13. 2) During initial rounds on 02/20/13 at 10:10 a.m., ADON O had described Resident #19 as ambulatory, continent and confused. Resident #19's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old male, was admitted on [DATE]. The MDS assessment indicated the resident had no difficulty expressing his wants and needs, was able to understand what was said to him and cognitively independent with decision-making. The MDS assessment reflected the resident was independent with ADLs required the assistance of one person to move in bed, to transfer, for personal hygiene, to eat and had a tube feeding, which provided 25% or less of the total calories needed throughout the day. The MDS assessment reflected Resident #19 was independent with mobility, dressing and toileting. Resident #19's comprehensive plan of care, which was updated 02/13/13, did not address the resident's [DEVICE]. LVN C was observed on 02/21/13 at 9:20 a.m. preparing to flush Resident #19's [DEVICE]. LVN C picked up a cup from the nurse medication cart and entered his room. LVN C went to the bathroom and filled the cup with water from the sink. LVN C did not wash/sanitize her hands or put on gloves. LVN C then checked for placement of the [DEVICE] and gave a 60 cc water flush through the [DEVICE]. When LVN C finished with the flush, she tugged on her uniform top to pull it down, got a paper towel, clamped the [DEVICE], dried the resident and returned the syringe and plunger to the plastic bag. LVN C then left the resident's room without washing/sanitizing her hands. 3) The Admission Record dated 10/11/11 reflected Resident #18, a [AGE] year-old male, was admitted on [DATE]. Review of Resident #18's February 2013 consolidated physician's orders [REDACTED]. FSBS were included to be conducted twice a day and orders were included for sliding scale [MEDICATION NAME] regular insulin. Resident #18's MDS assessment dated [DATE] reflected the resident was able to express his wants and needs, was able to understand others and was moderately impaired cognitively. The MDS assessment further reflected the resident was independent with all ADLs except for set-up help with eating and support during bathing. Resident #18's Comprehensive Plan of Care dated 04/12/12 reflected the resident's [DIAGNOSES REDACTED]. On 02/21/13 at 11:30 a.m., the surveyor observed LVN C enter Resident #18's room to conduct a fingerstick blood sugar check using a glucometer. LVN C did not wash her hands/conduct hand hygiene prior to starting the procedure, and she did not wear gloves. With her bare hands, she cleaned Resident #18's second finger on the right hand with an alcohol pad and lanced the finger to obtain a blood sample. After obtaining the blood sample, LVN C placed an alcohol pad directly onto the resident's bleeding finger. After a few seconds, she took the alcohol pad off and was observed rolling the blood-soiled pad between her fingers, transferring some of the blood to her fingers. LVN C left Resident #18's room, disposing of the lancet, strip and alcohol pad in the sharps container, and then returning the glucometer to a drawer inside the general-use cart. The LVN picked up two glucose testing strips (used with the glucometer), which had not been used from the top of the nurse's medication cart and replaced them in the community container of glucose testing strips. LVN C did not clean her hands, which were now soiled with Resident #18's blood, and she did not clean the glucometer. LVN C then left Resident #18's room and went directly to Resident #13's room. 4) Resident #13's Admission Record dated 03/08/13 reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE] with an original admission date of [DATE]. Resident #13's February 2013 consolidated physician orders [REDACTED]. Resident #13's MDS assessment dated [DATE] reflected he was able to make his needs and wants known, understood what was said to him, and was moderately impaired cognitively. The MDS assessment reflected the resident was independent with all ADLs. Diabetes Mellitus was identified as a current diagnosis. Resident #13's Comprehensive Plan of Care originally dated 03/22/12 and updated on 02/23/13 reflected the most current change in the resident's orders for FSBS. On 02/21/13 at 11:40 a.m., LVN C was observed leaving Resident #18's room going directly to Resident #13's room for FSBS monitoring. LVN C did not wash/sanitize her hands before removing the glucometer from the cart. LVN C was then observed to clean the glucometer with a Sani-wipe towel. (SANI-WIPE Hand Sanitizer Towels sanitizes and conditions skin, while eliminating germs and bacteria.) She removed a glucose test strip from the container and placed it in the glucometer. LVN C entered Resident #13's room and did not wash/sanitize her hands or put on gloves. LVN C cleaned and lanced Resident #13's second finger on the right hand to get a blood sample for the glucometer. The surveyor again observed LVN C, who was still not wearing gloves and again handling the alcohol pad, which was soiled with Resident #13's blood, rolling the pad with her fingers. She disposed of the lancet, strip and alcohol pad in the sharps container. LVN C then placed the glucometer in the drawer of the cart without cleaning it. The surveyor asked LVN C when she was going to clean the glucometer. LVN C stated she cleaned the glucometer before she used it, but not afterwards. Without washing and/or sanitizing her hands, LVN C was then observed to go to the nurse's station, where she sat down. She still did not wash/sanitize her hands. 5) Review of the CDC article dated 03/11/05 entitled "Transmission of Hepatitis B Virus Among Persons Undergoing Blood Glucose Monitoring in Long-Term-Care Facilities - Mississippi, North Carolina, and Los Angeles County, California 2003-2004," revealed the following recommendations: "...If a glucometer used for one patient must be reused for another patient, the device must be cleaned and disinfected. Glucometers and other environmental surfaces should be cleaned regularly and whenever contamination with blood or body fluids occurs or is suspected... Because of possible inadvertent contamination, unused supplies and medications taken to a patient's bedside during fingerstick monitoring or insulin administration should not be used for another patient... Perform hand hygiene (i.e. hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other patients." 6) On 02/20/13 at 9:35 a.m., the surveyor observed Resident #7 during the initial rounds in his room. His roommate was present. LVN B stated Resident #7 was alert and oriented to person, place and time, used the wheelchair for mobility in the facility, and was non-weight bearing due to having surgeries on both legs. LVN B stated Resident #7 had a non-union of the bones and would require more surgeries. The surveyor observed Resident #7 with a PICC line with a double lumen in his right upper arm. A bag of [MEDICATION NAME] 1 gm was infusing at that time. The Nursing 2012 Drug Handbook, copyright 2012 by Lippincott, Williams and Wilkins, page 1383, reflected [MEDICATION NAME] is ordered for "serious or severe infections when other antibiotics are ineffective or contraindicated, including those caused by Methicillin-resistant Staphylococcus aureus (MRSA)...." Resident #7's facility admission orders [REDACTED]. Resident #7's MDS assessment dated [DATE] reflected the resident was able to express his wants and needs, was able to understand what was said to him and was moderately impaired cognitively. The MDS assessment further reflected