Every finding on record at Downtown Health and Rehabilitation Center

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys 1 of 7 residents (Residents #1) reviewed for hazards. The facility failed to ensure Resident #1 did not have a bottle of Core Strength pills in his room on 06/16/26. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings include: Record review of Resident #1's Face Sheet, dated 06/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnosis that include Bilateral Primary Osteoarthritis of Knee (It happens when the slippery cartilage that cushions the ends of your bones gradually breaks down) Record review of Resident #1's MDS Assessment, dated 04/21/26, revealed BIMS score of 15 indicated thinking and memory are perfectly intact. The MDS assessment revealed the Resident was coded for Bilateral Primary Osteoarthritis of Knee, and chronic pain. Record Review of Resident #1's care plan dated 06/06/26, revealed focus area of care for Adverse medication effect and behaviorMonitoring, with interventions to: Continually monitor for behaviors and medication adverse effects and notify the MDor NP as required. In addition, note any behaviors and adverse effects on the Weekly Summary, Monitoring and accurate documentation of the resident's response to any treatment (such as, lab results, vital signs, progress notes, behavior flow sheets, medication administration records and the consultant pharmacist's drug regimen review) is essential to evaluate the ongoing effectiveness, benefits as well as risks of nonpharmacological approaches and medications. Record Review of Resident #1's Active physician's orders on 06/16/26 at 9:35 a.m. did not reveal an order for Core Strength Vitamins. Record Review of Resident #1's self-medication program assessment of skills dated 01/23/26 revealed Resident #1 was unable to demonstrate knowledge of dose/frequency of medication without assistance, it revealed that Resident #1 was unable to verbalize knowledge of common side effects of his medication. During an observation and interview on 06/16/26 at 9:35 a.m., Core Strength supplement bottle was observed on Resident # 1's bedside table. When asked if the nurses knew he had it, he stated that his family brings in the medications for him to use for pain and inflammation of his knees. He stated that the nurses were aware that he takes the supplements daily because they were on his bedside table. During an interview on 06/16/26 at 9:55 a.m. with RN P, she stated that the facility policy was that no medication was allowed in the resident's room unsupervised. She stated that all the medications the resident takes should be monitored by the nurse for any side effects. She stated that if the resident prefers a certain medication, they call the doctor for approval and obtain an order to be administered by the nurse. She stated that the nurse needs to know what medications the resident was taking so they can monitor side effects and safety. She stated that on admission the residents and family were educated about not bringing outside medications and to let the nurse know if they prefer any brand so it can be approved by the doctor. She stated that the nurse was responsible for making sure the resident does not have medication in their possession, and that if found by any other staff to report to the charge nurse. She stated she also removes the medication and educates the residents on the dangers of taking non prescribed medications and she reports to the ADON or DON. She stated that the residents having non prescribed medications in their rooms could be life threatening if there is an adverse effect or interaction with prescribed medications. During an interview on 06/16/26 at 10:00 a.m. with CNA K, she stated that if she finds a medication in any residents' room, she reports it to the nurse She stated that residents were not supposed to have medications in their rooms. She stated that it could cause side effects and could be bad for the residents. During an interview on 06/16/26 at 12:44 p.m. with ADON M, she stated that the policy was for all residents to turn in medication to the nurse to obtain an order from the doctor, complete an assessment if they want to keep it at bedside, before they can self-administer. She stated they do an inventory list during admission, and we get any medications they have and send back with family, and we educate the family to make sure to bring any medication to the nurse to obtain an order before it can be given to the resident.She stated that an assessment was completed for self-administering medication and completed 01/23/26, but it did not clear the resident to self-administer. She stated the resident could overdose if they don't know the directions and amount of medication they need to take and the danger exists that another resident could get a hold of it and take it. The admitting nurses and the charge nurses and the ambassadors that check the room were all responsible for making sure the residents do not have medication in their rooms. She stated that she will Inservice the staff on residents having medication their rooms Record review of the facility's PCU020 - Self-Administration of Medications by Residents Policy revealed: and/or facility policy allows or has determined that the practice would be safe for the resident and other residents ofthe facility.Procedure1. Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facilities interdisciplinary team.2. If the resident desires to self-administer medications an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility.3. The interdisciplinary team determines the residents' ability to self-administer medications by means of completing the Self Administration of Medication assessment in PCC.4. The results of the interdisciplinary team assessment are recorded5. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur:a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is ineffective. Adhere to the State Health Departments Rules on this matterb. The medications provided to the resident for bedside storage are kept in the containers dispensed bythe supplying pharmacy. Adhere to the individual State Health Departments rules as it relates to documentation for a resident that self-administers medications6. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage, and then give unauthorized medications to the charge nurse for return to the family or responsible party.7. Medications stored at the bedside are reordered in the same manner as other medications. The nursing staff is responsible for proper rotation of bedside stock and removal of expired medications.8. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication cart or medication room. The resident requests each dose from the medication nurse, who provides the medication to the resident in the unopened package for the resident to self-administer. The nurse then records such self-administration on the MAR in the manner described above.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 (Resident #2) reviewed for infection control. The facility failed to ensure that CNA C had on PPE when providing high contact care for Resident #1. This failure could place the residents at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Record review of Resident #2's Face Sheet, dated 06/16/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with diagnosis that include Gastrostomy status (Feeding Tube: a person has a surgically created, small opening in their belly that leads directly into their stomach and Senile degeneration of Brain (he gradual, permanent death of brain cells as a person ages, leading to cognitive decline) Record review of Resident #2's MDS Assessment, dated 03/27/26, revealed no BIMS score. The MDS assessment revealed the Resident was coded for feeding tube. Record Review of Resident #2's care plan dated 06/09/26, revealed focus area of care for enhanced barrierPrecautions with goal of : There will not be any transmission of infection from or to the resident; with intervention of: Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or otherhigh-contact activity and Posting at the resident's room entrance indicating the resident is on enhanced barrier precautions. During an observation on 06/16/26 at 1:19 p.m. CNA C was observed providing Incontinence care for Resident #2 who had an EBP signage on her room door. CNA C did not have a gown on. During an interview on 06/16/26 at 1:23 p.m. with CNA C, she stated that the facility policy for residents on EBP was that she must wear appropriate PPE when providing care including gloves, gown and mask if needed. She stated that not having appropriate PPE will spread germs and infection to other residents. She stated that the spread of germs will cause a good number of residents to get sick. During an interview on 06/16/26 at 1:28 p.m. with RN J, she stated that the facility policy was to wear masks, gowns, gloves when providing high care to residents on EBP. She stated that everyone was responsible for making sure the EBP procedure was always followed. She stated that if the procedure was not followed by all staff, it can cause infection for the residents and spread infection to other residents if the staff don't have the proper PPE on. She stated that this could make the other residents sick. During an interview on 06/16/26 at 1:46 p.m. with ADON M, she stated all staff should wear a gown and have proper PPE when providing direct care per facility policy on EBP. She stated that all staff that provide direct care were responsible for making sure that they were following the policy for residents on EBP by having an appropriate PPE which was placed by the room entrance.She stated that the need for proper PPE was for infection control. She stated that not wearing appropriate PPE was breaking the infection control barrier and can spread infection to other residents. She stated it prevents the spread of infection. She stated they provide services and education to staff on infection control and the need to have proper PPE on. Record review of the facility's undated Enhanced Barrier Precautions policy revealed: Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed toreduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning ofgown and gloves during high-contact resident care activities that provide opportunities fortransfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient.EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, andtracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff prior to entry to their room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. For example, staff entering the resident's room to answer a call light, converse with a resident, or provide medications who do not engage in a high-contact resident care activity would likely not need to employ EBP while interacting with the resident. Communication to StaffThe facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP. The policy revealed that when changing briefs or assisting with toileting, gloves and gown should be worn.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three of seven residents (Resident #1, Resident #2 and Resident#3) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2 was free from abuse by Resident #1. The facility failed to ensure Resident #3 was free from verbal abuse by LVN B. This failure could place residents at risk for abuse or neglect that could lead to serious harm.Findings included: Record review of Resident #1's face sheet, dated 05/06/26, reflected a [AGE] year-old male admitted [DATE]. Resident #1 had diagnoses which included: dementia (decline in mental ability), chronic obstructive pulmonary disease (a progressive, irreversible lung disease that restricts airflow and makes breathing difficult), protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), paranoid schizophrenia (a complex brain disorder marked by psychosis (losing touch with reality) through intense paranoia, delusions (false, fixed beliefs like being watched or targeted), and auditory hallucinations (hearing voices)), muscle weakness, difficulty walking, lack of coordination, reduced mobility, cognitive communication deficit (an impairment in communication caused by underlying disruptions in cognitive processes-such as attention, memory, and executive function rather than primary speech or language deficits), anemia (a condition where your body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to your tissues), depression (a common, serious medical illness causing persistent sadness, loss of interest, and physical symptoms that interfere with daily life), mood affective disorder (a mental health condition that primarily impacts your overall emotional state, causing long-term periods of extreme sadness, excessive elation, or both), insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early, often leading to daytime fatigue, irritability, and poor concentration), hypertension (a chronic condition where the force of blood against your artery walls is consistently too high), old myocardial infarction (scar tissue formation in the heart muscle following an injury that occurred more than four weeks ago, or one that was previously undetected), paroxysmal atrial fibrillation (a type of irregular, chaotic heart rhythm where episodes start suddenly and stop on their own within seven days), congestive heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently) and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should). Record review of Resident #1's Quarterly MDS assessment, dated 04/29/26, reflected a BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 was independent with eating and needed setup or clean-up assistance with toileting and supervision with walking 10 feet. The MDS assessment further revealed that Resident #1 used a walker. The MDS assessment under Section E-Behavior, reflected Resident #1 did not exhibit any physical, verbal or other behavior symptoms directed towards others. Record review of Resident #1's care plan, revised 01/29/26, reflected Resident #1 had potential for a mood problem. Interventions included: administering medications as ordered, assisting resident in developing/providing the resident with a program of activities that was meaningful and of interest, encouraging and providing opportunities for exercise, physical activity, assisting the resident to identify strengths, positive coping skills and reinforce these, monitoring/recording/reporting to MD PRN risk for harm to self. Resident #1 care plan also revealed he had impaired cognitive function/dementia. Interventions included: administering meds as ordered, communicating with the resident/family/caregivers regarding resident's capabilities and needs and using the resident's preferred name, identifying at each interaction, facing the resident when speaking and making eye contact, reducing any distractions, providing resident with necessary cues-stop and return if agitated, discussing concerns about confusion, disease process, engagingin the resident in simple, structured activities that avoid overly demanding tasks, keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion, monitoring/documenting/reporting to MD any changes in cognitive function, providing a program of activities that accommodate the resident's abilities, providing resident with a homelike environment, reviewing medications and recording possible causes of cognitive deficit. Resident #1 had potential for a mood problem. Interventions included: administering medications as order and monitoring/documenting side effects and effectiveness, assisting the resident in developing/providing the resident with a program of activities that are meaningful and of interest, encouraging and providing opportunities for exercise and physical activity. Assisting the resident to identify strengths, positive coping skills and reinforce them. Monitoring/recording/reporting to MD prn risk for harm to self. Monitoring/recording/reporting to MD prn risk for harming others. Resident #1's care plan also revealed he had a potential for maladaptive behaviors. Interventions included: administering medications as ordered and monitor/document side effects and effectiveness. Anticipating and meeting the residents' needs. Explaining all procedures to the resident before starting and allowing to adjust to changes. Intervening as necessary to protect the rights and safety of others. Approaching and speaking in a calm manner, divert attention, remove from situation and take alternate location as needed. Praise any indication of the resident's progress/improvement in behavior. Record review of Resident #1's progress note, dated 04/22/26 at 4:09 PM written by LVN E, reflected the following: Resident #1 during the end of supervised smoking. Resident #1 stood in front of the of the doorway with both open arms flexed in across position. [Resident #1] [refused] to allow anyone to pass inside the building. Another resident was passing by. The staff redirected resident and deescalated the agitation, which resulted in [Resident #1] striking [Resident #2] in the face, neither residents sustained physical injuries. [Resident #1] was placed on a 1:1 monitoring. NP notified with [family member]. ADON, DON, Abuse coordinator notified. [Resident #2] denied any pain or physical distress in ambulation. Refused to allow vital signs. Safety measures in place. Record review of Resident #2's face sheet, dated 05/06/26, reflected a [AGE] year-old male admitted [DATE]. Resident #2 had diagnoses that included: alcohol dependence with alcohol-induced persisting dementia (chronic alcohol use that cause significant, permanent cognitive decline in multiple domains (memory, reasoning, language) that persists after stopping alcohol consumption), protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), dysphagia (difficulty or discomfort when swallowing), dementia (decline in mental ability), major depressive disorder (a serious mental health condition characterized by persistent, pervasive low mood, loss of interest in activities (anhedonia), and low energy for at least two weeks), difficulty walking, lack of coordination, reduced mobility, history of falling, muscle weakness, unsteadiness on feet, cognitive communication deficit (an impairment in communication caused by underlying disruptions in cognitive processes-such as attention, memory, and executive function rather than primary speech or language deficits), anemia (a condition where your body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to your tissues), hyperlipidemia (high levels of fats), psychotic disorder (a group of severe mental illnesses that disrupt a person's thoughts and perceptions, causing them to lose touch with reality), anxiety disorder (persistent, excessive fear or worry that interferes with daily life, lasting for months rather than being temporary), insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early, often leading to daytime fatigue, irritability, and poor concentration), hypertension (a chronic condition where the force of blood against your artery walls is consistently too high), and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should). Record review of Resident #2's Quarterly MDS assessment, dated 03/12/26, reflected a BIMS score of 03, which indicated severe cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #2 was independent with eating and needed supervision with toileting, setup assistance when walking 10 feet. The MDS assessment revealed Resident #2 did not use any devices to walk. The MDS assessment under Section E-Behavior, reflected Resident #2 did not exhibit any physical, verbal or other behavior symptoms directed towards others. Record review of Resident #2's care plan, revised 10/24/24, reflected Resident #2 had potential to demonstrate maladaptive behaviors. Interventions included: analyzing of key times, places, circumstances, triggers, and what de-escalates behavior and document, assessing and addressing for contributing sensory deficits, providing provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, giving the resident as many choices as possible about care and activities and if the resident had physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. Record review of Resident #2's progress note, dated 04/22/26 at 4:30 PM written by LVN E, reflected the following: [Resident #2] during a staff supervised smoke break was involved in an altercation with [Resident #1] in which he sustained a slap on the face by the [Resident #1]. Residents were separated [and] safety measures were provided. According to the staff present [Resident #2] was not the aggressor. [Resident #2's] over all demeaner [was] calm, quiet. Skin check was conducted, no visible injuries, no pain or swelling. [Resident #2] denied any discomfort. Contacted the abuse coordinator, ADON, DON and family member. NP was contacted no new orders. Record review of Resident #3's face sheet, dated 05/06/26, reflected a [AGE] year-old male admitted [DATE]. Resident #3 had diagnoses including: heart failure (heart muscle does not pump blood as effectively as it should), personal history of transient ischemic attack and cerebral infarction (indicate a significantly elevated risk for future, more severe strokes, often referred to as a warning stroke), protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), vascular dementia with mood disturbance (rapid shifts between depression, anxiety, irritability, and apathy, often resulting from brain damage), major depressive disorder (a serious, common mental health condition characterized by persistent, severe sadness, loss of interest (anhedonia), and low energy, lasting at least two weeks), lack of coordination, cognitive communication deficit (an impairment in communication caused by underlying disruptions in cognitive processes-such as attention, memory, and executive function rather than primary speech or language deficits), muscle weakness, unsteadiness on feet, need for assistance with personal care, alcohol abuse, anxiety disorder (persistent, excessive fear or worry that interferes with daily life, lasting for months rather than being temporary), hypertension ( a common condition where the force of blood against the artery walls is consistently too high), atherosclerotic heart disease (when fatty deposits called plaque buildup inside the arteries supplying blood to your heart), old myocardial infarction (scar tissue formation in the heart muscle following an injury that occurred more than four weeks ago, or one that was previously undetected)and gastro-esophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into your esophagus). Record review of Resident #3's Quarterly MDS assessment, dated 04/10/26, reflected a BIMS score of 07, which indicated significant cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 was independent with eating and toileting. Resident #3 was able to ambulate independently without any assistive devices. The MDS assessment under Section E-Behavior, reflected Resident #3 did not exhibit any physical, verbal or other behavior symptoms directed towards others. Record review of Resident #3's care plan, revised 04/17/25, reflected Resident #3 had potential or uncontrolled pain. Interventions included: administrating analgesia (medication that acts to relieve pain) as per orders, giving 1/2 hour before treatments or care, anticipating the resident's need for pain relief and respond immediately to any complaint of pain, evaluating the effectiveness of pain interventions, reviewing for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact onfunctional ability and impact on cognition. Record review of Resident #3's physician order summary report, dated 05/07/26, reflected in part:Oxycodone-Acetaminophen Oral Tablet 7.5-325 MG (Oxycodone w/Acetaminophen)- Give 1 tablet by mouth every 6 hours as needed for Pain for 30 Days x 14 days. Hold for sedation. Start Date: 05/02/26 and End Date: 06/01/26. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 1:30 AM, reflected the following: [Resident #3] requested a pain pill and was informed that it is to early he stated, FUCK YOU and returned to his room. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 3:00 AM, reflected the following: Pain med. taken to room for resident and [Resident #3] would not accept so med. was wasted/with [LVN D]. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 3:29 AM, reflected the following: Resident #3 ambulated to desk and asked for pain pill. [Resident #3] was informed that the med had been taken to his room, but [LVN B]would give it to him now and he stated, FUCK [YOU] and turned and went to room. During an interview and observation on 05/06/26 at 11:25 AM, Resident #1 stated Resident #2 slapped him in the face first, and he hit him back. Resident #1 stated he was going outside to smoke when it happened. Resident #1 also stated Resident #2 fell when he slapped him. Resident #1 stated Resident #2 always gave him mean faces and asked what he was looking at. Resident #1 stated he believed a short staff lady was outside and separated them. Resident #1 stated staff told him he should not have slapped Resident #2. Resident #1 did not sustain any injuries. Resident #1 did not have any visible marks or bruises. During an interview and observation on 05/06/26 at 11:37 AM, Resident #2 stated he did not know Resident #1. Resident #2 stated maybe Resident #1 hit him but did not remember. Resident #2 stated he avoided fighting. Resident #2 stated if someone hit him, he would report it to the nurse. Resident #2 did not sustain any injuries. Resident #2 did not have any visible marks or bruises. During an interview on 05/06/26 at 2:23 PM, CNA A stated he worked on the memory care unit and witnessed an incident involving Resident #1 and Resident #2. CNA A stated Resident #2 had finished smoking and was going back inside while Resident #1 was going outside at the same time. CNA A stated in the middle of passing each other, Resident #1 got in Resident #2's face. CNA A stated Resident #1 told Resident #2, You have my hat. CNA A stated Resident #2 was about to say something, but Resident #1 yelled in his face saying, your momma, then proceeded and smacked Resident #2 in the face sending him to the ground. CNA A stated he caught Resident #2 head before it hit the ground. CNA A stated he separated the residents and ensured Resident #2 was safe. CNA A stated he then called for help. CNA A stated Resident #2 was assessed, and he did not sustain any injuries. During an interview on 05/07/26 at 1:35 PM, LVN B stated she worked 200 hall on 10:00 p.m. - 6:00 a.m. shift on 05/02/26. LVN B stated she worked with Resident #3. LVN B stated she was responsible for Resident #3's PRN medications. LVN B also stated she did not remember Resident #3 medications but believed he took Oxycodone for pain. LVN B stated on 05/03/26, Resident #3 requested his pain medication, and she gave him one Oxycodone pill. LVN B stated Resident # 3 returned early to get another pill. She stated it had not been six hours after his last administered pain pill. LVN B said she told him to try repositioning himself while lying down or propping his leg up to see if it would alleviate the pain until she could administer his next dose. LVN B stated she informed Resident #3 that she would bring him his pill as soon as it was time. LVN B stated Resident #3 responded to her saying, Fuck you, then returned to his room or walked around in the halls. LVN B stated LVN D was standing at the nurses' station and witnessed when he said it. LVN B stated LVN D told her that she never heard Resident #3 speak that way. LVN B stated approximately 30 minutes before his sixth hour to receive the next pain pill, she went to Resident #3's room and told him she had his pill, but he ignored her. LVN B stated she left his room with the medication and told LVN D that he ignored her. LVN B stated LVN D told her he would probably be back in 15-20 minutes asking for it again. LVN B stated she put the pill in a cup, covered, labeled and put the pill in the narcotics box. LVN B stated LVN D witnessed her do it. LVN B stated Resident #3 returned to the nurse's station asking for his pain pill. LVN B told Resident #3 she had previously gone into his room, and he did not respond. LVN B stated in response Resident #3 told her, Fuck You and walked away. She stated at that time a CNA was going into the restroom and heard it. LVN B stated the CNA stated he did that sometimes. LVN B stated she then disposed of the pill with LVN D as a witness. LVN B stated it was the last time Resident #3 had spoken to her. She stated she did not administer the medication, and he did not get it. LVN B denied ever saying, Fuck you to Resident #3. She stated she did not say anything disrespectful to Resident #3 when he cussed at her. LVN B revealed she had never had any issues with Resident #3 prior to the incident. During an interview on 05/07/26 at 2:11 PM, CNA C stated she worked 10:00 p.m. - 6:00 a.m. shift on 05/02/26. CNA C stated she worked on hall 200 and sat out in the hall during her shift to respond to any resident that needed assistance. CNA C stated she saw Resident #3 walking the hall and assumed he had come from the dining room. CNA C stated she witnessed Resident #3 go to the nurse's station and he asked LVN B for his medication. CNA C stated she heard LVN B tell Resident #3, Now you want to talk to me in the correct way. CNA C stated Resident #3 yelled out, Fuck you! and LVN B said, Fuck you too, I'm not giving you anything! CNA C stated Resident #3's face became red and he put his hand up as if he was frustrated then walked towards his room. CNA C stated it was around 3:30 a.m. when the incident occurred. CNA C stated she reported the incident to LVN D after she returned from her break. LVN D told CNA C that she needed to report the incident to the DON or the Administrator. CNA C stated she called the DON and reported the incident at the end of the shift. CNA C stated the DON told her to write a statement and it put under her door. During an interview on 05/07/26 at 3:55 PM, LVN D stated she worked 10:00 p.m. - 6:00 a.m. on 05/02/26. LVN D stated around 1:00 a.m. she was sitting at the nurse's station with LVN B when Resident #3 asked for his pain medication. LVN D stated LVN B told the resident it was not time, and he could get it at 3:00 a.m. LVN D stated, as she was headed to lunch, she asked Resident #3 if he had taken his pain medication. LVN D stated Resident #3 told her that he did not. LVN D told him he could go to the nurse's station to ask for it because it was after 3:00 a.m LVN D stated Resident #3 thanked her and told her, Okay. LVN D stated when she returned, LVN B asked if she could waste the medication with her. LVN D asked LVN B whose and what medication was it. LVN D stated LVN B told her it was Resident #3's medication. LVN D then stated, He did not come get his pill. I told him to come get his pill from you. LVN B told LVN D when she went to his room to give it to him, he did not acknowledge her. LVN D also stated LVN B told her Resident #3 said, Fuck you. LVN D told LVN B that she heard it earlier, but LVN B told her he said it again. LVN D stated she asked LVN B where the medication was because she would administer it to him. LVN D stated LVN B informed her she was going to waste it because he told her, Fuck you. LVN D stated LVN B told her she also needed to waste it because she had already charted that it was wasted, although she waited to waste it after LVN D got back from her lunch. LVN D stated she asked LVN B if the resident was in pain, why would she waste the medication. LVN D stated LVN B proceeded to dispose of the medication. LVN D stated LVN B put the medication in a plastic pocket which was used to crush pills and threw it in the sharp's container. LVN D stated it did not make sense for LVN B to waste the medication if the resident was in pain since 1:00 a.m. LVN D stated she thought to herself, LVN B would rather waste the medication than administer to Resident #3. LVN D stated as she walked down the hall, CNA C told her about an incident between Resident #3 and LVN B while LVN D was on lunch. LVN D stated CNA C told her while she was sitting on the hall, Resident #3 went to the nurse's station and asked for his pain medication. LVN D stated CNA C stated she did not hear exactly what LVN B initially said to the resident, but she heard Resident #3 say, Fuck you. and LVN B told Resident #3, Fuck you too. LVN D stated she told CNA C to call the Administrator because it was abuse. LVN D stated CNA C told her later that morning she had reported the incident to the Administrator. LVN D stated later that day the Administrator reached out to her via text. LVN D stated the Administrator's text asked if she saw or heard any staff being inappropriate with a resident. LVN D stated she informed the Administrator that Resident #3 tried to get his pain medication and LVN B did not give it to him when it was time. LVN D stated she informed the Administrator of LVN B wasting the medication instead of administering the medication. LVN D stated the risk of not administering the medication was the resident's pain would be unrelieved. During an interview and observation on 05/07/26 at 3:16 PM, Resident #3 stated he was asleep when LVN B came into his room. Resident #3 stated he was not sure what she wanted. Resident #3 stated he was unsure of the time, but when he woke, he went to the nurse's station for his pain medication. Resident #3 also stated when he asked for it, he did not remember exactly what LVN B said but it had to be disrespectful because he got upset. Resident #3 stated it was all uncalled for but one of those things that happened. Resident #3 stated he had not received his medication from LVN B. Resident #3 stated he was in pain and went back into his room. Resident #3 did not sustain any injuries. Resident #3 was observed with no visible marks or bruises. Record review if the facility's policy titled, Abuse/Neglect, no date, reflected in part the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions:Physical Abuse: Includes, hitting, slapping, punching and kicking. It also includes controlling behavior through corporal punishment. Abuse as defined in 40 TAC 19.101(1). The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions:Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able tosee her family again, etc. Abuse as defined in 40 TAC 19.101(1).

