Every finding on record at Diboll Nursing and Rehab

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 4 of 8 residents (Residents #9, #1, #4, and #21) reviewed for ADL care. 1.The facility failed to clean/groom Resident #9's fingernails that had a dark brown substance underneath them on 8/25/25 and 8/26/25.2.The facility failed to trim, clean/groom Resident #21's fingernails that were about 1/2 inch in length and had a dark, brown substance underneath them on 8/25/2025.3. The facility failed to trim, clean/groom Resident #4's fingernails that were about 1/2 inch in length on 8/25/2025 and 8/26/2025.4. The facility failed to trim, clean/groom Resident #1's fingernails that were about 1/2 inch in length and had a brown substance underneath them on 8/25/2025 and 8/26/2025. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care.Findings included:1. Record review of a facility face sheet dated 8/26/25 for Resident #9 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (uncontrolled blood sugar). Record review of Resident #9's Quarterly MDS assessment dated [DATE] indicated a BIMS score of 3 which indicated a severe cognitive impairment. She required maximum assistance with most ADLs. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 7/23/25 for Resident #9 indicated she had an ADL self-care performance deficit and had an intervention for substantial/maximal assistance with personal hygiene. Record review of a Point of Care History flowsheet dated 8/23/25 to 8/26/25 for Resident #9 indicated she was to have nail care done once a day on Monday, Wednesday, and Friday.During an observation and interview on 8/25/25 (a Monday) at 9:27 am Resident #9 was observed lying in bed. Her 2nd and 3rd fingernails on her left hand were observed with a dark brown, caked substance underneath them. She was asked when the last time her nails were cleaned and groomed, and she said she thought they trimmed them last week but could not say when the last time they were cleaned. She said she would like to have them cleaned. During an observation on 8/26/25 (a Tuesday) at 8:20 am Resident #9 was observed in bed finishing her breakfast. Her nails on her left hand were observed to still have a dark brown, cakey substance underneath them. 2. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he readmitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (wound at the bottom of the spine that extends through the skin into the tissue and fat), diabetes mellitus, and malignant neoplasm of upper lobe of lung (lung cancer).Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 10. He required substantial/maximal assistance with personal hygiene. Record review of a care plan for Resident #1 dated 10/28/2024 indicated he had an approach for nail care to be performed once a day on Monday, Wednesday, and Friday.During an observation and interview on 8/25/2025 at 1:41 PM, Resident #1 was in bed awake. His fingernails were about 1/2 inch in length and had a brown substance underneath them. He said the staff had cut and cleaned his nails before, but it had been a while. He said he would like to have his nails trimmed and cleaned.During an observation on 8/26/2025 at 9:07 AM, Resident #1 was in bed awake. His fingernails were still long in length and had a brown substance underneath them.3. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction (Stroke) affecting left non-dominant side (paralyzed on one side of the body), type 2 diabetes, heart failure and GERD (acid reflux disease).Record review of a care plan for Resident #21 dated 8/18/2025 indicated nail care to be done once a day on Monday, Wednesday, and Friday from 6 am-6 pm. She had impaired functional abilities related to hemiplegia with an approach for personal hygiene that indicated she was dependent on staff.Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene.During an observation and interview on 8/25/2025 at 1:19 PM, Resident #21 was in her room in bed. Her fingernails were about 1/2 inch in length and had a brown substance underneath them. She said the staff cut and cleaned her nails about once a month. She said she did not like long nails and liked to keep them short and clean.During an observation on 8/26/2025 at 2:58 PM, Resident #21 was sitting up in a wheelchair in her room watching tv. Her nails were still long and had a brown substance underneath them.4. Record review of a Face Sheet for Resident #4 dated 8/26/2025 indicated the resident admitted to the facility on [DATE] and was [AGE] years old with diagnoses of moderate intellectual disabilities (developmental delay that affects thinking) expressive language disorder (inability to use language and communicate effectively), and schizoaffective disorder (a mental illness that combines symptoms of mood disorders).Record review of a care plan for Resident #4 dated 7/23/2025 indicated nail care to be completed once a day on Tuesday, Thursday, and Saturday.Record review of an Annual MDS Assessment for Resident #4 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She was dependent on staff for personal hygiene.During an observation on 8/25/2025 at 9:52 AM, Resident #4 was sitting by the front entrance in a wheelchair. She was staring out the front door and did not answer when she was spoken to. Her fingernails were about 1/2 inch in length. During an observation and interview on 8/26/2025 at 2:59 PM, Resident #4 was sitting by the front entrance in a wheelchair with a visitor present. Resident #4 did not respond when she was spoken to. Resident #4 still had long fingernails. Her visitor said she had been with the resident for about 5 months and the resident had never refused to allow the staff to trim her nails. She said the Activity Director or Treatment nurse would trim the resident's fingernails. She said residents could scratch themselves or injure others if their nails were long.During an interview on 8/26/2025 at 3:01 PM, the Activity Director said she was responsible for nail care along with the nurse aides. She said the nurse aides were to clean and trim nails on the resident's shower days and she provided nail care on Monday during activities that included cleaning, trimming, and painting. She said the nurse aides would try to cut Resident #1's his nails but he would refuse at times. She said for the dependent residents who stayed in bed she would trim or file their nails as a 1:1 activity. She said if resident's nails were dirty and long, they could spread infections.During an interview on 8/26/2025 at 3:13 pm, LVN B said the treatment nurse was responsible for nail care for the residents in the facility and her last day working at the facility was one day last week. She said the treatments had been split up between management staff that included the ADON and MDS who would all rotate days during the week to perform treatments that started the week of 8/25/2025. She said she was not aware of any residents' nails in the facility being long or that needed to be cleaned.During an interview on 8/26/2025 at 3:17 PM, CNA A said nail care included cutting/cleaning and was the responsibility of the nurse aides and it was to be done on shower days and as needed. She said if the resident was diabetic, then the nurses were responsible for cutting the resident's nails. She said Resident #21 and Resident #1 were both diabetic residents and she did not cut their nails. She said she was not sure about Resident #4 if she was diabetic or not. She said she had cleaned her nails in the past but never trimmed them. During an interview on 8/27/2025 at 9:00 am, the DON said nail care was the responsibility of the nurse aides and the person who was responsible for completing skin assessments. She said nail care should be done weekly three times a week and as needed. Staff should trim, cut, file or clean as needed. She said nail care was taken care of on yesterday 8/26/2025 for the residents in the facility. She said residents could scratch themselves if nails were long and could get infections if not cleaned.During an interview on 8/27/2025 at 9:20 AM, the Administrator said nail care was the responsibility of the nurses and nurse aides. He said nail care should be done as needed. He said he planned to assign staff to perform nail care and have the administrative staff monitor daily during rounds. He said not having proper nail care could be a dignity issue and the residents could possibly scratch themselves or get ill from not having clean nails.Record review of a facility policy titled Nail Care dated 7/2025 indicated, .The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and were labeled and dated.The facility failed to ensure all foods stored in the dry storage area were not kept past their expiration dates.These failures could place residents at risk of foodborne illness and food contamination.Findings included: During an observation of the refrigerator on 8/25/2025 at 9:30 AM, the following items were observed:(1) 1 gallon container of unsweet tea dated 8/18/2025.(2) 1 gallon container of unsweet tea dated 8/19/2025.(3) 16 glasses of unsweet tea not labeled or dated.(4) 14 glasses of fruit punch not labeled or dated.(5) 2 glasses of orange juice not labeled or dated. During an observation of the dry storage area on 8/25/2025 at 9:30 AM, the following items were observed: (1) 5 bags of panko Japanese style toasted breadcrumbs 2.5 pounds with the expiration date of 9/27/2024.(2) 1 bag cookie pieces 2.5 pounds with the expiration date of 1/20/2025. During an observation and interview on 8/25/2025 at 9:30 AM, [NAME] C said the DM was not at the facility and did not know if she would be at the facility later. She said it was the DM's responsibility to check for expired foods and it was done on Mondays when they received their food truck. During an interview on 8/27/2025 at 9:40 AM Dietary Aide D said it was everyone's responsibility to check for expired food in the kitchen. She said they were supposed to check once a week and throw away any food that was past the expiration date. She said the refrigerator was last checked on 8/21/2025 or 8/22/2025 when they were checking to see what food needed to be ordered. She said the dry storage area was last checked on 8/18/2025 for expired food. She said if the residents consumed expired food, it could make them sick. During an interview on 8/27/2025 at 9:51 AM [NAME] C said it was the DM's responsibility to check for expired foods on Mondays when the food truck came. She said the DM did not come to the facility on 8/25/2025 the day the truck came and did not know why. She said if resident consumed food that was expired, they could get sick. During an interview on 8/27/2025 at 10:13 AM, the Administrator said it was the staffs and his responsibility to check for expired foods in the kitchen. He said they should be checking for expired foods daily. He said if the residents consumed expired foods, they could possibly get sick. Record review of facility policy titled Food Storage undated, indicated: .1. D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. D. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. E. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident's #1, #21, and #22) and 3 of 5 staff (CNA A, ADON and CNA E) reviewed for infection control. 1.The facility failed to ensure CNA A changed gloves and washed or sanitized her hands when providing care to Resident #21 on 8/25/2025.2. The facility failed to ensure ADON wore a gown during wound care to Resident #1 who was on enhanced barrier precautions on 8/26/2025.3. The facility failed to ensure CNA E wore a gown during incontinent care to Resident #22 who was on enhanced barrier precautions, and she failed to wash or sanitize her hands on 8/27/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:1. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction (stroke) affecting left non-dominant side (paralyzed on one side of the body), type 2 diabetes, heart failure (heart is not able to pump effectively) and GERD (acid reflux disease).Record review of a care plan for Resident #21 dated 8/18/2025 reflected she had impaired functional abilities related to hemiplegia with an approach for personal hygiene that indicated she was dependent on staff.Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene. She was always incontinent of bowel/bladder.During an observation on 8/25/2025 at 10:19 AM, CNA A was in the hallway gathering supplies to provide incontinent care to Resident #21. She placed the supplies in a plastic bag that included: wipes, gloves, brief and linens. CNA A entered the room of Resident #21; washed her hands and donned (put on) a gown, gloves, and shoe covers. She closed the door and the window blinds. CNA A removed the sheet and blankets from the bed and placed them in a chair. The fitted sheet on the bed was wet and the resident's brief was pulled down between her thighs. CNA A removed wipes from the plastic bag, and she wiped both inner thighs and down the middle of the vagina from front to back and placed the wipes in the trash. Resident #21 was rolled onto her right side and the brief was removed and placed in the trash. CNA A removed wipes from the plastic bag and wiped the rectal area using multiple wipes and feces was present and she placed them in the trash. CNA A removed the fitted sheet from the bed and placed it in a plastic bag. She placed a clean fitted sheet on the bed using the same dirty gloves and then placed a clean brief under the resident's buttocks. She removed her gloves and placed them in the trash, applied gloves and did not sanitize or wash her hands. She applied barrier cream to the resident's buttocks and removed her gloves and placed them in the trash. She applied gloves to both hands and did not wash or sanitize them. She secured the brief and repositioned the resident in the bed. The trash was placed in a biohazard bag in the bathroom. She removed her gown, gloves, and shoe covers and washed her hands and exited the room.During an interview on 8/25/2025 at 10:46 AM, CNA A said during the care provided to Resident #21 she should have changed her gloves after she cleaned her rectal area. She said she did not sanitize her hands between glove changes because she did not have sanitizer with her and should have. She said she was nervous and forgot. She said she had been trained on performing incontinent care. She said there was a risk for cross contamination and infections if staff did not change gloves or wash/sanitize their hands. Record review of a perineal care return demonstration skills check off for CNA A dated 3/28/2025 indicated she was satisfactory with peri-care for a female resident. 2. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body, typically bony prominences), diabetes mellitus, and malignant neoplasm (cancer) of upper lobe of lung.Record review of active physician orders for Resident #1 dated 7/3/2025 indicated an order for enhanced barrier precautions due to wound every shift with a start date of 7/3/2025.Record review of a care plan for Resident #1 dated 6/20/2025 indicated he had a pressure ulcer/injury with an approach for enhanced barrier precautions when performing wound treatment that started on 7/16/2024.Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 10. He required substantial/maximal assistance with personal hygiene. He was at risk for developing pressure ulcer/injuries but did not have any unhealed pressure ulcer/injuries during the look back period (the time period over which the resident's condition or status is captured by the MDS assessment and ends at 11:59 p.m. on the day of the Assessment Reference Date (ARD).During an observation on 8/26/2025 at 9:07 AM, the ADON was in the doorway for Resident #1's room gathering wound care supplies. The ADON cleaned the overbed table and applied wax paper and placed wound care supplies on top of it. The ADON washed her hands and donned (put on) gloves but did not don a gown. The ADON opened Resident #1's brief and cleaned his sacrum with normal saline and a gauze, gloves were removed and placed in the trash; hands were sanitized, gloves were applied; collagen (dressing that helps with wound healing) was applied to the wound bed and covered with a dressing. The ADON washed her hands and applied gloves. Resident #1 was rolled and positioned on his left side. Dressing from his right hip was removed and placed in the trash along with her gloves; hands were sanitized; gloves were applied; she cleaned the wound with vashe solution (wound cleanser) and patted it dry, applied gentamycin ointment (antibiotic used to treat skin infections) to his hip using a tongue depressor and applied a dressing. She removed her gloves and washed her hands.During an interview on 8/26/2025 at 9:35 AM, the ADON said she was one of the staff responsible for training staff on infection control. She said during wound care that was performed on Resident #1, she forgot to put on a gown, and it was left on the cart in the hallway. She said the resident was on enhanced barrier precautions for his wound and all staff that provided care to him should wear a gown and gloves. She said EBP was in place to keep residents from getting germs from other staff. She said residents could be at risk for infections if staff did not wear the appropriate PPE when care was provided. During an interview on 8/27/2025 at 9:00 AM, the DON said the ADON conducted random audits on hand hygiene/pericare often in the facility with staff. She said gloves should be changed when they are soiled and when changing from dirty to clean things. She said staff should never touch clean items with dirty gloves and hand hygiene should be performed after gloves were removed. She said EBP was to protect the residents and when care was provided staff should wear a gown, gloves, mask, and face shield if necessary. She said residents who had wounds would have enhanced barrier precautions. She said staff should wear a gown and gloves when wound care was provided. She said she was aware of the incident with the ADON on 8/26/2025 when she did not wear a gown when wound care was provided. She said there was a risk for spreading infections if staff did not follow hand hygiene and wear the appropriate PPE.During an interview on 8/27/2025 at 9:20 AM, the Administrator said the DON and ADON were the IPs for the facility who were responsible for training staff on infection control. He said staff should take off and change gloves when changing from dirty to clean. He said staff should wear the appropriate PPE for residents who were on EBP that included residents with chronic wounds. He said staff should wear a gown and gloves when care was provided. He said there was a risk for spreading infections if staff did not follow infection control practices.3. Record review of a facility face sheet dated 8/26/25 for Resident #22 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (uncontrolled blood sugar).Record review of a Quarterly MDS assessment dated [DATE] for Resident #22 indicated a BIMS score of 6, which indicated the resident had severely impaired cognition. She was always incontinent of bowel and bladder. She required maximal assistance with most ADLs. Record review of a comprehensive care plan dated 6/3/25 for Resident #22 indicated she had a feeding tube related to dysphagia (trouble swallowing).Record review of a physician's order summary report for Resident #22 indicated she had the following physician's order dated 7/31/25: .initiate enhanced barrier precautions. Special Instructions: G/tube (a tube inserted into the stomach via the abdomen to provide nutrition). During an observation on 8/27/25 at 11:45 am CNA E was observed providing incontinent care for Resident #22. She did not wear a gown for enhanced barrier precautions, and she was not observed to wash or sanitize her hands between glove changes. During an interview on 8/27/25 at 12:10 pm CNA E said she knew she forgot to put her gown on for the enhanced barrier precautions. She said Resident #22 had a G-tube and she was supposed to wear a gown when providing care for infection control. She said she also forgot to bring her hand sanitizer into the room and did not sanitize her hands between her glove changes. She said residents could be at risk for infection if infection control policy was not followed properly. Record review of a facility policy titled Enhanced Barrier Precautions dated 6/2025 indicated, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. 4. High-contact resident care activities include: h. wound care: any skin opening requiring a dressing .Record review of a facility policy titled Hand Hygiene dated 6/2025 indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6 a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene table: either soap and water or alcohol-based hand rub: after handling contaminated objects; before and after handling clean or soiled dressing, linens, etc., when during resident care, moving from a contaminated body site to a clean body site .

Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 4 of 5 residents (Residents #1, #4, #7, and #21) reviewed for immunizations.The facility failed to document education was offered for the influenza and pneumococcal vaccinations to Residents #1, #4, #7 and #21.These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.Findings include: 1. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (wound a the bottom of the spine that extends through the skin and tissue), diabetes mellitus, and malignant neoplasm of upper lobe of lung (lung cancer). Record review of a comprehensive care plan dated 7/3/2025 for Resident #1 indicated that he did not have any interventions for flu and pneumonia vaccinations. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated that he had moderate impairment in thinking with a BIMS score of 10. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive his influenza vaccine in the facility for this year's influenza season because it was offered and declined. He was not up to date on the pneumonia vaccination because it was offered and declined. Record review of Resident #1's electronic health record undated revealed on 10/4/2024 the influenza vaccine was refused by family. On 4/3/2024 the pneumonia vaccine was refused by the resident. 2. Record review of a Face Sheet for Resident #4 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of moderate intellectual disabilities, expressive language disorder, and schizoaffective disorder. Record review of a comprehensive care plan dated 7/23/2025 for Resident #4 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of an Annual MDS assessment dated [DATE] for Resident #4 indicated that she had moderate impairment in thinking with a BIMS score of 11. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She was not up to date on the pneumonia vaccination. She was up to date on the pneumonia vaccine. Record review of Resident #4's electronic health record undated revealed on 10/4/2024 the influenza was refused by family. She received the pneumonia vaccine on 11/19/2021. 3. Record review of a face sheet for Resident #7 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Raynaud's syndrome (a condition that causes areas such as fingers and toes to feel numb and cold in response to cold temperatures), bipolar disorder (mood swings), and hypertension (high blood pressure). Record review of a Quarterly MDS Assessment for Resident #7 dated 8/12/2025 indicated she did not have any impairment in thinking with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She did not receive the pneumonia vaccine because it was not offered. Record review of a care plan for Resident #7 dated 7/23/2025 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of the electronic health record for Resident #7 undated revealed the influenza vaccine was offered on 10/4/2024 and the resident refused. On 4/13/2024 the pneumonia vaccine was offered and the resident refused. 4. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction affecting left non-dominant side (paralyzed on left side of the body following a stroke), type 2 diabetes, heart failure (heart not able to pump effectively) and GERD (acid reflux). Record review of a care plan for Resident #21 dated 8/25/2025 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She did not receive the pneumonia vaccine because it was offered and declined. Record review of an electronic health record for Resident #21 undated revealed on 10/4/2024 the influenza vaccine was offered and the family refused. On 10/25/2023 the pneumonia vaccine was offered and declined by the resident. During an interview on 8/27/2025 at 9:00 AM, the DON said the ADON was responsible for ensuring the residents received immunizations. She said when immunizations were given education was provided to the resident/family. She said she was not aware there was not any documentation for the refusals of the vaccines that were offered. She said residents could be at risk of not knowing what they were refusing if they were not provided education. During an interview on 8/27/2025 at 9:18 AM, the ADON said she was responsible for resident immunizations. She said she did not have any record of the declinations that were provided to the residents or families. She said they were in a binder somewhere but could not locate them and they were not in the electronic record. She said education was provided to the resident/family at the time vaccines were given along with information from the CDC. She said if they declined, they should be given the VIS statement detailing the risks of vaccine refusal and she would let them know that they could change their mind at any time and provided education to them. During an interview on 8/27/2025 at 9:20 AM, the Administrator said declinations for vaccines should include education on the pros and cons of getting immunizations along with proof of verbal educations. He said he was not sure of the regulations regarding the documentation that should be provided to the resident/family. Record review of a facility policy titled General Immunization/Vaccination dated 6/2025 indicated, .It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases. 10. The resident's medical record or staff/volunteer's medical file will include documentation that the staff, volunteer, resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization(s), and that the resident received or did not receive the immunization(s) due to medical contraindication or refusal . Record review of a facility policy titled Infection Prevention and Control Program dated 6/2025 indicated, .7. Influenza and Pneumococcal Immunization: c. Education will be provided to the residents and/or representative regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations .

Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 6 residents (Residents # 6, #22, #26, and #27) reviewed for resident call system.1.The facility failed to ensure Residents #6, #22, and #26 had a call light within reach on 8/25/25 and 8/26/2025.2.The facility failed to ensure Resident #27 had a call light that was functional. Resident #27 did not have a pull cord attached to the call box on 8/25/25.This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1.Record review of a facility face sheet dated 8/26/25 for Resident #6 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 11, which indicated she had moderate cognitive impairment. She was always incontinent to bowel and bladder. She required maximum to total assistance with all ADLs. Record review of a comprehensive care plan dated 6/4/25 for Resident #6 indicated she was at risk for falls and had an intervention to keep the call light within reach. Record review of a facility face sheet dated 8/26/25 for Resident #22 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (uncontrolled blood sugar). Record review of a Quarterly MDS assessment dated [DATE] for Resident #22 indicated a BIMS score of 6, which indicated the resident had severely impaired cognition. She was always incontinent to bowel and bladder. She required maximal assistance with most ADLs. Record review of a comprehensive care plan dated 6/3/25 for Resident #22 indicated she was at risk for falls and had an intervention to keep the call light within reach. Record review of a facility face sheet dated 8/26/25 for Resident #26 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #26 indicated a BIMS assessment should not be conducted due to the resident being rarely/never understood. She had severely impaired cognition. She was totally dependent with all ADLs. She had an indwelling urinary catheter and was always incontinent of bowel. Record review of a comprehensive care plan dated 8/25/25 for Resident #26 indicated she was at risk for falls and had an intervention to keep the call light within reach. 2. Record review of a facility face sheet dated 8/26/25 for Resident #27 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (trouble breathing due to not having enough oxygen in the blood). Record review of a comprehensive MDS assessment dated [DATE] for Resident #27 indicated a BIMS score of 11, indicating moderate cognitive impairment. She was dependent with most all ADLs. She was always incontinent to bowel and bladder. Record review of a comprehensive care plan dated 6/18/25 for Resident #27 indicated she was incontinent of urine and had an intervention to keep the call light in reach. During an observation on 8/25/25 at 9:31 am Resident #6 was observed lying in bed sleeping. She did not speak when attempted to awaken. Her call light was observed on the floor between the bed and the wall, out of her reach. During an observation on 8/25/25 at 9:45 am Residents #22 and #26 were observed in their room. Resident #22 was observed lying in bed and her call light was observed on the floor behind the head of her bed, out of her reach. She did not answer questions appropriately. Resident #26 was observed lying in her bed. She did not speak. Her call light was observed on the floor out of her reach. During an observation and interview on 8/25/25 at 9:57 am Resident #27 was observed lying in bed. She said she did not use the call light very often, staff took care of her needs, and she said she had no complaints. No call light was observed within her reach and upon inspection, it was observed that there was no call light cord attached to the box on the wall for her. During an observation and interview on 8/25/25 at 2:00 pm Resident #27 was observed in bed awake and talking, but did not answer questions appropriately, she just kept repeating My name is and saying her name. There was still no call light cord from the box to her side of the room. No call light was observed within her reach. During an observation on 8/26/25 at 8:00 am Resident #22 was observed lying in bed, sleeping. Her call light was again observed lying on the floor at the head of the bed, out of her reach. During an observation on 8/26/25 at 8:05 am Resident #6 was observed in bed sleeping and her call light was observed clipped to the cord next to the box on the wall, out of her reach. During an observation on 8/26/25 at 8:15 am Resident #27 was observed in her room, lying in bed with the head of the bed elevated being assisted with breakfast by the COTA. Her call light was observed on her nightstand at the time the COTA was assisting with breakfast. During an observation on 8/26/25 at 9:15 am Resident #6 was observed lying in bed with her call light still clipped out of her reach. During an observation on 8/26/25 at 9:47 am Resident #27 was observed lying in bed with her call light still observed on the nightstand, out of her reach. During an observation and interview on 8/26/25 at 10:19 am the ADON was observed in Resident #27's room providing care. Upon exiting the resident room, the ADON did not place the call light within reach of the resident. After exiting the room with the ADON, she was asked if there was anything else that needed to be done. She walked back into the resident's room and looked around, and it was then she noticed the call light on the nightstand and she placed the call light within reach of Resident #27. She said residents should always have access to their call lights so they can call for help if needed. She said residents could be at risk of not being able to call for help and possibly dehydration if they could not ask for water, or skin breakdown if they could not call for help with incontinent care or repositioning. During an interview on 08/27/2025 at 12:03 pm the COTA said she was assisting Resident #27 with her breakfast yesterday on 8/26/25 and when she was done, her roommate needed something, so she then helped staff change the roommate and just must have forgotten to replace the call light within reach of Resident #27 when she left the room. She said residents could be hurt if they needed help and could not reach the call light to call for assistance. During an interview on 8/27/25 at 1:30 pm the DON said residents could not call for help if they needed assistance if they did not have access to call lights. During an interview on 8/27/25 at 1:35 pm the Administrator said residents may not get the help they need if they could not call for help. Record review of a facility policy titled Call Lights: Accessibility and Timely Response dated 7/1/25 read: .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . and .staff will ensure the call light is within reach of resident and secured, as needed . and .The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .

Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment 1 of 3 halls (room [ROOM NUMBER]) reviewed for environment.The facility failed to repair the window in Resident #8's room [ROOM NUMBER] that had a broken frame that was frayed and splintered on 8/26/2025 and 8/27/2025.This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.Findings include:Record review of a face sheet for Resident #8 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of severe intellectual disabilities (delay in language, motor, and social skills), expressive aphasia (difficulty speaking), and hypotension (low blood pressure). Record review of the maintenance log dated 7/30/2025 indicated that the window frame in Resident #8's room was reported and initialed by Maintenance. Record review of a care plan for Resident #8 dated 7/23/2025 indicated she had impaired functional abilities related to severe intellectual disabilities and she was dependent on staff for all adl's. Record review of a Quarterly MDS Assessment for Resident #8 dated 7/18/2025 indicated she was rarely/never understood and did not have a BIMS score. She was dependent on staff for all adl's. During an observation and interview on 8/26/2025 at 8:19 AM in Resident #8's room revealed she was in bed visiting with a friend . The window frame was frayed and splintered with pieces of wood sticking out. The friend said she had been working with Resident #8 for two weeks and had not noticed the window frame. She said the window frame was splintered it could be a hazard to the resident and said she was sure they would get it fixed. During an observation and interview on 8/26/2025 at 8:21 AM, CNA A was standing in the hallway of hall 100. She said she had been employed at the facility since April 2025. She said she reported the window frame in Resident #8's room last month to Maintenance. She said she had Maintenance go in the room and look at the window frame. She said she did not know if there was a logbook to report maintenance issues. She said she would report issues verbally to the nurse or would find Maintenance and report to him directly. She said the resident could get splinters, cuts, or injuries if the window frame was not repaired. During an observation on 8/27/2025 at 8:19 AM, Resident #8 was in bed resting with her eyes closed. The window frame was still not repaired and was splintered with pieces of wood sticking out. During an observation and interview on 8/27/2025 at 8:46 AM, the Maintenance Supervisor said he had been employed at the facility for three months. He said staff reported things that needed repair to him verbally but would log in the maintenance book that was kept outside of his office door. He said he checked the maintenance log daily. He observed the window in Resident #8's room and said it was splintered and needed to be repaired. He said he thought the staff were raising the bed too close to the window frames that was causing the frames to break. He said he was not aware of the window frame in Resident #8's room but would get it repaired. He said residents could get hurt if it was not repaired. During an interview on 8/27/2025 at 9:20 AM, the Administrator said he was aware of the windowsills in some of the resident rooms that needed repair. He said the Maintenance Supervisor had been working to repair them. He was not aware the window in Resident #8's room had been on the log for about a month. He said the Maintenance Supervisor would get the window repaired. He said there could be a risk for injury if the window was not repaired. Record review of a facility policy titled Homelike Environment revised February 2021, .Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment .

Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 1 of 5 residents reviewed for respiratory care (Residents #21).The facility failed to ensure the external filters of Resident #21's oxygen concentrators was free of dust build up from 8/25/2025-8/27/2025.These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.Findings included:Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction affecting left non-dominant side (paralyzed on left side of the body following a stroke), type 2 diabetes, heart failure (heart not able to pump effectively) and GERD (acid reflux). Record review of active physician orders for Resident #21 dated 8/26/2025 indicated an order to clean the oxygen concentrator filter weekly on Sundays with a start date of 6/12/2023. Record review of a care plan for Resident #21 dated 8/18/2025 indicated she needed oxygen therapy related to shortness of breath in an approach to administer oxygen as needed per MD orders. Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. Special Treatments, Procedures, and Programs during the 14 day look back period, she did not use oxygen therapy. During an observation on 8/25/2025 at 9:58 AM in the room of Resident #21, she was on oxygen via a nasal cannula at 2 L/min, the external oxygen concentrator filter had a large amount of white dust buildup. During an observation on 8/26/2025 at 2:58 PM, Resident #21 was in her room sitting up in a wheelchair not wearing oxygen. The external filter on the oxygen concentrator still had a large amount of white dust buildup. Resident #21 said the staff changed the oxygen tubing weekly on Sundays but had never seen anyone clean the filter on the concentrator. During an observation on 8/27/2025 at 8:21 AM, in the room of Resident #21, the external oxygen concentrator filter still had dust buildup. Resident #21 was in bed resting with her eyes closed. During an observation and interview on 8/27/2025 at 8:51 AM, LVN B said the oxygen concentrator filters were designated to get cleaned by the weekend nursing staff on Sundays. LVN B observed the concentrator of Resident #21 and said the filter was dusty and needed to be cleaned. She said if the filters were not kept clean, the residents could get infections, or the concentrator may not work properly. During an observation and interview on 8/27/2025 at 9:00 AM, the DON said the weekend supervisors were responsible for cleaning the oxygen concentrator filters on Sundays. The DON observed the concentrator for Resident #21 and said the filter was dusty. She said residents could be at risk for infections. She checked the filters and said they were hard to remove and would get the resident another concentrator to use. During an interview on 8/27/2025 at 9:20 AM, the Administrator said nursing staff were responsible for cleaning the oxygen concentrator filters when they changed the tubing weekly and as needed. He said if the filters were not cleaned it could inhibit the flow of oxygen to the resident. Record review of a facility policy titled Oxygen Concentrator dated 7/2025 indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. 5. Care of the concentrator: a. Follow manufacture recommendations for the frequency of cleaning filter and servicing the device .

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 5 months (February 2025) reviewed for pharmacy services. The facility failed to have 2 witness signatures on attached page of controlled substances at time of disposal on 2/11/25.This failure could put residents at risk for misappropriation and drug diversion.Findings include:Record review of facility drug destruction records dated August 2024 through August 2025 revealed that on February 11, 2025, the attached page containing controlled substances was signed by the consultant pharmacist and one witness, the DON, and did not contain 2 witness signatures as required.During an interview on 8/27/25 at 11:15 am the DON said she was responsible for drug destruction. She said she was unsure how the witness signature was missed on the attached sheet of controlled substances. She said she would ensure proper witness signatures were done going forward for drug destruction. She said a drug diversion could possibly occur, or drugs might not be properly destroyed.During an interview on 8/27/25 at 1:35 pm the Administrator said the DON was responsible for drug destruction and drugs could be misplaced if they were not properly destroyed according to the regulations.Record review of a facility policy titled Disposal of Medications and Medication-Related Supplies dated 6/1/22 read: .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations . Record review of 22 TAC S303.1 Destruction of Dispensed Drugs accessed online 08/27/2025 at https://texas-sos.appianportalsgov.com/rules-and-meetings?$locale=en_US&interface=VIEW_TAC_SUMMARY&queryAsDate=08%2F27%2F2025&recordId=212962 indicated: (a) Drugs dispensed to patients in health care facilities or institutions.(C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es).(D) The drugs are destroyed in a manner to render the drugs unfit for human consumption and disposed of in compliance with all applicable state and federal requirements.(E) The actual destruction of the drugs is witnessed by one of the following:(i) a commissioned peace officer;(ii) an agent of the Texas State Board of Pharmacy;(iii) an agent of the Texas Health and Human Services Commission, authorized by the Texas State Board of Pharmacy to destroy drugs;(iv) an agent of the Texas Department of State Health Services, authorized by the Texas State Board of Pharmacy to destroy drugs; or(v) any two individuals working in the following capacities at the facility:(I) facility administrator;(II) director of nursing;(III) acting director of nursing; or(IV) licensed nurse.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food safety (Resident #3 and Resident #14).The facility failed to ensure the refrigerator for Resident #3 did not contain expired cheddar cheese bars or canned sausage. The facility failed to ensure the refrigerator for Resident #14 did not contain expired pineapple tidbits, fruit cups or pineapple juice. This failure could place resident at risk for food borne illnesses.Findings include:1.Record review of Resident #3's electronic medical record and face sheet undated reflected she was admitted to the facility on [DATE]. Her diagnoses included: radiculopathy, cervical region (pain, weakness or numbness), cellulitis and abscess of mouth (bacterial infection of the skin and the deeper tissues beneath the skin), psychotic disorder with hallucinations (severe mental illness with false perceptions of things not there and false beliefs). Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected She could understand others and be understood. She scored a 13 on her BIMS which signified she was cognitively intact. She could ambulate with a walker 10 feet with maximum assistance. Resident #3 required partial to moderate assistance from staff with his ADLs. Record review of Resident #3's comprehensive care plan date initiated 8/05/2025 indicated had impaired functional abilities related to chronic obstructive pulmonary disease with interventions that included: eating: set up and clean up assistance.During an observation and interview on 8/25/2025 at 10:51 AM, Resident #3 said her personal fridge was usually cleaned by her and the facility staff. Resident #3 said she gets items out of the fridge herself. Resident #3 said she did not know that the observed 4 cans of 4.6-ounce canned sausage that expired on 8/9/2025 sitting on top of the refrigerator had expired. She said she also did not know the bag containing 6 cheddar cheese bars of 2.75 ounce inside the refrigerator had also expired on 7/20/2025. She said she also did not know the observed container of 5.3-ounce Greek yogurt had expired on 7/22/2025. She said her family member had just brought the cheddar cheese to her last week. 2. Record review of Resident #14's electronic medical record and face sheet undated reflected he was admitted to the facility on [DATE] with the most recent readmission [DATE]. His diagnoses included: intestinal adhesions (scar tissue on the intestines), alcohol induced persisting dementia (brain damage resulting from long term heavy alcohol use), hypertension (high blood pressure).Record review of Resident #14's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 11 on his BIMS which signified he had mild cognitive impairment. He could ambulate independently without devices or assistance. Resident #14 was independent with his ADLs. Record review of Resident #14's comprehensive care plan date initiated 3/28/2025 indicated he had impaired functional abilities with interventions that included: eating: set up and clean up assistance. During and observation and interview on 8/25/2025 at 10:21 AM, Resident #14 said he and the staff takes care of his personal refrigerator. He said he did not know that the 3 pineapple tidbits 4-ounce cups had expired on 8/21/2024. He said he did not know the 3 mixed fruit 3.23-ounce cups had expired on 3/23/2024. He said he did not know the 1.4 ounce can of pineapple juice had expired on 6/29/2025. He said could get food out of his refrigerator himself. During an interview on 08/27/2025 at 8:31 AM the Housekeeping supervisor said her and the Maintenance Director clean the residents' personnel refrigerators. She said they clean the fridges about twice a week and check for expired foods. She said they did not have a set schedule for cleaning the personal refrigerators. She said the nursing department helped with checking the temperatures. She said it had been about a month since Resident #14's refrigerator had been cleaned. She said Resident #3's refrigerator was cleaned last week, and they had thrown away milk and other expired foods and said these items must have just been missed. She said the potential hazard to resident by consuming foods would be stomach poisoning. During an interview on 08/27/2025 at 8:44 AM the Maintenance Director said housekeeping cleans the residents' personal refrigerators. He said he only moves them if needed. During an interview on 08/27/2025 8:56 AM the DON said it was housekeeping's responsibility to clean residents' personal refrigerators. She said she would have to check but assumed they would be cleaned 1 time a week. She said nursing will throw away food if they notice its expired, but housekeeping was responsible. She said it could make residents sick at their stomach by consuming expired food. During an interview on 08/27/2025 10:13 AM the Administrator said it was housekeeping's responsibility to clean residents' personal refrigerators. He said nursing should had not been designated to clean residents' personal refrigerators. He said they should be cleaned as needed. He said the residents could potentially get sick by consuming expired food. Record review of the facility policy Personal Resident Refrigerators dated 9/11/2023 indicated: The facility does not provide a refrigerator in the resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident owned refrigerators. 3. Housekeeping and/or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are not in compliance.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. 1. The Dietary Aide failed to properly wear hair net while in the kitchen on [DATE]. 2. Dietary Staff failed to check and log the dishwasher temperature and sanitation for month of [DATE]. 3. Dietary Staff failed to properly label and dispose of leftovers from the refrigerator. 4. Facility staff failed to clean Resident #7's water pitcher. These failures could place residents at risk for food contamination and foodborne illness. Findings: During an observation on [DATE] at 6:45 am the dietary aide had hair out of his hair net on his neck and had facial hair with no beard guard net. During an observation on [DATE] at 6:50 am there was a dishwasher temperature and sanitation log located on the side of the refrigerator. The log had no temperatures or sanitation levels listed. The log was not dated with the month and only included staff initials. During an observation on [DATE] at 7:00 am the refrigerator located in the kitchen had two containers of ready care thickened water dated [DATE] and 1 container of ready care thickened orange juice dated [DATE]. Directions on the ready care container read to use within 7 days of opening. There were leftovers in plastic containers with labels that read: smothered chicken dated [DATE], chicken patties dated [DATE], spiced apples dated use by [DATE], chicken dated [DATE], meatballs dated use by [DATE], rice dated use by [DATE], meatloaf dated use by [DATE], red beans and sausage dated use by [DATE], beef stew use by [DATE], and white gravy dated [DATE]. During an interview on [DATE] at 6:57 am the dietary aide said he had been at the facility for 5 weeks. He said he initialed the dishwasher log but was not sure about the temperature and sanitizer sections. He said the log posted was for [DATE] and he checked the temperatures and sanitation every day, but he was not sure what temperature the dishwasher needed to be. He said the previous dietary manager may or may not have told him and would make sure the water was steaming when he washed the dishes . He said he thought his hair was short enough on his beard and applied a beard guard and tucked his hair in the back under the hair net. He said that not washing dishes at the proper temperature could cause illness and not having his hair covered was unsanitary. During an interview on [DATE] at 7:10 am [NAME] G said she had been at the facility 1 year. She said all leftovers were to be labeled with name, date and use by date and should be discarded after 3 days. She said the ready care thickened beverages were to be dated when opened and discarded after 7 days. She said the cooks were responsible for checking and removing items from the refrigerator at least every other day. She said if residents were to consume expired foods it could make them sick. Record review of a facility face sheet dated [DATE] indicated Resident #7 was an [AGE] year-old female that admitted on [DATE] with diagnosis of Alzheimer's. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7had a BIMS of 04 indicating severely impaired cognition was dependent with all activities of daily living. During an observation on [DATE] at 10:05 am Resident #7 had a water pitcher at her bedside with thickened water and on inspection the water had a slimy green substance floating in the water. During an interview on [DATE] at 10:20 am CNA F said she had worked at the facility 1 year. She said she passed water to her residents every morning and afternoon. She said Resident # 7 was on thickened liquids and received her hydration in a cup from the kitchen . She said she was not aware there was a water pitcher in her room and would remove it. She said that water pitchers were to be changed out every night on the night shift and washed by the kitchen staff. She said if water pitchers were not cleaned it could cause residents to get sick. During an interview on [DATE] at 9:30 am [NAME] G said that the aides were to collect the water pitchers and bring them to the kitchen to wash. She said she was not sure if there was a schedule and could not recall the last time water pitchers were washed. She said that water pitchers that were not cleaned regularly could cause a resident to get sick. During an interview on [DATE] at 10:32 am the DON said that Resident #7 was on thickened liquids and the CNAs provide the already thickened liquids in individual cups and was not sure how she got a water pitcher at her bedside. She said the water pitchers should be changed nightly on the evening shift but there was no process in place to ensure the pitchers were being cleaned. She said dirty water pitchers could cause sickness and she expected all water pitchers to be cleaned and changed daily. During an interview on [DATE] at 9:10 am the Administrator said he was responsible for oversight of the kitchen and made rounds in the kitchen with staff for training weekly. He said he was between dietary managers and in the process of finding a new manager. He said that the staff were responsible for their daily duties and the dietary aides were to fill out the dishwasher log daily and ensure the temperature and sanitation was appropriate to prevent illness. He said leftovers should be discarded after 3 days because old food could make someone sick if it was served. He said water pitchers should be changed daily but there had not been a monitoring system in place. He said dirty water pitchers could cause illness. He said he expected the kitchen to be always maintained in a sanitary kitchen and water pitchers are cleaned and changed daily. Record review of a facility policy titled Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment dated 2018 indicated, . the facility will follow the cleaning and sanitizing requirements of the state. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. the temperature of the wash water must be at least 120F. Record review of a facility policy titled Food Storage dated 2018 indicated, .to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US food codes and guidelines. 2. Refrigerators e. use all leftovers within 72 hours. Discard items that are over 72 hours old .