the resident was independent with all ADLs except for receiving support when bathing. Resident #7's Comprehensive Plan of Care dated 12/14/12 reflected the resident was receiving IV antibiotic therapy. During an interview on 02/20/13 at 2:30 p.m., Resident #7 stated he was in a motor vehicle accident and hurt both legs, and they required surgery on both legs. Resident #7 stated he had two infections in his legs. He said the hospital Infectious Disease physician he saw in the hospital told him he had "MRSA and Staph" in his surgical wounds, which "got into his bones." On 02/21/13 at 1:35 p.m., the wound care nurse, LVN E, was observed providing wound care to Resident #7's right knee. LVN E was using gloves but no other PPE such as a mask, cap, gown or foot covers. The right knee incision had staples and had bloody drainage. The right shin had two incisions with staples. Resident #7's left leg also had bloody drainage from the foot, which was draining from the incision site. The left shin had an incision with a black scab on it. During the wound care, Resident #7 stated he was told by the infectious disease doctor in the hospital he had MRSA and a Staph infection. LVN E told the resident he had Osteo[DIAGNOSES REDACTED] and not MRSA. In an interview on 02/21/13 at 2:00 p.m., LVN B, LVN E and ADON A all confirmed Resident #7 was treated for [REDACTED]. They agreed the hospital did not tell them the resident had another infection. On 02/22/13 at 5:20 p.m., the surveyor interviewed the ADM about Resident #7 being administered [MEDICATION NAME] and whether the resident had a [DIAGNOSES REDACTED]. On 02/25/13 at 1:00 p.m., the ADM provided the surveyor a copy of Resident #7's hospital record, which was dated 02/08/13. Review of the Progress Notes dated 02/06/13 revealed the physician from Infectious Disease documented: "...Remains on vanc ([MEDICATION NAME]) and [MEDICATION NAME] for MRSA osteo (Osteo[DIAGNOSES REDACTED]) L tibia." However, review of the facility's Infection Control Log for November, December 2012, January and February 2013 r02/21/13 revealed Resident #7 was not included on the log for infection. ADON A added his name during a discussion on 02/21/13, saying she had forgotten to add the resident to the facility's Infection Control Tracking Log. 7) Resident #12 was initially observed during rounds with ADON A on 02/20/13 at 9:25 a.m. resting in bed. ADON A stated the resident was incontinent of bowel/bladder, confused at times and required total assistance with all ADLs. The Admission Record dated 03/08/13 reflected Resident #12, an [AGE] year-old female, was originally admitted on [DATE] and readmitted on [DATE]. Resident #12's MDS assessment dated [DATE] reflected she had no difficulty communicating her wants and needs, was able to understand what was said to her and was moderately impaired cognitively. Further review revealed Resident #12 required staff assistance with all ADLs and was always incontinent of bladder and bowel. Resident #12's Comprehensive Plan of Care dated 02/18/13 reflected the resident had a UTI and was to [MEDICATION NAME](antibiotic) 250 mg by mouth for ten days. A physician's telephone order dated 02/18/13 for Resident #12 reflected an order for [REDACTED]. Review of the facility's Infection Control Logs dated 02/18/13 revealed Resident #12 was receiving the [MEDICATION NAME] treat the UTI. According to the log, the resident was not experiencing any symptoms, a urine specimen had been cultured and the results were pending. However, the organism(s) had not been identified prior to Resident #12 receiving the antibiotic. Review of Resident #12's UA dated 02/18/13 revealed a urine specimen had been collected on 02/17/13, and the lab notified the facility of the results on 02/18/13. According to the report, Resident #12's urine was cloudy, contained a small amount of Leukocytes, and bacteria were too numerous to count. The UA had a notation indicating the physician had reviewed the report on 02/19/13. The surveyor reviewed Resident #12's entire clinical record looking for the final lab results from the resident's UA with the C&S, which would identify the bacteria causing the infection, but it was not on the chart. A copy of Resident #12's UA with C&S was requested from LVN B on 02/25/13 at 9:30 a.m. The LVN was unable to locate the final results of Resident #12's UA with C&S, and said she did not know why the report was not in the resident's clinical record. At that time, LVN B checked the computer and found Resident #12's UA with C&S in the computer and printed the report. LVN B reviewed the report and stated the [MEDICATION NAME] "good" for the identified organisms. The surveyor requested a copy of the report to review. The final report for the UA with C&S was dated 02/21/13. The report reflected the organisms Escherichia coli (bacteria found in the colon) and [MEDICATION NAME] faecalis (bacteria found in the GI tract) were identified in the resident's urine, which indicated the infection was from the bowel. The report further reflected both organisms were resistant to Cipro, the antibiotic Resident #12 was currently receiving. On reviewing Resident #12's C&S with LVN B, the surveyor queried whether the resident's physician had been provided the final report for review or whether he had been informed the organisms in the resident's urine were resistant to Cipro. LVN B acknowledged the organisms were resistant [MEDICATION NAME] said Resident #12's physician had not been provided the C&S report or been informed of the organisms' resistance to Cipro. Resident #12's February 2013 MAR reflected the resident had received [MEDICATION NAME] the past seven days (since 02/18/13). On 02/25/13 at 10:15 a.m., LVN B stated she had notified the physician and had received new orders to [MEDICATION NAME] start the antibiotic [MEDICATION NAME] (antibiotic) 100 mg by mouth two times a day for ten days to treat Resident #12's UTI. Review of Resident #12's Comprehensive Plan of Care on 02/25/13 revealed it was updated on 02/25/13. [MEDICATION NAME] been discontinued on 02/25/13 and [MEDICATION NAME] ([MEDICATION NAME]) 100 mg had been ordered to be given twice a day for ten days. 8) During a confidential interview, when queried about reporting the results of lab reports to the physicians, he/she told the surveyor there was no working system, which ensured nursing staff and/or physicians were informed of lab results. He/she stated the staff was expected to remember which labs were collected and then follow-up to ensure the lab results were received. He/she stated following up on lab results was difficult, because the logs at the nurses stations were not updated with current information, and the 24-hour nurses report did not always include information regarding the residents' labs, whether it was the results of the lab or the need to follow-up on lab work. During an interview on 02/25/13 at 10:10 a.m., the DON stated there had been problems with the facility's contracted lab providing her with a list of the residents, who had lab specimens collected. According to the DON, lab collections and pending results should have been documented on the nurses' twenty-four hour report. The DON further stated there was a log at each nurse's station of the orders received for lab work. 9) The surveyor int