Based on interviews and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for one of seven residents (Resident #3) reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report the incident of alleged verbal abuse on 05/03/2025 for Resident #3. This failure could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm. Findings included: Record review of Resident #3's face sheet, dated 05/06/26, reflected a [AGE] year-old male admitted [DATE]. Resident #3 had diagnoses including: heart failure (heart muscle does not pump blood as effectively as it should), personal history of transient ischemic attack and cerebral infarction (indicate a significantly elevated risk for future, more severe strokes, often referred to as a warning stroke), protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), vascular dementia with mood disturbance (rapid shifts between depression, anxiety, irritability, and apathy, often resulting from brain damage), major depressive disorder (a serious, common mental health condition characterized by persistent, severe sadness, loss of interest (anhedonia), and low energy, lasting at least two weeks), lack of coordination, cognitive communication deficit (an impairment in communication caused by underlying disruptions in cognitive processes-such as attention, memory, and executive function rather than primary speech or language deficits), muscle weakness, unsteadiness on feet, need for assistance with personal care, alcohol abuse, anxiety disorder (persistent, excessive fear or worry that interferes with daily life, lasting for months rather than being temporary), hypertension ( a common condition where the force of blood against the artery walls is consistently too high), atherosclerotic heart disease (when fatty deposits called plaque buildup inside the arteries supplying blood to your heart), old myocardial infarction (scar tissue formation in the heart muscle following an injury that occurred more than four weeks ago, or one that was previously undetected)and gastro-esophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into your esophagus). Record review of Resident #3's Quarterly MDS assessment, dated 04/10/26, reflected a BIMS score of 07, which indicated significant cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 was independent with eating and toileting. Resident #3 was able to ambulate independently without any assistive devices. The MDS assessment under Section E-Behavior, reflected Resident #3 did not exhibit any physical, verbal or other behavior symptoms directed towards others. Record review of Resident #3's care plan, revised 04/17/25, reflected Resident #3 had potential or uncontrolled pain. Interventions included: administrating analgesia (medication that acts to relieve pain) as per orders, giving 1/2 hour before treatments or care, anticipating the resident's need for pain relief and respond immediately to any complaint of pain, evaluating the effectiveness of pain interventions, reviewing for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact onfunctional ability and impact on cognition. Record review of Resident #3's physician order summary report, dated 05/07/26, reflected in part:Oxycodone-Acetaminophen Oral Tablet 7.5-325 MG (Oxycodone w/Acetaminophen)- Give 1 tablet by mouth every 6 hours as needed for Pain for 30 Days x 14 days. Hold for sedation. Start Date: 05/02/26 and End Date: 06/01/26. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 1:30 AM, reflected the following: [Resident #3] requested a pain pill and was informed that it is to early he stated, FUCK YOU and returned to his room. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 3:00 AM, reflected the following: Pain med. taken to room for resident and [Resident #3] would not accept so med. was wasted/with [LVN D]. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 3:29 AM, reflected the following: Resident #3 ambulated to desk and asked for pain pill. [Resident #3] was informed that the med had been taken to his room, but [LVN B]would give it to him now and he stated, FUCK [YOU] and turned and went to room. In an interview on 05/07/26 at 1:35 PM, LVN B revealed she worked 200 hall on 10:00pm-6:00am shift on 05/02/26. LVN B revealed she worked with Resident #3. LVN B stated she was responsible for Resident #3's PRN medications. LVN B also stated she did not remember Resident #3 medications but believed he took Oxycodone for pain. LVN B stated on 05/03/26, Resident #3 requested his pain medication, and she gave him one Oxycodone pill. LVN B stated Resident # 3 returned early to get another pill. She stated it had not been six hours after his last administered pain pill. LVN B said she told him to try repositioning himself while lying down or propping his leg up to see if it would alleviate the pain until she could administer his next dose. LVN B stated she informed Resident #3 that she would bring him his pill as soon as it was time. LVN B stated Resident #3 responded to her saying, Fuck you, then returned to his room or walked around in the halls. LVN B stated when he said it, LVN D witnessed standing at the nurse's station. LVN B stated LVN D told her that she never heard Resident #3 speak that way. LVN B stated approximately 30 minutes before his sixth hour to receive, she went to Resident #3's room and told him she had his pill, but he ignored her. LVN B stated she left his room with the medication and told LVN D that he ignored her. LVN B stated LVN D told her he would probably be back in 15-20 minutes asking for it again. LVN B stated she put the pill in a cup, covered, labeled and put the pill in the narcotics box. LVN B stated LVN D witnessed her do it. LVN B stated Resident #3 returned to the nurse's station asking for his pain pill. LVN B told Resident #3 she had previously gone into his room, and he didn't respond. LVN B stated in response Resident #3 told her, Fuck You and walked away. She stated at that time a CNA was going into the restroom and heard it. LVN B stated the CNA stated he did that sometimes. LVN B stated she then disposed of the pill with LVN D as a witness. LVN B stated it the last Resident #3 had spoken to her. She stated she did not administer the medication, and he did not get it. LVN D denied ever saying, Fuck you to Resident #3. She stated she did not say anything disrespectful to Resident #3 cussing at her. LVN B revealed she had never had any issues with Resident #3 prior to the incident. In an interview on 05/07/26 at 2:11 PM, CNA C stated she worked 10:00pm-6:00am shift on 05/02/26. CNA stated she worked on hall 200 and sat out in the hall during her shift. CNA C she saw Resident #3 walking through the hall and assumed he had come from the dining room. CNA C stated she witnessed Resident #3 go to the nurse's station and asked LVN B for his medication. CNA C stated she heard LVN B tell Resident #3, now you want to talk to me in the correct way. CNA C stated Resident #3 yelled out Fuck you and LVN B said, Fuck you too, I'm not giving you anything! CNA C stated Resident #3 face became red and he put his hand up as if he was frustrated then walked towards his room. CNA C stated it was around 3:30am when the incident occurred. CNA C stated she reported the incident to LVN D after she returned from her break. LVN D told CNA C that she needed to report the incident to the DON or the Administrator. CNA C stated she called the DON and reported the incident. CNA C stated the DON told her to write a statement and it put under her door. In an interview on 05/07/26 at 3:55 PM, LVN D stated she worked 10:00pm-6:00am on 05/02/26. LVN D stated around 1:00am she was sitting at the nurse's station with LVN B when Resident #3 asked for his pain medication. LVN D stated LVN B told the resident it was not time, and he could get it at 3:00am. LVN D stated as she was headed to lunch, she asked Resident #3 if he had taken his pain medication. LVN D stated Resident #3 told her that he did not. LVN D told him he could go to the nurse's station to ask for it because it was after 3:00am. LVN D stated Resident #3 thanked her and told her Okay. LVN D stated when she returned, LVN B asked if she could waste the medication with her. LVN D asked LVN B who and what medication was it. LVN D stated LVN B told her it was Resident #3's medication. LVN D then stated, He did not come get his pill. I told him to come get his pill from you. LVN B told LVN D when she went to his room to give it to him, he did not acknowledge her. LVN D also stated LVN B told her Resident #3 said, Fuck you. LVN D told LVN B that she had heard it earlier, but LVN B told her he had said it again. LVN D stated she asked LVN B where the medication was because she would administer it to him. LVN D stated LVN B had informed her she was going to waste it because he told her, Fuck you. LVN D stated LVN B told her she also needed to waste it because she had already charted that it was wasted, although she waited to waste it after LVN D got back from her lunch. LVN D asked LVN B that the resident was in pain, so why would she waste the medication. LVN D stated LVN B proceeded to dispose of the medication. LVN D stated LVN B put the medication in a plastic pocket which was used to crush it and threw it in the sharp's container. LVN D stated it did not make sense for LVN B to waste the medication if the resident had been in pain since 1:00am. LVN D stated she thought to herself, LVN B rather waste the medication than administer to the resident. LVN D stated as she walked down the hall, CNA C told her about an incident between Resident #3 and LVN B while LVN D was on lunch. LVN D stated CNA C told her while sitting on the hall, Resident #3 went to the nurse's station and asked for his medication. LVN D stated CNA C stated she did not hear exactly what LVN B initially said to the resident, but she heard Resident #3 say, Fuck you. And LVN B told Resident #3 Fuck you too. LVN D stated she told CNA C to call the Administrator because it was abuse. LVN D stated CNA C told her later that morning she had reported the incident to the Administrator. LVN D stated later that day the Administrator reached out to her via text. LVN D stated the Administrator text asked if she had seen or heard any staff being inappropriate with a resident. LVN D stated she informed the Administrator that Resident #3 tried to get his pain medication and LVN B did not give it to him when it was time. LVN D stated she informed the Administrator of LVN B wasting the medication instead of administering the medication. LVN D stated the risk of not administering the medication was the resident's pain would be unrelieved. In an interview on 05/07/26 at 3:16 PM, Resident #3 stated he was asleep when LVN B came into his room. Resident #3 stated he was not sure what she wanted. Resident #3 stated he was unsure of the time, but when he woke, he went to the nurse's station for his pain medication. Resident #3 also stated when he asked for it, he did not remember exactly what LVN B told, but it had to be disrespectful because he got upset. Resident #3 stated it was all uncalled for but one of those things that happened. Resident # revealed he had not received his medication from LVN B. Resident #3 stated he was in pain and went back into his room. During an interview on 05/07/26 at 4:35 PM, the DON stated she worked on 05/03/26. The DON stated when she got to work there was a note from CNA C under her door. The DON stated the note stated Resident #3 told LVN B Fuck you a few times. The DON stated the note further stated that LVN B said, Fuck you back to Resident #3. The DON stated CNA C was down the hall when she heard the cussing between Resident #3 and LVN B. The DON stated she conducted the investigation of the alleged incident. The DON stated she asked Resident #3 if he had any issues with any nurses, issues with receiving his medication, or if anyone said anything that upset him. The DON stated Resident #3 told her no. The DON stated she also talked to other residents and asked if they heard any shouting, cussing or noise on 05/02/26. She stated no residents had heard anything. The DON stated she talked with another aide and she did not hear anything. The DON stated LVN B informed them that Resident #3 cussed at her, but LVN B denied cussing back at the resident. The DON stated she did not have any reason to suspect that it occurred. The DON revealed if she had gotten any other confirmation about the alleged incident, she would have reported it to HHSC. She stated according to policy, the alleged incident should have been reported to HHSC. The DON stated risk of not reporting the alleged incident could affect other residents. During interview on 05/07/26 at 5:02 PM, the Administrator stated she received a call from CNA C regarding the alleged incident. The Administrator stated CNA C told her Resident #3 went to the nurse's station and said, Fuck you to LVN B and LVN B responded saying, Fuck you. The Administrator stated CNA C stated she was down the hall when it occurred. The Administrator stated she asked LVN B what happened. She stated LVN B told her Resident #3 came to the nurse's station several times asking for his pain medications and told LVN B, fuck you. The Administrator asked LVN B for her response and she said she did not respond. The Administrator stated LVN B said she did not say anything inappropriate to Resident #3. The Administrator stated she asked another aide, but she did not witness the alleged incident. She stated she asked LVN D if she heard anything inappropriate and was told no. The Administrator stated she received a text response from LVN D with her statement. The Administrator stated that Resident #3 had been to the nurse's station several times requesting his pain medication, but the medication was wasted by LVN B. The Administrator informed that LVN D stated LVN B wasted Resident #3's medication because he told her Fuck you. The Administrator stated she knew the DON would be working on 05/03/26, so she had her investigate the alleged incident. The Administrator stated she was informed that no residents heard anything. The Administrator revealed LVN B was already off during their investigation, so she did not suspend her. The Administrator stated she did not know why she did not report the alleged incident but should have reported it to HHSC. She stated the facility's policy was to report the alleged incident. Record review if the facility's policy titled, Abuse/Neglect, no date, reflected in part the following: E. Reporting1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called.3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/24.a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationb. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for one of seven residents (Resident #3) reviewed for abuse and neglect. The facility did not investigate an incident in which Resident #3 was cussed by LVN B. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included: Record review of Resident #3's face sheet, dated 05/06/26, reflected a [AGE] year-old male admitted [DATE]. Resident #3 had diagnoses including: heart failure (heart muscle does not pump blood as effectively as it should), personal history of transient ischemic attack and cerebral infarction (indicate a significantly elevated risk for future, more severe strokes, often referred to as a warning stroke), protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), vascular dementia with mood disturbance (rapid shifts between depression, anxiety, irritability, and apathy, often resulting from brain damage), major depressive disorder (a serious, common mental health condition characterized by persistent, severe sadness, loss of interest (anhedonia), and low energy, lasting at least two weeks), lack of coordination, cognitive communication deficit (an impairment in communication caused by underlying disruptions in cognitive processes-such as attention, memory, and executive function rather than primary speech or language deficits), muscle weakness, unsteadiness on feet, need for assistance with personal care, alcohol abuse, anxiety disorder (persistent, excessive fear or worry that interferes with daily life, lasting for months rather than being temporary), hypertension ( a common condition where the force of blood against the artery walls is consistently too high), atherosclerotic heart disease (when fatty deposits called plaque buildup inside the arteries supplying blood to your heart), old myocardial infarction (scar tissue formation in the heart muscle following an injury that occurred more than four weeks ago, or one that was previously undetected)and gastro-esophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into your esophagus). Record review of Resident #3's Quarterly MDS assessment, dated 04/10/26, reflected a BIMS score of 07, which indicated significant cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 was independent with eating and toileting. Resident #3 was able to ambulate independently without any assistive devices. The MDS assessment under Section E-Behavior, reflected Resident #3 did not exhibit any physical, verbal or other behavior symptoms directed towards others. Record review of Resident #3's care plan, revised 04/17/25, reflected Resident #3 had potential or uncontrolled pain. Interventions included: administrating analgesia (medication that acts to relieve pain) as per orders, giving 1/2 hour before treatments or care, anticipating the resident's need for pain relief and respond immediately to any complaint of pain, evaluating the effectiveness of pain interventions, reviewing for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact onfunctional ability and impact on cognition. Record review of Resident #3's physician order summary report, dated 05/07/26, reflected in part:Oxycodone-Acetaminophen Oral Tablet 7.5-325 MG (Oxycodone w/Acetaminophen)- Give 1 tablet by mouth every 6 hours as needed for Pain for 30 Days x 14 days. Hold for sedation. Start Date: 05/02/26 and End Date: 06/01/26. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 1:30 AM, reflected the following: [Resident #3] requested a pain pill and was informed that it is to early he stated, FUCK YOU and returned to his room. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 3:00 AM, reflected the following: Pain med. taken to room for resident and [Resident #3] would not accept so med. was wasted/with [LVN D]. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 at 3:29 AM, reflected the following: Resident #3 ambulated to desk and asked for pain pill. [Resident #3] was informed that the med had been taken to his room, but [LVN B]would give it to him now and he stated, FUCK [YOU] and turned and went to room. Record review of Resident #3's order summary report, dated 05/07/26, reflected in part:Oxycodone-Acetaminophen Oral Tablet 7.5-325 MG (Oxycodone w/Acetaminophen)- Give 1 tablet by mouth every 6 hours as needed for Pain for 30 Days x 14 days. Hold for sedation. Start Date: 05/02/26 End Date: 06/01/26. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 AT 1:30 AM, reflected the following: [Resident #3] requested a pain pill and was informed that it is to early he stated, FUCK YOU and returned to his room. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 AT 3:00 AM, reflected the following: Pain med. taken to room for resident and [Resident #3] would not accept so med. was wasted/with [LVN D]. Record review of Resident #3's progress note written by LVN B, dated 05/03/26 AT 3:29 AM, reflected the following: Resident #3 ambulated to desk and asked for pain pill. [Resident #3] was informed that the med had been taken to his room but I would give it to him now and he stated, FUCK [YOU] and turned and went to room. In an interview on 05/07/26 at 1:35 PM, LVN B revealed she worked 200 hall on 10:00pm-6:00am shift on 05/02/26. LVN B revealed she worked with Resident #3. LVN B stated she was responsible for Resident #3's PRN medications. LVN B also stated she did not remember Resident #3 medications but believed he took Oxycodone for pain. LVN B stated on 05/03/26, Resident #3 requested his pain medication, and she gave him one Oxycodone pill. LVN B stated Resident # 3 returned early to get another pill. She stated it had not been six hours after his last administered pain pill. LVN B said she told him to try repositioning himself while lying down or propping his leg up to see if it would alleviate the pain until she could administer his next dose. LVN B stated she informed Resident #3 that she would bring him his pill as soon as it was time. LVN B stated Resident #3 responded to her saying, Fuck you, then returned to his room or walked around in the halls. LVN B stated when he said it, LVN D witnessed standing at the nurse's station. LVN B stated LVN D told her that she never heard Resident #3 speak that way. LVN B stated approximately 30 minutes before his sixth hour to receive, she went to Resident #3's room and told him she had his pill, but he ignored her. LVN B stated she left his room with the medication and told LVN D that he ignored her. LVN B stated LVN D told her he would probably be back in 15-20 minutes asking for it again. LVN B stated she put the pill in a cup, covered, labeled and put the pill in the narcotics box. LVN B stated LVN D witnessed her do it. LVN B stated Resident #3 returned to the nurse's station asking for his pain pill. LVN B told Resident #3 she had previously gone into his room, and he didn't respond. LVN B stated in response Resident #3 told her, Fuck You and walked away. She stated at that time a CNA was going into the restroom and heard it. LVN B stated the CNA stated he did that sometimes. LVN B stated she then disposed of the pill with LVN D as a witness. LVN B stated it the last Resident #3 had spoken to her. She stated she did not administer the medication, and he did not get it. LVN D denied ever saying, Fuck you to Resident #3. She stated she did not say anything disrespectful to Resident #3 cussing at her. LVN B revealed she had never had any issues with Resident #3 prior to the incident. In an interview on 05/07/26 at 2:11 PM, CNA C stated she worked 10:00pm-6:00am shift on 05/02/26. CNA stated she worked on hall 200 and sat out in the hall during her shift. CNA C she saw Resident #3 walking through the hall and assumed he had come from the dining room. CNA C stated she witnessed Resident #3 go to the nurse's station and asked LVN B for his medication. CNA C stated she heard LVN B tell Resident #3, now you want to talk to me in the correct way. CNA C stated Resident #3 yelled out Fuck you and LVN B said, Fuck you too, I'm not giving you anything! CNA C stated Resident #3 face became red and he put his hand up as if he was frustrated then walked towards his room. CNA C stated it was around 3:30am when the incident occurred. CNA C stated she reported the incident to LVN D after she returned from her break. LVN D told CNA C that she needed to report the incident to the DON or the Administrator. CNA C stated she called the DON and reported the incident. CNA C stated the DON told her to write a statement and it put under her door. In an interview on 05/07/26 at 3:55 PM, LVN D stated she worked 10:00pm-6:00am on 05/02/26. LVN D stated around 1:00am she was sitting at the nurse's station with LVN B when Resident #3 asked for his pain medication. LVN D stated LVN B told the resident it was not time, and he could get it at 3:00am. LVN D stated as she was headed to lunch, she asked Resident #3 if he had taken his pain medication. LVN D stated Resident #3 told her that he did not. LVN D told him he could go to the nurse's station to ask for it because it was after 3:00am. LVN D stated Resident #3 thanked her and told her Okay. LVN D stated when she returned, LVN B asked if she could waste the medication with her. LVN D asked LVN B who and what medication was it. LVN D stated LVN B told her it was Resident #3's medication. LVN D then stated, He did not come get his pill. I told him to come get his pill from you. LVN B told LVN D when she went to his room to give it to him, he did not acknowledge her. LVN D also stated LVN B told her Resident #3 said, Fuck you. LVN D told LVN B that she had heard it earlier, but LVN B told her he had said it again. LVN D stated she asked LVN B where the medication was because she would administer it to him. LVN D stated LVN B had informed her she was going to waste it because he told her, Fuck you. LVN D stated LVN B told her she also needed to waste it because she had already charted that it was wasted, although she waited to waste it after LVN D got back from her lunch. LVN D asked LVN B that the resident was in pain, so why would she waste the medication. LVN D stated LVN B proceeded to dispose of the medication. LVN D stated LVN B put the medication in a plastic pocket which was used to crush it and threw it in the sharp's container. LVN D stated it did not make sense for LVN B to waste the medication if the resident had been in pain since 1:00am. LVN D stated she thought to herself, LVN B rather waste the medication than administer to the resident. LVN D stated as she walked down the hall, CNA C told her about an incident between Resident #3 and LVN B while LVN D was on lunch. LVN D stated CNA C told her while sitting on the hall, Resident #3 went to the nurse's station and asked for his medication. LVN D stated CNA C stated she did not hear exactly what LVN B initially said to the resident, but she heard Resident #3 say, Fuck you. And LVN B told Resident #3 Fuck you too. LVN D stated she told CNA C to call the Administrator because it was abuse. LVN D stated CNA C told her later that morning she had reported the incident to the Administrator. LVN D stated later that day the Administrator reached out to her via text. LVN D stated the Administrator text asked if she had seen or heard any staff being inappropriate with a resident. LVN D stated she informed the Administrator that Resident #3 tried to get his pain medication and LVN B did not give it to him when it was time. LVN D stated she informed the Administrator of LVN B wasting the medication instead of administering the medication. LVN D stated the risk of not administering the medication was the resident's pain would be unrelieved. In an interview on 05/07/26 at 3:16 PM, Resident #3 stated he was asleep when LVN B came into his room. Resident #3 stated he was not sure what she wanted. Resident #3 stated he was unsure of the time, but when he woke, he went to the nurse's station for his pain medication. Resident #3 also stated when he asked for it, he did not remember exactly what LVN B told, but it had to be disrespectful because he got upset. Resident #3 stated it was all uncalled for but one of those things that happened. Resident # revealed he had not received his medication from LVN B. Resident #3 stated he was in pain and went back into his room. In an interview on 05/07/26 at 4:35 PM, the DON stated she worked on 05/03/26. The DON stated when she got to work there a note from CNA C under her door. The DON stated it stated Resident #3 told LVN B Fuck you a few times. The DON stated the note further stated that LVN B said, Fuck you back to Resident #3. The DON stated CNA C was down the hall when she heard the cussing between Resident #3 and LVN B. The DON stated she conducted her investigation on the alleged incident. The DON stated she sked Resident #3 if he had any issues with any nurses, issues with receiving his medication, or if anyone said anything that upset him. The DON stated Resident #3 told her no. The DON stated she also talked to other residents and asked if they heard any shouting, cussing or noise the night before. She stated no residents had heard anything. The DON stated she talked with another aide and she did not hear anything. The DON stated she did not have any reason to suspect that it occurred. The DON revealed if she had gotten any other confirmation about the alleged incident, she would have reported it to HHSC. She stated according to policy, the alleged incident should have been reported to HHSC. The DON stated the risk of not reporting the alleged incident was it could affect other residents alleged abuse or neglect not being investigated. In interview on 05/07/26 at 5:02 PM, the Administrator stated she received a call from CNA C regarding the alleged incident. The Administrator stated CNA C told her Resident #3 went to the nurse's station and said, Fuck you to LVN B and LVN B responded saying, Fuck you. The Administrator stated CNA C stated she was down the hall when it occurred. The Administrator stated she asked LVN B what had happened. She stated LVN B told her Resident #3 came to the nurse's station several times asking for his pain medications and told LVN B, fuck you. The Administrator asked LVN B for her response and she said she did not respond. The Administrator stated LVN B said she did not say anything inappropriate to Resident #3. The Administrator stated she asked another aide, but she did not witness the alleged incident. She stated she asked LVN D if she had heard anything inappropriate and was told no. The Administrator stated she knew the DON would be at the 05/03/26, so she had her investigate the alleged incident. The Administrator stated she was informed that no residents heard anything. The Administrator revealed LVN B was already off during their investigation, so she did not suspend her. The Administrator stated she did not know why she did not report the alleged incident but should have reported it to HHSC. She stated the facility's policy was to report the alleged incident. Record review if the facility's policy titled, Abuse/Neglect, no date, reflected in part the following: F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC.2. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17.3. A report to the appropriate agency will include the following:c. The name and address of the suspected victim.d. The name and address of the suspected victim's care giver, if known.e. The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source.f. The nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome.g. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form.4. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation.The employee will have an opportunity to present a written statement to answer the allegation(s)of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The employee will have the opportunity to be advised of the outcome of the investigation in the determination of disciplinary action and/or reinstatement.5. Abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property of residents by employees of any facility will be grounds for immediate termination.6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personnel action deemed necessary. If a personnel action occurs, a copy of all pertinent documents will be placed in the employee's personnel file.7. The facility will report and cooperate with any and all investigations concerning reports of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source by the company's employees as set forth in state law (including to the state survey and certification agency).