Based on interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 1 resident group (resident council) reviewed for quality of life. The facility failed to ensure that staff were not talking on their cell phones while providing care to residents. The facility failed to ensure that staff did not speak rudely to residents. This failure could place residents at risk of decreased feelings of self-worth. Findings include: During an anonymous group interview, 6 of 12 residents in attendance of resident council meeting voiced the following concerns: 1. Staff members had been providing care while using their personal cell phones. One resident said that a staff member had given her a shower recently and was on her cell phone using ear buds the entire time she showered her, and it made her feel very uncomfortable, almost like the person on the other end of the phone could see me. She said she had already reported it to administration but it was still happening. Other residents said that staff would commonly be talking on their phones while providing personal care to them. 2. Staff members often speaking rudely to them and being disrespectful to them. Residents would not give staff member's names. During an interview on 07/16/24 at 03:58 PM Administrator said he was aware of some residents complaining of staff being rude and using cell phones while providing care. He said the Resident Council president had told him. He said staff should not be talking on their phones while providing care. He said it could make the residents feel bad about themselves. He said the residents had not given him specific employee names, but he would be holding in-services because that was unacceptable to him. He said that CNAs being rude to the residents was inhospitable. He said this was their home and they should be treated with respect. During an interview on 07/17/24 at 09:55 AM DON said that she would be providing education to staff regarding respect and not talking on their phones while providing care. She said it could make the residents feel bad about themselves. Record review of a facility policy titled Cell Phones dated December 2019 read .Use of these devices will be restricted to the employee break room or outside of the facility . Record review of a facility policy titled Dignity dated 2001 and revised in February 2021 read .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 4 hallways (north hallway and south hallway) reviewed for environment, in that. 1. The nursing supply storage room on the south hallway was open and accessible to visitor or resident tampering/contamination of sterile products and supplies kept in the nursing supply storage room. 2. The shower room on the north hallway (100 hallway) was open and accessible to residents and staff staff allowing access to toxic cleaners. These failures could place residents at risk for unsafe environment resulting in injury or unsafe conditions due access to toxic cleaners and visitor or resident tampering/contamination of sterile products and supplies kept in the shower room and nursing supply room. Findings included: 1. During an observation on 07/15/2024 at 06:55 AM Nursing supply storage room on the end of the south hallway was observed to be open. Upon entrance to the nursing supply storage room there are sterile supplies in the room, sterile foley catheters, lancets for skin punctures, gastric tube feeding supplies, wound cleanser, sterile dressing supplies no staff in area. Resident walking down the hallway nearby. 2. During an observation on 7/15/24 at 7:30 AM Shower room door on end of north hallway (100 hallway) was observed to be open. Upon entrance to shower room, observation revealed a supply closet in shower room was also open. There was a bottle of spray disinfectant inside supply closet. During an interview on 07/15/2024 at 07:30 AM LVN C said he had just gotten to the facility when the surveyors arrived. He was not aware the nursing supply closet was propped open, but he would go shut it. He said the door had a lock and it should be always locked to prevent resident or visitors from accessing to room. LVN C said nursing staff had a key to the door, but the night shift probably left it open for convenience. During an observation and interview 07/15/2024 at 07:43 AM, the door to the nursing supply room remained propped open. LVN B said the door should be closed and locked. LVN B said residents and visitors would have assess and could possibly tamper with supplies if the door is left open. She said that if the resident or visitors tampered with supplies include wound supplies and cleansers, sterile foley catheters, lancets glucometer supplies, and supplements they could become contaminated. During an interview on 07/15/2024 at 11:30 AM the DON said she was aware that the supply room was sometimes being left open. The door had a lock, and the nurses have the key. She said she has in-serviced the staff and ordered a punch key lock for the door. The DON said when the lock arrives the maintenance man will install it. The DON said there was a risk of theft or contamination to the supplies if a visitor or resident accessed the supply room and tampered with them. During an interview on 07/17/24 09:00 AM the Administrator said a punch lock had been installed on the door to the nursing supply to facilitate easy access for the staff and protect the supplies from contamination or theft. Record review of a facility policy titled Storage of Medications Policy . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing dressings and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Record review of a facility policy revision date February 2021 titled Homelike Environment . Policy Statement: Residents are provided with a safe, clean, comfortable, and home environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: Staff provides person-centered care that emphasizes the residents comfort, independence and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment . 46273

Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #9, Resident #22 and Resident #139) reviewed for beneficiary notice. The facility failed to ensure Resident #9, Resident #22 and Resident #139 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place the residents who were discharged at risk of not having knowledge of changes to services in a timely manner to allow the resident or their representative the option of appealing the denial of services. Findings include: Record review of a facility face sheet dated 7/16/24 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] after a qualifying hospital stay 1/11/24 through 1/16/24 with diagnoses including: metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), and thrombocytopenia (an abnormally low level of platelets). Record review of a facility census report for Resident #9 indicated that she had been admitted to Medicare A skilled services on 1/17/24 and discharged from Medicare A skilled services on 3/17/24. The facility failed to issue a NOMNC or a SNF ABN. Record review of a facility face sheet dated 7/16/24 for Resident #22 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and his last qualifying hospital stay was from 12/29/23 through 1/12/24. His diagnoses included: intestinal adhesions (bands), unspecified as to partial versus complete obstruction (a disease of the intestines and digestive system that can lead to obstructions); hypertension (high blood pressure); and type 2 diabetes (uncontrolled blood sugar). Record review of a facility census report for Resident #22 indicated that he was admitted to Medicare A skilled services on 1/12/24 and discharged from Medicare A skilled services on 3/14/24. The facility issued a NOMNC on 3/11/24 indicating that Medicare would not cover services after 3/13/24 but failed to issue a SNF ABN. Record review of a facility face sheet dated 7/16/24 for Resident #139 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] after a qualifying hospital stay of 10/4/23 to 10/30/23. His diagnoses included: Acute respiratory failure with hypoxia (a condition where the lungs cannot provide enough oxygen to the blood); bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows); and dysphagia (difficulty in swallowing). Record review of a facility census report for Resident #139 indicated that he was admitted to Medicare A skilled services on 10/30/23 and discharged from Medicare A skilled services on 2/10/24. The facility failed to issue a NOMNC or a SNF ABN. Record review of SNF Beneficiary Notice indicated Residents #9, Resident #22, and Resident #139 remained in the facility at the end of Medicare part A stay and did not receive the SNF ABN notification form. During an interview on 7/16/24 at 11:00 am DORC said she did not have the forms required because the facility did not complete them. During an interview on 7/17/24 at 9:33 am the Administrator said that Residents #3, #22, and #139 had been on Medicare A and the facility did not have an MDS nurse at the time. He said since they did not use all their 100 days, they should have received the notices. He said it was a lack of education and communication, and he would ensure better education and communication going forward. He said he had hired a new MDS nurse and BOM and they would both be expected to do things correctly going forward. He said residents may not be aware of any benefits remaining if they were not given the appropriate notices. Record review of Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 provided by the facility read .The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily . Record review of Form Instructions Advance Beneficiary Notice of Non-Coverage (ABN) OMB Approval Number: 0938-0566 provided by the facility read .The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice . Record review of a facility policy titled Medicare and Medicaid Benefits dated 2001 and revised in April of 2021 read .When changes are made to items and services covered by Medicare or Medicaid plans, residents are informed of these changes as soon as possible .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #6) reviewed for care plans. The facility failed to develop a comprehensive care plan that included Resident #6's nutritional status and requirement of a feeding tube. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings: Record review of a facility face sheet dated 7/16/24 indicated Resident # 6 was an [AGE] year-old female that admitted on [DATE] with diagnosis cerebrovascular disease (reduction of blood flow in the brain). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS of 14 indicating intact cognition and required a feeding tube. Record review of a physicians consolidated order dated 6/28/24 indicated Resident #6 required Jevity C 1.5 at 65 ml (milliliters) per hour times 12 hours per feeding tube and Jevity 1.5 237 ml bolus feeding daily at noon. Record review of a comprehensive care plan dated 7/02/2024 did not reflect Resident #6's nutritional status and requirement of feeding tube for nutrition. During an interview on 07/16/24 at 9:34 am the MDS nurse said she started at the facility February 2023 and was new to MDS and care plans. She said she had been trained by the corporate MDS nurse on hire and was still learning. She said that she was responsible for completing the MDS and care plans and Resident #6's care plan should have reflected her nutritional status and requiring a feeding tube. She said she captured the feeding tube on the MDS and was not aware that it did not generate to the care plan. She said by not having the feeding tube care plan it could affect resident care. During an interview on 7/17/24 at 9:00 am the DON said she and the MDS was responsible for developing and implementing care plans. She said care plans were developed on admission, quarterly and with any changes that occurred. She said Resident #6 should have had a nutrition care plan to include her tube feeding and expected all care needs to be in the care plan. She said if care plans were not in place, it could affect resident care. During an interview on 7/17/24 at 9:30 am the Administrator said he has worked at the facility since November 2023. He said the MDS nurse and DON were responsible for the care plans. He said they had been working on getting all the care plans updated and expected all care plans to be accurate and reflect all the care each resident needed. He said if care plans were not developed and implemented for resident problems it could affect resident care. Record review of a facility policy titled Comprehensive Care Plans dated 01/26/24 indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment .

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 7 residents (Resident #3) reviewed for accidents hazards and supervision, in that: CNA E and CNA F failed to properly transfer Resident #3 on 7/15/24. This deficient practice could result in a loss of quality of life due to injuries. Findings: Record review of a facility face sheet dated 9/16/2020 indicated Resident #3 was a [AGE] year-old female that admitted on [DATE] with diagnosis of Alzheimer's. Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 3 had a BIMS of 11 indicating moderately impaired cognition and required total dependence of two persons for transfers. Record review of a facility comprehensive care plan dated 5/07/24 indicated Resident # 3 required a mechanical lift to transfer times two persons. During an observation on 07/15/24 at 10:15 AM CNA E and CNA F were observed transferring Resident #3. Both CNAs positioned Resident #3 on the side of the bed and placed the shower chair in a locked position next to the bed. CNA E and CNA F placed their arms under Resident #3's arms, lifted Resident #3 into a standing position and sat Resident #3 in the shower chair. During an interview on 7/15/24 at 10:20 am CNA F said she had worked at the facility for 1 year and residents should be transferred either with a gait belt or lift. She said she was assisting CNA E and should have stopped and gotten a gait belt before proceeding because manually lifting a resident could cause injury to the resident. During an interview on 7/15/24 at 10:25 am CNA E said she had worked at the facility for 3 months and had been a CNA [AGE] years. She said she was assigned to care for Resident #3. She said Resident #3 was a two person lift and she should have used a gait belt or to transfer her. She said she forgot her gait belt and did not stop and go back for it. She said that each residents transfer ability was on their care plan in the computer but could not recall what Resident #3's care plan said about transfers. She said by manually transferring or transferring by the wrong method she could cause an injury to the resident. She said she had been trained on transfers and safety and was nervous. During an interview on 7/15/24 at 10:30 am LVN D said that each resident was care planned for their transfer status and the nurses and CNAs communicate with each other on resident care. She said that Resident #3 was care planned for a lift but did sometimes use a gait belt times two persons if she refused to use the . She said the CNA's will report transfer changes and therapy would evaluate them if needed. She said residents should not be transferred by lifting and pulling on them because of risk for injury. During an interview on 07/17/24 at 8:57 am the DON said she was responsible for oversight of all nursing staff to ensure proper transfer technique was used for each resident. She said she completed training with all staff on transfer and safety and the CNAs should have known the proper transfer technique. She said she expected each resident to be transferred safely and follow the care plan to prevent injuries to the residents. During an interview on 7/17/24 at 9:28 am the Administrator said that nursing management was responsible for oversight and training of the CNAs on transfers and expected all residents to be transferred safely to prevent injuries. Record review of a clinical skills checklist dated 4/03/2024 indicated CNA E had satisfactorily demonstrated competency for lifting and transferring, use of Hoyer lift and gait belt. Record review of a clinical skills checklist dated 10/31/2023 indicated CNA F had satisfactorily demonstrated competency for lifting and transferring, use of Hoyer lift and gait belt. Record review of a facility policy titled Safe Lifting and Movement of Residents dated 3/31/23 indicated, .in order to protect the safety and well-being of all staff and residents, and to promote quality of care, this facility uses techniques and devices to lift and move residents. 2. manual lifting of residents shall be eliminated when feasible, 4. staff responsible for direct care will be trained in the use of manual (gait belt) and mechanical lifting devices .