Based on observation, interview, and record review, the facility failed to ensure one (Resident #17) of two residents observed for IV therapy, received proper treatment and care for his PICC line from two (LVNs C and D) of four LVNs observed. Resident #17 was admitted with a PICC line (an IV line inserted into a vein and continuing until ending at a large vein near the heart), a [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED]. (MRSA causes infections, which are tougher to treat than most staph infections, are resistant to commonly used antibiotics and can be life-threatening.) LVN C failed to sanitize her hands and wear gloves, gown, mask, goggles and/or shoe covers when providing care for Resident #17's PICC line, resulting in contamination of everything she touched including the PICC line and carelessly allowed PICC line ports to become contaminated LVN D failed to sanitize her hands and wear a gown, mask, goggles and/or shoe covers when providing care for Resident #17's PICC line, resulting in contamination of everything she touched including the PICC line and carelessly allowed PICC line ports to become contaminated. An Immediate Jeopardy was identified on 02/22/13. While the Immediate Jeopardy (IJ) was removed on 02/25/13, the facility remained out of compliance at a scope of "pattern" and at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" due to the facility continuing to inservice staff and monitor the implementation of the plan of removal. These failures placed the three residents who were receiving IV therapy (including Resident #17) at risk for the potential of continued/repeated exposure to other contaminants, use of the PICC line, which provided direct central venous access, and could result in further infection to the residents along with the potential of cross-contamination [MEDICAL CONDITION] resulting [MEDICAL CONDITION], hospitalization and even death. Findings included: Per Administrative Review on 03/07/13, it was determined the surveyors needed to return to the facility for further investigation. 1) Resident #17's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE]. The MDS assessment reflected Resident #17 was cognitively intact. The MDS assessment reflected current diagnoses, which included: Hypertension, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION], Depression, [MEDICAL CONDITIONS] and Abscess, [MEDICAL CONDITION] Reflux and Anxiety. Further review of the MDS assessment revealed Resident #17 was independently mobile in the facility, but required assistance with dressing. The MDS assessment also reflected Resident #17 had a Stage III pressure ulcer with slough, which was present upon admission. On 02/22/13 at 1:15 p.m., the surveyor spoke with the resident. The surveyor found the resident to be alert and oriented and responded to questions appropriately and intelligently. When asked about activities, Resident #17 told the surveyor he enjoyed reading and did not like to attend group activities, but preferred activities in his room. Review of a transfer form, dated 02/06/13, revealed Resident #17 was transferred to the hospital for evaluation of his pressure ulcer located on the outside of his right foot. On 02/25/13 at 9:40 a.m., LVN E was observed providing treatment to the pressure ulcer on Resident #17's right foot. The surveor observed brown exchar covering approximately half of the wound bed of the resident's pressure ulcer. The pressure ulcer was approximately 1.5 cm by 1.5 cm with redness and swelling of the skin surrounding the pressure ulcer. The pressure ulcer had purulent drainage. The rest of the foot had very dry, scaly skin. An admission order dated 02/20/13 reflected Resident #17 was re-admitted to the facility on [DATE]. The admission orders [REDACTED]. A peripherally inserted central catheter (PICC) line is a long, slender, small, flexible tube inserted into a peripheral vein, typically in the upper arm. The PICC line is advanced up the vein until the catheter tip (end of the PICC line) reaches a large vessel near the heart to gain central venous access. The PICC line may have a single or multiple lumens for different purposes. Retrieved on 03/21/13 from http://picclinenursing.com/pic_why.html. Resident #17's telephone order dated 02/21/13 reflected the physician's standing orders to: 1) Flush PICC line with 10 cc normal saline before and after medication. 2) Flush PICC line with 3 cc [MEDICATION NAME] after medication administration. 3) Change PICC line dressing every three days. Another telephone order written by the DON, dated 02/21/13, reflected a contradictory order to flush the PICC line with 10 cc normal saline and 5 cc [MEDICATION NAME] following a blood draw. On 02/22/13 at 1:00 p.m., the surveyor asked ADON A what the facility protocol was for using [MEDICATION NAME] flushes. ADON A stated the facility protocol called for 3 ml of [MEDICATION NAME] for flushes. The DON was interviewed on 02/22/13 at 3:40 p.m. regarding the facility's procedures for flushing PICC lines. At that time, the DON stated she used 10 cc of NaCl and 5 ml of [MEDICATION NAME] to flush the red port on the PICC line to unclog it. The surveyor asked the DON if she had written the telephone order to use 5 cc to flush the PICC line. The DON stated she did. The surveyor inquired if 5 cc of [MEDICATION NAME] was the normal facility policy for flushing PICC lines. The DON stated the facility policy was for 3 cc of [MEDICATION NAME], and she was going to change the order immediately to use 3 cc of [MEDICATION NAME] for flushes. 2) On 02/21/13 at 1:15 p.m., the surveyor observed LVN C enter Resident #17's room without washing/sanitizing her hands, putting on gloves, wearing a mask, gown, cap or shoe covers. Observation of Resident #17's room revealed there was no stand outside of the resident's room, which contained gloves, masks, gowns, caps or shoe covers. There were no containers inside the resident's room for contaminated linen or trash. LVN C checked the bag of IV [MEDICATION NAME] hanging on a pole and stated it had finished infusing. LVN C came back to the nurse medication cart by the door in the hallway and obtained two alcohol pads, one 6 cc syringe of [MEDICATION NAME] and two 10 cc syringes of normal saline and then reentered the resident's room. LVN C opened the two syringes of normal saline and the syringe with [MEDICATION NAME]. The LVN also removed the caps from the syringes. LVN C placed the syringes on Resident #17's overbed table at the bed side, which she had not cleaned or covered with a clean barrier. LVN C then tried to disconnect the IV tubing from the PICC line, but was unsuccessful. LVN C then wiped both of her (bare) hands on her uniform pants and continued to attempt to disconnect the tubing from the PICC line's purple port (used for administration of the [MEDICATION NAME]). After finally disconnecting the IV tubing from the purple port, LVN C cleaned the purple port with an alcohol pad. LVN C had not washed or sanitized her hands and was not wearing gloves. LVN C then picked up the uncapped syringe with the normal saline from the overbed table, and without priming the syringe to remove the air, she flushed the purple port. LVN C dropped the PICC purple port allowing it to dangle. The tip was observed coming in contact with the resident's skin. LVN C then picked up the uncapped [MEDICATION NAME] syringe from the overbed table and again, without priming it to remove the air, LVN C flushed the line with five cc of [MEDICATION NAME] (instead of only three cc). LVN C left Resident #17's room without washing or sanitizing her hands and returned to the nurse's station. 