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for one of eight residents (Resident #4) and the facility's water management system reviewed for infection control. 1. The facility failed to perform wound care by not covering Resident #4's right foot prior to leaving the room and being in common areas.2. The facility failed to identify situations that could lead to Legionella growth and to implement measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. This failure could place residents at risk of cross-contamination, increased risk of infection and the spread of infection. Findings included: In an interview on 3/11/2026 at 02:20 p.m., the Maintenance Director stated he was not aware of a facility water management plan and he was unable to describe or provide evidence of identification of situations that could lead to Legionella growth, measure used to control the introduction and/or spread of Legionella, or documentation of implementation of these measures. He stated that the facility does not need to flush their water lines because they were on city water. He stated the facility's water system was not at risk for any bacterial growth because, we have water softeners. He stated he did not know what Legionella or Legionnaires' disease was and did not know of any risks of failing to have a water management plan. In an interview and record review on 3/11/2026 at 03:45 p.m., the DON when asked for the facility's water management program documentation provided the facility, undated, policy titled, Legionella Water Management Program as well as a list titled, Water Management Team with four names which included the name of the Administrator, the DON, Maintenance, and the Medical Director. A facility map was provided with areas highlighted and labeled, tankless, hot water heaters basement and water heater. The DON was unable to describe or provide documentation of a water management program which included identification of situations that could lead to Legionella growth, measure used to control the introduction and/or spread of Legionella, or documentation of implementation of these measures. The DON stated failing to have a water management program could place residents at risk of disease, breakouts, and respiratory issues. She stated the facility had not had any diseases, breakouts, or respiratory issues related to water management. In an interview on 3/12/2026 at 01:30 p.m., the Administrator stated water management was not an issue because the facility did not have any stagnant water and water temperatures were monitored. The Administrator stated the facility had two resident rooms which were not in use, one of which was out of commission. She stated residents' rooms were often moved around and housekeeping, when cleaning, turned on sinks and flushed toilets. She stated the facility had not had any outbreak of waterborne illness or Legionnaires' Disease. The Administrator stated she, the DON, the Maintenance Director, and the Medical Director were responsible for the water management plan. She stated the risk of not having a water management plan would be Legionnaires' Disease. A record review of the facility's, undated, policy, , Legionella Water Management Program reflected, our facility has a water management program, which is overseen by the water management team, the water management plan included, the identification of situations that can lead to Legionella growth.specific measures used to control the introduction and/or spread of Legionella.the Maintenance Director or designee will perform weekly flushing for at least 10 minutes of all water source locations that are utilized on a less than daily basis. 2. Record review of Resident #4's admission Record revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted ton 10/16/2025. Resident #4 had a primary diagnosis which included Unspecified Atherosclerosis of native Arteries of Extremities Right Leg (indicates plaque buildup in the leg arteries, causing narrowing and reduced blood flow) Record review of Resident #4's Care Plan Report, dated 01/21/2026, revealed; Focus: skin issues r/t incontinence and impaired mobility AEB; Arterial wound to right foot; Interventions: Skin checks weekly per facility protocol, document findings. Focus: Behavior exhibits maladaptive behaviors r/t difficulty communicating h/o CVA mental illness, dementia (a decline in mental ability), cognitive impairments, verbal aggression toward others, refusal of care (cleaning/trimming nails/wound care, refuses eye exams, refuses meds at times, physical aggression toward others, places self on floor at times and crawls. Goal: will have fewer episodes of (yelling out behavior) Interventions: Allow choices within individual's decision-making abilities. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. Focus: Resident 4 is on enhanced barrier precautions. Goal: there will not be any transmission of infection from or to the resident. Interventions: Gloves and gowns should be donned if any of the following activities are to occur; linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care. Focus: Resident #4 refuses treatment assessment and evaluations from providers and wound care NP. Wound care to Right Foot. Goal: Resident #4 will deal with his decision X 90 days. Interventions: Attempt to get other staff who he trusts to assist with resident compliance with treatment. Ensure pain is managed to attempt resident to be compliant with treatment, Staff will listen to resident concerns. Record review of Resident #4's Team Care Plan, dated 02/03/2026, revealed; Care Plan H160; Skin/Wound; skin remains intact within limits of disease process. Interventions; wound care performed daily by facility nurse. Normal saline used to cleanse the wound, pat dry and apply dressing. Record review of Resident #4's Minimum Data Set (MDS) Nursing Home Quarterly (NQ ) Item Set dated [DATE] revealed; no BIMS score recorded No (resident is rarely/never understood). Record review of Resident #4's Treatment Administration Record, dated 03/01/2026, revealed; Apply Betadine to open areas of the right foot one time a day for wound care-D/C date 03/10/2026. Dates: 03/09/2026-2 (Drug refused Effective); 03/10/2026-2 (Drug refused Effective). Cleanse open areas to right foot with normal saline, pat dry, and Apply Betadine to the open areas of the right foot. Daily and PM. Apply bandage to draining areas and wrap with roll gauze. Every evening shift for Wound care. Date; 03/11/2026-Administered. During an observation on 03/10/2025 at 2:46 p.m., revealed Resident #4 was sitting up in his wheelchair self-propelling himself down the hallway in front of the dining room with his right foot uncovered. During an observation on 03/10/2026 at 2:55 p.m. revealed Resident #4 was sitting up in his wheelchair in his room right foot was uncovered with subcutaneous drainage lower extremity edema onto the floor under Resident #4's wheelchair. During an attempted interview on 03/10/2026 at 2:55 p.m. revealed Resident #4 was verbally unresponsive to investigate questions. Resident #4 moved his foot and body away when attempting to observe the right foot. During an interview on 03/10/2026 at 2:57 p.m. with RN B revealed Resident #4 was not compliant with wound care. She stated he would refuse treatment. He would self-propel to smoke. RN B stated there was drainage from the right foot. She stated the risk was the foot could get infected. During an interview on 03/10/2026 at 4:04 p.m. with the Treatment nurse revealed she Resident #4 was non-compliant with wound care, when they tried to clean and cover the foot the resident would non-verbally refuse by becoming physical and showed resistance. Resident #4 was able to verbally say Akoo. She stated they made several attempts to provide wound care sometimes we get lucky and he would allow treatment. She stated his foot did not always drain. She stated someone usually took him to smoke and if drainage was noted, they cleaned it up with disinfectants. During an interview on 03/12/2026 at 2:55 PM with the DON revealed if Resident #4 had active drainage staff should clean it up with disinfection wipes. The risk was if he had an infection, it could spread to the other residents. Record review of facility policy, Skin Integrity Management, revised 10/05/16, revealed .minimize environmental factors leading to skin drying, such as low humidity .additional heel protection may be needed .

Based on observation, interview, and record review, the facility failed to provide services to residents with reasonable accommodations of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 12 (Resident #91) reviewed for call lights. The facility failed to keep Resident #91's call light off the floor and within his grasp so Resident #91 could communicate to staff when he needed assistance. This failure placed residents at risk for not getting their needs met and a diminished quality of life. Findings included: Record review of Resident #91's Face Sheet, dated 3-10-2026, revealed a [AGE] year-old male with an initial admission date of 8-29-2024 and a re-admission date of 7-26-2025. Resident #91 had a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (a chronic disorder characterized by high blood sugar [hyperglycemia] that causes widespread damage to peripheral nerves.), Dysphagia (difficulty swallowing), Cognitive Communication Deficit (an impairment in communication-including listening, speaking, reading, or writing-caused by underlying cognitive issues such as memory loss, poor attention, executive dysfunction, or impaired reasoning rather than a primary language or speech-motor deficit), PTSD (a chronic mental health condition triggered by witnessing or experiencing a terrifying, life-threatening, or violent event), and Acquired Absence of Right and Left Legs below the knee (An amputee of both legs below the knee). Record review of Resident #91's Quarterly MDS dated [DATE] reflected a BIMS score of 11, which indicated being mildly cognitively impaired. The GG-Functional Abilities Section revealed he was totally dependent on staff for toilet hygiene, maximal assistance where a helper lifts the trunk or limbs and provides more than half of the effort to transfer from chair to bed or bed to chair, and in need of moderate assistance where a helper lifts, holds, or supports trunk or limbs but provides less than half the effort to move from a lying position in bed or a sitting position to a lying position in bed. Record review of Resident #91's Care Plan, dated 8-30-2024, indicated Resident #91 had Hemiplegia/Hemiparesis (a neurological conditions causing one-sided body weakness or paralysis, usually resulting from stroke, brain injury, or tumor) and was a fall risk stating, be sure resident's call light is within reach and encourage him to use it for assistance.In an observation and interview on 3-10-2026 at 11:35 AM, Resident #91 was observed lying in his bed. Resident #91 was observed to be a double amputee in his legs from the knees down. Resident #91's call light was on the floor underneath his wheelchair next to the wall. Resident #91 said he did not know where his call light was, he used the call light to get help from the staff, but it did not bother him.In an observation and interview on 3-10-2026 at 3:20 PM, Resident #91's call light was observed to be in the same location as it was at 11:35 AM. The call light was still on the floor, underneath Resident #91's wheelchair, next to the wall. Resident #91 was observed coughing repeatedly and was unable to answer my questions. In an interview on 3-10-2026 at 3:25 PM, CNA A said she had worked at the facility for 6 months, worked the 2:00 PM-10:00 PM shift, and was responsible for the care of Resident #91 during the evening shift. CNA A said she had just arrived at work and did not know why Resident #91's call light had been on the floor for 4 hours. CNA A said CNA C had worked the 6:00 AM - 2:00 PM Shift and was responsible for Resident #91's care during that time. CNA A said the reason it was important for Resident #91 to have his call light within reach was because he would not be able to contact staff when he needed help. CNA A said they made rounds in the hallways, as much as they could, to ensure Resident's call lights were kept within reach. In an interview on 3-10-2026 at 3:30 PM, RN B said she worked the hallway responsible for Resident #91's care on the 6:00 AM-2:00 PM shift. RN B said every staff member who went into Resident #91's room was responsible for making sure his call light remained within his reach. RN B said, the risk to a resident, who was a double amputee, not being able to reach his call light was he would not be able to call for help when he needed it. RN B said she believed staff were just too busy to notice Resident #91's call light was on the floor. In an interview on 3-11-2026 at 3:30 PM, CNA C said she had worked at the facility for 1 year, worked the 6:00 AM-2:00 PM shift, and was responsible for Resident #91's care. CNA C said the CNAs were responsible to ensure Resident's call lights were kept within reach and if a Resident could not reach his call light, he would not be able to call staff for help. CNA C said staff clip the call light onto the clothes of Residents when they were lying in bed to keep the call lights within reach. CNA C said she thinks she was just too busy yesterday to ensure Resident #91's call light was kept within his reach. In an interview on 3-11-2026 at 4:00 PM, the DON said she expected Resident's call lights to always remain within their reach when they were in their rooms. The DON said all staff were responsible for ensuring call lights remained within a Resident's reach. The DON said if a call light was not kept within a Resident's reach, it could cause him to not have his needs met. In an interview on 3-12-2026 at 2:10 PM, the Administrator said her expectations were for all Resident's call lights to remain within their reach. The Administrator said the CNAs and the nurses were responsible for ensuring call lights were kept in place for the hallways they were working in. The Administrator said if a resident could not reach his call light, he would not be able to call for help or assistance. In an interview on 3-16-2026 at 1:00 PM, the Administrator said the facility did not have a call light policy. Record review of the facility's undated policy titled Resident Rights stated: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview, and record review, the facility failed to ensure at the time each resident was admitted the facility had a physician order for the resident's immediate care for 1 of 5 (Resident #25) reviewed for residents receiving care and services upon admission. The facility failed to ensure Resident #25 had a current physician's order for use of oxygen after readmission to the facility. This failure could place residents at risk of not receiving necessary care and services. Record review of Resident #25's annual MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #25 had diagnoses which included interstitial pulmonary disease (a group of over 200 disorders causing progressive inflammation and scarring [fibrosis] of lung tissue, making it difficult to breathe and transfer oxygen to the blood), end-stage renal disease (when kidneys no longer function well enough to meet a body's needs), and chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs resulting in swelling and irritation). Section J1100 reflected Resident #25 had other health conditions such as shortness of breath or trouble breathing when lying flat. Resident #25 had a BIMS score of 15, which indicated Resident #25 was cognitively intact with high cognitive functioning. Record review of Resident #25's care plan, dated 12/11/25, reflected the resident had altered respiratory status, difficulty breathing, and shortness of breath anxiety. The care plan reflected: Goals: The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review. Interventions: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to yawn. Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for s/sx of respiratory distress and report to MD PRN; Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis (excessive sweating due to a secondary condition) ; Headaches; Confusion; Hemoptysis(coughing up blood from the lower respiratory tract); Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Position resident with proper body alignment for optimal breathing pattern. Provide oxygen as ordered. Use pain management as appropriate. Monitor/document side effects and effectiveness. Record review Resident #25's progress note, dated 03/09/26 at 10:53 PM, by LVN D, reflected: Resident readmitted from hospital to room . under the care of the Medical Director. Resident #25 is alert and able to make needs known. Oxygen at 2 lpm via nasal cannula. Record review of Resident #25's physician orders, dated 03/10/26, reflected no physician orders for oxygen. Observation and interview on 03/10/26 at 11:23 AM revealed Resident # 25 was resting in her bed and not feeling well. Resident #25 stated she did not feel like answering questions from the state surveyor. Observation revealed Resident #25 had an oxygen concentrator in her room that was set to 3.5 liters per minute, and Resident #25 was wearing oxygen tubing from the oxygen concentrator correctly. Observation on 03/11/26 at 2:59 PM of Resident #25 revealed Resident #25 was resting peacefully in bed with her eyes closed. The resident's oxygen concentrator was set to 3.5 liters per minute. Resident #25 was wearing oxygen tubing from the oxygen concentrator correctly. Observation on 03/12/26 at 12:20 PM revealed Resident #25 was resting peacefully in bed with her eyes closed. Interview on 03/11/26 at 4:21 PM with LVN D revealed she was the evening shift nurse (Monday through Friday) for Resident #25. LVN D stated Resident #25 had no order for oxygen upon admission when reviewed with the state surveyor. LVN D stated there should be an order for oxygen with its liters per minute from the physician based on Resident #25's admitting diagnoses. LVN D stated Resident #25 needed oxygen due to her low oxygen levels. LVN D also stated the admitting nurse should have contacted the physician and obtained an oxygen order for Resident #25 upon admission. LVN D revealed the importance of getting an order for oxygen was to ensure the resident's oxygen was set to the correct liters per minute because too much oxygen was bad for a resident (LVN D did not know specifically how it affected the body). LVN D stated it was all nurses' responsibility to ensure residents had an order for oxygen which included the ADON, if they were using oxygen. LVN D concluded by stating their policy stated nurses were allowed to use nursing judgement and place oxygen on a resident using 2-3 liters per minute based on their admitting diagnosis. LVN D stated in Resident #25's case, she failed to contact the physician and obtain an order for oxygen at a 3.5 liter per minute rate when she admitted Resident #25 on 3/9/26. Interview on 03/12/26 at 9:01 AM with RN E revealed she was the dayshift nurse (Monday through Friday) for Resident #25. RN E revealed due to the resident's diagnoses of COPD, Resident #25 could experience hypoxia (low levels of oxygen in the blood). RN E stated upon admission, all residents' vitals should be taken including oxygen saturation. RN E stated if the saturation level was low, the supervisor should be informed. Then oxygen should be placed on the resident, and the physician notified to get an order for oxygen for the correct liters per minute. RN E stated Resident #25 should have an order for the correct oxygen liters per minute from her physician. RN E revealed it was the admitting nurse's responsibility to ensure the resident had an order for oxygen. RN E stated she should have checked the resident's orders as well to ensure the resident had an order for oxygen and it was set to the correct liters per minute. RN E stated if the nurse did not verify the physician's order for oxygen, the nurse could set it too high, and then the resident could get sick. Interview on 03/12/26 at 12:27 PM with the DON revealed the ADON was not available for interview. The DON revealed Resident #25 had a diagnosis of COPD. The DON stated it was the admitting nurses' responsibility to ensure residents' orders were received and entered correctly into the electronic health record. The DON stated the admitting nurse for Resident #25 should have notified the physician and received an order for oxygen and the appropriate liters per minute so the resident had adequate oxygenation due to her diagnosis. The DON stated if a resident received too much oxygen, it could depress the respiratory drive which could lead to exasperation and resident decline. Record review of the facility's, undated, Physician's Orders policy reflected: Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.Person responsible: Medical Records/Designee.Verbal or Telephone Orders by the Physician or Nurse PractitionerNurse will receive the order and read the order back to the prescriber to ensure it is correct.If needed, the nurse will contact the prescriber for any clarificationsThe nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the nurse received the order .Preventing Verbal or Telephone Order Errors. 4. Ensure all elements of the order are included; being clear about the unit of measure for each dose and the frequency of administration.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of 12 (Resident #104) reviewed for ADLs. The facility failed to ensure Resident #104's shirt and pants were changed, which were covered in food, after being fed lunch on 3-10-2026. This failure could place residents at risk for low self-esteem and self-worth causing negative psychosocial outcomes affecting their health. Findings included:Record review of Resident #104's Face Sheet, dated 3-10-2026, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Parkinson's Disease (a neurodegenerative disorder that impairs motor function due to the loss of brain cells that produce dopamine) and secondary diagnoses of Type 2 Diabetes Mellitus (high blood glucose [sugar] levels, often stemming from insulin resistance. In this condition, the pancreas cannot produce enough insulin), Muscle Weakness, Unsteadiness on feet, Cognitive Communication Deficit (a difficulty with communications such as speaking, listening, reading, or writing-caused by underlying cognitive impairments rather than primary language or speech deficits), and Glaucoma (a group of eye conditions that damage the optic nerve-the vital connection between the eye and brain-often due to abnormally high eye pressure). Record review of Resident #104's Nursing Home Comprehensive MDS, dated [DATE], reflected a BIMS Score of 14, which indicated she was cognitively intact. The F - Preferences for Customary Routine Activities Section, of the MDS, revealed it was very important to Resident #104 to choose what clothes to wear and take care of her personal things. In the GG - Functional Abilities Section, of Resident #104's MDS, revealed Resident #104 needed partial/moderate assistance to dress and undress from the waist up and needed substantial/maximal assistance to dress and undress from the waist down. In the GG0115 - Functional Limitation in Range of Motion, of Resident #104's MDS assessment, revealed she used a wheelchair to ambulate. Record review of Resident #104's Care Plan, dated 2-25-2026, indicated Resident #104 had a communication difficulty requiring 1 staff member for assistance dressing and eating. Resident #104 had ADL Self Care Performance Deficient needing assistance choosing clothes to wear. In an observation and interview on 3-10-2026 at 3:37 PM, Resident #104 was observed having a substantial amount of food debris on the front of her shirt and in front of both pants legs while sitting in her wheelchair in her room. Resident #104 stated she had gotten the food on her while eating lunch in the dining room. Resident #104 said she wanted help changing into clean clothes as it made her feel dirty. In an interview on 3-10-2026 at 3:50 PM, RN B said Resident #104 should have had her clothes changed when she came back from lunch. RN B said it could be a dignity issue if residents needing ADL Care were left with dirty clothes on. RN B said the staff member who transported Resident #104 into the dining room should have been the one to change Resident #104 into clean clothes after lunch. In an interview on 3-10-2026 at 4:00 PM, CNA A said the nursing staff worked 8-hour shifts, she worked 2:00 PM-10:00 PM and was responsible for Resident #104's care. CNA A said it was the responsibility of the CNA, working the hallway where the Resident lived, to change the Resident's clothes when they got dirty. CNA A said if a resident's clothes became dirty at lunch time, it was the responsibility of the CNA working the 6:00 AM -2:00 PM shift to change her clothes. CNA A said if a Resident was left in clothes with food on her, it could be a dignity problem and make the Resident feel like staff did not care for her. In an interview on 3-11-2026 at 11:00 AM, it was revealed that CNA C brought Resident #104 to the dining room, in her wheelchair, for lunch on 3-10-2026 because Resident #104 was getting confused about eating lunch. CNA C said the reason Resident #104 was left with food on her clothes, on 3-10-2026 after lunch, was because she got busy and did not have time to change Resident #104. CNA C said not changing a Resident's clothes, when they had gotten food on their clothes, could make a Resident feel dirty. CNA C said she was responsible for ensuring Resident #104 had clean clothes on after lunch. In an interview on 3-11-2026 at 4:00 PM, the DON said her expectations were that Residents who needed ADL Assistance got the help they needed in a timely manner. The DON said Residents who have spilt food on themselves should get help changing their clothes in a timely manner. The DON said the CNAs were responsible to ensure ADL dependent Residents got the assistance they needed as it could affect the Resident's dignity. In an interview on 3-12-2026 at 2:15 PM, the Administrator said she expected the Residents, who needed ADL assistance, not be left with food on their clothes after eating. The Administrator said the CNAs or nurses, who were working in the hallway where the Resident resided, were responsible for ensuring proper and timely ADL care was given. The Administrator said if an ADL dependent Resident was left with food on her clothes, it could make her feel bad because she would not be able to clean herself. Record Review of the EMR, for Resident #104 dated 3-10-2026, revealed CNA C assisted Resident #104 with eating lunch on 3-10-2026. Record review of the facility's undated policy titled Resident Rights without a date stated: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source.Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review, the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living (ADLs) to maintain good personal hygiene, for 1 of 8 residents (Resident #1) reviewed for ADLs.The facility failed to ensure Resident #1 was provided with a shower on 01/20/2026 and 02/09/2026.This failure could place residents at risk of not receiving care and services needed to maintain quality of life and prevent decline in their mental and psychological well-being. Record review of Resident #1's admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted from an acute care hospital on [DATE]. She was assessed as cognitively intact with a BIMS score of 15. She was independent with eating, oral hygiene, upper body dressing, required set-up or clean-up assistance with person hygiene, and supervisory assistance with shower/baths. She was documented as having a fall in the last month prior to admission. She was frequently incontinent of bowel and bladder and had complex medical conditions that included: heart failure (heart unable to pump enough blood to meet the body's needs,) kidney failure (kidney(s) that lose ability to function properly,) diabetes (body cannot properly use blood sugar,) cerebrovascular accident (interruption of blood flow to the brain,) and depression (mood disorder that causes a persistent feelings of sadness.)Record review of Resident #1's Electronic Medical Record for her Shower/ADLs, with a look-back period of 20 days, her showers on 01/30/2026 and 02/09/2026 were documented as not applicable. Resident #1 had no documentation of a shower between 02/07/2026 and 02/10/2026. In an interview with Resident # 1 on 02/17/2026, she was resting on her bed in her room. She reported that earlier in the month, she went without a shower for multiple days because the aide stated she would do it at the end of her shift, but then at the end of her shift, she came in and stated she ran out of time and would not be able to provide her with a shower. She stated she was not offered an alternative shower opportunity. She stated she did not report this to nursing; but was upset as she wanted to feel clean and did not feel clean after not having a shower for three days. She stated she expected to get a shower every other day and this was not provided. In an interview with CNA A on 02/17/2026 at 11:41 am, she stated she worked with Resident #1 frequently, and her shower days were Monday, Wednesday, and Friday. She stated on the shower days for Resident #1 where she documented not applicable, she stated she just ran out of time that day. She stated she had enough staff to do her job, but she just ran out of time. She stated Resident #1 did not refuse and was compliant overall with care. She stated she did not coordinate with other staff to get Resident #1 a shower because she did not want to bother anyone [staff.] She stated it was her responsibility to ensure Resident #1 received a shower, and it was her responsibility to report to the nurse if this was not possible. In an interview with the DON on 02/17/2026 at 1:52 pm, she stated it was not acceptable for Resident #1 to not be offered showers on her shower days. She reported her expectations were for residents to receive a shower twice a week, or they can get more often if they want. She stated it was not acceptable for CNA A to not offer Resident #1 one on her shower days, and it was her responsibility to coordinate an alternative way to do so. She stated it was important to offer ADLs to residents because she wanted her residents to be offered showers for resident rights and to be clean. The DON stated it was her responsibility to ensure residents received ADL care, but she was not told by CNA A that she was not able to provide a shower for Resident #1 so she could not accommodate. She stated she was aware of the issue and would provide in-service to CNA A. In an interview with the Administrator on 02/17/2026 at 2:17 pm, she stated she expected her CNAs to provide showers and ADL care to residents on their assigned days. She stated if it had been a busy day, the CNAs need to coordinate with other staff to get it done. She stated this was not done in this incident. She stated it was the DON's responsibility to ensure residents receive their ADL care because it was important for resident rights to get hygiene care. In a review of the facility's policy, Bath, Tub/Shower, undated, provided by the Administrator on 02/17/2026 at 2:42 pm revealed Goals 1. The resident will experience improved comfort and cleanliness by bathing. 3. The resident will be free from soil, odor, dryness. following bathing. Procedure 1. The resident will receive assistance with bathing according to their resident centered plan of care.In a review of the facility's policy, Resident Rights, undated, provided by facility Administrator on 02/17/2026 at 2:42 pm revealed The resident has a right to a dignified existence.