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents for one resident (Resident #16) of six residents reviewed for medication storage. The facility failed to ensure topical medications and skin cleanser were stored in a manner to prevent possible diversion or contamination. This failure could place residents at risk for drug diversion and access to medications that could cause harm, sickness, or hospitalization . Findings included: Review of Resident #16's face sheet dated 07/14/2024 reflected an eighty-three-year-old female admitted on [DATE] with diagnoses that included: Senile Degeneration of Brain (gradual loss of thinking ability), Diaper dermatitis (skin rash to the diaper area) Pressure-induced deep tissue damage of right ankle, (open skin break on the right foot), and Pressure ulcer of left ankle, stage 3 (open skin break of the left ankle). During an observation and interview on 07/15/2024 at 07:00 AM Resident #16 is lying in bed in her room, wound cleanser was on the bedside table, Zinc Oxide tube and 3 small packets of Zinc Oxide were on the bedside table, skin barrier cream and antifungal skin powder on bedside table. All containers are labeled keep out of reach from Children. Resident #16 said the staff use the products on her and they must have left them there after providing her wound care and care to her peri-area. During an observation on 07/15/20/24 at 01:26 PM revealed Resident #16, sleeping in her room. Wound cleanser at bedside table. Zinc Oxide tube and 3 small packets of Zinc Oxide are on the bedside table, skin barrier cream and antifungal skin powder on bedside table. During a record review of a physician order summary dated 7/15/2024, Resident # 16 had orders with an origin date of 06/24/2024 for Calmoseptine (menthol-zinc oxide) ointment; 0.44-20.6 %; amount- dime size; topical three times a day and apply Zinc Oxide to buttocks & coccyx every shift, origin date 03/01/24 twice a day. During an interview on 07/15/2024 at 01:30 PM LVN C, said that medications should not be keep in residents' room, including medications for wound care. He said that he will remove the barrier cream, antifungal powder and zinc oxide ointment and place them in a bag for storage in the wound care cart. LVN C said that the items could harm residents if they used them incorrectly or ingested topicals labeled keep away from children. He said the topical medications could be contaminated if the resident or family opened them with unclean hands. During an Interview on 07/15/2024 01:45 PM the DON she said the residents are not allowed to keep medications at bedside, unless they have a doctor's order and arrangements for safe storage are developed for that specific resident. The DON said it was unsafe to have any medications or substances labeled to keep out of reach from children at bedside and topicals could become contaminated if not handled correctly by the resident or family. During an interview on 07/16/2024 03:30 PM the Administrator said the DON is responsible for oversight of medication storage and will start an Inservice for all staff safe storage of medications. The Administrator said leaving topical medications or cleanser at bedside pose a risk to residents for possible ingestion and contamination. Record review of a facility policy titled Storage of Medications Policy . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 2. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing dressings and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Record Review of a facility policy dated 06/01/2022 titled Administrative Procedures for all Medications To administer medications in a safe and effective manner. A. Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide.

46436 Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 12 residents (Resident #6 and Resident #27) reviewed for infection control. The facility failed to ensure the COTA (certified occupational therapy assistant) followed enhanced barrier precautions when she provided care to Resident #6 on 07/15/2024. The facility failed to ensure LVN (licensed vocational nurse) followed infection control precautions when she administered medications to Resident #27 on 07/26/2024. These failures could place residents at risk for cross contamination and infection. Findings: 1.Record review of a facility face sheet dated 07/16/2024 indicated Resident # 6 was an [AGE] year-old female that admitted on [DATE] with diagnosis cerebrovascular disease (reduction of blood flow to the brain). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS of 14 indicating intact cognition and had a feeding tube. Record review of a physician order dated 04/29/2024 indicated Resident #6 required EBP (enhanced barrier precautions). Record review of a comprehensive care plan dated 06/21/2024 did not reflect Resident #6's requirement of feeding tube nor EBP. During an observation on 07/15/2024 at 10:26 am the COTA was present in Resident # 6's room providing care. Resident #6 requires Enhanced Barrier Precautions (EBP)and the COTA did not have on PPE with providing therapy. During an interview on 07/15/2024 10:27 am the COTA said she thought PPE was only required for high-risk task or if care was being provided directly to whatever it was that the resident required the precautions for. She said the DON and ADON had trained her on the new EBP, and she must have misunderstood the requirement. She said by not properly wearing PPE could cause a spread in infections. During an interview on 07/15/2024 at 10:29 am the DON said she did not realize that providing therapy required PPE when a resident was in EBP and must have misread the new regulations. She said Resident #6 required EBP due to feeding tube. She said she and the ADON had provided the training to staff and would retrain on the correct use of PPE for EBP. She said she expected staff to follow the EBP to prevent the spread of infections. 2. Record review of a facility face sheet dated7/16/2024 indicated Resident #27 was a [AGE] year-old female admitted on [DATE] with a diagnosis of end stage renal disease (kidneys no longer filter toxins from the blood), age related decline, and dependence on renal dialysis (the artificial removal of toxins from the blood by machine and filter). Record review of a MDS (OSA) optional state assessment dated [DATE] indicated Resident #27 had a BIMS of 14 indicating intact cognition and had a dialysis port. Record review of consolidated orders dated 07/16/2024 indicated Resident #27 had no order for EBP (enhanced barrier precautions). Record review of a comprehensive care plan revised 07/03/2024 indicated interventions for care of a dialysis port. During an observation and interview on 07/16/2024 07:40 AM of medication administration LVN A prepared Resident #27's medications. Signage was posted on doorway of Resident #27 room with indications that Resident #27 required EBP. LVN A said that resident required donning (to apply) with gown and gloves because she had a dialysis port which made her at risk for infection that could be spread to other residents. LVN A sanitized hands with alcohol-based wipes to the palms of her hands only and donned gown and gloves. LVN A administered medications per mouth to Resident #27 and returned to the medication cart with her gown, gloves on and proceeded to touch her pen, medication cart surface and papers on the medication cart. LVN A said she had worked at the facility for approximately 1 and a half years and had received training on the EBP requirements, infection control practices and hand hygiene but she was confused about exactly what she needed to do. LVN A said she should have removed her gown and gloves before exiting the room. She said she should have sanitized her hands before returning to the medication cart. She said by not removing her PPE and sanitizing she could spread infection. During an interview on 07/16/2024 at 08:20 AM with the DON and the Regional Nurse Consultant, the DON said she would provide education to the staff on EBP, infection control and hand hygiene. The DON said that not removing PPE after contact with Resident #27 and sanitizing hands before returning to the medication cart the nurse could spread infection. The Regional Nurse Consultant said that LVN A had broken basic infection control process by not doffing (to remove) her PPE and sanitizing before she exited the room. During an interview 07/16/2024 at 09:00 AM The ADON said LVN A had been trained on correct procedures for infection control. The ADON said not removing PPE and sanitizing before leaving the room and touching items on the medication cart could spread infection. During an interview on 07/17/2024 09:00 AM the Administrator said the DON and ADON/IP are responsible ensuring basic infection control, handwashing, sanitizing and EBP for infection control are followed. The Administrator said that not following guidelines for infection control could spread infection. Record review of a facility policy titled Enhanced Barrier Precautions dated 04/01/2024 indicated, .enhanced barrier precautions should be followed when working with residents in therapy and while assisting with transfers and mobility d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room . Record review of a facility policy titled Administration Procedures for All Medications dated 06/01/2022 indicated, .cleanse hands using microbial soap and water or facility- approved hand sanitizer before beginning a med pass, before handling medication, and before contact with resident.

Based on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in working order. One of six gas stove burners (back right) had excessive carbon buildup and the burner did not fully light on 7/16/2024. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings: During an observation on 7/16/24 at 10:53 am, 1 of 6 burners on the stove located in the kitchen did not light completely. The burner had carbon build up to the right side of the burner. During an interview on 7/16/24 at 10:54 am [NAME] H said she was the cook for the day, and it was her first day back from a month break. She said she was not sure who was responsible for burners on the stove, but the cooks cleaned the covers and grill daily. She said that the burner not lighting correctly could cause an injury, During an interview on 7/16/24 at 11:15 am the maintenance director said he was not sure who was responsible for the stove burners and could not recall anyone coming to clean them. He said he was not sure what could happen if the burners did not light correctly. During an interview on 7/16/24 at 12:10 pm the administrator said he was not sure who was to clean the burners on the stove. He said the cooks clean daily after meals but the actual removal of carbon buildup he was not sure who was responsible but would get someone to the facility to clean them. He was not sure what could happen if the burners did not work correctly and would advise staff to not use that burner until it was cleaned. Record review of a facility a facility policy titled Range and Grill dated 2018 indicated, .the facility will maintain the range and grill in a clean manner to minimize the risk of food hazards .

Based on observation, interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #35) of 8 residents reviewed for parameters to notify Physician of critical lab levels The facility failed to notify Resident # 35's primary care physician of critical low blood sugar readings of (46 mg/dl on 05/17/23 and 44mg/dl, on 05/21/23). The facility failed to train the staff of when to report changes to the physician. An Immediate Jeopardy (IJ) situation was identified on 06/13/23 at 3:00 PM. The IJ template was provided to the facility on [DATE] at 3:03pm. While the IJ was removed on 06/14/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death. Findings included: Record review of Resident # 35's face sheet dated 04/25/23 indicated Resident #35 admitted [DATE]. and was a 59-year- old-female with diagnosis: Bacteremia (blood infection, sepsis), Diabetes Mellitus a disease that occurs when your blood glucose, also called blood sugar, is too high (abnormal blood sugars) due to underlying condition with neuropathy, chronic viral hepatitis C, (liver disease),neuromuscular dysfunction of the bladder,(bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation, (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus, (pressure sore). Record review of the Physician Orders for Resident #35 dated 04/25/2023: Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicated, there were no physician orders to check resident #35's BS even though nurses were checking BS before administering Insulin. Resident #35 had no parameters for notification of critical BS values to be reported to the physician. Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS (activities of daily living), and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident was able to feed herself with set up assistance from staff. Resident had a foley catheter due to diagnosis of neuromuscular bladder, (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx and was incontinent of bowel. Record review of a care plan dated 05/31/23 indicated Resident #35 had diagnosis of Diabetes Mellitus, and intervention of: medications as ordered. Record review of Resident #35's progress note dated 05/17/23 at 10:44PM completed by CCM, (previous MDS coordinator) indicated CMS entered room for routine check, resident complained of, my sugar is dropping. Resident #53's Accucheck, (blood glucose monitor) Blood Sugar was 46mg/dl, glass of apple juice with sugar and bowl of cereal with milk given at this time, assisted resident to reposition in bed, Resident requested fan at the foot of the bed to be turned on, this nurse turned on fan as requested, hob elevated and snack set up, resident sitting up in bed eating cereal and drinking juice at this time. The progress note did not indicate that the Physician was notified of critical low blood sugar levels. 11:00 PM Entered room for follow up Accucheck BS 66. Noted to be lying in bed, awake and alert, respiration even and unlabored, skin warm/dry. Offered and accepted package of peanut butter crackers. No signs/symptoms of distress noted, resident states I feel a lot better now, just hungry, but I really like these crackers. Resident encouraged to consume package of crackers and assisted to reposition self and linens in bed for comfort. 11:29PM Repeat Accucheck BS level 82. Noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. No s/s of distress noted. Arouses easily to verbal stimuli, Resident stated, Thank you for everything, I feel better. Record review of a progress note dated 05/21/23 at 10:00AM indicated the Treatment Nurse was called to Resident #35's room to check blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes BS 80mg/dl. WCTM. Wound treatment provided this shift. PRN Tylenol #4 administered prior to treatment. Resident tolerated well no complaints. Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, results 130. Stated her thanks to this writer and Good, it should not drop much lower Record review of a progress note dated 05/24/23 at 2:15AM Called to room by resident requesting this nurse, (CCM) to, check my sugar, Accucheck BS level 66. Resident offered and accepted small package of peanut butter crackers at this time. No s/s of distress noted. Record Review of Consultant Pharmacist's Medication Regimen review dated 5/23 indicated there were no recommendations from the Pharmacist for Glucagon, (Hormone, it can treat severe low blood sugar) or parameters for notification to the Physician of critical values. During an interview 06/12/23 at 3:45 PM, Resident # 35 said she had tried to get the nurses to not give her full dosage of Insulin and to only give half, because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar dropping. A Record Review of Residents #35 progress notes dated 06/12/23 at 4:11 PM, order received for blood sugar checks BID, but still no parameters to hold Insulin, notify the Physician or Glucagon Orders. During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had worked for corporation for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at documentation. She was not aware there were no orders for blood sugars or parameters to hold Insulin on Resident #35. She said she had texted the Physician regarding the Resident's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed by her this morning with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility was for the nurses to follow morning meeting process, monitor vital signs, blood sugars and if out of range notify the Physician. She said she would monitor this when she comes to the facility twice a week. She said she would join the meeting through TEAMS. She said everyone taking Insulin will have BS checks, and parameters to hold Insulin if BS was to low or high and orders to notify the Physician. During a phone interview on 06/13/23 at 9:44 AM, the Physician said, (the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl). The Physician said he would call orders to the facility to notify him if blood sugars were below 100mg/dl. During an interview 06/13/23 at 10:03AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident has a critical lab value. She said resident #35 had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at nursing facility were not aware of sliding scale order. She said she had texted the Doctor multiple times since yesterday when they became aware of no parameters, and physician has not replied. LVN A, said she had notified Physician regarding Resident #35's scheduled Humulin Insulin at bedtime to see if facility could get orders for The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included: Notification of Changes. Resident #35: Resident's physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 5/17/23 and 5/21/23. New orders received for labs to include hemoglobinA1C, one time order, and accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. Date: 6/12/2023. Resident on 6/13/2023 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. Medical Director, was consulted regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar check orders to: Accuchecks BID, Special Instructions: **NOTIFY MD FOR BLOOD SUGARS <80 OR >400** Twice A Day 06:30 AM, 08:00 PM Blood sugar prn for symptoms of hyperglycemia or hypoglycemia. Special Instructions: Notify MD of results <80 or >400 As Needed PRN 1, PRN 2, PRN 3 Notification parameters have added to all residents with finger stick blood sugar orders per the MD's request. Action 1: Educate all nurses regarding physician notification and change of condition. The licensed nursing staff will have an understanding to report out of range (less than 80 and higher than 400)/critical blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per physician order). Staff will have an understanding on when to report changes to the physician through the above education physician notification and change of condition. All current, new and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. Out of range, per the Medical Director, that he would like notified about, is lower than 80 and higher than 400. These parameters have been added to the accucheck orders. Date of Completion: 6/14/2023 by 11AM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 2: Clinical Resource Nurse and/or Clinical Company Leader to perform blood sugar audit to check for out of range blood sugars for previous 30-days. Any blood sugars identified outside the Physician Prescribed range per his order(s) will be reported to the Medical Director and any new orders received will be entered and followed. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse and/or Clinical Company Leader Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. Clinical Resource Nurse and Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Per the Medical Director he would like to be notified of blood sugar outside the range of 80-400, this reflects in the order set inputted for residents receiving accuchecks. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse Action 4: Adhoc QAPI meeting performed with interim administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents. Date of Completion: 6/13/2023 Staff Responsible for Completion: Administrator and Clinical Resource Nurse On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test. Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl. On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol.