3) LVN D was observed on 02/22/13 at 10:00 a.m. to pull the nurse medication cart close to Resident #17's room. LVN D took from the cart one bag of [MEDICATION NAME], IV tubing, dial-a-flow tubing, alcohol wipes, gloves, two syringes with normal saline and one syringe containing [MEDICATION NAME]. LVN D entered the room and set her supplies on Resident #17's overbed table. LVN D had not cleaned the overbed table or covered it with a clean barrier. Without washing/sanitizing her hands, LVN D donned gloves but did not put on a gown, cap, mask or shoe covers. The LVN rolled the resident's sleeve up on his left upper arm. LVN D used an alcohol swab to clean the PICC line's red port (used for blood draws) first and then the purple port. She dropped both ports, allowing them to dangle, while she opened up the syringes she had brought into the resident's room. The surveyor observed both ports come in contact with the resident's sleeve. LVN D then connected the syringe with normal saline to the red port, without recleaning it and without priming the syringe to remove the air in the syringe. When the surveyor queried whether the LVN had checked the PICC line for patency (because she had not observed the LVN to do so), LVN D replied she had checked for patency, had pulled back and had obtained a blood flash in the tube. However, when LVN D tried to flush the red port, she was unable to flush the line as the PICC line's red port was clogged. LVN D then picked up the purple port she had cleaned earlier (which had then come into contact with the resident's sleeve), opened the syringe and without priming the syringe and/or re-cleaning the port, flushed the PICC line's purple port with 10 cc of normal saline. (Note: [MEDICATION NAME] was for flushing after the PICC line medication had infused.) LVN D picked up the bag of [MEDICATION NAME], which the label indicated contained [MEDICATION NAME], one gram in 250 cc of normal saline and was to be infused per IV over one hour every twelve hours. The surveyor observed LVN D open the small medication vial in the IV bag mixing the white, powdered [MEDICATION NAME] by shaking it, but bag still had clumps of the [MEDICATION NAME] undissolved in the bag when LVN D spiked the bag and hung it on the IV pole for administration. LVN D then set the medication on the dial-a-flow tubing to run at 125 cc/hr for one hour; (note: the correct setting should have been 250 cc/hr to run over one hour) the medication would infuse over an hour. After hanging the medication for administration, LVN D removed her gloves, but did not wash/sanitize her hands. She picked up six syringes: three unopened syringes (now contaminated from being in Resident #17's room), which LVN D had found in the room, and her three syringes, one of [MEDICATION NAME] and two of normal saline from Resident #17's room and returned to the nurse medication cart. After writing on Resident #17's February 2013 MAR, LVN D then placed the three unopened syringes back into the nurse medication cart, contaminating it, and pushed the cart back to the nurse's station. 4) On 02/22/13 at approximately 10:45 a.m., during an interview with LVN D, LVN E and ADON A, when the surveyor asked why Resident #17 was being given [MEDICATION NAME], they confirmed the resident had Osteo[DIAGNOSES REDACTED]. The surveyor queried whether the facility had information from the resident's discharging hospital identifying the resident's Osteo[DIAGNOSES REDACTED]. ADON A stated she would call the hospital for further information about Resident #17. At that time, ADON A called the discharging hospital and was told Resident #17 was on contact isolation while he was in the hospital and was being treated for [REDACTED]. ADON A was observed to become angry with the person she was speaking to at the hospital, because the hospital did not provide the facility with the resident's [DIAGNOSES REDACTED].#17's right foot pressure ulcer. MRSA causes infections in different parts of the body and is tougher to treat than most strains of staph, because it's resistant to some commonly used antibiotics. [MEDICAL CONDITION] can cause serious kin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract. [MEDICAL CONDITION] infections can be life-threatening. Because it's hard to treat,[MEDICAL CONDITION] is sometimes called a "super bug." [MEDICAL CONDITION] is spread by contact with touching another person or touching objects contaminated [MEDICAL CONDITION]. Retrieved on 03/21/13 from http://www.webmd.com, "[MEDICAL CONDITION] Infection -- the Basics." Residents on contact isolation with contact precautions have an infection such [MEDICAL CONDITION] or VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]). Procedures for contact isolation include the use of PPE (personal protective equipment), which include wearing special gear, such as gloves, goggles or mask, gown, cap and/or shoe covers. A sign at the resident's room would reflect PPE was required or to see the nurse before entering the resident's room. Contact isolation also includes the proper handling and disposal of infected waste and materials. Retrieved on 03/19/13 from www.ehow.com/info_ 24_protocols-contact-precautions.html. Resident #17's hospital records included a transcription from Physician Q dated 02/20/13, which indicated the resident's right foot pressure ulcer was infected [MEDICAL CONDITION]. The bone biopsy was negative [MEDICAL CONDITION], but as the pressure ulcer was tracking to the bone, Resident #17 had been given a clinical [DIAGNOSES REDACTED]. Physician Q recommended treatment for [REDACTED]. 5) Observation on 02/22/13 at 3:45 p.m. revealed Resident #17's IV [MEDICATION NAME] had finished infusing. Observation of the hall outside Resident #17's room revealed there was no stand containing PPE for staff and visitors to use. There was no sign directing visitors to the nurses' station. Inside the room, Resident #17's roommate was still there. There were no containers noted for disposal of contaminated linen or trash. LVN D moved the nurse medication cart to the resident's door, removed two syringes of NaCl and one syringe of [MEDICATION NAME] from the cart and entered Resident #17's room. In the room, LVN D donned gloves without washing/sanitizing her hands. The LVN did not wear any mask, cap, gown or shoe covers. LVN D disconnected the empty bag of [MEDICATION NAME]. LVN D cleaned the purple port and left it hanging. As LVN D turned around to open the syringe with NaCl, the surveyor observed the port touch Resident #17's upper arm and sleeve. Without recleaning the port, LVN D flushed the PICC line with NaCl and then tried to flush the PICC line with [MEDICATION NAME]. After several attempts, leaving the resident's room without washing her hands and returning with extra [MEDICATION NAME], LVN D flushed the port with approximately 2.5 cc of [MEDICATION NAME] (not the 3 cc orderd by the physician). LVN D then left the resident's room without washing/sanitizing her hands. (Note: the facility had already found Resident #17 was infected [MEDICAL CONDITION] at that time and he was not in contact isolation.) Resident #17's care plan dated 01/17/13 was reviewed again on 02/25/13. The care plan still had not been updated to address the resident's pressure ulcer,[MEDICAL CONDITION] infection, contact isolation, and PICC line. No other care plan was provided for Resident #17 prior to the survey team's exit from the facility on 02/25/13. 