Based on interviews and record reviews, the facility failed to ensure the resident's right to be free from abuse for one (Resident #1) of 4 residents reviewed for abuse, in that: On 09/16/2025 the facility failed to ensure that Resident #1 was not spoken to in a verbally abusive way by CNA A who called Resident #1 an expletive. This failure could result in resident abuse and mental decline. Findings included:Record review of Resident #1's admission record revealed a [AGE] year-old female admitted on [DATE] with a primary diagnosis of [NAME]-[NAME] Syndrome (a rare genetic disorder characterized by a constant feeling of hunger (hyperphagia), which leads to obesity if not managed.)Review of Resident #1's Quarterly Minimum Data Set, dated [DATE] revealed a BIMS score of 09(Moderate cognitive impairment.) Review of Resident #1's Care Plan dated 11/24/2025 revealed Focus: Behavior: Resident #1 exhibits maladaptive behavior at times r/t intellectual disability poor coping skills behave at an age lower than her chronological age impaired cognition. Intervention: Caregivers to provide opportunity for positive interaction, attention. Stop and talk with her as passing by. Focus; Cognitive Status; Resident #1 has impaired cognitive function R/T [NAME]-[NAME] Syndrome. Interventions: Attempt to NOT react to negative behavior. In an interview with Resident #1 on 11/25/2025 at 10:39 AM revealed; she stated I remember when she (CNA A) called me a bitch. She stated she felt bad when staff called her a name. Interview with HR conducted on 11/25/2025 at 10:45 AM revealed she stated she was in her office and heard words going back and forth between Resident #1 and staff. She stated she was able to denote Resident #1's voice and heard the word bitch and then heard another voice (identified as CNA A) respond you a bitch, too. She stated she left her office and went to look for CNA A. When she arrived at Resident #1's room the resident stated that lady just called me a bitch. She stated she located CNA A in another resident's room and asked what happen with Resident #1. She stated CNA A did not deny that she cussed at Resident #1. She stated she told CNA A that language was unprofessional, followed by reporting the suspected abuse to Administration. In an interview with SW on 11/25/2025 at 11:06 AM revealed she conducted the trauma assessment for Resident #1; however, due to Resident #1's impaired cognitive level she was unable to answer questions. Attempted interview with CNA A on 11/25/2025 at 3:05 PM revealed call went to voicemail; message left with reason for calling and call back number. In an interview with DON on 11/25/2025 at 3:44 pm revealed she learned of the incident the CNA A was suspended immediately, staff were educated not to engage with Resident #1 when she used inappropriate language. The staff are in-serviced on respect and dignity of resident's rights. The risk was it created an unsafe environment where the resident would feel unsafe.In an interview with ADMIN on 11/25/2025 at 4:24 PM revealed CNA A was suspended immediately and investigation was conducted. Resident #1 identified CNA A as the one who cussed at her. She stated CNA A admitted to calling Resident #1 the word in response to being called bitch. The expectation was staff should have maintained a professional behavior even when Resident use foul language. The risk was it made the resident feel less than, demined and hurt feelings. Record review of Exclusions Search Results for CNA A dated 06/09/2025 revealed; no results were found.Record review of Texas Unified Licensure Tinfomration Portal undated revealed; CNA A had a NA Certification Status of Active and current Certified Nurse Aide certificate.Record review of employee training transcript dated 06/23/2025 revealed; CNA A received Abuse and Neglect Prevention and Reporting training.Record review Downtown Health and Rehabilitation Center Termination form dated 09/17/2025 revealed; CNA A was terminated on 09/17/2025. Reason for separation; Veral abuse towards resident. Last day worked 09/16/2025 not eligible for rehire based on verbal abuse. Record review of in-training attendance roster dated 09/17/2025 revealed; personnel from all departments were in-service on topics; Abuse/Neglect and Behavior Management. The in-service materials reviewed were Abuse/neglect policy, Behavior Management Policy and De-escalation Training. Record review of Abuse policy revised 3/29/2018 revealed Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 3 (Resident #2) residents reviewed for abuse and neglect. The facility LVN A, LVN B, CNA C and CNA D did not report Resident #2's allegations of abuse and neglect to the Admin who was the abuse coordinator. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: Record review of Resident #2's face sheet, dated 01/16/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses which included: paraplegia unspecified (the symptom of paralysis that mainly affects your legs though it can sometimes affect your lower body and some of your arm abilities, too)., major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), single episode, unspecified, insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep) other chronic pain (lasts months or years and can affect any part of your body), neurogenic bowel (refers to what happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function) and neuromuscular dysfunction of bladder. Record review of Resident #2's quarterly MDS assessment, dated 04/12/25 reflected his BIMS score was 15, which indicated no cognitive impairment . Review reflected Resident#2 needed Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for toileting hygiene. Record review of Resident#2's care plan, dated reflected Resident #2 had Paraplegia r/t Bicycle/MVA on 07/03/23. Goals Initiated on 07/03/2023 reflected, will have decreased likelihood of complications or discomfort related to Paraplegia. Intervention initiated on 07/03/2023 assist with ADLs/Mobility as needed. Review of Resident#2 care plan reflected bowel and bladder incontinence R/T paraplegia which initiated on 07/03/2023. Goals Initiated on 07/03/2023 reflected a decreased likelihood of skin breakdown due to incontinence and brief use. Intervention initiated on 07/03/2023 reflected incontinent care at least every 2 hours and apply moisture barrier after each episode. Record review of CNA D's time sheet reflected she clocked in on 05/11/25 at 9:47 pm and clocked out at 10:03 AM. Record review of a self- report as of 05/14/25 reflected an incident report was created on 05/12/25 at 5:00 AM by the DON. The report revealed, Nursing Description: Resident reported that a CNA tried to strangle him. Resident Description: Resident stated that a CNA tried to choke him. He was waiting for a while to be changed . He found the CNA in the shower room with another resident and when he confronted her the CNA tried to put her hands on him . Immediate action taken reflected: CNA was suspended pending investigation resident interviewed. No injuries observed at time of incident and no injuries observed post incident. Record review of Resident#2 progress note, dated 05/12/25 at 9:00 AM reflected: resident had alleged that a staff member had strangled him then he changed his story stating that the aide attempted to reach out to chock him. Resident has no signs of trauma around neck or to shoulders. No redness, bruising or swelling noted. Resident denies pain or any emotional stress at this time. completed by ADON. Record review of Resident#2 progress note, dated 05/12/25 at 11:35 AM reflected: SW (Social Worker) and 200 Hall Unit Nurse spoke with resident his report of a staff member trying to strangle him around 3 a.m. Nurse asked What happened? Resident stated, he was wet and needed changed and was needing changed. He stated, he pushed his call light and when it was not answered then he rolled to the nurse's station and complained to the nurse staff. When he was asked to wait, someone would be with him. He seen an aide and rolled in front of the shower to ask about why he wasn't changed. The aide attempted to explain but he said she appeared to reach for him but did not touch him. Completed by the SW. Record review of LVN A's signed electronic statement undated, is extremely difficult to read and understand. Please refer to LVN A over the phone interview on 05/14/25 at 8:30 AM. Record review of CNA D's written statement , undated, reflected: To whom it may concern I [CNA D] was attending to other residents on May 13th at 4:30 AM when co-worker [LVN A] and [Resident#2] approached me at shower room and I was assisting another resident when he shouted that he had his call light for 3 hours and I personally neglected to render him service I put my hands up in my defense and asked if I could speak now at that moment she stated that he was going to call the police and make a report on me because the state told him that he could. As I was trying to deescalate the situation [LVN A] stated don't touch or say anything. But I kindly stated to him that I was making rounds since I clocked in at 9:45 pm. I haven't made it his vicinity because I been doing showers since I have documented on the floor. We also only had (2) assistants on the date stated. I let him know that I was doing the best I could possibly for each and every one . Interview at 05/13/25 at 9:55 PM CNA C stated on 05/12/24 she was told by LVN B that Resident #2 on the 200-hall needed assistance and for her to go provide care. CNA C stated she was told by Resident #2 on 05/12/25 that CNA D choked him. Interview on 05/13/25 at 11:00 PM LVN A stated she had not heard about or seen any residents complain of being physical or verbally abused by staff. Interview on 05/13/25 at 11:30 PM CNA E stated she had heard from Resident #2 that CNA D was not answering the call light and he went to confront CNA E because he was wet for hours; and he had already called to the front and LVN B said they would be with him. Resident #2 stated staff tried to choke him and he cussed CNA D out when she tried to tell him why she had not answered the call light yet she touched his shoulder. CNA E stated it was no reason for staff to touch the resident and continue to agitate the resident. CNA E stated she worked PRN and Resident#2 told her what happened on 05/13/25. Interview on 05/14/25 at 12:45 AM LVN B stated Resident #2 called the facility phone and stated CNA D did not answer the call light and he needed to be changed. LVN B told Resident #2 that the aide would be with him. LVN B was told that Resident #2 cussed at CNA D because she did not answer the call light for hours. LVN B stated he did not call the Admin or the DON about the incident. LVN B stated he did not complete an incident report. LVN B did not provide additional information. Interview over the phone on 05/14/25 at 8:30 AM LVN A stated Resident #2 had approached her at the nursing station and stated his call light was on for a long time and CNA D had not come to help him LVN A stated that she went with Resident #2 to find the CNA D. CNA D was giving another resident a shower. LVN A stated, CNA D told Resident #2 that she was giving a resident a shower and would help him after she completed the shower. LVN A stated that CNA D put her hands up and the stop motion. LVN A stated CNA D tried to pat the resident's shoulder and resident pulled back at that point LVN A stated she told CNA D to go back to her work and to back off. LVN A stated she would find another aide to assist Resident#2. LVN A stated CNA D was not being threatening to Resident#2. LVN A stated that she did not think the incident needed to be reported to the Abuse Coordinator (Admin). Interview on 5/14/25 at 8:50 AM Resident #2 stated the regular overnight shift were good about changing him every 2 hours. Resident #2 stated it was about 4:30 AM on 05/12/25 and he had his call light on for a couple of hours and he called the front desk. LVN B waited another 30 minutes before he wheeled himself to the nursing station to find CNA D. Resident #2 stated the nurse who was at the desk stated she did not know who the CNA was working because she usually worked on the unit. Resident #2 stated they went and found CNA D who was given a resident a shower. Resident#2 stated he felt like CNA D was reaching for his throat. Resident#2 stated that LVN A then told CNA D not to put her hands on him. Resident #2 stated CNA C came to change him. Resident #2 stated CNA D did not assist him anymore, but he saw here in the dining hall around breakfast time. Resident #2 stated he told CNA E and AD, about the incident. Resident#2 stated he had a meeting with his family member and the Admin, the SW and the ADON about the incident and other concerns on 05/12/25. Interview on 5/14/25 at 9:47 AM the ADON stated she was informed on 05/12/25 by the AD that CNA D was accused of choking a resident. The DON and the SW went to talk to Resident #2, and he said CNA D tried to choke him and he told her not to touch him. The ADON stated they did an assessment on Resident #2 and found he was not in pain and had no bruises at that time. The ADON stated CNA D was sent home immediately. The ADON stated staff should walk away when a resident was being aggressive and come back later when the resident was calm. The ADON stated another aide came and provided incontinent care to Resident#2. Interview on 5/14/25 at 9:59 AM the SW stated Resident #2 was cussing and upset because he was not changed and checked on for hours. SW stated Resident #2 stated CNA D raised her hand and it looked like her hands were going towards him. The SW stated another nurse aide provided care to Resident #2. Interview one 05/14/25 at 10:10 AM the AD stated that he was informed by Resident #2 on 05/13/25 around 9:00 AM that CNA D was aggressive towards him, and he thought she was going to hit him. The AD stated abuse should be reported immediately to the Abuse Coordinator who was the Admin to prevent residents from being harmed. Interview on 05/14/25 at 1:43 PM with the Admin, the DON and the CN stated they found out about the incident after the morning meeting on 5/12/25 and around 9:30 AM. The Admin stated CNA D was suspended immediately pending investigation. The DON stated they did an in-service with CNA D before sending her home. The Admin stated that abuse allegations were supposed to be reported immediately to them. The DON stated when staff were in-serviced staff were required to sign off on the in-service training sheet to show they had completed the in-services. DON stated staff are in-serviced to prevent abuse from occurring or reoccurring. The DON stated in-services were usually done at the beginning of shifts and when needed. Interview ed on 5/14/25 at 3:35 PM the family member stated she is not sure what happened; she was told two different stories by Resident#2 and drove from out of state to the facility. The family member stated she had a meeting with staff and they addressed concerns that Resident #2's concerns. Interview over the phone at 05/14/25 at 5:10 PM after exit, CNA D stated she was told to go to the Admin's office and she explained what happened. CNA D stated she did a written statement about the incident with Resident #2 before she clocked out on 05/12.25 . CNA D stated Resident #2 was outside the shower room cussing at her because he said he had his call light on for 3 hours and no one had come to change him. CNA D stated she put her hands up with open hands to explain that she was finishing a shower and had not made it to him yet. CNA D stated she did not touch the resident and was in-serviced 05/12/25 by the DON before she left the facility. Record review of an in-service on abuse/neglect dated 05/12/15 completed by the [NAME] reflected LVN A and CNA D did not sign off on the completed training. Record review provided after exit of an in-service on abuse/neglect/aggressive behaviors dated 05/12/25 completed by the ADON reflected only CNA D's signature. Record review of in-service on 02/25/25 titled De-escalating taught by the DON reflected: Verbal de-escalation .Remember, reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce level of resident arousal . Do not try to argue or convince Avoid overacting .Minimize body movements such as excessive gesturing, pacing, fidgeting, or weight shifting. These all indications of anxiety and will tend to increase agitation. Record review of facility policy titled abuse/neglect, dated 03/18 reflected: E. Reporting When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (medication cart) of 1 medication cart on the memory care unit reviewed for pharmacy services The facility failed to ensure discontinued medication were removed from the medication cart. Resident #1's Diazepam that was DC on 12/30/24 was in the narcotic box on the secure unit medication cart. This failure could place residents at risk of unnecessary medication error and/or lead to possible harm or drug diversion. The findings included: Interview on 5/13/25 at 9:50 PM LVN A stated when medications were wasted, they should be crushed and disposed of and two people, 2 nurses, were to sign off on the narcotics sheet and document medication was wasted. Observation and record review on 05/13/25 at 11:00 PM revealed a secure unit narcotic sheet that was not filled out completely for Resident #1's Diazepam 5 mg tablet. Review of Resident#1's Diazepam 5mg narcotic sheet reflected the 10th pill was given with no date and no signature. Further review revealed the 9th pill was removed on 4/11 /25and on 5/4/25 the 8th pill was marked off as wasted. Observation of Resident #1's Diazepam 5 mg package reflected the medication was still in the bubble pack for the 8th tablet. Observation of the Diazepam bubble package revealed medication was filled on 11/12/24. Review of the Diazepam narcotic sheet revealed the Diazepam was put on the medication cart on 11/14/25. Record review of Resident #1's order summary revealed to give 1 tablet Diazepam by mouth every 6 hours as needed and not to exceed 3 daily until 12/30/24 for anxiety. Record review of Resident#1's November MAR reflected Diazepam was administered on 4/11/24. Record review of Resident #1's March 2025 MAR reflected Diazepam was not a listed medication. Interview on 05/13/25 at 11:00 PM LVN A stated Resident#1's Diazepam was DC and the DON was responsible for coming to pick up the DC medication from the medication cart. LVN A stated when medication was wasted two nursing staff would sign off on the medication. LVN A stated narcotics were crushed and put in water. Interview on 05/14/25 at 12:15 PM the DON stated she had not been informed of staff taking narcotic medications for personal use off the medication cart. Interview and observation on 5/14/25 at 1:43 PM the DON stated Resident #1's 5mg Diazepam was DC on 12/30/24. She stated that DC medication needed to be brought to her as soon as possible. The DON stated that nurses was responsible for taking DC medications off the medication cart. The DON stated the pharmacy comes every other month to destroy medications. The DON stated residents are at risk of being given medications that are no longer needed. The DON stated when medications are wasted two nursing staff members are supposed to sign off. Observed the CN leave out of the DON, and she went to pull the DC medication off the secure unit cart. The CN stated the nurse must have written the number backwards instead of 04/11/24 it should have been 11/04/24. Record review of the facility policy titled, Medication Administration Procedures revealed, 3. Open the unit dose package only when you are administering medication directly to the resident. Record review of the policy titled Controlled Medication Disposal, undated, revealed, 3. Schedule II, III, IV and V medications remaining in the facility after the resident has been discharged , or the order discontinued, are disposed either in the facility by legally authorized personnel, Director of Nursing, and Consultant Pharmacist . Record review of the facility policy titled, Discontinued Medications, undated, reflected : Policy .When medications are discontinued by physician order, . the medications are marked appropriately and destroyed .Procedure 1. If a physician discontinues a medication .the medication container is marked the date discontinuance is indicated along with the initials of the nurse. 2. Medications awaiting disposal are stored in a locked secure area designated for that purpose until disposed of medications are removed from the medication cart immediately upon receipt of an order to discontinue avoiding inadvertent administration. 3. Discontinued medications are destroyed in accordance with destruction policy and procedure .

Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of four residents reviewed for medications. 1. Resident #1's Lisinopril and Metoprolol (medications used to lower blood pressure) were not held per physician's order on 07/13/25, 07/21/25, 07/23/24, and 07/25/24 when the resident's blood pressure was below parameters. These failures could place residents at risk of not receiving their medications as ordered or possible illness. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had a diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), Essential Hypertension (high blood pressure), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face sheet noted a discharge date of 09/17/24. Record review of the active physician's order dated 07/11/24, reflected the following: Lisinopril Tablet 2.5 MG give one tablet one time a day by mouth for hypertension hold for SBP <110, DBP <60, HR <60 Metoprolol Succinate ER Oral Tablet 50 MG Give one tablet by mouth one time a day for HTN hold for SBP <110, DBP <60, HR <60 Record review of Resident #1's Medication Administration Record dated July 2024 reflected that Lisinopril and Metoprolol were both given by RN A on 07/13/24 when Resident #1's SBP was 106, outside of the ordered perimeters. RN A also administered both medications outside of the ordered perimeters to Resident #1 on 07/21/24 when Resident #1's SBP was 104 and DBP was 59. Both medications on both days were marked as given. Record review of Resident #1's July 2024 Medication Administation Record reflected on 07/23/24 and 07/25/24 LVN B administered both medications outside of the ordered perimeters when Resident #1's SBP was 98. Both medications on both days were marked as given. Record review of the progress notes on Resident #1's electronic record reflected no documented adverse effects. Record review of the Employee roster reflected RN A and LVN B no longer worked at the facility. In an interview on 05/08/25 at 2:30 PM, the DON stated she was not working at the facility at the time Resident #1 lived there. She stated the two medications should have not been given outside of the perimeters. She stated all physician orders should be followed. The DON stated the risk of not following the physician orders and giving the medications outside of the perimeters was a sentinel event or hypotension (low blood pressure). In an interview on 05/08/25 at 2:40 PM, the Administrator stated all physician orders should be followed and the risk of not following orders was adverse effects. Record review of the facility's policy titled, Medication Administration Policies, dated 10/25/15, reflected the following: 13. When ordered or indicated, Include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. 20. The 10 rights of medication should always be adhered to 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Right assessment 10. Right evaluation

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. 1. The facility failed to address Resident #1's multiple refusals of care and services on the comprehensive care plan This failure could place residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face sheet noted a discharge date of 09/17/24. Record review of Resident #1's Admitting MDS Assessment, dated 07/17/24, reflected Resident #1 had a BIMS score of 11, which meant Resident #1 had a moderate level of cognition. The MDS noted the resident did not exhibit any behaviors. Record review of Resident #1's care plan with an initial date of 07/12/24, reflected no interventions for Resident #1's multiple refusals of wound care, perineal care, medication administration, or showers. Record review of the progress notes on Resident #1's electronic record, dated, 05/08/25, reflected the following: 07/19/24 15:36 (3:36 PM)- Resident #1 refused wound debridement after multiple attempts, application of Nystatin Powder (antifungal medication for skin infections), application of Hydrocortisone External Cream (medication used to treat skin conditions) for wound care 07/23/24 at 16:17 (4:17 PM)- Resident #1 refused the application of Nystatin Powder for wound care 07/24/24 at 12:20 PM- Resident #1 refused the application of Hydrocortisone External Cream 08/01/24 at 9:38 AM- Resident #1 refused Pro-Stat AWC (protein drink for wound healing) 3 times 08/02/24 at 8:31 AM- Resident #1 refused Pro-Stat AWC 3 times 08/09/24 21:47 (9:47 PM)- Resident #1 refused a blood sugar check 08/10/24 at 8:37 AM- Resident #1 refused the application of Nystatin Powder and Hydrocortisone External Cream for wound care, cleansing of wound, and dressing change 08/10/24 at 8:45 AM- Resident #1 refused a shower 08/10/24 at 13:21 (1:21 PM)- Resident #1 refused a blood sugar check In an interview on 05/08/25 at 2:30 PM, the DON stated she did not work at the facility when Resident #1 was living there. She stated the refusals should have been addressed and interventions should have been in place to encourage Resident #1 not to refuse care. The DON stated the risk of refusals not addressed was a possible decline in health. In an interview on 05/08/25 at 2:40 PM, the Administrator stated she was not working at the facility last year when Resident #1 lived there. She stated the refusals should have been addressed so staff would know how to best assist the resident. She stated the risk would have been Resident #1 not receiving the services she needed. Record review of the facility's undated policy, titled, Comprehensive Care Planning, reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - o The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and o the right to refuse treatment Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. In situations where a resident's choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 3 residents reviewed for infection control. 1. The Treatment Nurse failed to discard contaminated gauze after performing wound care on Resident #2 on 05/07/25. This failure could put residents at risk of infection from cross contamination. Findings included: Record review of Resident #2's face sheet dated 05/08/25, reflected a [AGE] year-old female, with an admission date of 05/05/25. Resident #2 had diagnoses of Chronic Venous Hypertension with Ulcer of Bilateral Lower Extremity (damaged leg veins that causes blood pressure build up and skin breakdown), and Type 2 Diabetes with foot ulcer (body cannot regulate blood sugar levels). In an observation and interview on 05/08/25 starting at 8:40 AM, the Treatment Nurse was observed as she provided wound care to the toes and heel of Resident #2. The Treatment nursed wiped the toes of Resident #2, put her gloved hand into the package of clean gauze, took a few out, wiped the toes of Resident #2, then put her gloved hand back into the package of clean gauze to get a few more out. The Treatment Nurse was observed as she closed the package of remaining gauze and placed the package back in the drawer of the treatment cart and locked it. The Treatment Nurse stated she had a few more residents to treat on 05/08/25. In an interview on 05/08/25 at 11:39 AM, the Treatment Nurse stated she was not aware she put the gauze back on the treatment cart after she put her gloved hand into the package. The Treatment Nurse stated that was something she would not normally do. The Treatment Nurse stated the risk of putting her gloved hand into the package after touching Resident #2's wounds, then putting the gauze back on the treatment cart was infection. In an interview on 05/08/25 at 2:30 PM, the DON stated all employees were trained on infection control, but the staff get nervous when The State is in the building. She stated the Treatment Nurse was probably nervous during the observation. The DON stated the Treatment Nurse putting a contaminated hand in the gauze package and placing the gauze back on the treatment cart was contamination and infection. In an interview on 05/08/25 at 2:40 PM, the Administrator stated the risk of the Treatment Nurse putting her gloved hand into the gauze package during wound care was infection being spread to other residents. She stated all employees were trained on infection control. Record review of the facility's policy titled, Infection Control Plan: Overview, dated 03/2024, reflected the following: Infection Control The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

51419 Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #1) of two residents reviewed for nutrition. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 experiencing a 25.96% weight loss in 4 months. She had an active decline in her weight from 01/08/25 - 04/15/25. This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization . Findings included: Review of Resident #1's admission record reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), diabetes mellitus (a group of metabolic diseases characterized by high blood sugar levels), dependence on renal dialysis (when a person's kidneys are no longer functioning properly and they rely on dialysis to filter their blood and remove waste products), end stage renal disease (a medical condition where the kidneys have permanently lost the ability to function adequately), and Parkinson's Disease (a progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slowness of movement) . Review of Resident #1's quarterly MDS assessment, dated 03/30/25, reflected a BIMS score of 15, indicating no cognitive impairment. Section GG (Functional Abilities) reflected she required Setup or clean-up assistance with eating. Section K (Swallowing/Nutritional Status) reflected she was on Mechanically altered diet. Section K0300 (Weight Loss) reflected that she had weight loss, but she was not on physician- prescribed weight-loss program. Review of Resident #1's quarterly care plan revised 03/30/25 reflected that Resident#1 has a diet order other than regular and was at risk for unplanned weight loss or gain. The interventions included: Determine food preferences and provide within dietary limitations. Encourage meal completion and document amount consumed. Monitor weight per facility protocol. Offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. Praise resident for eating well. RD assess per facility protocol. Serve diet and snacks as ordered. Speech Therapy to eval and treat per Physicians orders as condition warrants. The resident has a no salt on tray diet. Review of Resident #1's weights reflected an active decline in her weight from 01/08/25 - 4/15/25. Her weight on 01/08/25 reflected 195.00 pounds and a weight of 169.40 pounds on 04/15/25. Review of Resident #1's Nutrition Assessment, dated 01/16/2025 and documented by the RD, reflected the following: Height:63.0, Weight: 195.0. Diet Renal Texture Order was Regular, and that Residents#1 Food Intake was 50-75%. Review of Resident #1's Nutrition assessment dated [DATE] and documented by the RD, reflected the following: During that visit, the dietician noted Resident #1 had a significant weight loss of 9.7% (18.8 lbs.) over the past month. The only recommendation made at that time was for Resident #1's diet order be changed from a renal mechanical soft diet to a regular mechanical soft diet. Review of Resident #1's meal intake documentation reflected that the resident refused 6 meal trays. She refused dinner on the following dates: 4/5/2025, 4/7/2025, 4/9/2025, 4/22/2025, 4/27/2025, and lunch on 5/1/2025. Review of the list of residents on the red cup program (a program in which residents received a red cup at meals to alert staff that they were at risk for weight loss/malnutrition) did not include Resident #1. During an interview on 05/04/25 at 11:45 AM with Resident #1 revealed that she goes to dialysis Monday Wednesday and Friday. She stated that she has lost weight in the last few months because she did not like the food, especially ground up meat or the mashed food. She stated that the alternative meal was a sandwich which she did not like because the meat was salty. She stated that she liked the chicken pot pie whenever they served it. During an interview on 05/04/2025 at 12:07 PM with the DM revealed that the dietitian was responsible for monitoring residents weight loss, dietary recommendations, and also which residents needed to be on the Red Cup program . The program alerts staff to pay attention to the resident on the program monitor their intake. She stated that if a resident were placed on the red cup program the charge nurse would send a communication slip to dietary. She stated that since she started working at the facility in March no residents had been added to the red cup program. She stated that the dietitian monitors weight loss every other week. During an observation on 05/04/2025 at 12:35pmResident#1 only ate her desert and stated that she did not like the ground chicken that was served at lunch. Resident#1 declined offer for alternative food from CNA A. During an interview 05/04/25 at 12:45 PM with the Dietician , she stated she was aware of Resident #1's weight loss. She stated she had noted discrepancies with the facility's weights in the past, so she was not sure if Resident #1's weights were actually accurate. She stated she felt as though the facility should be monitoring and recording post-dialysis weights for consistency purposes. She stated she was not sure if she had made that recommendation to the facility, and she stated she did not review dialysis communication logs (which documented weights taken at the dialysis facility) when assessing residents for further recommendations. She stated Resident #1 could definitely be put on a supplement and/or increased weights for additional weight support. She stated she does not necessarily monitor the facility's Red Cup program; she was not sure who monitored this program. During an interview on 05/04/25 at 1:25pm with the Director of Nursing (employed by the facility for approximately 4 months), she stated she was aware of Resident #1's weight loss, as she was the individual who entered weights into the electronic charting system. She stated although she knew of Resident #1's weight loss, she did not realize how significant the issue of severe weight loss could be until she completed her DON training this past week. She stated she felt as though Resident #1 should have weekly weights as well as supplements for appetite stimulation/extra nutrition. She also stated Resident #1 should have been placed on the facility's Red Cup program. The Director of Nursing stated she had left weight monitoring and intervention plans up to the dietician. During an interview on 05/04/2025 at 2:00pm with a CNA A who was assigned to Resident #1's care, she stated she could tell that Resident #1 had lost weight because during ADL care, Resident #1 felt much lighter. CNA stated that the resident requires set up for meals but can feed herself. She also stated Resident#1 was not on the red cup program and that staff was required to pay extra attention to resident on the Red Cup program. During an interview on 5/04/2025 at 3:21 with LVN B assigned residents care revealed that she did not work on the 300 hall usually and was not familiar with her weight loss or meal intake. She stated that the charge nurses monitored the dialysis communication sheets and reported any concerns to the MD and administration. During an interview on 05/04/2025 at 2.06pm with the MD revealed that Resident #1 had abdominal surgery hemicolectomy where she had removed part of her colon . The MD stated that Resident#1's weight loss started after the abdominal surgery, and she has had a lot of Gastrointestinal issues. The MD stated that some of the weight loss was good because she was over 200 pounds so losing some weight was beneficial if the resident was still eating. He stated that the facility continued to monitor Resident#1's weight monthly. The MD stated that the resident had complained of acid reflux, and she was started on Protonix to help with reflux . He stated that the resident had also complained of the food, and the facility had tried to adjust her diet to what she could tolerate and was seen by speech therapy who recommended mechanical soft diet. The MD stated that because the resident was on dialysis the only supplement, she could take was Nepro however she has not shown signs of malnourishment and was taking renal vite tabs for dialysis supplement. Review of the facility's Red Glass/Red Napkin and Fortified Food Program reflected : These programs are a way for residents with unintended weight loss to receive increased nutrients as soon as the weight loss is identified, and for facility staff to be aware of residents increased nutritional needs and to provide encouragement to complete their meal. Procedure: 1. Nursing is to supply dietary on a weekly basis with an updated list of residents with unfavorable weight loss who may need additional supplements and additional encouragement to complete their meals. This list may be generated in the weekly weight meeting. 2. Residents on enteral feedings with unfavorable weight changes will be re-evaluated for protein, calorie and vitamin/mineral needs with adjustments recommended as needed by the registered dietitian. 6. Nutrition intervention may be needed for residents with weight loss. If warranted, a red napkin or red glass will be used on the resident's meal tray to alert the dietary and nursing staff to pay close attention to the resident's food/fluid intake and to encourage the resident to eat and drink as much as possible. Review of the Facility' Resident Weight policy reflected that the following assessments and Recognition: Nursing Policy & Procedure Manual 2003 Revised: February 13, 2007 All residents will be weighed by the 10th of the month and their weights documented correctly. The appropriate actions regarding significant changes will be carried out. Procedure: 1. Weights shall be obtained and documented at admission, readmission, and monthly unless ordered otherwise by the physician, or unless dictated more frequently by the resident's condition. Factors indicating the need for more frequent weights include significant weight loss, drastic decrease in food consumption, prolonged nausea, vomiting, or diarrhea, significant weight gain, swelling or edema, poor appetite during adjustment period to the facility, recent change from tube feeding to oral intake, or pressure ulcers that are not resolving as expected. The Dietary Profile will be completed upon admission and quarterly thereafter by the dietary manager. The Nutrition Risk Assessment form will be completed by the Registered Dietitian upon admission, annually, and updated if the resident has a significant change. The RD and dietary manager will also chart in the dietary Progress Notes as needed regarding visits, nutritional issues, updates to food preferences, etc. 4. All residents must be weighed as indicated, unless otherwise ordered by the attending physician. Pre-medicate resident for pain or discomfort, as per physician's orders, as needed prior to weighting. 5. Monitor fluid intake and output because body weight may increase as a result of fluid retention. 6 7. Significant Weight Loss The facility review resident weights after monthly weights are obtained, to determine residents with significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. The weight change will be recorded on the appropriate weight watcher's form along with interventions, and follow-up will also be recorded in the designated location. The physician and family will be notified. In addition, an acute care plan for weight loss will be initiated and the clinical record reviewed for possible need of a significant change of condition MDS assessment. Assess the resident for possible reason for weight loss to include: 9. All significant weight changes will be referred to the Regional Dietitian on the next visit. The Regional Dietitian will generate a copy of the facility weight report and can review the weight watchers' forms in PCC. The Regional Dietitian will complete an assessment on all significant weight losses. The Regional Dietitian will review all facility interventions, and will make appropriate recommendations, which will be approved by the physician, if necessary.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Residents #6) of four reviewed for adequate supervision. LVN R failed to complete a fall assessment and implement interventions for Resident #6 after a fall, to prevent reoccurrence. The facility failed to ensure an updated fall assessment was complete for Resident #6. This failure could affect residents by not having the necessary resources to ensure appropriate care, interventions, and supervision were provided. Findings included: Review of Resident #6's Face Sheet dated 04/01/2025 revealed the resident was a [AGE] year-old female was initially admitted on [DATE], and again on 08/20/2024. Relevant diagnoses were alcohol dependence with alcohol-induced persisting dementia, unspecified protein-calorie malnutrition, other reduced mobility, history of falling, other lack of coordination, unsteadiness on feet, muscle weakness (generalized), other abnormalities of gait and mobility, atherosclerosis of native arteries of extremities with intermittent claudication bilateral leg(buildup of fats, cholesterol and other substances in and on the artery walls), and unilateral primary osteoarthritis, right hip )the most common type of arthritis, characterized by the breakdown of cartilage in joints, leading to pain, stiffness, and reduced movement.) Review of Resident #6's Comprehensive MDS Assessment, dated 03/20/2024, revealed the resident had a BIMS score of 9, indicating she was moderately impaired cognitively. Section GG - Functional Abilities and Goals revealed Resident #6 requires set up and clean up for oral hygiene and upper body dressing. She requires supervision and touching assistance for toileting hygiene, lower body dressing, putting on and taking off footwear, and personal hygiene. She requires partial moderate assistance with showering and bathing. Section J900 revealed the resident had one fall with no injuries. Review of Resident #6's Comprehensive Care Plan, dated 03/17/2025, reflected the resident had cognitive loss r/t impaired cognitive functional dementia with intervention. Keep the resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion .Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. limited physical mobility and the goal was the resident would be free from complications related to immobility including contractures and skin breakdown admitted to hospice due to a dx of lung cancer .Resident has had actual falls and remains at risk of falls . interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Educate on use of walker, locking brakes on walker, and environmental check .Educate the resident family/care fall occurs .Hospital evaluation; Keep furniture in locked position: Provide visual cues in room. Record review of Resident #6's progress note dated 3/22/2025 at 11:45 AM reflected Resident had a fall this morning. Provider notified and other appropriate staffs also notified. Family will also be notified. Hospice also notified. Resident is oriented at baseline, knows her name and where she is but does not know what year it is. Neuro checks initiated. Resident found on the floor with knee twisted, Norco PRN given for reported pain- 6/10. Further review of clinical records revealed that a fall assessment was not completed for Resident #6. In an observation and interview on 04/01/2025 at 12:38 PM with Resident #6 revealed Resident #6 sitting on her bed and denied falls or hospital transfers or injuries. She denied pain or recent injuries. There were no observations of skin tears, bruising or pain facial grimacing at the time of the observation. In an interview with the ADON on 04/01/2025 at 3:45 PM, the ADON stated that nursing staff were responsible for ensuring fall interventions were in place and followed, by checking during routine rounds. She stated that LVN R was trained upon being hired for PRN nursing. ADON was notified by LVN R that Resident #6's fell on [DATE]. ADON said this fall was unwitnessed. ADON contacted LVN R by phone on 03/23/2025 and requested that she return to complete the assessment for the fall. LVN R agreed to return to the facility and complete the nursing assessment. ADON said that she was unable to complete the fall assessment in LVN R's absence, due to all gathered such as, vital signs, pain, and other fall protocol task were completed by LVN R, so the ADON waited for LVN R to return and complete on 04/01/2025 at 2:00 PM for her shift. The ADON said that she met with LVN R and conducted education and coaching regarding nursing assessments and protocols. The ADON said failing to complete an assessment could lead to the resident not receiving adequate interventions, monitoring, and supervision during the first 72 hours of the fall. In an interview with the DON on 04/01/2025 at 4:04 PM, the DON stated the fall assessment should reflect the actual functionality of the resident. She said if the resident had fallen, an assessment should have been completed and mirrored the fall note 03/22/2025. If the residents were not assessed, the proper care and needs would not be met. The DON said the expectation was the residents were assessed not only after the fall but monitor every day to see if there was a change in condition, or resident acting different than usual. She said she would coordinate with the ADON Nurse to educate, audit, and monitor assessment timeliness for resident care. In an interview with the Administrator on 04/01/2025 at 4:55 PM, the Administrator stated accurate assessments should be done to know what kind of care and services would be required. She said if the assessment were not completed, the needed care of the resident would not be met. She said the expectation was the residents would be assessed accurately to provide the appropriate care needed. She said he would coordinate with the DON and the ADON Nurse to educate, audit, and monitor resident assessments for timeliness and accuracy. Record review of facility policy, Fall Risk Assessments revised February 1, 2007, revealed Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The assessment tool should be scored, and interventions implemented as indicated. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. Interventions will be designed to maintain the resident's privacy. The facility will be responsible for ensuring training and ongoing education to facility personnel regarding identification of residents who are high risk for falls. After risk is assessed, individualized plans of care will be implemented to prevent falls. The Charge Nurse will investigate all falls. The nurse will complete an event report and forward to the DON or designee. Falls resulting in sentinel event will be reported to the DON. The DON or designee will be responsible for investigating all resident falls on a concurrent basis. The nursing department will be responsible for submitting a fall trend report. Appropriate education will be provided to all staff members as needed on fall prevention.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #6) of 3 residents reviewed for Respiratory Care. The facility failed to ensure that Resident #6's nasal cannula and tubing was off the floor, properly stored when not in use, and her humidifier bottle water was dated. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #6's Face Sheet, dated 04/01/25, reflected the resident was a [AGE] year-old female was initially admitted on [DATE], and again on 08/20/2024. The resident was diagnosed with alcohol dependence with alcohol induced persisting dementia (cognitive decline from alcohol use), Chronic pain, History of falling, benign neoplasm of left bronchus and lung (non-cancerous tumor in the lung). Review of Resident #6's Comprehensive MDS Assessment, dated 03/20/2024, revealed the resident BIMS score was 9, indicating she was moderately impaired cognitively. Functional Abilities and Goals revealed Resident #6 requires set up and clean up for oral hygiene and upper body dressing. She requires supervision and touching assistance for toileting hygiene, lower body dressing, putting on and taking off footwear, and personal hygiene. She requires partial moderate assistance with showering and bathing. The Comprehensive MDS Assessment indicated the resident was receiving hospice care. Review of Resident #6's Comprehensive Care Plan, dated 01/15/2025, reflected the resident was on hospice. One of the interventions was to monitor for signs and symptoms of respiratory distress. Review of Resident #6's Physician's Order, dated 12/05/2024, reflected Admit to hospice for lung cancer. Review of Resident #6's Physician's Order, dated 12/05/2024, reflected Ipratropium-Albuterol Solution 0.5 - 2.5 (3) MG/3ML .3 milliliter inhale orally as needed for SOB or wheezing via nebulizer. Observation and interview on 04/01/2024 at 12:38 PM revealed Resident #6 sitting on the side of her bed, awake. The resident nasal cannula and tubing were observed on the ground, and the water bottle was not dated. on oxygen therapy via nasal cannula at 3 liters per minute and was connected to an oxygen concentrator. The resident said it was okay to open his drawer. Inside the drawer, was a nebulizer with a breathing mask connected to it. The breathing mask was not bagged. The resident said she was given a breathing treatment every morning. She said the nurse would put it on and the nurse would take it off when it was done. She said she was not aware where the nurse would put it after the breathing treatment. She said she did not notice the tubing on the floor. In an interview on 04/01/2025 at 4:16 PM with LVN E, revealed LVN E was the charge nurse for the 2PM to 10 PM shift. She said all nursing staff are responsible for conducting rounds and monitoring resident treatment devices and equipment for safe operations and clean devices. All respiratory equipment should be dated, labeled, clean, and stored when not in use. She stated resident tubing found on the floor, or unbagged when not in use, should be removed, discarded, and installing new equipment and dating. She said the risk to the resident could result in respiratory infections or overuse of equipment. In an interview with the ADON on 04/01/2025 at 3:45 PM, the ADON stated the nasal cannula and tubing for respiratory equipment should be bagged when not in use. She said not bagging them could result in cross contamination and respiratory infection. She said the expectation was for the nursing staff to bag all the respiratory apparatuses used by the residents when not in use . She said she would coordinate with the DON pertaining to education and in-services about respiratory care. She said she would include checking on the respiratory apparatuses being bagged during her walk around and water bottles on the concentrator are dated. In an interview with the DON on 04/01/2025 at 4:04 PM, the DON stated the nasal cannula, tubing should be stored properly when not in use to keep them clean. She said if those breathing apparatuses were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and oxygen administration could be compromised. She said the nasal cannula and tubing should be discarded and replaced when found on the floor, undated, and not stored in a clean back with date. She said the nursing staff installing the humidifier bottles on concentrators should always be dated to prevent overuse. She said the staff should monitor during rounds and ensure the equipment was dated as soon as they saw it because they never knew when they could come back to the resident's room. She said moving forward, she would make an in-service and re-educate the staff about dating tubing, storing when not in use and ensure the bottle for the nebulizer was dated upon administering or replacing equipment. In an interview with the Administrator on 04/01/2024 at 4:55 PM, the Administrator stated everything that the residents were using should be kept clean to prevent infection. She said the expectation was for the staff to be trained proficiently, follow basic protocols, and ask if something needed clarification. She said they would monitor the staff and discuss the issue. Record review of facility's policy, Respiratory Policies and Procedures 2.0 Nasal Canula revised June 1, 2006, revealed Policy: Oxygen therapy via nasal cannula is administered as ordered by a physician .Oxygen is set up, delivered, and monitored by a licensed nurse or a respiratory therapist. Purpose: To provide oxygen concentrations (approximately 22-52%) at per minute Process: Replace entire set-up every seven day. Date and store in treatment bag when not in use If using a non-disposable humidifier, change bottle every seven days and change water every 24 hours to prevent bacterial contamination .date.