Based on 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 8 residents (Resident #35), reviewed for quality of care. The facility failed to obtain orders for finger stick blood sugars for resident #35 and to follow their policy on Management of Hypoglycemia, (low blood sugar), when resident # 35's blood sugar reading was at critical levels of 46mg/dl on 05/17/23 and 44mg/dl on 05/23/23 and hold parameter for Insulin if blood sugar reading is at a critical level of below 70mg/dl. Resident #35 experienced sweating and shakiness when her blood sugar fell below 80mg/dl. Resident #35 had no orders for finger stick blood sugars and no parameters for holding Insulin for blood sugar levels below 70mg/dl. An Immediate Jeopardy (IJ) situation was identified on 06/13/23. The IJ template was provided to the facility on [DATE] at 3:03pm, while the IJ was removed on 06/14/23. The facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm, due to the facility's need to evaluate the corrective actions. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death. Findings included: Record review of Resident #35's face sheet dated 04/25/23 indicated Resident #35 admitted to the facility on [DATE] and was a 59-year- old-female with diagnoses: Bacteremia (blood infection, sepsis), Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), (abnormal blood sugars) due to underlying condition with neuropathy, (dysfunction of peripheral nerves), (chronic viral hepatitis C (liver disease), neuromuscular dysfunction of the bladder (bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus (pressure sore). Record review of Physician Orders dated 04/25/2023 Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicates, there were no physician orders to check resident's BS and no parameters for notification of abnormal values to be reported to the physician. Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS, and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident #35 was able to feed herself with set up assistance from staff. Resident #35 had a Foley catheter due to diagnosis of neuromuscular bladder (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx (small triangular bone at the base of the spine) and was incontinent of bowel. Record review of a care plan dated 05/31/23 indicated Resident #35 had a diagnosis of Diabetes Mellitus, and intervention of: medications as ordered. Record Review of Physician orders dated 04/25/23 through 06/12/23 indicated Resident #35 had no orders for routine finger stick blood sugars, no parameters to hold insulin if blood sugar reading below 70mg/dl, and no orders to notify the physician of critical blood sugar levels of below 70mg/dl and above 250 mg/dl. Record review of MAR (medication administration record) indicates nurses were checking residents BS twice a day before Insulin administration but had no Physician orders to check Resident's BS and no parameters to hold Insulin or parameters to notify the Physician of critical values. Record review of Resident #35's progress note dated 05/17/23 at 10:44 PM completed by the CCM (previous MDS coordinator) indicated the CCM entered the room for a routine check and the resident complained of, my sugar is dropping. Resident #35's Accucheck (blood glucose monitor) Blood Sugar was 46mg/dl. A glass of apple juice with sugar and a bowl of cereal with milk was given at that time. The resident was assisted to reposition in bed. The resident requested a fan at the foot of the bed to be turned on, and the nurse turned on the fan as requested. The head of bed was elevated, and a snack was set up. The resident was sitting up in bed eating cereal and drinking juice at this time. At 11:00 PM, CCM entered room for follow up Accucheck, BS at 66. Resident noted to be lying in bed, awake and alert, respiration even and unlabored, skin was warm/dry. The resident was offered and accepted a package of peanut butter crackers. There were no signs/symptoms of distress noted, and the resident stated she felt a lot better now, was just hungry, but he really like the crackers. The resident was encouraged to consume package of crackers and was assisted to reposition self and linens in bed for comfort. At11:29 PM a repeat Accucheck, BS level 82. The resident was noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. There was no signs/symptoms of distress noted. The resident aroused easily to verbal stimuli. The resident stated, Thank you for everything, I feel better. Record review of a progress note dated 05/21/23 at 10:00 AM indicated the Treatment Nurse was called to Resident #35's room to check his blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes and BS 80mg/dl. WCTM. Wound treatment was provided on shift. PRN Tylenol #4 was administered prior to treatment. The resident tolerated well no complaints. Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, and results were 130mg/dl. Stated her thanks to this writer (CCM) and Good, it should not drop much lower. Record review of a progress note dated 05/24/23 at 2:15 AM CCM called to resident #35's room by resident, requesting this nurse, (CCM) to, check my sugar, Accucheck BS was level 66. The resident was offered and accepted a small package of peanut butter crackers at the time. There were no signs/symptoms of distress noted. Record Review of the Consultant Pharmacist's Medication Regimen Review dated May 2023 indicated there were no recommendations from the Pharmacist for Glucagon, (hormone, it can treat severe low blood sugar,) parameters to hold insulin, or parameters for notification to the Physician of critical values. During an interview on 06/12/23 at 3:45 PM, Resident #35 said she had tried to get the nurses to not give her a full dosage of Insulin 20mg/dl and to only give half (10mg/dl) because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar dropping. She said she has seen the Physician but didn't think to tell him. Resident #35 said she experienced sweating and shakiness when her blood sugar fell below 80mg/dl. During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had notified the Physician regarding the Resident #35's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed with no signs or symptoms of Hypoglycemia. The Regional Nurse said she had worked for corporate for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at nursing documentation. She was not aware there were no orders for blood sugars or parameters to hold insulin for Resident #35. During an interview 6/12/23 a 4:10 PM, the Regional nurse said Resident #35 had been assessed today with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility is for the nurses to follow the morning meeting process, (look at documentation, monitor vital signs, blood sugars and if out of range to notify the Physician). She said she would join the meeting through TEAMS. (Messaging APP). She said everyone taking insulin will have BS checks, and parameters to hold Insulin if BS is to low or high. Record Review of a Progress notes dated 06/12/23 at 4:11 PM revealed, new order for HbA1C (blood test for diabetes determines the three-month average blood sugar level), next lab draw and Accuchecks twice a day. During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she [NAME] formally been shown how to do an admission but said the nurses should have known to get blood sugar checks and parameters with insulin orders. She said the facility had been without a DON since 5/26/2023 but the Regional Nurse did come to the facility a couple times a week as needed. She said she was often called to work the floor and was doing the best she could. During a phone interview on 06/13/23 at 9:44 AM the Physician said, the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl. Physician said he had not been notified of Resident #35's critical low blood sugar levels or her requesting to have Insulin dosage lowered. During an interview 06/13/23 at 10:03 AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident had a critical lab value. She said the resident had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at the nursing facility were not aware of the sliding scale order. She said she had texted the Physician multiple times since yesterday when they became aware of no parameters, and the physician has not replied. LVN A said she had notified the Physician regarding Resident #35's scheduled Humulin 70/30 U-100 Insulin (NPH and regular Human) [OTC] suspension; 100 unit/ml (70-30); Amount to Administer: 20 units; subcutaneous twice a day, to see if the facility could get orders for parameters. LVN A notified the Physician that Resident #35 was requesting to get half of her insulin dosage when her blood sugar is low. During an interview 06/13/23 at 10:15 AM, the Treatment Nurse said she had worked at the facility for two years. She said if the facility was short staff she got pulled from doing treatments to work the floor. She said Resident # 35 was a very brittle diabetic and her blood sugars were hard to control. She said they do check the resident's blood sugar before giving her insulin. She said there were no physician's orders to check her blood sugar or parameters as to when to notify the physician. She said she had to give her orange juice and sugar before and a snack to bring her bloodsugar up. She said once the blood sugar was stable she did not think to notify the Physician. During an interview 06/13/23 at 10:34 AM the Interim Administrator said she expected her staff to notify the Physician of any change in the resident including low or high blood sugars. She said she expects her staff to be trained and have competency checks offs regarding Hypoglycemia or Hyperglycemia and to know when to notify the Physician. The Administrator said the resident could have gone into a coma if her BS is not controlled. She said she expects her staff to follow protocol for hypoglycemia, and the Regional Nurse was inservicing the staff on the policy today, she hopes to improve education for the staff. She said she will meet with families during care conference meetings and make sure they are doing everything they can to take care of the residents During an interview 06/13/23 at 10:47 AM Resident #35 said she didn't always get her snacks at bedtime, and that her blood sugar would drop. She said she could feel her blood sugar dropping sometimes and would call the nurse to come check it. She said the nurse would give her orange or apple juice with sugar and give her snacks to bring it up. She said she tried to keep snacks in her room. Resident #35 said she had tried to get the night nurse to only give her half of her insulin dosage because she kept dropping. The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included: Resident #35: The resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day with hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by the Clinical Resource Nurse and there were no signs or symptoms of hypo or hyperglycemia (low or high blood sugar). The Medical Doctor was consulted regarding current orders. The Medical Director has changed Resident #35's finger stick blood sugar; changed orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl; and Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED PRN 1 PRN 2, PRN 3. Action 1: Educate all nurses regarding the diabetic/managing hypoglycemia policy, physician notification, and change of condition (to include blood sugars out of range per the Physician's prescription below 80 and above 400). The licensed nursing staff will have an understanding to report out of range blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per the Physician's preference below 80 and above 400). Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference. The facility will ensure competency of licensed nursing staff and ensure licensed nursing staff understand our management of hypoglycemia policy through the above education. The charge nurses will notify the doctor immediately if the blood sugar reading is above or below the parameters set by the residents' physician (the MD would like to be notified if blood sugar is outside 80-400), the charge nurse at that time will follow the MD's orders. The updated orders read as follows per the physician: Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Policy Managing Hypoglycemia has been updated to reflect follow provider orders/instructions for blood sugars under 80 and over 400 and/or to administer oral glucose/glucagon/call emergency services per policy. Orders will reflect PRN oral glucose/glucagon per policy and MD orders for residents receiving accuchecks. All nurses will be educated regarding the policy and policy changes. All current, new, and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. Date of Completion 6/14/23 @ 12 PM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 2: Perform Blood Sampling- Capillary (Finger Stick) Competency competencies on all licensed nurses. All new and temporary (agency) nurses shall be checked off on Blood Sampling- Capillary (Finger Stick) Competency prior to working their next shift/first shift. Date of Completion: 6/14/2023 @ 12 PM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. The Clinical Resource Nurse and the Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference and physician's order/instruction upon notification of blood sugars lower than 80 and higher than 400. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse Action 4: Adhoc QAPI meeting performed with the Interim Administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents. Date of Completion: 6/13/2023 Staff Responsible for Completion: Administrator and Clinical Resource Nurse These interventions were completed based on staff (Interim Administrator, ADON, Clinical Resource Nurse, and 4 LVNs (Treatment Nurse, Nurse A, Nurse G, Nurse H) on the morning and evening shift, were interviewed to ensure these interventions had been completed. Nursing staff were able to appropriately indicate they would follow the policy, Management of Hypoglycemia, the parameters of notification. A policy, Management of Hypoglycemia-Diboll Specific, updated 06/14/23 was reviewed by Surveyors. MANAGEMENT of HYPOGLYCEMIA: The following is a suggested protocol thaat should be implemented without the approval of the Medical Director and Director of Nursing. If there is already a protocol in place, disregard this and follow the existing approved protocol instead. 1. Classification of hyperglycemia: a. Level 1 hypoglycemia:blood glucose <80 mg/dl and >54 mg/dl b. Level 2 hypoglycemia: blood glucose is <54mg/dl: and c. Level 3 hypoglycemia: altered mental and or physical status requiring assistance for hypoglycemia. 2. For Level 1 hypoglycemia (<80mg/dl a. Give resident an oral form of rapidly absorbed glucose 1tube/15grams Notify the Physician immediately. b. Remain with the resident c. Recheck blood sugar in 15 minutes: 1. If blood glucose within establish reference range, pprovide the resident with a meal or snack. 2. If blood sugar is greater than established reference range (rebound Hyperglycemia) administer diabetic medication as ordered or 3. If blood sugar remains <80mg/dl, repeat oral glucose and notify physician for further orders. 3. For Level 2 hypoglycemia (<54mg/dl) a. Administer glucagon 1 vial/1mg I b. Notify the Physician Immediately c. Remain with the Resident d. Place resident in a comfortable and safe place (bed or chair) e. Monitor vital signs and f. Recheck blood glucose in 15 minutes (as Above) 4. If a resident has a Level 3 hypoglycemia and is unresponsive a. Call 911(in accordance with resident's advance directives b. Administer Glucagon 1 vial/1mg IM. c. Notify the Physician immediately d. Remain with the resident e. Place the resident in a comfortable and safe place (bed or chair); and f. Monitor vital signs During an interview on 6/14/2023 at 4:00 PM, the Interim Administrator said she had been at the facility since Monday 6/12/23. She said they had no DON, and the last DON left two weeks ago. She said her expectations were for the staff to be in-serviced on the Management of Diabetes. She said the Regional Nurse had audited the physician's orders on all resident to be ensure BS checks, and parameters to hold Insulin, and to notify the Physician of abnormal values, BS <80 and >400mg/dl had been implemented on all diabetics. On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test. Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl. On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent the elopement for 1 of 8 residents reviewed for elopement and the environment was free of accident hazards for 1 of 8 doors reviewed for the delayed egress system. (Resident #1) The facility did not provide interventions to prevent Resident #1 from leaving the facility without staff knowledge. The resident was assessed as an elopement risk and had a history of [REDACTED]. The facility staff did not respond to the alarms on the exit doors timely, taking from 1 minute and 15 seconds to 6 minutes and 5 seconds to respond. The resident was found by passing drivers approximately one tenth of a mile from the facility propelling in his wheelchair on the shoulder of a major highway. The delayed egress system on the front exit doors did not function properly. The front door did not open within 15 seconds after pressure was applied for 3 seconds. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 09/18/19. While the IJ was removed on 09/20/19, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at high risk for elopement and residents needing to exit through the front doors in an emergency at risk of injury and death. Findings included: Physician orders [REDACTED].#1 was a [AGE] year-old male, admitted on [DATE] with [DIAGNOSES REDACTED]. A Wandering/Elopement Risk Assessment Tool dated 07/08/19 for Resident #1 indicated he was a high risk to wander due to the following indicators: *a history of wandering prior to admission; *exhibited wandering behavior; *attempted to exit the facility on 1 or more occasion; * followed others around; if someone exited the facility, the resident would follow; and *verbalized the need and /or desire to go home or to another location and had the ability to act on that verbalization. A Wandering /Elopement assessment summary dated 07/08/19 indicated the following interventions for Resident #1: *Personal safety alarm devices (no specific device listed); *Staff was aware of resident's elopement risk; and *Staff aware of resident's wander risk. A nursing progress note dated 07/09/19 at 8:55 p.m., indicated Resident #1 attempted to go out of the door by the laundry room. The note indicated Resident #1 was redirected but continued to go to other doors and attempt to exit the facility. A daily skilled nursing note dated 07/11/19 on the day shift, indicated Resident #1 was at the doors in the front lobby pushing the handles and trying to get out. The note indicated the resident was redirected by staff. A daily skilled nursing note dated 07/11/19 on the evening shift, indicated Resident #1 continued to wander the hallways. A daily skilled nursing note dated 07/11/19 on the night shift, indicated Resident #1 was up wandering all night and refused to go to bed. A nursing progress note dated 07/12/19 at 2:20 p.m., indicated Resident #1 was noted outside of the building at the end of 200 hall by CNA's when they returned from taking out the trash. The note indicated Resident #1 was brought back into the building and placed on every 15 minutes checks for 72 hours. A daily skilled nursing note dated 07/12/19 on the evening shift, indicated Resident #1 continued to be confused and was on every 15-minutes checks related to elopement. The note indicated Resident #1 wandered constantly and attempted to go out of doors and into other resident's rooms. The noted indicated Resident #1 was redirected often but would continue the behaviors. A care plan with a start date of 07/19/19 and reviewed on 08/13/19 indicated Resident #1 required a wander guard device and was at risk for injury from wandering in an unsafe environment. Interventions included monitor and document wander guard device for placement every shift and monitor resident's location every two hours. The MDS dated [DATE] indicated Resident #1 he was severely cognitively impaired and had no wandering behaviors. The MDS indicated he required extensive assistance of 1 person with walking and limited assistance of 1 person with transfers. A nursing progress note dated 08/1/19 at 8:24 p.m., indicated Resident #1 had exit seeking behaviors. The note indicated the resident was redirected from the doors 5 times and stated, I'm going home and I'm going to the store to get cigarettes. The note indicated Resident #1 was easily redirected with snacks and distraction. A nursing note dated 8/2/19 at 12:15 a.m., indicated Resident #1 was wandering in the wheelchair all night and refused to go to bed. A nursing progress note dated 08/3/19 at 8:39 p.m., indicated staff was notified by the AD (activity director) Resident #1 had opened a door and tried to get out. The note indicated the wander guard was in place and working. Resident #1 stated I just hold the door until the alarm goes off, and it will open. Resident then demonstrated and was successfully able to open the door. Resident #1 stated, all you have to do is read. The note indicated the DON was notified and the resident was placed on every 15 minutes checks. The note indicated staff would continue to monitor the resident and he was currently on one on one with the nurse. A nursing progress note dated 08/04/19 at 8:56 p.m., indicated Resident #1 had increased agitation and was trying to elope and received 1:1 distraction. The note indicated at 9:15 p.m., Resident #1 got out of bed and said he was going to catch a ride. The note indicated Resident #1 continued to try to elope and was placed on every 15 minutes checks and one on one with the nurse. A social work note dated 08/05/19 at 9:30 a.m., indicated Resident #1's information was sent to a facility with a secured unit. The note indicated the SW spoke with Resident #1 about exit seeking behaviors. Resident #1 said he was not trying to leave but he knew how to get out of doors. The note indicated the SW explained to Resident #1 he did not need to get out for safety reasons and Resident #1 agreed the highway was busy and dangerous. A social work note dated 08/07/19 at 7:58 a.m., indicated Resident #1 was at the front door pushing the door handle. The note indicated he was redirected, and the charge nurse was notified. A nursing note dated 08/13/19 at 8:00 a.m., written by the DON indicated she spoke with Resident #1's RP and explained Resident #1 continued to attempt to leave the facility. The note indicated Resident #1 had been denied admission to 2 other local facilities. A nursing note dated 08/15/19 at 10:00 p.m., indicated Resident #1 was exit seeking. The note indicated staff heard the door alarm going off and Resident #1's wheelchair was found at the back door. The noted indicated Resident #1 was found walking outside next to the parking lot. The note indicated Resident #1 would continue to be monitored for any abnormal changes . An event report dated 08/28/19 at 6:45 p.m., indicated Resident #1 was located off facility grounds. The report indicated prior to eloping the resident was repeatedly opening doors, setting off the alarms on secured doors, wandering with no rational purpose and attempting to open doors. The reported indicated Resident #1 made elopement attempts in the past. An SBAR communication form dated 08/28/19 (no time recorded), completed by LVN B indicated Resident #1 had eloped and had been brought into the facility by the MDS nurse. The form indicated the resident was propelling down the street in his wheelchair and a couple pulled over and called the police. had face redness and deep breathing. The form indicated the Resident #1 had face redness and deep breathing and the physician was notified. During an interview on 09/18/19 at 3:22 p.m., LVN B said she was the charge nurse for Resident #1 when he exited the facility on 8/28/19. LVN B said Resident #1 was exit seeking daily. She said the day of the incident she last saw Resident #1 between 5:35 p.m. and 5:40 p.m. She said at approximately 6:20 p.m., she saw the MDS nurse coming into the front door with the resident. LVN B said Resident #1 told the MDS nurse he had left out of the door on the south unit, which is the door leading to the smoking area. She said Resident #1 told the MDS nurse he waived at her when he went past her door. LVN B said Resident #1 was put on 1:1 monitoring after the incident. LVN B said she voiced concerns to the DON a couple days prior to 8/28/19 about Resident #1 because he needed to be on 1:1 constantly due to his exit seeking behaviors. She said no new interventions were put into place. During a telephone interview on 09/18/19 at 11:44 a.m., the MDS nurse said she got a call from the police department while at the facility on 8/28/19 at around 6:45 p.m. asking if they had a resident missing from the facility. She said the police said the resident was found going down the side of the highway in his wheelchair. She said she went outside and saw it was Resident #1 and brought him back to the facility. She said Resident #1 told her he was out on the highway because he was going home for the weekend. She said Resident #1 said he had gotten out of the door going to the smoking area by pushing the door open. She said her office was on the hall going to the smoking area and she did not hear the door alarm go off or see Resident #1 pass by. The MDS nurse said it was unknown how long Resident #1 had been gone from the facility. During an interview on 09/19/19 at 3:15 p.m., the MDS nurse said she was told by the police Resident #1 was found self-propelling himself in his wheelchair on the shoulder of the highway. She said concerned citizens stopped and moved Resident #1 in the grassy area by the busy highway for his safety. She said all staff knew he was at risk for elopement and had a wander guard. During an observation on 09/19/19 at 3:20 p.m., the highway where Resident #1 was found on 8/28/19 was a busy four-lane highway with heavy traffic including private and commercial vehicles. The location was approximately one tenth of a mile from the facility and the speed limit was 55 miles per hour. The website https://www.timeanddate.com/weather/@ 31/historic?month=8&year=2019, accessed on 9/30/19 indicated it was 88 degrees on 8/28/19 at 6:30 p.m. An event report investigation follow-up dated 08/28/19 completed by the DON, indicated Resident #1 left the facility and was able to get off facility grounds. The report indicated Resident #1 was an elopement risk and currently had a wander guard on and the wander guard was working. The report indicated the resident was able to read the doors and knew to hold the bar down for 15 seconds to get out and the resident told the nurse how he managed to get out without the alarms going off. The report indicated Resident #1 was placed on 1:1 monitoring until he was no longer actively exit seeking and the doors and wander guard system was checked, and all were functioning properly. The report indicated Resident #1's wander guard bracelet was checked, and was working properly. The report indicated all door codes were updated. During an interview on 09/18/19 at 11:28 a.m., the DON said Resident #1 had a wander guard in place on 8/28/19. She said the wander guard was checked for placement every shift and checked to ensure it was working correctly every week. She said this information was documented on the wander guard check list. The DON said staff was aware Resident #1 was at risk for elopement and kept the resident at the nursing station and redirected him if he went to a door. A Wander Guard Check List dated 7/2010 indicated Wander guards would be checked for operation every Wednesday on the day shift by the nurse with no exceptions. The check list indicated wander guards would be checked for placement every shift. The (MONTH) 2019 warder guard checklist for Resident #1 indicated the wander guard was checked for placement (MONTH) 10th - (MONTH) 31st .There was no documentation for operating status. The operating status checkbox was blank. The (MONTH) 2019 wander guard checklist for Resident #1 indicated the wander guard was checked for placement (MONTH) 1st - (MONTH) 31st. The operating status checkbox was blank. During an interview on 9/18/19 at 3:43 p.m., the DON indicted there was no documentation for when Resident #1 was placed on every 15 minute checks after exiting the the facility on 7/12/19, 8/3/19 and 8/4/19. During an interview on 09/18/19 at 9:00 a.m., LVN C said she was working on 8/28/19 when Resident #1 was found on the side of the road. She said she had last seen Resident #1 at around 5:50 p.m. when staff took the Resident #1 to his room. She said Resident #1 was exit seeking all the time and staff checked to make sure the resident had the wander guard bracelet on daily. She said they would keep Resident #1 at the nursing station and redirect him as needed to make sure he didn't go outside. She said the wander guard system were tested but she was unsure how often. During an interview on 9/18/19 at 6:25 p.m., LVN [NAME] said Resident #1 would exit seek 75% of the shift . LVN [NAME] said she was working on 08/15/19 when Resident #1 got out of the building and was found on the sidewalk. LVN [NAME] said she was at the nursing station but did not hear the alarm. LVN [NAME] said on 08/15/19 when Resident #1 got out of the facility the DON was notified by another nurse and they were told to monitor him as usual and no new interventions were put in place. LVN [NAME] said tried to keep him at the nursing station and would redirect him if he went to the doors. LVN [NAME] said staff were in the dining room earlier when the surveyors where checking the alarms and they did not hear the alarms. During an interview on 09/18/19 at 8:41 a.m., the administrator said the facility had gotten a call from the police department on 8/28/19 at approximately 6:45 p.m. and asked if they had a resident missing. The administrator said the MDS coordinator went and got Resident #1 from the side of the highway. He said it was unknown how long Resident #1 had been gone from the facility. He said Resident #1 had a history of [REDACTED]. During an observation on 9/18/19 at 2:05 p.m., all 8 exit doors had a sign indicating Please do not let anyone exit without speaking to staff member. Push until alarm sounds, door can be opened in 15 seconds. During an observation and interview on 09/19/19 at 3:40 p.m., the dining room exit door alarmed for 1 minute and 58 seconds before the administrator responded to the alarm. The administrator said he had been at the nursing station and did not hear the alarm until he walked into the lobby area. During an observation and interview on 9/18/19 at 5:09 p.m., the west exit door alarmed for 6 minutes and 5 seconds before CNA D responded. CNA D said she was in the dining room and could not hear the alarm until she got to the nursing station. She said Resident #1 was always exit seeking and tried to get out the back door every day she worked. CNA D said she was working the day Resident #1 was found on the side of the road. She said she had already redirected him from a door once that day. She said Resident #1 was put on 1:1 monitoring after he was found on the road. CNA D said Resident #1 was not on 1:1 monitoring prior to that incident. During and observation on 9/18/19 at 5:06 p.m., the east exit door alarmed 1 minute and 15 seconds before staff responded. During an observation and interview on 09/18/19 at 11:15 a.m., the administrator tested the front door with a wander guard. The key pad began to blink but no alarm sounded. The administrator pushed the release bar on the door for 40 seconds and the key pad began to beep. After another 16 seconds the door opened, and the alarm sounded. The administrator said when someone with a wander guard approached the door, it would lock and disable the keypad so that no one could go out using the keypad. He said the door release bar had to be held, then the alarm would sound when the door was open. He said the door should release within 15 seconds. He said he did not know why the door did not release within 15 seconds. He said the local fire and safety company came and adjusted the doors on 9/4/19 and said they were working properly. During an observation on 09/18/19 at 2:05 p.m., all 8 of the facility exit doors were tested with the administrator for release time and alarms. The front exit door released and alarmed after 2 minutes of pushing the release bar. During an observation on 09/18/19 at 3:43 p.m., the DON attempted to open the front exit door with a wander guard. The door did not release for 2 minutes and 16 seconds. The DON said the door should have released within 15 seconds. During an observation on 9/18/19 at 4:46 p.m., the maintenance worker attempted to open the front door by pushing the release bar. The door opened after 30 seconds. He said the door should open after 15 seconds. He reset the door and tested again, the door opened after 15 seconds. The NFPA® 101 Life Safety Code® 2012 Edition Delayed-Egress Locking Systems indicated .(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS . The administrator was notified on 09/18/19 at 4:47 p.m. an Immediate Jeopardy situation was identified due to the above failures. On 09/09/19 at 5:23 p.m., the facility plan of removal was accepted and included: Plan of Removal oAll staff will immediately be in-serviced regarding appropriate response to door alarms by the DON. This has been completed for all staff currently in the facility. 10-6 shift will be completed by the ADON. 6-2 shift will be completed at 6 AM by DON. oAll residents with wander guards will be monitored at a minimum of every 2 hours as with all residents in the facility. Residents with wander guards will be checked Q shift to ensure proper placement by the charge nurse. Operation of the Wander Guard will be checked weekly each Wednesday per policy by the 6-2 charge nurse. Results will be documented on the Wander Guard Check List. This will be monitored weekly by the DON and/or designee. All residents' elopement risk assessments will be updated by the DON/ADON immediately and care planned accordingly to ensure that any residents at risk for elopement are assessed and monitored to meet their needs. All nursing staff will immediately be in serviced regarding this policy and procedure. All nursing staff currently in the facility have been completed. 10-6 shift will be completed by the ADON. 6-2 shift will be completed at 6 AM by DON. o All delayed egress doors will immediately be checked to ensure they are in working order and release within 15 seconds of engagement per regulation. o Maintenance will continue checking door functionality weekly each Wednesday. This is part of our TELS checklist and will be documented in TELS. o Any found not to be in working order will be serviced immediately. This process will be monitored by the Administrator and/or designee. o All staff will be in-serviced to notify administration immediately in the event of a failed door alarm. This is in process for all staff currently in the facility. 10-6 shift will be completed by the ADON. 6-2 shift will be completed at 6 AM by DON. o Door sirens will be added to all doors that do not currently have them installed and only beep when activated on 9/19/2019. The sirens are currently in route from College Station, TX and will be delivered and installed tonight. Sirens will be installed by the facility maintenance director with the assistance of the Administrator. o South Wing Front Door o Dining Room South Door o Dining Room North Door o North Wing 100 Hall Front Door o North Wing 100 Back Door o Until the sirens are in place the affected doors will be placed on 1 to 1 monitoring and be documented accordingly on the Q15 minute monitoring form. o Staff monitoring doors will be relieved by a charge nurse when a break is necessitated. o Staff monitoring will be supervised by the DON. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by: An in-service training report dated 9/18/19 presented to all staff indicated staff must immediately stop and respond to door alarms, make sure no one has left the building and look outside the doors. Report any door malfunction to the administrator and maintenance immediately. Report any wander guard malfunction to the DON immediately. During an interview on 09/20/19 at 11:45 a.m., the maintenance worker said louder alarms were installed on doors. During an observation on 09/20/19 at 12:40 p.m., all exit doors were tested and released within 15 seconds. The alarms could be heard throughout the building and staff responded appropriately. During interviews on 9/20/19 at 12:52 p.m., 2 LVNs, 3 CNAs and 2 dietary staff said they had been in-serviced concerning wander guards and door alarms. The staff said they would respond to all door alarms immediately and check for residents who may be attempting to exit the building. Staff said they would notify the charge nurse if an alarm sounded even if they did not see a resident had exited. Staff indicated they would report any malfunction of a wander guard to the DON and report any malfunctioning doors or alarms to the administrator or maintenance. Nursing staff identified how and when to check wander guards. On 09/20/19 at 1:00 p.m., the administrator DON and ADON were notified the IJ was removed. However, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 4 of 4 residents reviewed for abuse. (Resident #s 2, 3, 4, and 5) The facility did not implement effective interventions to prevent Resident #1 from verbally and physically sexually abusing Resident #s 2, 3, 4, and 5. The comprehensive assessment for Resident #1 was not accurate and the care plan did not address the physical behaviors of sexually touching others. Resident #1 received treatment from a behavioral hospital on [DATE] for sexually touching Resident #2; he returned to the facility on [DATE] and his behaviors worsened. On 3/26/19 Resident #1 groped Resident #2 against her will. On 4/12/19 or 4/13/19 Resident #1 touched Resident #3 on the breast. During (MONTH) 2019 Resident #1 was verbally and physically sexually inappropriate with Resident #4 and Resident #5. Resident #1 touched Resident #4 on the breast. Resident #1 touched Resident #5 between the legs in the dining room. The administrator, DON, and ADON did not consider Resident #1's behavior was abuse due to his cognitive status. This failure could place residents at risk for sexual abuse and decreased psychosocial well-being. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/18/19. While the IJ was removed on 4/19/19, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE] was an [AGE] year-old male with [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 3/12/19, indicated Resident #1 had moderate difficulty hearing but did not use a hearing aid. The assessment indicated Resident #1 had clear speech, was able to make himself understood and usually understood others. The assessment indicated Resident #1 was not oriented to day, month, or year and had severe cognitive impairment. The assessment indicated Resident #1 had no potential indicators of [MEDICAL CONDITION], no physical behaviors directed toward others, but did have verbal behaviors towards others less than daily. The assessment indicated Resident #1 used a wheelchair and had no impairment in range of motion with his extremities. A care plan with a start date of 11/21/18 and updated on 3/25/19 indicated Resident #1 was socially inappropriate/disruptive with behavioral symptoms as evidenced by: will make sexually inappropriate statements and touch staff at times. Interventions included: administer medications ([MEDICATION NAME]), monitor and record effectiveness; assess whether the behavior endangers the resident and/or others and intervene if necessary; maintain a calm environment and approach to the resident; obtain a psychological consult/psychosocial therapy. Refer to counseling services and psychiatrist when resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). The care plan did not address Resident #1 sexually touching female residents. A behavior tracking form dated 12/1/2018 to 12/31/2018 for Resident #1 indicated the following: *12/12/18 at 3:10 p.m. - Behavior-sexually inappropriate; Intervention- redirected; Outcome- unchanged. *12/12/18 at 5:30 p.m. - Behavior-sexually inappropriate; Intervention- redirected; Outcome- improved. *2/16/19 at 8:00 a.m. - Behavior-sexually inappropriate; Intervention- redirected; Outcome- unchanged. *2/16/19 at 12:15 p.m. - Behavior-sexually inappropriate; Intervention- redirected; Outcome- unchanged. *3/9/19 at 12:00 p.m. - Behavior-sexually inappropriate, cursing, and name calling or racially motivated slurs; Intervention- redirected and assisted with task, cueing; Outcome- worsened. *3/9/19 at 4:30 p.m.