6) The surveyor interviewed LVN D on 02/22/13 at 1:30 p.m. regarding the training she had received in regard to PICC lines. LVN D told the surveyor she had received PICC line training on 02/15/13 (one week earlier). The facility's staff training records, which the ADM had provided to the survey team on 02/22/13, reflected the only training LVN D had participated in was on 05/01/12. There was no documentation of training conducted by the facility on 02/15/13. An Inservice Training Report dated 05/01/12 reflected the subject covered was "Nurse's Practice Act." The hand out included an advertisement from a corporation, which offered IV training. The rest of the inservice covered information from the Board of Nurse Examiners. There was no actual training in regard to IV or PICC lines. An Inservice Training Report dated 06/15/12 reflected it was for "Exposure Control/Bloodborne Pathogens" and neither LVN C nor LVN D had signed the sign-in sheets, which indicated they had not attended. An Inservice Training Report dated 12/31/12 identified the subject as Infection Control and was conducted by the facility's Administrator. Subjects covered included: Management of Infectious Waste, Body Substance Precautions, Prevention Strategies for Seasonal Influenza. Review of the sign-in sheets revealed neither LVN C nor LVN D had signed the sign-in sheets, which indicated they had not attended and no confirmation was received of their having attended training. The ADM also provided the facility's IVPB Competency Validation Checklist, Central Vascular Competency work sheets and certificates for Cenral Vascular Access and "Central Catheter Care & Maintenance. Neither LVN C nor LVN D had any evidence of having received competency with PICC lines. During an interview with the DON on 02/22/13 at 3:13 p.m., she informed the surveyor PICC line training was scheduled for 03/15/13. 8) The facility's policy on PICC lines (undated) provided to the surveyor by the Administrator on 02/22/13 and identified as current reflected the following: Procedures Peripherally Inserted Central Catheters (PICC): Care and Maintenance 1. Purpose: To safely care for, maintain and monitor PICC lines... 2. Guidelines a. Definition: A PICC line is an IV catheter, which is inserted peripherally through a vein located in the inside of the elbow using sterile technique. The tip of the catheter is threaded to the desired location... ...k. It is recommended an infusion pump be used to deliver all therapies through the PICC line. 3. Procedure a. Use of [MEDICATION NAME] when flushing the PICC line i. PICC lines and their injection ports should be flushed as follows: [MEDICATION NAME] flush solution 10 units/cc 1-3 cc when the line is not in use.... On 02/25/13, the ADM provided the facility's complete infection control P/P and identified it as current. The P/P was entitled, "Operational Policy and Procedure Manual, Infection Control," and was dated as revised August 2001. The Manual reflected the following: Gloves - Policy Statement Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Policy Interpretation and Implementation "1. All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. 2. When gloves are indicated they shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. ...8. Hand washing is necessary when gloves are removed." Handwashing - Policy Statement "Handwashing shall be regarded by this facility as the single most important means of preventing the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow our established handwashing procedures to prevent the spread of infections and disease to other personnel, patients, and visitors. 2. Employees must perform appropriate ten (10) to fifteen (15) second hand washing procedures under the following conditions: a. When coming on duty; b. Whenever hands are obviously soiled; c. Before performing invasive procedures; d. Before preparing or handling medications; ...f. After handling used dressings, contaminated equipment, etc.; g. After contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin; h. After handling items potentially contaminated with blood, body fluids, excretions, or secretions; ...j. After removing gloves; ...m. Upon completion of duty. ...4. The use of gloves does not replace hand washing...." Infection Control Policies/Practices - Policy Statement "The primary purposes of this facility's infection control policies and practices are to establish guidelines to follow in providing a safe, snaitary and comfortable environment and to aid in preventing the development and transmission of diseases and infections." Isolation Precautions, Categories of - Policy Statement "Transmission based isolation precautions will be used for residents who are documented or suspected to have infections... that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. Transmission-based isolation precautions are to be used in addition to Standard Precautions...." MRSA - Policy Statement "When a resident is diagnosed with [REDACTED]. Standard Isolation Precautions - Policy Statement "Standard Isolation Precautions will be used in the care of all residents regardless of their diagnosed or presumed infection status. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, nonintact skin, and mucous membranes. Policy Interpretation and Implementation 1. Handwashing a. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. b. Wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. c. Use a plain (nonantimicrobial) soap for routine handwashing. d. Use an antimicrobial agent or waterless antiseptic agent for specific circumstances (e.g., control of outbreaks...). 2. Gloves a. Wear gloves (clean, nonsterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on clean gloves just before touching mucous membranes and nonintact skin. c. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. d. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other residents or environments. ...5. Resident-Care Equipment ...b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. 9) On 02/22/13 at 5:11 p.m., an IJ was identified. The ADM and DON were notified of the IJ at that time and a plan of removal for the IJ was requested. 10) The facility's Plan of Removal was accepted on 02/24/13 and reflected the following: The facility addressed and corrected areas specific to infection control, including universal precautions found to be deficient during PICC line procedures. LVN D and LVN C were not proficient when following universal precautions specific to hand washing, wearing gloves, and were both unaware of the resident's medical condition [MEDICAL CONDITION] requiring contact isolation. All residents have the potential to be affected by this deficient practice although none were. An RN attempted teaching and training including return demonstration with LVN D and LVN C and ultimately made the decision to terminate both employees and permanently remove them from the nursing staff including the schedule at the facility as of 02/23/13. The facility's RN initiated proficiency checks with all scheduled licensed nurses on 02/22/13 and completed them on 02/23/13. The following policy and procedures were reviewed and in-serviced by an RN or designee to ensure the deficient practice does not recur: 1. The facility's RN conducted an in-service on Universal Precautions/Standard Precautions on 02/22/13 and 02/23/13 (including PICC line procedures). 2. The facility's RN conducted an in-service on Isolation Precautions on 02/22/13 and 02/23/13. 3. The facility's RN in-serviced Hand Washing on 02/22/13 and 02/23/13. 4. The facility's RN in-serviced Medication and Injection Administration on 02/22/13 and 02/23/13. 