Based on interviews, observations, and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #2) of five residents reviewed for abuse. The facility failed to prevent Resident #2 from being abused by Resident #1 on the secure unit, who had a history of being verbally and physically aggressive to other residents. Resident #1 physically attacked Resident #2 which resulted in him being sent to the hospital and sustained a serious injury to his right eye on 12/29/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/29/24 and ended on 12/29/24. The facility corrected the non-compliance before surveyor's entrance. This failure could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 01/16/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses which included: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skill), unspecified, unsteadiness on feet, cognitive communication deficit, personal history of transient ischemic attack (a short period of symptoms similar to those of a stroke), and cerebral infarction (stroke) without residual deficits and personal history of traumatic brain injury (a head injury causing damage to the brain by external force or mechanism. It causes long term complications or death). Record review of Resident #1's quarterly MDS assessment, dated /30/24, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Resident#1 coded behavior for wandered daily. Record review of Resident #1's care plan, initiated 06/06/24 and revised 10/25/24, reflected: the resident was at risk for behaviors: [Resident#1] has a potential for maladaptive behaviors .Physical aggression toward others .Verbally aggressive. Interventions included intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Administer medication as ordered. Monitor/document for side effects and effectiveness. Record review of Resident#1 progress notes dated 05/09/24 to 01/16/25 reflected, Resident#1 had a history of being physically and verbally aggressive towards staff and residents. Progress notes reflected the incident on 12/29/24 was the first time a resident needed to be sent out to the hospital. On 07/04/24, LVN B reported: Resident verbally abusive with other residents calling them idiots and zombies On 07/09/24, LVN A reported: Ambulating in hall and stopped to yell at another resident that was confused On 7/12/24, LVN B reported: Resident yelling at other residents calling them idiots and stupid this nurse reminded resident that he needs to respect the other residents On 07/19/24, LVN B reported Resident yelling at another resident calling him a retard zombie resident redirected, resident walked away. On 08/12/24 LVN B reported Resident mocking other residents CNA explained to resident that he needed to stop that behavior . Resident yelling at resident from room [Resident#1] states I will kick his ass if he comes to my room . On 08/14/24, SSD reported SSD submitted referral to [Psy MD] for psych consult. On 08/20/24 LVN B reported On Gabapentin 300 for aggressive behavior, resident yelling at residents at dining room table. On 09/02/24, LVN B reported Resident verbally abusive with other residents On 09/04/24, SSD reported IDT team care plan carried out by [DON, DOR, ADON], . Family seeking possible admission to all male unit, wanting to stay localized, per family request . Referral sent to [Facility] per family request. On 10/20/24, LVN A reported [Resident#1] was observed unbuttoning and unzipping his jeans. He pulled his penis out and urinated on the floor. When ask to stop and go to his room he started yelling at staff. He was informed by this nurse . rest room. he was informed besides exposing himself to non-employees that it created a danger to residents staff. On 10/23/24, P Admin reported Resident observed displaying agitating and aggressive behavior towards staff and other residents. On 12/26/24, reported by LVN A [Resident#1] behaviors is getting worse and he is getting more aggressive both physically and verbally. Record review of Resident #1's progress notes and incident report in the EHR, dated 12/29/24 by LVN C , reflected: Nursing description: This nurse called to hallway when heard hollering and yelling, resident as on floor bleeding, when I approach him, he said he was ???? [sic]unable to comprehend, Full body assessment laceration on his head and eye area. Called 911 and police and advised admin and other in group text also called them, contacted [Family member], left message to call. Police came [PD #] to get report, and info. then EMS came and evaluated and took to [Hospital]. [Resident#1] stated he did nothing, the whole incident was witnessed by Housekeeping, had her write out a statement. Description of action taken: Immediately look to see where blood was coming from head and right eye. Record review of LA A's handwritten statement dated 12/31/24 reflected: To whom it may concern [LA A] was present when [Resident#1] was yelling down the hall he assaulted me. As [LA A] was putting linens in the closet on the unit. [LA A] looked down the hall and saw [Resident#1] push [Resident#2] down causing him to bleed. [LA A] yelled out for the nurse and she assisted [Resident#2]. Resident 21 was transported to hospital. Record review of police report, dated 12/29/24, reflected: injured persons report by [Resident#1] to [Resident#2]. Record review of Psy consults reflected: Record review of Psy consult, dated 10/28/24 reflected, Resident#1 increase Gabapentin for aggressive behavior. Continue Lexapro for depression. 10 mg, 1/2 tablet PO QD. Increase Neurontin 300 mg PO BID. Record review of Psy consult, dated 12/09/24 reflected Resident#1 started Depakote 250 mg, BID. Record review of Resident#1 January MAR reflected Resident#1 had received medication as ordered: Aricept Tablet 10 MG (Donepezil HCl) Give 1 tablet by mouth one time a day for Dementia. Depakote Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for Seizures and Aggressive Behaviors related to other seizures. Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for Aggressive behavior. 2. Record review of Resident #2's face sheet, dated 01/17/25, reflected an [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, muscle weakness (generalized), cognitive communication deficit, personal history of transient ischemic attack (a short period of symptoms similar to those of a stroke), and cerebral infarction (stroke) without residual deficits. Record review of Resident #2's quarterly MDS assessment, dated 12/30/24, reflected his BIMS score was 04, which indicated severe cognitive impairment. Resident#2 coded behavior for wandered daily. Record review of Resident #2's care plan, revised 9/30/24, reflected Resident#2 had behavior problem r/t dementia. Physical aggression towards other. Interventions included: Administer medications as ordered. Monitor/document for side effects. Record review of Resident#2's hospital records dated 12/29/24 reflected: Resident#2 had right forehead with small laceration, large medial lower lid laceration. Lower puncta was displaced for temporally, past the midpoint of cornea. Resident#2 had to have right lower eyelid canalicular repair, repair of laceration on 01/02/25. Record review of Resident #2's December 2024 progress notes reflected: On 12/29/24, LVN C reported [Resident #2] Full body assessment laceration on his head and eye area. Called 911 . PD Incident report [number]. On 12/30/24, LVN C reported [Resident#2] returned from [Hospital] Resident has sutures to right eye and head from his injuries on 12/29/24. On 01/02/25 resident returned from surgery has instructions for eye care and next 2 appointments this month. In an interview on 01/16/25 at 1:21 PM, LVN D stated she worked at the facility for almost 3 weeks. Resident #1 was on Q15 monitoring since the incident on 12/29/24 with Resident#2. LVN D did not see the incident on 12/29/24. LVN D stated she has not witnessed any behaviors since the incident. In an interview on 01/16/25 at 1:25 PM, CNA E stated she has worked in the facility for 3 months and Resident #1 had been verbally and physically aggressive toward residents and staff. CNA E did not witness the incident on 12/29/24. Resident#1 has been verbally aggressive and physically aggressive towards staff and verbal aggressive to residents CNA E stated she would redirect residents and the nurse on duty documents the Q15 monitoring. CNA E stated in the secure unit staff had to pay attention and stay alert to care for the residents. In an interview on 01/16/25 at 1:45 PM, LA A stated she heard two residents yelling at each other and saw Resident#1 push Resident#2. Resident#2 fell face first and it was a lot of blood. LA A stated she called for help and the nurse came and provided help. LA A stated she had not witnessed more behaviors recently. LA A stated she would yell for help for a nurse when residents were being verbally/physically aggressive to each other. Attempted to call LVN C on 01/17/25 at 5:40 PM and voicemail box was full. Attempted to call LVN B on 01/17/25 at 5:42 PM and left voicemail. Attempted to call LVN A on 01/17/25 at 5:45 PM and left voicemail. Record review of the facility's policy titled Abuse/Neglect, revised 03/2018, reflected in part the following: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, Definitions . Abuse is the willful infliction of injury . Willful, as used in this definition of abuse, means the individual must have acted deliberately . C. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect. The non-compliance was identified as past non-compliance (PNC). The IJ began on 12/29/24 and ended on 12/29/24. The facility had corrected the non-compliance before the state's investigation began. On 02/11/25 at 1:00 PM the Administrator, DON and Corporate Nurse were notified of the PNC IJ. The facility took the following actions to correct the non-compliance prior to the survey: Record review of incident/accident reports, from 12/19/24 to 02/11/25, reflected no other incidents involved Resident#1. Record review of in-service dated 12/29/24, reflected behavior management by DON to all staff members. Record review of Q15 monitoring dated 12/29/24 to 01/07/25, by LVN C and LVN D showed Resident#1 was checked on every 15 minutes and no behaviors were documented. Record review of order recap report dated 01/30/25 reflected, Depakote oral tablet delayed release 500mg (Divalproex Sodium) Give 1 tablet by mouth two times a day for Seizures and Aggressive Behaviors related to other seizures was increased by PCP. In an interview on 01/16/25 at 3:00 PM the Administrator and the DON stated the Administrator had worked in the facility since 12/29/24 and the DON had worked in the facility since 12/20/24. The and the DON stated Resident#1 had no aggressive behaviors since they started at the facility. The Administrator stated they were looking for placement for Resident#1. In an interview on 01/17/25 at 5:15 PM the Corporate Nurse and Administrator stated the facility had been searching for placement for Resident#1 and he has been denied placement because of his behaviors. The Corporate Nurse stated Resident#1 has not had behaviors since his Depakote has been increased. The corporate Nurse and Administrator stated Resident#1 was no longer on Q15 and he had no behaviors since the incident on 12/29/24. The corporate Nurse and Administrator stated Resident#1 was to be redirected when he displayed aggressive behavior, Resident#1 medications had been adjusted and Resident#1 was on Q15 monitoring for 72 hours. In an interview on 01/20/25 at 12:15 PM LVN D stated Resident#1 had not had any behaviors in the past month. Resident#2 was able to see out of his eye and has not wanted to come out of his room today. An observation on 1/16/25 at 1:30 PM both Resident#1 and Resident#2 were in their rooms asleep. Observation of the secure unit on 01/20/25 from 12:15 PM to 1:45 PM revealed: An attempted interview and observation on 01/30/25 at 12:30 PM, Resident#1 did not recall any incidents with the other resident. Resident#1 ate lunch and talked about his college. An observation on 01/30/25 at 1:15 PM revealed Resident#2 was in the bed asleep. An interview on 01/30/25 at 4:00 PM the Administrator stated Resident#1 had no behaviors since the incident and the facility was looking for placement for him and he was not accepted. In an observation on 02/11/25 in the secure unit from 5:30 AM to 9:00 AM revealed: In an observation on 02/11/25 at 5:40 AM revealed Resident#1 was no longer in the facility. In an observation on 02/11/25 at 6:30 AM revealed Resident#2 was awake in his wheelchair. Attempted to interview Resident#2 on 02/11/25 at 7:00 AM and he did not respond back. Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM with LA A, LVN C, LVN D, LVN F, CNA E (1st and 2nd shift) staff were able to provide competency regarding in-service over ANE and behavior management. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE and how to care for resident with physical and verbal aggressions. An interview on 02/11/25 at 5:45 AM to 9:30 AM with LVN B (overnight shift) and SC G, AD H, DON And Administrator (1shift) staff were able to provide competency regarding in-service over ANE and behavior management. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE and how to care for resident with physical and verbal aggressions. In an interview on 02/11/25 at 7:00 AM the Administrator stated Resident#1 was transported to the new facility on 02/10/25. Record review of Resident#2 follow-up appointment on 01/14/25 reflected: right eyelid laceration was healing well, no drainage. Continue current care, no change in current therapies. Forehead laceration was healed and no further treatment needed.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed for quality of care. The facility failed to ensure medication administration and storage protocols were implemented when the facility lost Resident # 1's medications (narcotics used for withdrawal symptoms) upon admission into the facility, which resulted in Resident #1 not receiving the medication and experiencing withdrawal symptoms. The noncompliance was identified as PNC. The noncompliance began on 02/10/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death. Findings included: Review of Resident #1's Face Sheet, retrieved on 03/05/24, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included uncomplicated Opioid dependence (a strong desire or need to use opioids, experiencing tolerance or withdrawal symptoms when opioids are not used without any significant physical or psychological complications due to opioid use), uncomplicated Psychoactive substance abuse (a condition in which the use of one or more substances leads to a clinically significant impairment or distress), and other toxic Encephalopathy (a neurologic disorder caused by exposure to various toxic substances). Review of Resident #1's MDS Assessment, dated 2/16/24, revealed the resident had a BIMS score of 15 suggesting the resident was cognitively intact. The resident's Mood Interview revealed the resident had expressed little interest or pleasure in doing things, felt down, depressed, or hopeless over a period of 2-6 days. Review of the facility's PIR, dated 2/20/24, revealed Resident #1 was admitted to the facility and the nurse misplaced Resident #1's medication. Review of Resident #1's Hospital Discharge orders, dated 2/10/24, revealed the resident was discharged from the hospital at 5:47 PM on 02/10/24. The medication list at discharge included buprenorphine-naloxone 4-1 mg Film with a start date of 02/09/2024 and an end date of 2/23/2024. The medication orders described the medication was to be taken daily for 14 days for opioid use disorder. Review of Resident #1's MAR for February 2024, retrieved on 3/05/2024, revealed orders for the medication Buprenorphine HCl-Naloxone HCl Sublingual Film 4-1 to be administered until 2/26/24. The MAR revealed the resident was administered the medication starting on 2/13/24 and subsequently daily until 2/23/24. The resident did not receive the medication on 2/24/24. The resident was administered the medication again on 2/25/24 and 2/26/24. Resident #1 missed a total of 5 doses of his ordered medication. There were no progress notes between 2/10 and 2/13 related to the missing medication. Review of Resident #1's Progress Notes with an effective date range of 2/04/24 to 3/06/24 revealed the following: Review of Progress Note dated 2/13/24 at 2:02 PM written by LVN C revealed a new admission follow-up assessment was conducted on Resident #1. The entry stated the resident had no complaint of pain and no aggressive behaviors were noted. Review of Progress Note dated 2/15/24 at 11:11 AM written by RN E revealed the resident had no complaint of pain. Review of Progress Note dated 2/16/24 at 11:26 AM written by LVN D revealed no concerns noted. Review of Progress Note dated 2/16/24 at 3:18 PM written by RN H revealed Resident #1 had no complain of pain at this time. Review of Progress Note dated 02/18/24 at 7:18 PM written by LVN E revealed Resident #1 was adjusting well to admission. Review of Progress Noted dated 2/22/24 at 2:24 PM written by LVN D revealed a call was placed to the pharmacy to refill Buprenorphine HCl-Naloxone HCl sublingual Film 4-1 mg for Resident #1. A pharmacy representative advised the nurse there were no refills. The nurse notified Resident #1's physician to send a prescription for the resident. Record review of RN G's personnel record revealed a current nursing license and a clear EMR. Interview on 3/5/24 at 9:23 AM with the facility Administrator during the Entrance conference revealed that RN G stated that she had the medication on the desk at the nurse's station while she was admitting Resident #1. The administrator stated RN G was conducting the admission and walked away and when she came back, she realized the medication was gone. The administrator stated that RN G called her around 3:00 PM Sunday, 2/11/24, to let her know the medication was missing. The administrator stated RN G provided her the name of the missing medication and when the Administrator looked up the medication, she realized the missing medication was not a narcotic. The Administrator stated that she confirmed with the pharmacy that the missing medication was not a narcotic. The Administrator stated she called the hospital that discharged Resident #1 to confirm the medications that were sent to the facility with Resident #1, and they told her that the medications the hospital pharmacy sent to the facility with Resident #1 were left at the resident's bedside at the hospital. The Administrator stated that RN G stated that she was almost certain she saw the missing medication before it went missing. Observation and audit on 3/5/24 at 12:45 PM of one of five medication carts. A count of the controlled substance medications and a review of the controlled medication log was conducted with MA A. No inaccuracies were noted. Observation and audit on 3/5/24 at 12:54 PM of two of five medication carts. A count of the controlled substance medications and review of the controlled medication log was conducted with MA B. No inaccuracies were noted. Interview on 3/5/24 at 1:25 PM with the DON revealed that only one of Resident #1's medication was missing. The DON stated the name of the medication was Naloxone. He stated Resident #1 missed two days of the medication. He stated that Resident #1 was assessed frequently for any side effects of the missed doses. The DON stated that during an interview with RN G, she stated that she left Resident #1's medication on the nurse's station desk in Station 2, walked away from the desk and when she returned, the medication was gone. The DON stated that Resident #1 was admitted into the facility on [DATE] around 7:00 PM, which was a Saturday night. The DON stated the missing medication was ordered from the pharmacy once it was discovered missing. He stated that because it was the weekend, the replacement took longer than usual. The DON stated the medication was controlled so they did not have it in stock at the facility. He stated that when a resident is admitted into the facility, their medication is counted to ensure an accurate medication count and that all medications are accounted for. The DON stated that it was common sense not to leave medication on the desk or cart unattended. The DON stated it was a risk to leave medication on the desk because it could go missing or a resident could take it, possibly causing harm to themselves. He stated the facility had regular in-service/training to educate the nurses on how to handle medication when the residents are admitted and how to store medications. The DON stated that Resident #1 did not suffer any adverse reactions because he was not previously taking the missing medication, so it did not matter if the medication was missed or that it was taken later than ordered as long as no harm came to the resident. Interview on 3/5/24 at 2:00 PM with RN G revealed that she had never completed a new admission and was unaware of the process. RN G stated that she was completing the admission for Resident #1 on the evening of 2/10/24 and that Resident #1's medication was next to her on the desk. She stated that when she was ready to put Resident #1's medication in the drawer, the medication was missing. RN G stated she notified everyone that need to be informed and that she was suspended pending an investigation. She stated that LVN F arrived at 7:00 PM and was also near the desk prior to the medication going missing. RN G stated that she received one-on-one in-service when she returned to work. She stated that narcotic medication should be locked immediately. RN G stated the missing medication was sitting on the desk throughout the admission. She stated the medication was in a box and the whole box of the medication was gone. RN G stated another nurse was supposed to do the new admission of Resident #1 but left it up to her to finish up. She stated that the missing medication was on the desk in Station 2. RN G stated that she must've walked away and when she returned, the medication was gone. Interview on 3/5/24 at 2:40 PM with Resident #1 revealed that he suffered withdrawal symptoms throughout the time he did not receive his medication such as bad nausea and bad stomach cramps. Resident #1 stated he knew his medication to control his withdrawal symptoms had been lost because he stated a staff member told him and he did not take it for a couple of days. He did not remember who the staff member was that told him. Interview on 3/5/24 at 3:34 PM with LVN D revealed that she relieved RN G and that the medication was already missing. She stated that RN G told her that the medication went missing from the nurse's desk. LNV D stated that her shift was from 6AM to 6PM and that she took over from RN G. LVN D stated that RN G told her that she had reported the missing medication to the DON and the Administrator. She said she herself did not report it because it was the responsibility of the staff member who lost the medication. LVN D stated that if she had lost the medication then she would have reported it herself. She stated that she looked up the missing medication and stated the medication was not life threatening so it was not an issue. LVN D stated she completed an assessment on Resident #1 because he was a new admission but did not complete any special assessments for Resident #1 regarding his missing medications. Interview on 3/5/24 at 4:37 PM with the DON revealed that he was informed about the missing medication on 2/11/24, on Sunday night. He stated the Administrator contacted him through a text message. The DON stated he called the Administrator immediately after receiving her text and the Administrator told him that she thought the missing medication was an over-the-counter medication. He stated that he called RN G and asked her to look for the medication and to call him back if she did not find it. The DON stated that RN G never called him back, so he figured she found the missing medication. He stated that when he returned to work on 2/12/24, he asked for Resident #1's medications and a staff member provided him with Resident #1's medications. The DON stated he did not realize that the missing medication was a controlled medication/narcotic until 2/13/24 at which time the police were notified. He stated that he did not ask RN G the name of the resident nor the name of the medication when he contacted her on 2/11/24. He said that on 2/12/24, a nurse called in the missing medication stat (immediately) to the pharmacy for a replacement. He said Resident #1 was not showing any signs of withdrawal. The DON stated that Resident #1 was assessed and was only found to be fatigued. Interview on 3/5/24 at 4:59 PM with LVN F revealed he did not participate in Resident #1's admission into the facility or his care. Record review of the facility's Ordering Schedule II Controlled Medications policy dated 2003 showed, Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications Record review of the facility's Medication Administration Procedures policy dated 2003 showed, Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence . Record review of the facility's Diversion of Medications policy dated 2003 showed, Immediately following the diversion 1. Notify administration or person in charge 2. Notify the police. 3. Notify the Consultant Pharmacist. 4. Screen employees who had potential contact with the missing medication 5. Notify the IP as required. 6. Itemize as closely as possible the items removed . The facility implemented the following interventions to address the non-compliance: Review of the facility's employees' drug tests conducted on 2/15/24 revealed 4 staff were tested yielding negative results. Review of four of the facility's medication cart audits conducted on 2/15/24 revealed no inconsistencies in medication counts. Review of the facility's AD Hoc QAPI meeting sign-in sheet dated 2/14/24 revealed the following contributors attended the meeting: Administrator, DON, ADONs, Medical Director, Social Worker, Dietary Manager, and Activity Director. Review of the facility's one-on-one in-service (training) titled Mishandling of Control Medication upon admitted d 2/15/24 provided to RN G indicated RN G understood that when a resident is admitted with narcotic medications, the admitting nurse must confirm the count with one other nurse and secure the medication under lock as soon as it is confirmed correctly. Narcotic medication should not be left out unsupervised under any circumstances, it must be double locked immediately. Any inaccuracy should be reported immediately to the administrator and DON. Review of the facility's in-service (training) titled Ordering Schedule II Controlled Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting. Review of the facility's in-service (training) titled Medication Administration Procedures sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting. Review of the facility's in-service (training) titled Diversion of Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting. Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Medication counting procedure: Outgoing nurse and med aide must count together to make sure the count is right/correct and log in control meds at the time of meds administration. The sign-in sheet revealed 20 staff members were in attendance. Review of the facility's in-service (training) dated 2/14/24 conducted by the DON described the subject matter as, Medication Reconciliation. The sign-in sheet revealed 24 staff members were in attendance. Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the DON described the subject matter as, Drug Diversion/Storage. The sign-in sheet revealed 28 staff members were in attendance. Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Timely reporting of incorrect control count/diversion/robbery immediately to DON/Admin (management). The sign-in sheet revealed 19 staff members were in attendance. Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, When a resident admits with a narcotic medication or a narcotic medication is delivered from the pharmacy the medication count must be confirmed by 2 nurses then secured under double lock as soon as the medication arrives and A narcotic medication should never be left out unsupervised under any circumstances. The sign-in sheet revealed 32 staff members were in attendance. 1. Review of the facility's Drug Diversion Monitoring in which the DON and/or designee monitored the medication carts for 19 days to ensure the count sheet for all medication carts matched the doses remaining in the medication cards revealed no discrepancies were found as evidenced by the DON and/or designee's signatures. Drug Diversion Monitoring was conducted on the following dates: 2/14/24 through 2/25/24 and 2/27/24 through 3/04/24 for a total of 19 days.