- Behavior-sexually inappropriate, cursing; Intervention- redirected; Outcome- worsened. A behavior tracking form dated 4/14/19 for Resident #1 indicated the following: *4/14/19 at 10:30 a.m.: Behavior-screaming, sexually inappropriate, cursing, name calling or racially motivated slurs, threatening others, and trying to leave; Intervention- distraction, redirected and modify environment; Outcome- unchanged. *4/14/19 at 1:50 p.m.: Behavior-screaming, cursing, threatening others, wandering unsafely, and trying to leave; Intervention- calming reassurance, one to one attention, distraction, redirected; Outcome- unchanged. *4/14/19 at 2:21 p.m.: Behavior-name calling or racially motivated slurs; Intervention- redirected and move to a quiet place; Outcome- unchanged. *4/14/19 at 5:00 p.m.: Behavior-cursing, sexually inappropriate; Intervention- redirected and move to a quiet place; Outcome- unchanged. *4/17/19 at 6:40 p.m.: Behavior-persistent attention seeking, screaming, cursing, name calling or racially motivated slurs, sexually inappropriate; Intervention- redirected and move to a quiet place; Outcome- unchanged. The clinical record from (MONTH) (YEAR) to (MONTH) 2019 for Resident #1 did not contain any other behavior tracking forms. During an e-mail conversation on 4/24/19 at 9:00 a.m. the DON indicated the only formal documentation regarding tracking behaviors for Resident #1 were on the behavior tracking form. Social Worker notes for Resident #1 indicated the following: *1/2/19 at 8:00 a.m. - an unnamed resident reported to the SW Resident #1 made inappropriate comments to her. He said he wanted to kiss her and take her to bed. The note indicated the SW spoke to Resident #1 in the dining room and he did not deny making the comments. The note indicated Resident #1 asked the social worker if she wanted to go to bed with him. *1/14/19 at 8:00 a.m. - the note indicated the SW spoke to Resident #1 about his inappropriate comments to another resident. The note indicated Resident #1 seemed to understand what he was saying was not appreciated by other residents and agreed to stop speaking that way to other residents. *1/16/19 at 7:45 a.m. - the note indicated the SW spoke to Resident #1 about his language when speaking to other residents, especially females. The note indicated the SW reminded Resident #1 he could not use language like he did because female residents found it offensive. The note indicated Resident #1 was confused and it was not clear if he understood why he could not use that language. *1/21/19 at 8:00 a.m. - the note indicated the administrator spoke to the SW about complaints from female residents regarding Resident #1's inappropriate sexual language. *1/23/19 at 9:50 a.m. - the note indicated the SW completed an MDS assessment with Resident #1 and he was identified as having moderate cognitive impairment. The note indicated Resident #1 continued to be seen by a counseling services group and physician for inappropriate sexual language. The clinical record for Resident #1 did not have SW notes from February, (MONTH) or (MONTH) 2019. Nursing Notes for Resident #1 indicated the following: *2/17/19 at 12:00 p.m. completed by LVN P indicated Resident #1 was in the dining room and was observed near a resident (unnamed) with his hand on her thigh. The note indicated Resident #1 was assisted from the dining room to his room to help decrease stimulation. *2/17/19 at 7:00 p.m. completed by LVN P indicated transportation was at the facility to transfer Resident #1 to the behavioral health hospital. *3/5/19 at 12:15 p.m. completed by an unidentified staff indicated Resident #1 returned to the facility from the behavioral health hospital. *3/9/19 at 6:08 p.m. completed by LVN G indicated Resident #1 was verbally abusive to an unnamed CNA. He called the CNA [***] , he said all you women are [***] es . *3/10/19 at 3:22 p.m. completed by LVN G indicated Resident #1 continued to be verbally abusive calling staff and residents [***] es. *4/13/19 at 5:30 a.m. completed by LVN P indicated Resident #1 was up in his wheelchair in the hallway making inappropriate comments to staff and residents, such as look at that ass swing, come let me grab it, and let me grab those titties and suck on them. The noted indicated staff attempted to redirect Resident #1 with snacks and water and he returned to his room. *4/13/19 day shift, completed by LVN G indicated Resident #1 continued to be inappropriate verbally and physically. The note indicated another unnamed resident reported Resident #1 touched her breast and Resident #1 was immediately removed from the dining area. *4/14/19 day shift, completed by LVN G indicated Resident #1 continued to be verbally abusive to other residents and staff. The note indicated Resident #1 was removed from the dining area that morning for touching unnamed female residents. *4/14/19 evening shift, completed by LVN G indicated Resident #1 continued inappropriate behavior making inappropriate and racial comments to staff and other residents. The note indicated Resident #1 was removed from the dining area because he was making other residents angry. The Twenty-Four-Hour reports dated 4/10/19, 4/11/19, 4/12/19, 4/13/19, 4/14/19, 4/15/19, 4/16/19, 4/17/19, 4/18/19 indicated monitor behaviors on each shift. A hand-written timeline provided by the DON on 4/18/19 indicated the following: *1/24/19 - UA (urine analysis) collected from Resident #1 as ordered for increased sexual behaviors - grievances. *1/24/19 - Resident #1 attempted to touch a nurse inappropriately. *1/25/19 - Resident #1 attempted to hit a staff member in the dining room because she attempted to prevent him from drinking after other residents. Redirected him and made referral to mental health hospital and was denied. The Ombudsman was notified. *1/26/19 - Resident #2 was verbally sexually aggressive during care with staff and was redirected. *2/17/19 - Resident #1 was observed in the dining room with his hand on a resident's thigh. The residents were separated, the physician was notified, and resident was transferred to a behavioral health hospital. *3/5/19 - Resident #1 was returned from the behavioral health hospital. *3/5/19 - Resident #1 was sexually inappropriate and attempted to grab a nurse. A referral was made to the behavioral health hospital and resident was denied. *3/26/19 - Resident #1 touched a resident inappropriately and was transferred to the behavioral health hospital. *4/10/19 - Resident #1 returned from the behavioral health hospital. During an interview on 4/18/19 at 5:03 p.m., CNA F said she started working for the facility 3 days ago. She said she was told today that Resident #1 had to be watched around other residents. CNA F said Resident #1 could move on his own in his wheelchair. CNA F said Resident #1 had to be monitored for being combative or anything else. CNA F said she was not told specifically to watch Resident #1 around female residents, just to watch him around residents. During an interview on 4/18/19 at 6:20 p.m., Resident #1 was lying in bed. Resident #1 said he did not recall how long he had been at the facility. He said he had never tried to get to know any of the women at the facility and had never touched any of the female residents at the facility. During an interview on 4/18/19 at 2:12 p.m., the ADON said the only female resident Resident #1 actually touched was Resident #2. The ADON said Resident #1 was transferred to the behavioral hospital for approximately two weeks. She said Resident #1's behavior was no different when he came back from the behavioral hospital. The ADON said she heard Resident #3 said something about her breasts, but it was not reported to her that Resident #1 touched Resident #3. The ADON said Resident #1 was monitored frequently when it was alleged he said or done something. The ADON said staff was documenting every shift on Resident #1's behaviors. She said Resident #1's mental status was such that he could not control his behavior and she did not think trying to touch Resident #3's breasts was abuse. The ADON said if Resident #1 touched Resident #3 it would have been abuse. During an interview on 4/18/19 at 3:06 p.m., the administrator said Resident #1 had two instances of touching Resident #2 inappropriately and both times he was transferred to a behavioral hospital. The administrator said Resident #1 had numerous episodes of racially and sexually inappropriate comments with staff and residents. The administrator said there were two allegations of him attempting to touch female residents' breasts inappropriately. He said the most recent incident occurred this past weekend on 4/13/19 or 4/14/19 when Resident #1 attempted to touch Resident #3's breast. The administrator said the facility was doing behavior monitoring and documenting. The administrator said he felt Resident #1's actions were not abuse because of his cognitive impairment. The administrator said he did not feel that Resident #1 had the capacity for willful behavior. He said that if there was no injury or adverse effect from an attempted unwanted physical touching it was not abuse. 2. Physician orders [REDACTED].#2, admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 3/27/19, indicated Resident #2 had minimal difficulty hearing and was sometimes understood/understands others. Staff assessment of Resident #2 's mental status indicated severe cognitive impairment. The assessment indicated Resident #2 was totally dependent on staff for transfers, locomotion, eating, and toileting. A care plan dated 3/28/19 indicated focus areas for Resident #2 included behavioral symptoms, anxiety, and assistance with ADLs. A witness statement dated 3/26/19 by CNA Q indicated as she was walking down the hall she heard Resident #2 yell Stop!. CNA Q saw Resident #1 with his hand on Resident #2's private area. CNA Q separated the residents and reported the incident to RN M. An incident report dated 3/26/19 by RN M indicated Resident #2 was groped by another resident against her will. The report indicated another resident had touched Resident #2's inner thigh. The incident report indicated Resident #1 was placed on 1:1 monitoring until he could be transported to the behavioral hospital. The incident report indicated Resident #1 repeatedly asked the staff monitoring him to go to bed with him, and when she told him she was pregnant he said, [***] that baby. During an interview on 4/18/19 at 11:26 a.m., the DON said Resident #1 touched Resident #2 in the past and was transferred to the behavioral hospital. The DON said staff witnessed Resident #1 place his hand on Resident #2's thigh. During an interview on 4/19/19 at 2:27 p.m., RN M said she did not see Resident #1 touch a resident, but it was reported to her by the CNA Q who was working on the hall. RN M said CNA Q separated Resident #1 and Resident #2 when she observed Resident #1 touching Resident #2 inappropriately. RN M said she notified the administrator, the DON, and the ADON of the incident. 3. Physician orders [REDACTED].#3 admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 2/3/19, indicated Resident #3 was cognitively intact and required supervision and set-up help with eating and locomotion, extensive assistance of one staff for dressing, toileting, and personal hygiene, and was totally dependent for transfers. A care plan dated 3/6/19 indicated focus areas for Resident #3 included left sided [MEDICAL CONDITION] and weakness related to [MEDICAL CONDITION], risk of pressure ulcers, and assistance with ADLs. During an interview on 4/18/19 at 9:50 a.m., the Ombudsman said Resident #3 told her Resident #1 had touched her in her chest area. The Ombudsman said when she spoke to the administrator and the DON about it, they said Resident #3 reported to them Resident #1 had attempted to touch her breasts but was unsuccessful. During an interview on 4/18/19 at 11:47 a.m., Resident #3 said Resident #1 touched her breast last Friday morning (4/12/19). Resident #3 said she told one of the nurses (unnamed) on the evening shift. Resident #3 said Resident #1 had been popping staff on the rear end. During an interview on 4/18/19 at 1:45 p.m., DA D said on the morning of 4/13/19 Resident #3 was coming into the dining room and Resident #1 reached out and grabbed her breast. DA D said she told Resident #1 it was inappropriate, and he could not do that. DA D said she reported the incident to LVN S. DA D said Resident #1 tried to grab Resident #4's breast as she was coming into the dining room on her scooter that same morning. She said Resident #1 said to Resident #4 come here and let me see one of those big titties. DA D said Resident #1 always wanted to touch and see. She said she reported the events to her supervisor but did not know if the incidents were brought up at the morning meeting. During an interview on 4/18/19 at 2:41 p.m., CNA B said Resident #3 told her Resident #1 had rubbed her breasts when she was trying to get some coffee this past weekend CNA B said she knew Resident #1 had just returned from the behavioral hospital for inappropriately touching Resident #2. CNA B said she reported Resident #3's allegations to LVN G who told her she had already documented the incident. During an interview on 4/18/19 at 6:57 p.m., CNA E said Resident #3 told her Resident #1 had touched her breast and Resident #3 had already reported it. During an interview on 4/18/19 at 11:26 a.m. and 2:53 p.m., the DON said Resident #3 was cognitively intact and was the Vice President of the Resident Council. The DON said she received a call from LVN G on 4/14/19 informing her Resident #3 said Resident #1 had grabbed her breast the day before. The DON said no one called the administrator. The DON said she told LVN G to monitor Resident #3 for emotional distress and make sure Resident #1 and Resident #3 were separated. The DON said when she and the administrator followed up on the allegation on 4/15/19, Resident #3 said Resident #1 grabbed at her breasts but did not actually touch her. The DON said Resident #1 was in a wheelchair, so he could not make a female do something. The DON said Resident #3 kept asking when they were going to send Resident #1 back to the behavioral health hospital or get him out of the facility. The DON said other than seeking alternate placement Resident #1 was being monitored for behaviors, and it was documented every shift. The DON said this incident was not abuse because of Resident #1's low cognition. 4. Physician orders [REDACTED].#4, admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most current MDS assessment, dated 3/7/19, indicated Resident #4 was cognitively intact. The assessment indicated Resident #4 required supervision and set-up help only with all activities of daily living, used a wheelchair for mobility and was always continent of bowel and bladder. A care plan dated 3/19/19 indicated Resident #4 had focus areas which included fall precautions, use of a [MEDICAL CONDITION] machine at night, and oxygen therapy. A grievance report dated 2/16/19 initiated by Resident #4 indicated Resident #1 told Resident #4 I like your pants. I would like them better on my floor with you in my bed. The grievance report stated Resident #1 displayed similar behaviors toward other residents that were witnessed by staff. Based on those witnessed behaviors it is likely that this also occurred. The grievance report indicated Resident #1 was referred to and accepted to a behavioral health hospital. The report was signed by the administrator and dated 2/18/19. During an interview on 4/18/19 at 11:47 a.m., Resident #4 said on an unnamed date she was in the dining room and Resident #1 started using racial slurs. Resident #4 said she told Resident #1 to hush, and Resident #1 said to her do those big titties keep you warm? Resident #4 said she told Resident #1 to never say that again. Resident #4 said an unnamed kitchen staff saw the incident and told someone (unnamed). Resident #4 said Resident #1 said the same thing to her on 4/16/19. Resident #4 said she reported the incident to the ADON and to LVN K at separate times and they told her they were working on it. During an interview on 4/19/19 at 11:15 a.m., DA H said Resident #4 told her Resident #1 touched her in the hall. During an interview on 4/19/19 at 11:30 a.m., LVN K said she never saw Resident #1 touch another resident, but she heard in report last weekend he pinched Resident #4 on the breast. She said it was reported the DON and administrator had been notified. During an interview on 4/19/19 at 1:17 p.m., CNA L said Resident #3 and Resident #4 told him Resident #1 had grabbed their titties. CNA L said Resident #3 and Resident #4 were really upset. He said Resident #1 mostly messed with residents that were more active. CNA L said Resident #3 and Resident #4 told him about Resident #1 touching them a couple of times. CNA L said he always told the nurses (unnamed) about the allegations, but they would say they were already aware of it. During an interview on 4/19/19 at 2:45 p.m., LVN O said Resident #4 complained about Resident #1 saying sexually inappropriate things. She said in (MONTH) 2019 Resident #1 went to the nursing stations and asked for a banana. He peeled the banana and said, I used to be like this. LVN O said Resident #1 asked her to go to bed with him, and she told him that was inappropriate. Resident #1 told her he would eat her pussy all night if she would lay down with him. LVN O said Resident #1 popped one of the CNAs on the behind. 5. Physician orders [REDACTED].#5, admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most current MDS assessment dated [DATE], indicated Resident #5 was cognitively intact. The assessment indicated Resident #5 required limited assistance of one staff to transfer and extensive assistance of one staff for dressing, toileting, and personal hygiene. A care plan reviewed on 3/15/19 indicated Resident #5 had focus areas including assistance with ADLs, pressure injury, [MEDICAL CONDITION] care, preference to dress only in hospital gowns, and delusional thought content. During an interview on 4/19/19 at 11:15 a.m., DA H said in (MONTH) 2019 she saw Resident #1 go up to Resident #5's table in the dining room and Resident #5 told Resident #1 to go away. DA H said Resident #1 said to Resident #5 let me see what's between your legs and he started touching her between her legs under her gown. DA H said Resident #5 immediately left the dining room and has not been back to the dining room since. DA H said she told her supervisor about the incident. During an interview on 4/18/19 at 1:45 p.m., DA D said Resident #1 would go to Resident #5's table in the dining room and say let me see what you've got under your gown. DA D said Resident #1 told Resident #5 I'm going to find out what room you are in and come to your room. During an interview on 4/19/19 at 11:20 a.m., the dietary manager said DA D told her Resident #1 touched Resident #4 and DA D reported it to the nurse (unnamed). The dietary manager said an unnamed staff told her Resident #1 had touched Resident #5 in the dining room, but she could not remember who told her. The dietary manager said she had not reported abuse or neglect regarding Resident #1. She said she heard things second or third hand but had never witnessed abuse. The dietary manager said Resident #1 was always appropriate when she interacted with him. During an interview on 4/18/19 at 6:50 p.m., Resident #5 said Resident #1 had been rude and inappropriate but had never touched her. Resident #5 said if Resident #1 touched her she would call her brother who was an attorney. During an interview on 4/22/19 at 2:40 p.m., the Ombudsman indicated she came to the facility on [DATE] after receiving a call regarding Resident #1's behavior. She said Resident #1 told Resident #5 he was going to come to her room and have his way with her. The Ombudsman said Resident #1 touched a nurse between the legs. She said Resident #1 was sent to a behavioral health facility. A policy of abuse, reportable events, revised 3/18, indicated it was the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there was cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy defined willful as meaning the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy defined sexual abuse as nonconsensual sexual contact of any type with a resident. The policy indicated if another resident was the alleged perpetrator, they should immediately be assessed for treatment options. The safety and protection of other residents was the home's primary concern. The policy indicated for resident to resident abuse, if the alleged perpetrator was placed on location monitoring, staff would be instructed on the reason for monitoring and the targeted behaviors being monitored. A policy on behavior assessment and management interventions, dated 8/17, indicated the intent of the policy was to have a behavior intervention and management program to prevent, reduce, or eliminate inappropriate behaviors which may be detrimental to the individual or others. Behavior is defined as anything a person does or says in response to how they feel or what they experience. The policy indicated the home should consider resident behavior inappropriate if it presents a risk of danger or harm to the resident or others, interferes with resident or other residents' optimal functioning, or significantly interferes with the staff's ability to provide care. Inappropriate behaviors will be maintained, and interventions put in place to manage the behavior. Inappropriate behaviors will be documented on the behavior flow sheet. A policy on behavior tracking, dated 5/18, indicated the behavior tracking was utilized to document behavior symptoms, the frequency of the behaviors, and the interventions implemented by staff to redirect, change, or stop the behavior or situation in order to improve quality of life for the resident and those around him/her. The policy indicated document behaviors as they occur every time there is occurrence that requires intervention and documentation on the behavior tracking form may be completed by any staff member in the facility-licensed or non-licensed-who observes and/or intervenes when there is a behavior noted or a situation that requires attention. An undated statement of resident rights indicated residents have the right to be free from abuse both physical and mental including corporal punishment, neglect and exploitation. The facility administrator, the facility DON, and the Regional Director of Clinical Services were notified on 4/18/19 at 4:56 p.m., an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal was accepted on 4/18/19 at 7:40 p.m. and included the following: Alternate placement would be located for Resident #1. The facility will recognize potentially abusive situations and thoroughly investigate and report all allegations of abuse and/or neglect. The plan indicated upon notification of allegation that resident inappropriately touched another resident, offending resident was placed on 1-1 monitoring with a facility staff member to remain within an arm's reach, while investigation initiated. Documentation of 1-1 monitoring kept at 15-minute intervals 24/7 until alternate placement is found for resident. The plan indicated the administrator, DON and facility staff was responsible for reviewing monitoring sheets daily and perform visual observation daily and document on monitoring sheet. Facility staff education initiated by DON with all staff on duty on 1-1 monitoring and how to document, remaining staff will be educated by administrator or DON prior to performing 1-1 monitoring. The surveyor confirmed the implementation of the plan of removal by the following: During an interview on 4/19/19 at 10:45 a.m., the DON said Resident #1 was transferred to a behavioral health hospital this morning at 2:00 a.m. and the behavioral hospital understood the facility would not accept him back. All licensed staff and CNAs on the 6 a-2 shift (2 LVNS/2 CNAs) and the 2-10 shift (2 LVNS/2 CNAs) were interviewed and correctly identified what constitutes abuse, how to report abuse, and to whom to report abuse. They indicated they had been in-serviced on monitoring residents who touched a resident inappropriately. On 4/19/19 at 3:20 p.m., the administrator was notified the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as a pattern.