5. The facility has completed specific training on clarifying medication orders on admission /readmissions (including antibiotics and the reason for use/duration of treatment), including the notification to proper staff of precautions when isolation procedures are required. All licensed staff at the facility have been checked for proficiency by the DON, facility's RN or designee. No further nurses were found to be incompetent or not proficient on items 1 - 7 listed above. All new hire licensed staff will receive training, including the above mentioned areas, by an RN or designee during initial orientation. The facility's RN will complete a licensed charge nurse proficiency checklist at the end of orientation and thereafter, quarterly, to ensure nursing competency. No current licensed nurse including new hires will be assigned a schedule if they are found not to be proficient. In addition, the facility has taken the initiative to register all licensed staff to attend an IV certification course for central lines held by ___ (IV Certification Company), which has been scheduled on Friday, 03/08/13, from 8 a.m. - 1 p.m. and on Sunday, 03/23/13 from 9 a.m. - 2 p.m. All nurses will be reevaluated on proficiency in the areas listed above on a quarterly basis. The DON or designee will perform all quarterly competency checks. This process will be monitored by the ADM and reported to the Quality Assurance Meeting each quarter. 11) Observation on 02/24/13 at 10:00 a.m. revealed Resident #17's room was set up for Contact Isolation. There was a cabinet outside the room containing gloves, masks, gowns, caps and shoe covers. Inside were containers for disposing of contaminated linen and/or trash. 12) Interviews with staff following the implementation of the Plan of Removal revealed the following: Interview on 02/24/13 at 9:00 a.m. with Dietary Aide (DA) F revealed she had an in-service on 02/23/13 concerning hand washing while in the dining area and serving the residents. DA F said they told them how to handle an injury in the kitchen resulting in a bloody wound. Interview on 02/24/13 at 9:30 a.m. with MA G revealed she had been in-serviced on 02/24/13 when she came to work this morning before she started on her shift. MA G said she had been told how to wash her hands, she had to do a return demonstration and the in-service discussed wearing gloves. Interview on 02/24/13 at 9:40 a.m. with LVN H revealed she was in-serviced on 02/23/13 about how to wash your hands and when to wear gloves. Interview on 02/24/13 at 9:35 a.m. with CNA I revealed she had a hand washing in-service with return demonstration and when to wear gloves this morning (02/24/13) prior to taking the floor. Interview on 02/24/13 at 9:50 a.m. with DA J (cook) revealed he had in-service training on 02/23/13 when he completed work concerning hand washing in the kitchen, when to wear gloves serving food, and if you have a cut occur when in the kitchen. Interview on 02/24/13 at 10:00 a.m. with RN L revealed he had been in-serviced concerning wearing gloves for direct care of any kind and hand washing with return demonstration. RN L said he could not believe the nurses were not wearing gloves during "finger sticks." Interview on 02/25/13 at 10:30 a.m. with CNA K revealed she had been in-serviced when she came to work "this morning" (02/25/13) before going to work about hand washing and wearing gloves. 13) During an interview on 02/25/13 at 9:15 a.m. the DON stated she was the Infection Control Representative for the facility. She further stated the facility's ADONs assisted with data collection. During this interview, she stated normally physicians ordered follow-up labs three days after antibiotics were completed. The DON also stated occasionally antibiotic treatments were initiated prior to cultures being completed. However, if the results of the culture reflected a different antibiotic should be used, the physician would change it. 14) Interview on 02/25/13 at 9:30 a.m. with the ADM revealed he was going to continue to monitor his staff through his morning "startup process." The administrative nursing staff had to be aware of problems in the facility, which had occurred overnight or through the weekend and then report them to him in the morning meeting. The ADM said the administrative nursing staff had not been doing this, evidently. The surveyor queried how he thought the IJ had occurred, and the ADM said it was a lack of hand washing. The ADM said there had not been any infection control problems identified in the Quality Assurance Process, but now it would be included and improved training would be discussed concerning employees. The ADM said there had been in-services on infection control and hand washing in the past. 15) On 02/25/13 at 10:00 a.m., when the DON was asked what she thought caused the IJ, she responded by saying the staff was not following the Infection Control Policy, by not doing good hand washing, or just not hand washing and the staff did not find out when the residents were either admitted and/or readmitted from the hospital the [DIAGNOSES REDACTED]. The DON said she would have to increase her observations, instead of just doing them annually. When the surveyor queried whether there had been any infection control issues identified during the staff meetings, she replied, "No." The DON said she would have to show her ADONs what to do, because she had not really followed-up on what they were doing, and get them better "acclimated" to their jobs. The DON said, "I just had in-services done on infection control and hand washing not too long ago." 16) Interview on 02/25/13 at 10:35 a.m. with ADON A revealed the charge nurses used the Infection Control Report form, and when the charge nurses call the physician, they fill out the top portion of the form. If the resident came from the hospital, the charge nurses had to fill out the bottom portion of the form. The charge nurse also was to originate a care plan related to the resident's infection and place it in the resident's chart. The charge nurse was to put the Infection Control Report in the book at the nurses' station and the ADON was supposed to check it. The back of the form was for the follow-up. ADON A showed the surveyor a form, which had not had any follow up, when there should have been. When the surveyor queried who did the follow-up on the forms, ADON A said she had no idea. ADON A said each Infection Control Report was filled out by each ADON on their specific halls, and then the ADONs conduct tracking and trending of infections for each of their assigned halls. 17) While the Immediate Jeopardy was removed on 02/25/13, the facility remained out of compliance at a scope of "pattern" and at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" due to the facility continuing to inservice staff and monitor the implementation of the plan of removal. 18) An interview with the DON on 02/22/13 at 3:40 p.m. revealed three residents in the facility had PICC lines.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of seven residents reviewed for implementation of Advance Directives. Resident #1 was found non-responsive, without a heartbeat or respiration on [DATE]. LVN A and RN C did not know whether the resident was to have emergency measures, or if he had orders for a DNR and had to check his clinical record. It was seven minutes from the time the resident was found nonresponsive until emergency measures were initiated. The facility's system of identifying residents with a DNR was not reliable and not used by staff, who referred to Resident #1's clinical record to determine his code status before starting CPR. Resident #1 expired. These findings resulted in an Immediate Jeopardy (IJ) situation for the facility's 43 residents, plus Resident #1, on [DATE], in the area of Quality of Care with Substandard Quality of Care (SQC). While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "isolated" due to the facility's continued training of staff on the new system, providing CPR classes to licensed staff and monitoring implementation of the new system. This failure could affect the facility's 43 residents, who wanted CPR initiated in the event it was needed, plus having affected Resident #1, and placed them at risk for not having their desires followed, whether to implement CPR or not, and could result in a delay in the implementation of CPR when every minute delayed could further jeopardize the resident and result in death. Findings included: 1) According to the Face Sheet dated [DATE], Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. A History and Physical dated [DATE] reflected Resident #1 was admitted to the facility on following a craniotomy procedure related to a [MEDICAL CONDITION] sustained in a motor vehicle accident. His [DIAGNOSES REDACTED]. According to the Nurses Notes dated [DATE], Resident #1 expired in the facility on [DATE] at 10:03 AM. Review of Resident #1's entire clinical record revealed there was no "Do Not Resuscitate" (DNR) order or DNR instructions for the resident. NOTE: Instructions by a resident or responsible party regarding commencing emergency resuscitation procedures in the event the resident suffers a respiratory or [MEDICAL CONDITION] are customarily documented in an Advance Directive. In the event the resident does not want emergency measures employed and a physician writes a confirming order, the resident is then reflected as having a DNR. Review of LVN A's Nurse's Notes dated [DATE] revealed six minutes elapsed during the effort to confirm Resident #1's DNR status, with the total time elapsed between discovery of Resident #1 being nonresponsive and the initiation of CPR being seven minutes. The notes reflected the following: 9:25 AM - CNA called nurse to resident's room. Resident #1 was nonresponsive. Notified DON and (the facility's only) ADON immediately. 9:31 AM - Full code status for Resident #1 confirmed by ADON. 9:32 AM - CPR was initiated by ADON and floor nurse. 9:41 AM - Paramedics arrived at facility and relieved staff providing CPR. 10:03 AM - Resident was pronounced by Practitioner E. 2) During an interview with LVN A on [DATE] at 1:30 PM, the LVN stated CNA B called her to Resident #1's bedside at approximately 9:30 AM on [DATE]. LVN A reported finding Resident #1 non-responsive, with no heartbeat or respirations. She stated she went to the nurse's station to check Resident #1's chart to determine if he had a "DNR." She stated she was "hollering" down the hall to attract the attention of RN C. LVN A then stated when she and RN C confirmed the resident did not have a "DNR," she and RN C performed Cardiopulmonary Resuscitation (CPR) on Resident #1. During an interview with RN C on [DATE] at 2:00 PM, he reported walking out into the hallway the morning of [DATE] to see LVN A and an (unnamed) CNA standing in the hall outside Resident #1's room calling to him to see Resident #1, who was unresponsive. RN C stated he went to the nurse's station to check the chart to determine Resident #1's Advanced Directive status, pulled the crash cart (cart containing emergency medical supplies) into Resident #1's room, sent the CNA to call "911" and performed CPR with LVN A. He stated he and LVN A performed CPR until the paramedics arrived, and they continued the CPR. The physician Resident #1's family members arrived while the resident was receiving CPR from the paramedics. At that time, Physician E spoke with the resident's family members, who agreed to discontinue the CPR. The Physician pronounced the resident as having expired. In an interview with Physician E on [DATE] at 3:05 PM, he stated, "I had questions about this incident as well. They originally called my nurse practitioner (NP). She reported to me what happened. She was called by the nurse on shift, who reported, "____ (Resident #1) died . Who do I need to report this to?' As soon as she (NP) hung up the phone, it hit her (NP), he (Resident #1) was not a DNR, and she called them right back and said, 'I hope you are doing CPR.' There are conflicting stories from the facility and my NP. I'm inclined to believe her (NP). She has no reason to lie and is completely trustworthy." At that time, when questioned about the impact of the seven-minute delay in commencing CPR, Physician E stated, "A seven-minute delay is never OK." In an interview with Nurse Practitioner (NP) D (Physician E's NP) on [DATE] at 3:45 PM, she reported, "I'm not even sure I even know everything that went on. I got a call from his (Resident #1's) nurse, who said, 'I need to tell you ___ (Resident #1) died .' I asked her what she meant, and she replied, 'We walked in, and he was dead. He had no blood pressure and no heart rate. Who do I need to report this to?' I told her (the nurse) I didn't know about her reporting responsibilities, but that she should follow her protocol. As soon as I hung up, it dawned on me that ___ (Resident #1) was a "full code." I called the facility back immediately and ___ (RN C) answered the phone. I asked him about ___ (Resident #1's) status and he replied, 'I think they did CPR.' I told him they don't have the authority to stop. He beat around the bush for a little bit. Then I said, '___ (RN C), you have a big problem.' " When questioned by the surveyor if the first nurse she spoke to was ___ (LVN A), NP D replied, "I think so." When asked if she had anything further to add to the interview she stated, "Whatever happens with this incident, there needs to be some education on what is a code and what isn't." The NP further stated care for Resident #1 was delayed in part due to "a lack of clearly communicated information and as a result, this patient's (Resident #1's) wishes were not honored (in a timely manner)." 3) During an interview with LVN F on [DATE] at 3:20 PM, she stated there should be a red or green sticker on each resident's door name tag indicating the resident's DNR status and green stickers meant the resident was a "full code" while red stickers meant DNR. During an interview with LVN G on [DATE] at 3:25 PM, she stated, "I really don't know if the red dot affixed to the door tag on room [ROOM NUMBER] meant DNR, but (I) knew there was usually a red sheet in the front of the chart to indicate (the resident's) DNR status." She stated she had not been employed at the facility long enough to "have everybody down." She stated, "Most everyone is DNR on my hall." During an interview with RN C, Interim DON, on [DATE] at 4:00 PM, he responded to a question as to the meaning of green dot stickers on resident room door signs by explaining that green stickers meant the resident was a "full code," but added the stickers were not always relied upon due to resident room changes or short stays. He stated staff relied mostly on the residents' charts. If a resident arrested, the staff went to the chart and looked for the resident's Advance Directive. 