Based on interview and record review, the facility failed to ensure the written policy and procedure to prevent abuse was implemented for 4 of 4 residents reviewed for abuse. (Resident #s 2, 3, 4, and 5) The facility did not implement effective interventions to prevent Resident #1 from verbally and physically sexually abusing Resident #s 2, 3, 4, and 5 and the facility did not report the incidents to the state office. The comprehensive assessment for Resident #1 was not accurate and the care plan did not address the physical behaviors of sexually touching others. Resident #1 received treatment from a behavioral hospital on [DATE] for sexually touching Resident #2; he returned to the facility on [DATE] and his behaviors worsened. On 3/26/19 Resident #1 groped Resident #2 against her will. On 4/12/19 or 4/13/19 Resident #1 touched Resident #3 on the breast. During (MONTH) 2019 Resident #1 was verbally and physically sexually inappropriate with Resident #4 and Resident #5. Resident #1 touched Resident #4 on the breast. Resident #1 touched Resident #5 between the legs in the dining room. The administrator, DON, and ADON did not consider Resident #1's behavior was abuse due to his cognitive status. This failure could place residents at risk for sexual abuse and decreased psychosocial well-being. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/18/19. While the IJ was removed on 4/19/19, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: A policy for abuse, reportable events, revised 1/18, indicated it was the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there was cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy defined willful as meaning the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy defined sexual abuse as nonconsensual sexual contact of any type with a resident. The policy indicated if another resident was the alleged perpetrator, they should immediately be assessed for treatment options. The safety and protection of other residents was the home's primary concern. The policy indicated for resident to resident abuse, if the alleged perpetrator was placed on location monitoring, staff would be instructed on the reason for monitoring and the targeted behaviors being monitored. The policy indicated sexual abuse was defined as non-consensual sexual contact of any type with a resident. Verbal abuse was defined as the use of oral, written, and gestured language that includes disparaging derogatory term to a resident. The policy indicated all alleged allegations of abuse would be reported to the appropriate state agencies as required by regulations. A policy on behavior assessment and management interventions, dated 8/17, indicated the intent of the policy was to have a behavior intervention and management program to prevent, reduce, or eliminate inappropriate behaviors which may be detrimental to the individual or others. Behavior is defined as anything a person does or says in response to how they feel or what they experience. The policy indicated the home should consider resident behavior inappropriate if it presents a risk of danger or harm to the resident or others, interferes with resident or other residents' optimal functioning, or significantly interferes with the staff's ability to provide care. Inappropriate behaviors will be maintained, and interventions put in place to manage the behavior. Inappropriate behaviors will be documented on the behavior flow sheet. A policy on behavior tracking, dated 5/18, indicated the behavior tracking was utilized to document behavior symptoms, the frequency of the behaviors, and the interventions implemented by staff to redirect, change, or stop the behavior or situation to improve quality of life for the resident and those around him/her. The policy indicated document behaviors as they occur every time there is occurrence that requires intervention and documentation on the behavior tracking form may be completed by any staff member in the facility-licensed or non-licensed-who observes and/or intervenes when there is a behavior noted or a situation that requires attention. An undated statement of resident rights indicated residents have the right to be free from abuse both physical and mental including corporal punishment, neglect and exploitation. 1. Physician orders [REDACTED].#1, admitted [DATE] was an [AGE] year-old male with [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 3/12/19, indicated Resident #1 had moderate difficulty hearing but did not use a hearing aid. The assessment indicated Resident #1 had clear speech, was able to make himself understood and usually understood others. The assessment indicated Resident #1 was not oriented to day, month, or year and had severe cognitive impairment. The assessment indicated Resident #1 had no potential indicators of [MEDICAL CONDITION], no physical behaviors directed toward others, but did have verbal behaviors towards others less than daily. The assessment indicated Resident #1 used a wheelchair and had no impairment in range of motion with his extremities. A care plan with a start date of 11/21/18 and updated on 3/25/19 indicated Resident #1 was socially inappropriate/disruptive with behavioral symptoms as evidenced by: will make sexually inappropriate statements and touch staff at times. Interventions included: administer medications ([MEDICATION NAME]), monitor and record effectiveness; assess whether the behavior endangers the resident and/or others and intervene if necessary; maintain a calm environment and approach to the resident; obtain a psychological consult/psychosocial therapy. Refer to counseling services and psychiatrist when resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). The care plan did not address Resident #1 sexually touching female residents. Nursing Notes for Resident #1 indicated the following: *2/17/19 at 12:00 p.m. completed by LVN P indicated Resident #1 was in the dining room and was observed near a resident (unnamed) with his hand on her thigh. The note indicated Resident #1 was assisted from the dining room to his room to help decrease stimulation. *2/17/19 at 7:00 p.m. completed by LVN P indicated transportation was at the facility to transfer Resident #1 to the behavioral health hospital. *3/5/19 at 12:15 p.m. completed by an unidentified staff indicated Resident #1 returned to the facility from the behavioral health hospital. *3/9/19 at 6:08 p.m. completed by LVN G indicated Resident #1 was verbally abusive to an unnamed CNA. He called the CNA [***] , he said all you women are [***] es . *3/10/19 at 3:22 p.m. completed by LVN G indicated Resident #1 continued to be verbally abusive calling staff and residents [***] es. *4/13/19 at 5:30 a.m. completed by LVN P indicated Resident #1 was up in his wheelchair in the hallway making inappropriate comments to staff and residents, such as look at that ass swing, come let me grab it, and let me grab those titties and suck on them. The noted indicated staff attempted to redirect Resident #1 with snacks and water and he returned to his room. *4/13/19 day shift, completed by LVN G indicated Resident #1 continued to be inappropriate verbally and physically. The note indicated another unnamed resident reported Resident #1 touched her breast and Resident #1 was immediately removed from the dining area. *4/14/19 day shift, completed by LVN G indicated Resident #1 continued to be verbally abusive to other residents and staff. The note indicated Resident #1 was removed from the dining area that morning for touching unnamed female residents. *4/14/19 evening shift, completed by LVN G indicated Resident #1 continued inappropriate behavior making inappropriate and racial comments to staff and other residents. The note indicated Resident #1 was removed from the dining area because he was making other residents angry. Social Worker notes for Resident #1 indicated the following: *1/2/19 at 8:00 a.m. - an unnamed resident reported to the SW Resident #1 made inappropriate comments to her. He said he wanted to kiss her and take her to bed. The note indicated the SW spoke to Resident #1 in the dining room and he did not deny making the comments. The note indicated Resident #1 asked the social worker if she wanted to go to bed with him. *1/14/19 at 8:00 a.m. - the note indicated the SW spoke to Resident #1 about his inappropriate comments to another resident. The note indicated Resident #1 seemed to understand what he was saying was not appreciated by other residents and agreed to stop speaking that way to other residents. *1/16/19 at 7:45 a.m. - the note indicated the SW spoke to Resident #1 about his language when speaking to other residents, especially females. The note indicated the SW reminded Resident #1 he could not use language like he did because female residents found it offensive. The note indicated Resident #1 was confused and it was not clear if he understood why he could not use that language. *1/21/19 at 8:00 a.m. - the note indicated the administrator spoke to the SW about complaints from female residents regarding Resident #1's inappropriate sexual language. *1/23/19 at 9:50 a.m. - the note indicated the SW completed an MDS assessment with Resident #1 and he was identified as having moderate cognitive impairment. The note indicated Resident #1 continued to be seen by a counseling services group and physician for inappropriate sexual language. The clinical record for Resident #1 did not have SW notes from February, (MONTH) or (MONTH) 2019. A behavior tracking form dated 12/1/2018 to 12/31/2018 for Resident #1 indicated the resident was redirected on the following after a behavior of being sexually inappropriate: *12/12/18 at 3:10 p.m. - Outcome- unchanged, *12/12/18 at 5:30 p.m. - Outcome- improved, *2/16/19 at 8:00 a.m. - Outcome- unchanged, *2/16/19 at 12:15 p.m. - Outcome- unchanged, *3/9/19 at 12:00 p.m. - cursing, and name calling or racially motivated slurs; Outcome- worsened. *3/9/19 at 4:30 p.m.- cursing, Outcome- worsened. A behavior tracking form dated 4/14/19 for Resident #1 indicated the following: *4/14/19 at 10:30 a.m.: Behavior-screaming, sexually inappropriate, cursing, name calling or racially motivated slurs, threatening others, and trying to leave; Intervention- distraction, redirected and modify environment; Outcome- unchanged. *4/14/19 at 1:50 p.m.: Behavior-screaming, cursing, threatening others, wandering unsafely, and trying to leave; Intervention- calming reassurance, one to one attention, distraction, redirected; Outcome- unchanged. *4/14/19 at 2:21 p.m.: Behavior-name calling or racially motivated slurs; Intervention- redirected and move to a quiet place; Outcome- unchanged. *4/14/19 at 5:00 p.m.: Behavior-cursing, sexually inappropriate; Intervention- redirected and move to a quiet place; Outcome- unchanged. *4/17/19 at 6:40 p.m.: Behavior-persistent attention seeking, screaming, cursing, name calling or racially motivated slurs, sexually inappropriate; Intervention- redirected and move to a quiet place; Outcome- unchanged. The clinical record from (MONTH) (YEAR) to (MONTH) 2019 for Resident #1 did not contain any other behavior tracking forms. During an e-mail conversation on 4/24/19 at 9:00 a.m. the DON indicated the only formal documentation regarding tracking behaviors for Resident #1 were on the behavior tracking form. The Twenty-Four-Hour reports dated 4/10/19, 4/11/19, 4/12/19, 4/13/19, 4/14/19, 4/15/19, 4/16/19, 4/17/19, 4/18/19 indicated monitor behaviors on each shift. A hand-written timeline provided by the DON on 4/18/19 indicated the following: *1/24/19 - UA (urine analysis) collected from Resident #1 as ordered for increased sexual behaviors - grievances. *1/24/19 - Resident #1 attempted to touch a nurse inappropriately. *1/25/19 - Resident #1 attempted to hit a staff member in the dining room because she attempted to prevent him from drinking after other residents. Redirected him and made referral to mental health hospital and was denied. The Ombudsman was notified. *1/26/19 - Resident #1 was verbally sexually aggressive during care with staff and was redirected. *2/17/19 - Resident #1 was observed in the dining room with his hand on a resident's thigh. The residents were separated, the physician was notified, and resident was transferred to a behavioral health hospital. *3/5/19 - Resident #1 was returned from the behavioral health hospital. *3/5/19 - Resident #1 was sexually inappropriate and attempted to grab a nurse. A referral was made to the behavioral health hospital and resident was denied. *3/26/19 - Resident #1 touched a resident inappropriately and was transferred to the behavioral health hospital. *4/10/19 - Resident #1 returned from the behavioral health hospital. During an interview on 4/18/19 at 2:12 p.m., the ADON said the only female resident Resident #1 actually touched was Resident #2 and that incident was not reported to the state agency. The ADON said it was reported that Resident #1 touched Resident #2 on the leg. The ADON said Resident #1 was transferred to the behavioral hospital for approximately two weeks. She said Resident #1's behavior was no different when he came back from the behavioral hospital. The ADON said she heard Resident #3 said something about her breasts, but it was not reported to her that Resident #1 touched Resident #3. The ADON said Resident #1 was monitored frequently when it is alleged that he said or done something. The ADON said staff was documenting every shift on Resident #1's behaviors. She said Resident #1's mental status was such that he could not control his behavior and she did not think trying to touch Resident #3's breasts was abuse so the incident was not reported to the state agency. The ADON said if Resident #1 touched Resident #3 it would have been abuse. During an interview on 4/18/19 at 3:06 p.m., the administrator said Resident #1 had two instances of touching Resident #2 inappropriately and both times he was transferred to a behavioral hospital. The administrator said Resident #1 had numerous episodes of racially and sexually inappropriate comments with staff and residents. The administrator said there were two allegations of him attempting to touch female residents' breasts inappropriately. He said the most recent incident occurred this past weekend on 4/13/19 or 4/14/19 when Resident #1 attempted to touch Resident #3's breast. The administrator said the facility was doing behavior monitoring and documenting. The administrator said he felt Resident #1's actions were not abuse because of his cognitive impairment therefore he did not report the incidents to the state agency. The administrator said he did not feel that Resident #1 had the capacity for willful behavior. He said that if there was no injury or adverse effect from an attempted unwanted physical touching it was not abuse. During an interview on 4/18/19 at 5:03 p.m., CNA F said she started working for the facility 3 days ago. She said she was told today that Resident #1 had to be watched around other residents. CNA F said Resident #1 could move on his own in his wheelchair. CNA F said Resident #1 had to be monitored for being combative or anything else. CNA F said she was not told specifically to watch Resident #1 around female residents, just to watch him around residents. During an interview on 4/18/19 at 6:20 p.m., Resident #1 was lying in bed. Resident #1 said he did not recall how long he had been at the facility. He said he had never tried to get to know any of the women at the facility and had never touched any of the female residents at the facility. 2. Physician orders [REDACTED].#2, admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 3/27/19, indicated Resident #2 had minimal difficulty hearing and was sometimes understood/understands others. Staff assessment of Resident #2 's mental status indicated severe cognitive impairment. The assessment indicated Resident #2 was totally dependent on staff for transfers, locomotion, eating, and toileting. A care plan dated 3/28/19 indicated focus areas for Resident #2 included behavioral symptoms, anxiety, and assistance with ADLs. A witness statement dated 3/26/19 by CNA Q indicated as she was walking down the hall she heard Resident #2 yell Stop!. CNA Q saw Resident #1 with his hand on Resident #2's private area. CNA Q separated the residents and reported the incident to RN M. An incident report dated 3/26/19 by RN M indicated Resident #2 was groped by another resident against her will. The report indicated another resident had touched Resident #2's inner thigh. The incident report indicated Resident #1 was placed on 1:1 monitoring until he could be transported to the behavioral hospital. The incident report indicated Resident #1 repeatedly asked the staff monitoring him to go to bed with him, and when she told him she was pregnant he said, [***] that baby. During an interview on 4/19/19 at 2:27 p.m., RN M said she did not see Resident #1 touch a resident, but it was reported to her by the CNA Q who was working on the hall. RN M said CNA Q separated Resident #1 and Resident #2 when she observed Resident #1 touching Resident #2 inappropriately. RN M said she notified the administrator, the DON, and the ADON of the incident. During an interview on 4/18/19 at 11:26 a.m., the DON said Resident #1 touched Resident #2 in the past and was transferred to the behavioral hospital. The DON said staff witnessed Resident #1 place his hand on Resident #2's thigh. The DON said this incident was not reported to the state. 3. Physician orders [REDACTED].#3 admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 2/3/19, indicated Resident #3 was cognitively intact and required supervision and set-up help with eating and locomotion, extensive assistance of one staff for dressing, toileting, and personal hygiene, and was totally dependent for transfers. A care plan dated 3/6/19 indicated focus areas for Resident #3 included left sided [MEDICAL CONDITION] and weakness related to [MEDICAL CONDITION], risk of pressure ulcers, and assistance with ADLs. During an interview on 4/18/19 at 11:47 a.m., Resident #3 said Resident #1 touched her breast last Friday morning (4/12/19). Resident #3 said she told one of the nurses (unnamed) on the evening shift. Resident #3 said Resident #1 had been popping staff on the rear end. During an interview on 4/18/19 at 1:45 p.m., DA D said on the morning of 4/13/19 Resident #3 was coming into the dining room and Resident #1 reached out and grabbed her breast. DA D said she told Resident #1 it was inappropriate, and he could not do that. DA D said she reported the incident to LVN S. DA D said Resident #1 tried to grab Resident #4's breast as she was coming into the dining room on her scooter that same morning. She said Resident #1 said to Resident #4 come here and let me see one of those big titties. DA D said Resident #1 always wanted to touch and see. She said she reported the events to her supervisor but did not know if the incidents were brought up at the morning meeting. During an interview on 4/18/19 at 9:50 a.m., the Ombudsman said Resident #3 told her Resident #1 had touched her in her chest area. The Ombudsman said when she spoke to the administrator and the DON about it, they said Resident #3 reported to them Resident #1 had attempted to touch her breasts but was unsuccessful. During an interview on 4/18/19 at 2:41 p.m., CNA B said Resident #3 told her Resident #1 had rubbed her breasts when she was trying to get some coffee this past weekend CNA B said she knew Resident #1 had just returned from the behavioral hospital for inappropriately touching Resident #2. CNA B said she reported Resident #3's allegations to LVN G who told her she had already documented the incident. During an interview on 4/18/19 at 6:57 p.m., CNA E said Resident #3 told her Resident #1 had touched her breast and Resident #3 had already reported it. During an interview on 4/18/19 at 11:26 a.m. and 2:53 p.m., the DON said Resident #3 was cognitively intact and was the Vice President of the Resident Council. The DON said she received a call from LVN G on 4/14/19 informing her Resident #3 said Resident #1 had grabbed her breast the day before. The DON said no one called the administrator. The DON said she told LVN G to monitor Resident #3 for emotional distress and make sure Resident #1 and Resident #3 were separated. The DON said when she and the administrator followed up on the allegation on 4/15/19, Resident #3 said Resident #1 grabbed at her breasts but did not actually touch her. The DON said Resident #1 was in a wheelchair, so he could not make a female do something. The DON said Resident #3 kept asking when they were going to send Resident #1 back to the behavioral health hospital or get him out of the facility. The DON said other than seeking alternate placement Resident #1 was being monitored for behaviors, and it is documented every shift. The DON said this incident was not abuse because of Resident #1's low cognition, and it was not reported to the state agency. 4. Physician orders [REDACTED].#4, admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most current MDS assessment, dated 3/7/19, indicated Resident #4 was cognitively intact. The assessment indicated Resident #4 required supervision and set-up help only with all activities of daily living, used a wheelchair for mobility and was always continent of bowel and bladder. A care plan dated 3/19/19 indicated Resident #4 had focus areas which included fall precautions, use of a [MEDICAL CONDITION] machine at night, and oxygen therapy. A grievance report dated 2/16/19 initiated by Resident #4 indicated Resident #1 told Resident #4 I like your pants. I would like them better on my floor with you in my bed. The grievance report stated Resident #1 displayed similar behaviors toward other residents that were witnessed by staff. Based on those witnessed behaviors it is likely that this also occurred. The grievance report indicated Resident #1 was referred to and accepted to a behavioral health hospital. The report was signed by the administrator and dated 2/18/19. During an interview on 4/18/19 at 11:47 a.m., Resident #4 said on an unnamed date she was in the dining room and Resident #1 started using racial slurs. Resident #4 said she told Resident #1 to hush, and Resident #1 said to her do those big titties keep you warm? Resident #4 said she told Resident #1 to never say that again. Resident #4 said an unnamed kitchen staff saw the incident and told someone (unnamed). Resident #4 said Resident #1 said the same thing to her on 4/16/19. Resident #4 said she reported the incident to the ADON and to LVN K at separate times and they told her they were working on it. During an interview on 4/19/19 at 11:15 a.m., DA H said Resident #4 told her Resident #1 touched her in the hall. During an interview on 4/19/19 at 11:30 a.m., LVN K said she never saw Resident #1 touch another resident, but she heard in report last weekend he pinched Resident #4 on the breast. She said it was reported the DON and administrator had been notified. During an interview on 4/19/19 at 1:17 p.m., CNA L said Resident #3 and Resident #4 told him Resident #1 had grabbed their titties. CNA L said Resident #3 and Resident #4 were really upset. He said Resident #1 mostly messed with residents that were more active. CNA L said Resident #3 and Resident #4 told him about Resident #1 touching them a couple of times. CNA L said he always told the nurses (unnamed) about the allegations, but they would say they were already aware of it. During an interview on 4/19/19 at 2:45 p.m., LVN O said Resident #4 complained about Resident #1 saying sexually inappropriate things. She said in (MONTH) 2019 Resident #1 went to the nursing stations and asked a banana. He peeled the banana and said, I used to be like this. LVN O said Resident #1 asked her to go to bed with him, and she told him that was inappropriate. Resident #1 told her he would eat her pussy all night if she would lay down with him. LVN O said Resident #1 popped one of the CNAs on the behind. 5. Physician orders [REDACTED].#5, admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most current MDS assessment dated [DATE], indicated Resident #5 was cognitively intact. The assessment indicated Resident #5 required limited assistance of one staff to transfer and extensive assistance of one staff for dressing, toileting, and personal hygiene. A care plan reviewed on 3/15/19 indicated Resident #5 had focus areas including assistance with ADLs, pressure injury, [MEDICAL CONDITION] care, preference to dress only in hospital gowns, and delusional thought content. During an interview on 4/18/19 at 1:45 p.m., DA D said Resident #1 would go to Resident #5's table in the dining room and say, let me see what you've got under your gown. Da D said Resident #1 told Resident #5 I'm going to find out what room you are in and come to your room. During an interview on 4/19/19 at 11:15 a.m., DA H said in (MONTH) 2019 she saw Resident #1 go up to Resident #5's table in the dining room and Resident #5 told Resident #1 to go away. DA H said Resident #1 said to Resident #5 let me see what's between your legs and he started touching her between her legs under her gown. DA H said Resident #5 immediately left the dining room and has not been back to the dining room since. DA H said she told her supervisor about the incident. During an interview on 4/19/19 at 11:20 a.m., the dietary manager said DA D told her Resident #1 touched Resident #4 and DA D reported it to the nurse (unnamed). The dietary manager said an unnamed staff told her Resident #1 had touched Resident #5 in the dining room, but she could not remember who told her. The dietary manager said she had not reported abuse or neglect regarding Resident #1. She said she heard things second or third hand but had never witnessed abuse. The dietary manager said Resident #1 was always appropriate when she interacted with him. During an interview on 4/18/19 at 6:50 p.m., Resident #5 said Resident #1 had been rude and inappropriate but had never touched her. Resident #5 said if Resident #1 touched her she would call her brother who was an attorney. During an interview on 4/22/19 at 2:40 p.m., the Ombudsman indicated she came to the facility on [DATE] after receiving a call from who regarding Resident #1's behavior. She said Resident #1 told Resident #5 he was going to come to her room and have his way with her. The Ombudsman said Resident #1 touched a nurse between the legs. She said Resident #1 was sent to a behavioral health facility. The facility administrator, the facility DON, and the Regional Director of Clinical Services were notified on 4/18/19 at 4:56 p.m., an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal was accepted on 4/18/19 at 7:40 p.m. and included the following: Alternate placement would be located for Resident #1. The facility will recognize potentially abusive situations and thoroughly investigate and report all allegations of abuse and/or neglect. The plan indicated upon notification of allegation that resident inappropriately touched another resident, offending resident was placed on 1-1 monitoring with a facility staff member to remain within an arm's reach, while investigation initiated. Documentation of 1-1 monitoring kept at 15-minute intervals 24/7 until alternate placement is found for resident. The plan indicated the administrator, DON and facility staff was responsible for reviewing monitoring sheets daily and perform visual observation daily and document on monitoring sheet. Facility staff education initiated by DON with all staff on duty on 1-1 monitoring and how to document, remaining staff will be educated by administrator or DON prior to performing 1-1 monitoring. The surveyor confirmed the implementation of the plan of removal by the following: During an interview on 4/19/19 at 10:45 a.m., the DON said Resident #1 was transferred to a behavioral health hospital this morning at 2:00 a.m. and the behavioral hospital understood the facility would not accept him back. All licensed staff and CNAs on the 6a-2p shift (2 LVNS/2 CNAs) and the 2p-10p shift (2 LVNS/2 CNAs) were interviewed and correctly identified what constitutes abuse, how to report abuse, and to whom to report abuse. They indicated they had been in-serviced on monitoring residents who touched a resident inappropriately. On 4/19/19 at 3:20 p.m., the administrator was notified the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as a pattern.