4) Six resident room door stickers were observed on [DATE] at 3:00 PM to determine the accuracy of the red and green stickers. Four of the six doors with the red/green tags were incorrect and did not reflect the resident's documented wishes. Residents #2, #3, #4 and #5 were found to have the wrong colored dots on their doors. A) Resident #2 was a DNR as confirmed by a review of Resident #2's clinical record and finding a signed Out-of-Hospital DNR form in the front of the clinical record. A green dot was observed on the door name tag next to Resident #2's name. B) Resident #3 was a DNR as confirmed by review of Resident #3's clinical record and finding a signed Out-of-Hospital DNR form in the front of the clinical record. A green dot was observed on the door name tag next to Resident #3's name. C) Resident #4 was a full code as confirmed by review of Resident #4's clinical record and finding a signed Out-of-Hospital DNR form in the front of the clinical record . A red dot was observed on the door name tag next to Resident #4's name. D) According to the facility's Daily Census dated [DATE], Resident #5 was receiving hospice services. Having a green dot on the door by Resident #5's name, which meant the resident was to be provided with CPR, was inconsistent with the resident being on hospice. Resident #5 had a signed Out-of-Hospital DNR form in the front of the clinical record. 5) In an interview with the facility's Administrator on [DATE] at 1:00 PM, a request was made for evidence of current CPR certification for all of the facility's licensed nurses. The ADM stated the facility did provide these services and then added, "We have a respiratory therapist coming in to conduct CPR training for all nurses (on [DATE])." During the same interview, the ADM was asked what the facility had done in response to the incident, which had occurred with Resident #1. The ADM responded by saying a chart audit had been conducted confirming the residents' Advance Directive status. The ADM added a binder had been compiled with the residents' names, which reflected whether the resident was a DNR or required CPR. Review of the facility's personnel records revealed seven nurses employed by the facility lacked current CPR certification. LVN A's certification had expired and was renewed on [DATE] via an online certification service. 6) Review of the undated, facility policy entitled "Emergency Procedure-[MEDICAL CONDITION]" provided by the facility as current revealed the following: Purpose: 1. To provide early treatment to maintain adequate oxygenation and circulation... Equipment: ...3. Sphygmomanometer (blood pressure cuff) and stethoscope Procedure: ...4. Do not leave the patient alone. Call for assistance... ...7. If patient is not responding, start artificial respiration. If breathing does not resume, and there is no pulse, start CPR.... The policy did not reflect any information regarding Advance Directives or DNR orders. No other policies were provided related to the facility's Advance Directives or Emergency Response procedures prior to the surveyor's exit on [DATE]. 7) Review of the Emergency Cart Checklist revealed a list of items required on the cart. The list included a blood pressure cuff and a stethoscope. The checklist also included a note and a date list, which reflected the cart was to be inspected every 24 hours starting [DATE]. The following dates were blank: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 9:00 AM the facility crash cart was inspected. The following items were missing: blood pressure cuff, stethoscope and functioning batteries for the flashlight. 8) On [DATE] at 4:50 PM, these findings resulted in an Immediate Jeopardy (IJ) situation in the area of Quality of Care with Substandard Quality of Care (SQC) for Resident #1 and the 43 residents in the facility, who did not have DNR orders. The ADM and the DON were notified at that time. 9) The facility's Plan of Removal for the IJ originally dated [DATE] and updated on [DATE] was accepted on [DATE]. It reflected the following: 1. A complete chart audit was performed to confirm the Advance Directive status of all 63 residents in the facility. Each chart was flagged with either a green insert reading "FULL CODE" or a red insert reading "Do Not Resuscitate." 2. For each resident confirmed as a DNR, the original DNR order was removed to the financial office for safekeeping, and copies were displayed in the resident's chart. 3. All red and green dots were removed from resident door tags. 4. Residents with confirmed DNR status had a wrist band bearing a red dot placed on his or her wrist, and a red dot placed next to his or her name on the resident's door name tag. 5. Red DNR binders were placed at each nurse's station and designated as a backup in case the resident's facility record was unavailable for immediate inspection. Each binder contained an alphabetical listing of residents designated as DNRs. 6. All staff members were educated on: a. The requirement to identify Advance Directive status on admission, b. Placement of the appropriate red or green chart inserts, c. The significance of the wrist band and the red dot on the door name tag, and d. The location and contents of the DNR binders. 7. Arrangements were made to obtain CPR certification for all LVNs and staffing changes were made to ensure the presence of at least one CPR-certified LVN on each shift. 8. Arrangements have been made for the Restorative Aide or designee to conduct daily physical checks of the resident's bands, and for administrative staff to conduct weekly reviews of residents' DNR status. The facility provided a new policy and procedure for review entitled "Code," with an effective date of [DATE]. The procedure reflected all residents were to be considered a full code unless identified with a DNR band. Personnel discovering a nonresponsive resident will use the call light for assistance and verify whether the resident has a DNR wrist band. If there is no wrist band, staff will announce the code "STAT" and initiate CPR. Staff discovering the resident do not have to leave the resident's side. The continuation of CPR will be provided for the resident until emergency personnel arrive and take over CPR. Review of an in-service sign-in sheet dated [DATE] revealed 21 facility employees had attended inservice training on Code status and Emergency Response. 10) On [DATE] at approximately 4:00 PM a binder was observed at the main entry nurse's station. The binder contained signed copies of DNR instructions and physicians orders for DNR status for 21 (Residents #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23) of 63 residents. (Forty-two residents were to receive CPR if needed.) On [DATE] at 11:00 AM, a tour of the facility revealed: a. All green stickers had been removed from the resident door name tags. b. Red stickers were affixed to the door name tags for Residents #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23. c. Residents #2, #3, #6, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 were observed wearing DNR wrist bands bearing a single red dot. No other identifiers were observed on the bands. d. Residents #5 and #8, who were their own responsible parties, refused to wear the band and had instead been educated regarding the purpose of the band and had care plan revisions made communicating these residents refused to wear the band. On [DATE] at 10:00 AM, a CPR instructor was observed in the facility conducting a CPR certification class to five employees. 11) While the IJ was removed on [DATE] at 11:00 AM, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "isolated" due to the facility's continued training of staff on the new system, providing CPR classes to licensed staff and monitoring implementation of the new system. The Administrator and the DON were informed at that time. 12) The facility's Daily Census dated [DATE] reflected the census was 63 residents.