Based on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident that residents received treatment and care in accordance with professional standards or practice, the comprehensive person-centered care plan and the residents' choices for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure fall protocols were implemented when Resident # 1 was found on the floor on 9/15/23. The noncompliance was identified as PNC. The noncompliance began on 9/15/23 and ended on 9/16/23. The facility had corrected the noncompliance before the survey began. This failure could residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death. Findings include: Record review of Resident #1's face sheet, dated 9/26/23, revealed a [AGE] year-old male, who was readmitted to the facility on [DATE] with diagnoses which included hypertensive heart and chronic kidney with heart failure, dementia, osteoporosis and Vitamin D deficiency. Record review of Resident # 1's MDS change of condition Assessment, dated 8/30/23, revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. The resident required extensive assistance of two people in bed mobility, transfers, dressing, personal hygiene, and toileting. The resident required one person assist for supervision with eating. Record review of Resident # 1's Care Plan on 9/26/23 revealed the following, not limited to: Resident #1 was at risk for falls due to impaired mobility, cognitive deficits, and dementia with a goal of falls will be minimized to the greatest extent possible. Interventions included: encourage and assist Resident #1 with toileting prior to putting Resident #1 to bed, encourage the resident to participate in activities that promote exercise to strengthen mobility and strength, floor mat to be placed while resident is in bed, frequent monitoring, ensure call light is in reach, staff to redirect as needed, IDT meeting to review medications, scoop mattress, staff in-service on fall prevention and protocol, bed in lowest position, ensure resident has appropriate footwear when ambulating or in his wheelchair, and so on. Record review of the facility's Provider Investigation Report, dated 9/21/23, involving Resident #1 revealed Resident # 1 had a fall on 9/15/23 that was unreported, and the resident was placed back in bed. On 9/16/23 at 9:50 AM Resident # 1 was noted to have decreased movement, guarding his arm and a small bruise on his arm. Pain medication was administered, MD notified, and X-ray ordered. Resident # 1 was transferred to the hospital on 9/16/23 after the x-ray results came back which indicated fracture to left forearm. Record review of the Medication Administration Record (MAR) in the electronic medical record for Resident # 1 revealed he received his routine dose of Tramadol 50 MG for pain twice on 9/15/23 and twice on 9/16/23. The AM and PM doses were administered by LVN E on 9/16/23. Record review of Progress Note dated 9/16/23 at 10:22 AM written by LVN E revealed, During AM care this resident was noted to have a discolored area on the upperback of his (L) arm. Guarding of the arm present and it appears painful to move. MD notified and stat xray ordered., ADM. DON and Dtr [name] notified of findings and new order from MD. Head to toe assessment completed and no additional skin issues present. Record review of Progress Note dated 9/16/23 at 10:25 AM written by LVN E revealed, Resident has received his routine pain medication and is showing no signs of pain unless his arm is moved. Is up in w/c after incontinent care and assist with dressing completed. Resident propels self and is talkative to staff. Is holding (L) arm steady with (R) hand and lifting (L) arm with (R) hand. No s/s or c/o pain unless he forgets and attempts to move (L) arm without assist of his (R) hand. NVS started per facility P & P. Record review of Progress Note dated 9/16/23 at 3:02 PM written by LVN E, revealed, Radiology here x-rays of (L) shoulder and humerus completed. Results pending. Record review of Progress Note dated 9/16/23 at 5:15 PM written by LVN E revealed, Results of x-rays received and reported to MD. Awaiting orders. Resident starting to display signs of increased pain. PM dose of pain med administered and request for increased pain med or added PRN med sent to MD. Record review of Progress Note dated 9/16/23 at 5:24 PM written by LVN E revealed, Order received from MD to send to ED for eval and TX, daughter notified of MD orders. Observation on 09/26/23 at 5:03 PM of Resident #1 revealed the resident was in his room on the scoop mattress with the bed at the lowest position. There were green cushion booties on his heels and a pillow under his lower leg. A fall mat was observed on the floor next to the bed. Interview on 09/26/23 at 10:31 AM with the Administrator revealed Resident #1 had a fall on 09/15/23 around 9:40 pm. She stated this occurred on the 2-10 shift. The 2 CNAs CNA D and CNA F found him in the restroom of his room on the floor. The Administrator stated both CNAs picked him up and put him in bed, but they did not tell the nurse. Per the night shift CNA, Resident #1 slept through the night on the 10pm to 6am shift. On 9-16-23 the CNAs on the 6AM-2 PM shift went in and noticed Resident #1 was guarding his arm, grimaced and had a bruise so she went to tell the nurse. She stated the nurse came to see and called the doctor and got a notice for a stat x-ray. The Administrator stated the nurse medicated him and when the x-ray tech came the aide CNA D who had worked 2 PM-10PM on 9/15/23 was now working the 6AM to 2PM shift on 9/16/23. The x-ray tech went to put the board under [Resident # 1] and he groaned which was when CNA D told the Activity Director Resident #1 had fallen the night before and they got him up. The Administrator stated that was when she was notified of the fall. The Administrator stated she called the nurse who worked 2-10PM shift on 9/15/23 and asked him why there was no documentation on the fall, and he said neither aide told him about the fall. The Administrator stated she called and asked CNA F if there was any incident last night and she said no and but when asked if anyone fell and CNA F stated ,yes, Resident #1 did. The Administrator stated she removed both the aides from the schedule and sent them up for a write-up and for in-service education. They had to pass a post test before they could come back to work. She stated she did in-services with nursing as well and with the entire building (dietary, housekeeping, etc) with the emphasis on if there was a resident is on the floor, do not touch them. Interview on 09/26/23 at 1:55 PM with CNA A revealed she had been in training for a few days since she had just started today (09/26/23). She stated during her orientation, she was trained on fall protocols. If a resident was found on the floor, CNA A was to report it to the charge nurse and not touch the resident. Interview on 09/26/23 at 2:00 PM with CNA B revealed he was in-serviced on fall protocols. He stated if a resident was found on the floor, CNA B was to report it to the charge nurse and not touch the resident. He stated the resident could have broken bones and moving them could hurt them. He stated the facility had him take a competency test on fall protocols. CNA B stated Resident #1 was currently in bed and had sustained a fracture. CNA B stated Resident #1 received pain medication for it and the resident was currently back on hospice. Interview on 09/26/23 at 2:42 PM with LVN C revealed she and the facility staff did frequent checks on Resident #1. She stated Resident #1 would not keep his sling on. She stated the resident had a left humerus fracture and broken ribs on the left side. She was given an in-service on falls and with the nurses, the facility reviewed fall assessments and other fall protocols. She had to pass a post-test. Interview on 09/26/23 at 2:50 PM with Resident #1 revealed he was not in any pain at the moment and did not recall being in any pain when he fell . Resident # 1 was unable to provide any details about his fall. Interview on 09/26/23 at 3:04 PM with CNA D revealed she worked on the shift Resident #1 fell . The other CNA (CNA F) found Resident #1 on the floor. CNA F came to look for CNA D to help her. CNA F stated she told the nurse so CNA D thought the nurse was notified of the fall. CNA D was suspended and in-serviced. She was in-serviced on if a resident was on the floor to not touch them at all and to hurry up and notify the nurse. She stated she was not to move the resident until the nurse completed the assessments. CNA D stated Resident #1 stated he was okay and he was trying to get himself up by himself. She stated he said he was not in pain. CNA D stated she had to take a test and review the information. CNA D stated the interventions done for Resident #1 were to lower the bed and check on him often. She stated he tried to stick his legs out from the bed and CNA D would help him get repositioned and sit up in the bed. Resident #1 had not gotten up out the bed since he came back from the hospital. CNA D stated Resident #1 received bed baths, because of the fracture on the arm Resident #1 could not be leaning on the side of the fracture. CNA D would give him a pillow for his arms and for his legs. Interview on 09/26/23 at 3:56 PM with LVN E revealed she worked the Saturday morning shift (09/16/23). The morning CNA came and informed her Resident #1 had a bruise on his arm and he seemed to be in pain. LVN E immediately went to check on the resident and he yelped when LVN E touched his arm. She stated she had given him his morning meds and he was in bed so she didn't notice initially that Resident #1 was in pain. It was the aide who noticed the bruise when they were getting him dressed. LVN E stated she could tell by the way he was holding the arm it was possibly fractured. LVN E stated she called the doctor and got the x-ray order. Resident #1 was not really able to give a pain scale number of the pain but it was not like him to seem like he was in pain so she knew something was wrong. Currently, Resident #1 was on a low bed and if he was awake, staff tried to keep him in the line of sight. Facility staff checked on him often. He had not gotten up out of bed since he came back from the hospital. LVN E stated the facility had not used a fall mat for him recently because he had one before, but he tripped and fell over it. LVN E stated she did not know for sure if Resident #1 had not gotten up to sit in a chair, just that he had not gotten up on her shift. Resident #1 had a sling ordered but he would take it off and curse and refuse to put it on like he should. When LVN E asked him what happened regarding his fall, Resident #1 stated the quarterback spun him around and slammed him. LVN E was in-serviced and had to take a post-test. LVN E stated she did put in the nurses notes that she did a head-to-toe and pain assessment. Resident #1 could not say his pain level. LVN E gave Resident #1 his night dose of Tramadol early about 6:00 PM before her shift ended. It was not due till 8pm. LVN E stated she did not think he had prn pain meds at that time. She communicated to the evening nurse to contact the MD to get more pain meds ordered. LVN E stated she got the okay from the MD to send Resident #1 out to the hospital before the x-ray results came back. By the time the paramedics came the x-ray results were back so LVN E gave a copy to the paramedics. Interview on 09/26/23 at 4:32 PM with CNA F revealed she and another aide (CNA D) were looking for another resident when they came across Resident #1 getting up off the floor in his room. Resident #1 was talking and said he was okay. CNA F asked him if he fell or if he put himself on the floor. CNA F stated Resident #1 was trying to brush her and CNA D off. CNA F insisted she help him because she did not want him to fall again. CNA F stated if he did fall, then she made a mistake in getting him up. She stated she did not know residents with dementia could break a bone and would not know they were in pain. CNA F was in-serviced on if a resident was on the floor or trying to get up from the floor to get the nurse right away. CNA F stated she was to not touch the residents and encourage the residents not to get themselves off the ground. CNA F stated she was suspended and written up. CNA D also had to complete a post-test. Some of the interventions for Resident #1 was to check him very often and keep his bed low. CNA D stated she tried to keep him comfortable. Record review of the facility's one on one in-service (training) titled When a Resident Fall was provided to CNA D on 9/16/23 indicated a Resident was not to be touched or moved, and the nurse was to be notified immediately of any resident fall. Record review of the facility's one on one in-service (training) titled Reporting Incidents immediately was provided to CNA F on 9/16/23 indicated a Resident was not to be touched or moved, and the nurse was to be notified immediately of any resident fall. If resident tried to get up on their own, the aide was to attempt to redirect and if the resident was successful, then aide was to report all facts to charge nurse immediately. Record review of the facility's In-service for all staff on Fall Events, fall prevention, Abuse, Injury of Unknown origin, when a fall was to be reported to nurses were conducted on 9/16/23 by the ADM and DON. Record review of additional in-services dated and completed on 9/18/23, revealed In-services were conducted by ADM and DON with nurses only on completion of neuro checks and post-fall documentation. Record review of staff Post Test revealed 83 staff members successfully passed the test from 9/16/23 to 9/18/23. The test had 11 questions covering the topics of abuse, falls, pain and where to look to determine a resident's plan of care and ADL needs.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for skin integrity. The facility failed to identify drainage, blisters, and redness to Resident #1's right thigh surgical incision. The Wound Care Nurse failed to transcribe Resident #1's physician's orders on 04/20/23 for the treatment of his surgical wound on the bottom of his amputated leg when the wound was draining. The deficient practice could affect residents with skin conditions and place them at risk for not receiving the appropriate care and services. Findings include: A record review of Resident #1's face sheet reflected that Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, fluid overload, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, generalized edema , and acquired absence of right leg below knee. A record review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected, Resident #1 had a BIMS score of 09, which indicated the resident's cognition was moderately impaired. Further review of the MDS section M1040. Other Ulcers, Wounds, and Skin Problems revealed Resident #1 had open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion). A record review of Resident #1's Care Plan dated 04/04/23, revealed a focus in integumentary and that Resident #1 had actual impairment to skin integrity r/t: surgical procedures [as evidence by right below the knee amputation bilateral] inguinal surgical incisions BL thigh surgical incisions skin tear to hand. The goal included Resident #1 will have no complications [related to] his surgical sites through the review date. Interventions included Follow facility protocols for treatment of injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration (occurs when skin is in contact with moisture for too long) etc. to MD . A record review of Resident #1's Physician Discharge Summary, dated 04/03/23, revealed there were no wound care orders. An observation and interview on 04/25/23 at 8:50 AM revealed Resident #1's bed sheet had circular shaped light yellow and pink stains. Resident #1 stated the stains were from discharge from the wounds on his amputated leg. The resident pulled up his right pant leg and at the bottom of resident's below knee amputated leg there appeared to be an open wound. On his right thigh of the amputated leg there was a bordered dressing that was half attached to the surgical incision site. The bordered dressing was dated 04/20 and had the Wound Care Nurse's initials. Resident #1 was observed to take off the bordered dressing on his thigh. The back of the bordered dressing had come off and was stuck to Resident #1's surgical incision site on his thigh. When Resident #1 was asked if there was a dressing on the end of his amputated leg, he stated the bandage (dressing) came off when he used the bathroom , and he could not stick it back on. Resident #1 stated he asked the male night nurse (identified as RN C by the facility's schedule)for wound care last night/early morning because there was discharge coming from his wounds on his leg and his bandages would not stay on. Resident #1 stated he was told by the night nurse that wound care would be provided by the wound nurse. Resident #1 stated RN C would not check the wounds even though he explained they were draining, and the dressing was off. He stated since RN C would not provide care, he asked RN C to at least provide bandages, so he could cover the wounds himself. He stated RN C gave him two bandages. Two bordered dressings were observed on Resident #1's bedside table. One bordered dressing was slightly larger than the other. Resident #1 stated the large dressing was for the bottom of his amputated leg and smaller one was for his thigh . Resident #1 stated he was going to take a bath and put on the bandages. Attempts were made to contact RN C. The Investigator left a voicemail providing a contact number. RN C did not call back. A record review of Resident #1's clinical record revealed a Progress Note dated 04/10/23 by LVN B, which reflected, resident refused wound care. A record review of Resident #1's TAR revealed there were no treatments for the surgical incision sites on the bottom of Resident #1's amputated leg and thigh. A record review of Resident #1's Weekly Skin Assessments completed by LVN B, dated 04/10/23, 04/12/23, and 04/19/23, revealed there were no surgical incisions or skin issues documented for Resident #1. In an observation and interview on 04/25/23 at 12:55 PM, LVN A stated she looked through Resident #1's clinical records and stated she did not see any orders for treatment of Resident #1's surgical incision on his right thigh. Resident #1 pulled his pant leg up and the piece of the bordered dressing that was stuck to the incision site on resident's thigh from the previous observation was no longer there. Resident #1's incision site revealed a cluster of blisters (fluid filled sacs). LVN A was observed to look at the incision site on Resident #1's thigh and confirmed there were blisters at the incision site and stated the surrounding area looked as if it could be opened. Resident #1 was asked if the Investigator could take a picture of the wound, which he replied yes. Resident #1 stated the Wound Care Nurse was providing wound care daily. He stated the nurse used a cleaner, cream, and then put bandages on the wounds. Resident #1 stated the wound nurse had not been back since 04/20/23. The DON entered Resident #1's room and LVN A told him there were no orders for the surgical incision sites and Resident #1 was complaining of drainage. The DON stated he would complete a skin assessment for Resident #1 and contact the MD for orders. The DON stated the Wound Care Nurse was on [NAME] duty, and in her absence the nurse's were responsible for providing wound care to their assigned residents. In a phone interview with the Wound Care Nurse on 04/26/23 at 12:49 PM, she stated on 04/20/23 Resident #1 came to her in the hall and said his wound was draining. She stated she examined the surgical incisions on the bottom of Resident #1's amputated leg and thigh. She stated the surgical wound on the bottom of his amputated leg was draining so she contacted the MD and got orders for treatment. The Wound Care Nurse stated she did not put the physician orders into Resident #1's clinical record, nor did she document she had spoke to the physician in Resident #1's clinical record. She stated she was supposed to add the orders and document in Resident #1's clinical record. When she was asked about the surgical incision site on Resident #1's thigh, she stated there was slight drainage coming from it but denied seeing any blisters. The Wound Care Nurse stated she had observed scar tissue at the incision site on Resident #1's thigh, but it was not raised nor had blisters. She stated she had no observed the site, since 04/20/23 becasue she was out on [NAME] duty. The Wound Care Nurse denied providing any treatments to Resident #1's thigh. She stated she would only put barrier cream on it because the skin was flaky. When the Wound Care Nurse was asked why there was a dressing observed on Resident #1's thigh dated 04/20 with her initials, which she confirmed were her initials, she stated she did not recall providing treatment to Resident #1's thigh. When the Wound Care Nurse was asked why she did she not notify the MD about the drainage coming from Resident #1's thigh when she spoke to him about the drainage coming from the bottom of his amputated leg, she stated she was focused on the bottom of Resident #1's amputated leg because it had the most drainage. The Wound Care Nurse stated she should have notified the MD about Resident #1's thigh as well because it did have drainage. In an interview on 04/26/23 at 2:30 PM LVN B stated he did document the Progress Note on 04/10/23 in Resident #1's clinical record. He stated the Wound Care Nurse had asked him to complete wound care on Resident #1 because she was really busy that day. LVN B stated the Wound Care Nurse told him to use wound care cleaner, which was a basic saline, to clean the bottom of his amputated leg and thigh. He stated the Wound Care Nurse told him to use a 4x6 dressing for the bottom of the amputated leg and 4x4 dressing for his thigh. LVN B stated he attempted to complete the wound care but Resident #1 refused and he documented. He stated he recalled doing wound care one more time after 4/10/23 . He stated he had followed the same instructions. LVN B stated he completed the Weekly Skin Assessments on 04/10/23, 04/12/23, and 04/19/23. He stated he filled them out incorrectly and did not document Resident #1's surgical incisions on the bottom of his amputated leg and thigh. He stated he did not observe Resident #1's skin on 04/19/23 but had observed Resident #1's skin several times before and was aware of his surgical wounds. LVN B stated he just made an error in completing Resident #1's skin assessments. He stated the risk to the residents from the error was that the residents may not receive appropriate care or treatment. In an interview on 04/26/23 at 1:53 with the DON and Regional DON, they were asked if the physican had provided orders for surgical incision site on Resident #1's thigh. The DON stated no and the physician had only provided orders for the site on the bottom of Resident #1's amputated leg. The DON and the Regional DON were shown the picture of the Resident #1's surgical incision on his thigh. The DON stated he was unaware of this and he had assessed the surgical site located on the bottom of Resident #1's amputed leg. The Regional DON stated the Wound Care Nurse should have notified the MD about the drainage on Resident #1's thigh, when she spoke to him on 04/20/23. She stated the Wound Care Nurse was probably focused on the bottom of the amputated leg because it was more concerning. The DON stated he would assess the area and notify the MD to get orders. The DON stated he would in-service staff . On 04/26/23 the Regional DON was asked for a wound care policy and stated the facility did not have a wound care policy. She stated their procedures regarding wounds, pressure or non-pressure wounds, were to follow physician orders. The Regional DON provided a policy titled Skin Integrity Management. The Investigator pointed out to the Regional DON that on the bottom of the policy titled Skin Integrity Management it reflected, Wound Care Policy & Procedure Manual 2003 and asked was there in policies from the manual regarding process of identifying and reporting wounds and she stated no. In observations and record reviews a sample of residents were reviewed for wound care and there were no issues with the other residents. A record review of the facility's policy titled Skin Integrity Management from the facility's, dated 10/05/16 revealed it did not address skin integrity concerns regarding surgical wounds or incisions. The policy revealed General Guidelines . 1. If pressure causes changed in the resident's skin, it is the responsibility of the charge nurse to document on the 24-Hour Report form and initiate Protocols for Pressure Sores. Notify the Treatment Nurse/designee, then do an assessment and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified and treatment applied. 2. [Pressure Sore, Localized Rash and Skin Tears may be utilized if the attending physician has approved.} Long Term Care Protocol drives an assessment and gathers information for reporting and permits treatment to being in a timely manner. If the attending physician has not approved these protocols, continue with the protocols in this policy and procedure until an order can be obtained.

Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings include: A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers. A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift. A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on 01/18/23 at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter. An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell . In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know. A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

Based on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with the comprehensive assessment, professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one resident (Resident #1) of four residents reviewed for wound assessments. The facility failed to assess and document a detailed description of Resident #1's wounds on admission. The facility failed to ensure that Resident #1 was turned and repositioned every 2 hours. Resident #1 was discharged to an acute care facility and diagnosed with an unstageable pressure ulcer on his sacrum which required debridement in the OR. This failure could place residents at risk for unidentified development of new wounds and unidentified deterioration of existing wounds/skin injuries. Findings include: Review of Resident #1's clinical records admission record, dated 1/12/2022 reflected a [AGE] year-old male admitted to the facility 1/12/2022 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/26/2022 Resident #1 was discharged to an Acute Care Facility for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's admission skin assessment, dated 1/12/2022 revealed a description of skin issue as area on bottom. The entry lacked components of a complete assessment such as location, color, description of the presence or absence of drainage and the presence or absence of odor. Review of Resident #1's baseline care plan, dated 1/12/2022, revealed the absence of a pressure ulcer. Resident has an indwelling foley catheter and bowel incontinence. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of transfer documents from the Acute care facility dated 1/12/2022, revealed Resident #1 had a resolved sacral pressure injury at the time of discharge. Review of Resident #1's admission MDS, dated [DATE], revealed no cognitive impairment as indicated by a BIMS score of 15. He required extensive assistance of two people for bed mobility/transfers, and the assistance of one person for dressing and personal hygiene. Section E of the MDS related to behaviors, reflected Resident #1 has rejected care 1 - 3 days. Section M of the MDS related to skin conditions, reflected the resident had an unstageable deep tissue injury to his left heel was present on admission, no additional documentation provided. Review of Resident #1's weekly skin assessment completed by LVN D, dated 1/19/2022 revealed a wound on the sacrum, described as dark blackish-purple and measured 13x12cm appearance like a Kennedy (sudden onset, indication of skin failure associated with the dying process) pressure ulcer . The wound caused pain for Resident #1. Physician was contacted, orders received. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of TAR dated January 2022 reflected the treatments were provided as initiated on 1/19/2022. Review of the clinical record revealed no additional documentation of the appearance of the wound after 1/19/2022. Nodocumentation of refusals to reposition found in the clinical record. No documentation of notification of physician regarding Resident #1's refusal to reposition. Resident #1 was discharged to acute care, prior to the next scheduled weekly skin assessment. Review of Admission Assessment written documentation from the Acute Care Facility dated 1/26/2022, the wound on Resident #1's sacrum was described as very deep (unstageable) and involved muscle and bone (full thickness.) The wound bed measured 8x9cm, 100% soft black eschar (deep scab-like band of tissue) with malodor (foul odor), purulent (pus) drainage. Review of Physician Note from the Acute Care Facility dated 1/31/2022, Resident #1 was taken to the OR for debridement (removal of dead tissue) of the wound on his sacrum. In an interview on 2/7/2022 at 2:55 PM, CNA B stated Resident #1, did not like to be turned and he would not let us turn him. Would let the nurse know when this happened. In an interview on 2/7/2022 at 4:00 PM, CNA A, stated Resident #1 he did not recall seeing Resident #1 off his back when he assisted with his care. In an interview on 2/8/2022 at 2:03 PM, CNA C stated Resident #1's bottom was okay-nothing was open when he first got here. He was always laying on his back, he would not turn off his back because of pain. On 1/19/2022 noted a reddened area on his sacrum and reported it to the treatment nurse. In an interview on 2/8/2022 at 2:37 PM DON, stated the physician did not believe the wound was a Kennedy ulcer, based on the clinical picture of the resident. When performing the admission skin assessment, the skin is to be examined head-to-toe, which includes examination of the resident's bottom. Documentation of recent and new injuries to the skin including a description of the location and appearance. Admission skin assessments are completed by the treatment nurse when available. The assessment of skin on admission tells us how they were when they came into the facility. When a resident refuses treatment such as repositioning it is important to determine the reason for the refusal, educate them on the risk and document the refusal. In an interview on 2/8/2022 at 3:10 ACRN stated during his hospitalization he developed 3 pressure injuries Lt. and Rt. ischium and sacral each wound was healing well. Upon hearing that he was in the ER, she rounded with the physician and was surprised to see the extent of the deterioration that occurred since leaving the hospital on 1/12/2022. In her opinion it appears as if he had not been turned for the past 2 weeks. In an interview on 2/9/2022 at 3:35 PM LVN D, stated when completing the admission skin assessment for Resident #1, examination of his buttocks was not performed. LVN D, stated that the resident preferred to be on his back and he had refused to be examined earlier in the day she hurried to get it done. LVN D, stated it's important to look at a new resident's buttocks as that area is prone to pressure injuries. LVN D stated the assessment should be documented as that is our baseline for the condition of the skin when they enter the facility. LVN D, stated the assessment of his bottom was not done as it was late, and she was distracted. LVN D provided the treatments as ordered by the physician and explained that when the condition of a wound changed, documentation was required. LVN D did not assess the wound prior to discharge to the acute care facility. In an interview on 2/9/2022 at 5:03 PM Adm, stated the expectation that the admission skin assessment is to be a through head-to-toe assessment. Documentation of all skin issues, including evidence of a recently healed skin issue/problem. Documentation should contain a description of what is seen and its location, what can be done or is needed to either maintain or improve the condition. This is important as it provides a record of the residents' skin when they arrived. The nurse is to document when a resident refuses care or treatment including repositioning. Review of Skin Management Practice Guidelines revised, 7/2017 revealed .documentation of identified skin issues must include a description of the issue, its location the absence or presence of drainage.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for one (Resident #1) of four residents reviewed for abuse. The facility failed to prevent Resident #1 from being physically abused. On 12/09/19 Resident #1 was forcefully shoved by CNA A, causing her to fall. As a result of the fall Resident #1 sustained a fractured right femur (upper leg bone). This failure could place residents at risk for physical abuse and injury. Findings included: Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had re-entered the facility on 03/08/19 from the hospital. The resident had a BIMS score of 12, indicating moderate cognitive impairment. The resident required supervision with set-up help only with all ADLs. The resident's balance during transitions and walking was not steady but she was able to stabilize without staff assistance and normally used a walker. Resident #1's active [DIAGNOSES REDACTED]. Review of Resident #1's Care Plans revealed the following: 10/15/19: Resident #1 was dependent on staff for meeting emotional, intellectual, physical and social needs r/t cognitive deficits. 10/15/19: Resident #1 had an ADL self-care performance deficit r/t dementia fatigue, impaired balance. Review of the facility's Incident/Accident report for the incident on 12/09/19 involving Resident #1 dated 12/09/19 reflected, Found on Floor 12/09/19 at 5:10 AM. (LVN C) found resident on floor. Normal breathing, no negative vocalization, smiling or inexpressive facial expression, relaxed body language, no need to console. Alert. Non-ambulatory. Oriented to person, oriented to situation. EMT admin prn pain med via IV prior to departure. Environmental factors: poor lighting. Predisposing physiological factors: impaired cognitive status, confused. Found in hallway. Predisposing situation factors: wandering. Pt noted without cane. No witnesses found. Notified physician on 12/09/19 at 0600. Review of Resident #1's nursing note dated 12/09/19 at 7:18 AM revealed at 5:15 AM Resident #1 was found on the floor outside of room [ROOM NUMBER] sitting upright on her left side. Resident #1 complained of right hip pain and stated she fell . When asked to rate her pain, Resident #1 rated pain 10/10 and stated she thought her right leg was broken and could not move. No obvious head injury, bleeding, or dislocation of any extremities noted at time found. Emergency call made, and resident taken to hospital. Patient given routine [MEDICATION NAME] by mouth prior to leaving with EMT. Notifications made to physician and family. Review of the facility's provider investigation report dated 12/13/19 indicated on 12/09/19 at 5:00 AM, Resident #1 claimed she was pushed by CNA A early that morning. Resident #1 was sent out to the hospital and the hospital informed the facility of a [MEDICAL CONDITION]. Upon learning of the allegation, the Administrator reviewed security camera footage that captured the event. At approximately 5:00 AM the camera showed Resident #1 being pushed out of a room into the hallway by CNA A. Resident #1 fell to the floor and CNA A shut the door to the resident room and remained inside the room, leaving the resident on the floor in the hallway, alone. Minutes later, CNA A continued to walk past Resident #1 on the floor without trying to help her. No other facility staff were present. CNA A wrote a statement and denied what happened. The floor nurse arrived to determine/assess the resident since she was on the floor. CNA A did not cooperate further with the investigation and was terminated from the facility for acting in an abusive manner toward a resident. The local Police Department was assisting with data collection. The facility to in-service staff regarding abuse. During an observation and interview with Resident #1 on 12/11/19 at 9:40 AM, Resident #1 said , Someone wasn't nice to me. Resident #1 said she had left her coat in another resident's room and went to get it early in the morning. This obnoxious person (the aide) opened the door and pushed me, and I fell on my butt. The aide said, ''Get out! You can't come in here!' Resident #1 said her right hip was broken and the left hip was very sore. She said her hips started hurting when the aide pushed her and caused her to fall . The aide handed me my coat, grabbed my arm and shoved me, and I went to the floor. My right hip popped and my elbows are bruised. She shoved me with both hands. Resident #1 said once she was on the floor, the aide left her there in the hallway and passed by several times. The nurse found her. Resident #1 said when the nurse asked the aide about it, the aide was cutting me down (berating). Review on 12/10/19 at 12:00 PM with the Administrator of a surveillance video time-stamped 4:51:40 AM - 05:11:45 AM revealed on 12/09/19 at 4:51:40 AM CNA A walked a resident into room [ROOM NUMBER]. At 4:58 AM, Resident #1 wandered down the hall and waited outside the door of room [ROOM NUMBER]. At 4:59:27 AM, Resident #1 opened the door of room [ROOM NUMBER] and entered the room. The door shut at 4:59:48 AM. At 4:59:49 AM the door suddenly opened and Resident #1 was shoved out of room [ROOM NUMBER] by an arm with a gloved hand. The gloved hand was placed on Resident #1's right, upper arm and Resident #1 went backwards against the open-door surface as the arm guided Resident #1 out of the room. Then at 4:59:52 AM, Resident #1 was forcefully pushed by the gloved hand touching her left shoulder/upper arm out of the room [ROOM NUMBER], resulting in Resident #1 falling to the floor onto her right side . Resident #1 pushed the rolling 55-gallon barrel approximately 3 feet on her way down and knocked off an incontinent pad from the top of the barrel. She hit the floor at 4:59:55 AM. As Resident #1 reached up with her left hand toward room [ROOM NUMBER], the door shut. Resident #1 laid down in the floor and then raised herself to a sitting position. She attempted to get up but was unsuccessful. At 5:01:36 AM, Resident #1 was expressing facial grimacing as if in severe pain and rubbed her right leg and hip area. At 5:02 AM CNA A came out of room [ROOM NUMBER] and passed Resident #1 while Resident #1 was moving her lips as if talking. CNA A walked past Resident #1 and went into room [ROOM NUMBER] across the hallway and shut the door and left Resident #1 on the floor. At 5:02:39 Resident #1 appeared to say something to CNA A who was just inside the door of room [ROOM NUMBER]. CNA A shut the door, again leaving Resident #1 alone on the floor. At 5:03:21 AM CNA A came out into the hallway from room [ROOM NUMBER] and appeared to say something to Resident #1 as she got something from on top of the 55-gallon barrel and returned to room [ROOM NUMBER] shutting the door. Resident #1 remained on the floor rubbing her right hip. At 5:06:59 AM CNA A came out of room [ROOM NUMBER], stepped over Resident #1, and went into room [ROOM NUMBER] and shut the door leaving Resident #1 on the floor for the third time. At 5:07:31 AM CNA A came out into the hallway from room [ROOM NUMBER] and entered room [ROOM NUMBER] again shutting the door and passing Resident #1 for the fourth time. A nurse pushing a medication cart appeared at the end of the hallway at that time. At 5:05:10 AM, LVN C arrived beside Resident #1 on the floor. LVN C left Resident #1 and returned to her medication cart. At 5:08:59 CNA A came out of room [ROOM NUMBER] and returned to the room with a bed sheet and shut the door, leaving Resident #1 on the floor for the fifth time as she rubbed her right leg. At 5:10:20 AM, LVN C returned with a wheelchair and assessed Resident #1. At 5:10:45 AM, CNA A went to the 55-gallon plastic barrel and appeared to start talking to Resident #1 while LVN C stood there. CNA A used many arm and hand gestures while standing over Resident #1, communicating verbally and pointing her finger at Resident #1 many times in a demeaning manner with a frowning expression on her face. At 5:11:30 AM LVN C held her hand up to CNA A and CNA A walked away. Review of Resident #1's medical records from a local hospital revealed on 12/09/19 Resident #1 was brought into the hospital with right trochanteric femur fracture after a fall. Resident #1 presented to the Emergency Department after she fell due to being pushed down. Diagnostic imaging revealed an acute minimally displaced right femoral greater trochanter (outer bony prominence below the femoral neck) fracture on CT pelvis. Radiology Report for Resident #1 dated 12/09/19 at 10:15 AM revealed: CT Pelvis Impression: Acute minimally displaced right femoral greater trochanter fracture. Interview on 12/11/19 at 5:52 PM revealed CNA A stated she remembered Resident #1 and her fall on the morning of 12/09/19. She stated she was doing care in room [ROOM NUMBER] for two difficult residents. She stated Resident #1 opened the door to room [ROOM NUMBER] and she told Resident #1 that she had to close the door. Resident #1 said she had to get something. CNA A said she kept telling Resident #1 to give me a minute and told her to hold on I will get your stuff-just give me a minute. CNA A stated she was trying to prevent one of the other residents from exiting the room without clothes on. She stated Resident #1 wouldn't leave the room and was going off on her. She stated Resident #1 elbowed her in the face as soon as she turned around. CNA A stated I am not denying I pushed her to where she fell . She stated Resident #1screamed to not touch her so she did not touch her after that. CNA A stated, I am not denying pushing her. I had to wait for the nurse. I didn't realize I pushed her that hard. She stated she just walked by Resident #1 in and out of the room trying to dress the other resident. CNA A stated the nurse was down the hall and asked if Resident #1 was on the floor. CNA A said she confirmed the resident was on the floor. She stated Resident #1 was on the floor for about 5 minutes before the nurse got to her. Resident #1 had moved herself against the wall and gotten out of her way. CNA A stated Resident #1 told the nurse she hurt her leg, and they were fussing back and forth after the nurse came down there. CNA A stated Resident #1 said she pushed her and told the nurse what she was trying to get out of the room. She stated she just got out of the way. CNA A stated she did realize Resident #1 had fallen when she shut the door because Resident #1 screamed, 'I fell you idiot!' CNA A stated she wasn't going to move Resident #1 because they were trained not to pick resident's up if they fall. CNA A stated she was also trained to report falls immediately, and she saw the nurse coming down the hall, so she didn't report it right then. CNA A stated she has been in nursing [AGE] years and it was her fault and she knew she was wrong. She stated she was very frustrated. CNA stated, She wouldn't give me a minute. It was a quick flash reaction of frustration. It was a lot at that moment .for me. During an interview on 12/11/19 at 1:55 PM, CNA B revealed she was working the other end of the hall the day Resident #1 fell and she saw CNA A walking up the hallway. Resident #1 was on the ground leaning on the wall at the time and was rubbing her leg. Resident #1 did not want CNA A near her. CNA B heard Resident #1 say to CNA A, Get away from me. I don't want you touching me. CNA B said she did not know Resident #1 very well. CNA A told CNA B to help Resident #1 into the wheelchair that was nearby, but the nurse was already on the phone with the DON. CNA A was then told to leave the hall by the DON by speaker phone. Resident #1 was not crying just rubbing her leg and yelling and cussing at CNA A. During an interview on 12/11/19 at 2:02 PM, LVN C revealed she was completing medication rounds the day Resident #1 fell and CNA A did not report anything to her when the incident occurred. Once LVN C became aware Resident #1 was on the floor, CNA A told LVN C she had opened the door to the resident room she was in and Resident #1 was on the floor in the hallway. LVN C stated CNA A had continued working once seeing Resident #1 on the floor in spite of being trained to report falls immediately. She stated CNA A denied pushing Resident #1, but the resident argued that she was pushed. CNA A said the resident threw herself to the floor. LVN C stated she called the DON on speaker phone and CNA A was told she needed to leave immediately, and she left the building immediately. Resident #1 said she couldn't move her leg and thought it was broken. During an interview on 01/12/20 at 1:00 PM, the Administrator said he could not understand what the facility had done wrong since they had followed the abuse policy completely. The facility had screened the alleged perpetrator before hiring, trained her when hired and regularly afterwards, identified the allegation when the resident stated she was pushed, protected the resident by immediately suspending the CNA, and self-reported the event to the state. The investigation was already started by the facility and the police when this surveyor entered on 12/10/19. Corrective actions included safe surveys of other residents, and in-services of all the staff members on 12/9/19. CNA A had not set one foot back in the facility since her suspension and termination. Review of CNA A's employee file revealed she was hired on 10/17/17 and required screenings and reference checks revealed no concerns. CNA A's file contained the following disciplinary action forms: 12/29/17. Employee violated policy by sleeping while on company premises .Action: This is a final warning for any violation in company policy performance and standard of care duties. Any further violation will result in termination. Employee will not sleep while on company premises. 02/15/18. Failure to attend to mandatory in-service. 05/30/18. Employee violated work rule #1 which stated, Employees must maintain acceptable standards of respect for residents, visitors, co-workers and supervisors. Despite numerous in-services given to all employees regarding excellence in customer service, employee failed to treat a family member with respect and dignity. Action: Employee will follow facility rules and professionalism without further incidence of violations. 12/12/19. A resident in our facility alleged that this CNA pushed her causing her to fall. Employee was then suspended pending investigation. Facility has reviewed all supporting data and the allegation has been confirmed. Action: Termination. Interview with the Administrator on 01/31/20 at 4:43 PM revealed he had about 100 employees at the facility in December. The January in-service probably had some prn (as needed) employees that rarely work and the staff roster changes from month to month with new hires, etc. Review of Abuse Training attendance signature sheets revealed : 12/09/19 (103 attended ) 01/16/20 (119 attended) 01/18/20 (28 attended) 01/19/20 (1 attended) 01/20/20 (30 attended) 01/21/20 (2 attended) During interviews on 01/21/20 from 2:00 PM - 4:59 PM, eight staff members (CNA D, CNA G, LVN E and RN F from day shift, and CNA H, CNA I, LVN J, and RN K from evening shift ) said they received training on abuse and neglect last month and this month with dates unsure because it was very frequently . They were trained to report any suspicion of abuse to the Administrator. They said they were accountable if they failed to report abuse or neglect. They could identify different types of abuse and gave examples. They knew the signs of abuse a resident might exhibit. They revealed knowledge of signs of caregiver burnout and how residents were to be protected from anyone suspected of abusive behaviors. An interview on 12/17/19 at 8:34 AM with a police detective revealed he was familiar with and actively investigating the case involving CNA A and Resident #1 and was pursuing criminal charges against CNA A. A review of the facility's Abuse and Neglect Prohibition policy dated July 2018 reflected, Each resident has the right to be free from abuse, neglect, mistreatment injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator.Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Training: 1. The facility will train each employee on this policy during orientation, annually, and more often as determined by the facility. 2. The facility will provide training regarding related policies and procedures.Investigation: .Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended immediately, and allegations of abuse/neglect are unsubstantiated. ***NO PLAN OF CORRECTION REQUIRED***

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 3 of 4 residents (Resident #12, #19, and #20) reviewed for abuse. Resident #9 had a history of [REDACTED]. Resident #9 had access to the alleged victims (Resident # 12, #19, #20), and the other vulnerable females living on the secured Memory Care Unit. Resident #9 was found on top of Resident #12 naked from his waist down (12/2/19). An Immediate Jeopardy situation was identified on 01/17/2020. The Immediate Jeopardy was lowered on 01/19/2020; The facility remained out of compliance at a level of no actual harm with potential for more than minimal harm, with a scope of isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure could place residents at risk for abuse or neglect. Findings include: Record review of the facility's Abuse and Neglect policy dated July 2018 states: Any observations of abuse, neglect, or mistreatment must be reported immediately to the Administrator. The Administrator is the Abuse Prevention Coordinator. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. PREVENTION: Facility Supervisors will immediately investigate and correct reported or identified situations in which abuse is at risk of occurring. IDENTIFICATION: The facility supervisory staff will monitor all staff and residents for behavior indicative of high stress levels that may lead to abuse. INVESTIGATION: The facility will timely conduct an investigation of any alleged abuse in accordance with state law. REPORTING AND RESPONSE: STATE REPORTING OBLIGATIONS: The facility will report all allegations of abuse to the ADMINISTRATOR, STATE SURVEY AGENCY, in accordance with Federal and State Law through established procedures. Timeline for reporting: a. If the events that caused the allegation result in serious bodily injury, a report is made not later than 3 Hours after the facility is notified of the allegation. b. If the events do not involve abuse and did not result in serious bodily injury a report is made not later than 24 hours after the facility is notified of the allegation. A. Sexual Abuse Resident #9 (Closed Record) Record review of Resident #9's electronic medical record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's significant change Minimum Data Set ((MDS) dated [DATE] revealed his hearing was adequate, his speech was unclear, sometimes he has the ability to make himself understood, and can sometimes has the ability to understand others. Review of his Brief Interview for Mental Status (BI[CONDITION]) revealed he scored 9 out of 15 which indicates his cognitive skills for daily decision making is moderately impaired. He has no [MEDICAL CONDITION] or [MEDICAL CONDITION] documented during this assessment period, however it is documented that he wanders. Continued review of the same MDS revealed his functional status as follows: Resident # 9 requires extensive assistance with assist of one person for bed mobility, transfers, toileting, personal hygiene, and bathing. He requires minimal assistance of one person for walking in his room and in the corridors. He requires supervision of one person for locomotion on and off the unit. He is able to eat with set-up and supervision. Resident # 9 is frequently incontinent of bowel and bladder. He uses a wheelchair for mobility. Review of Resident #9's care plan dated 11/07/19 revealed he is incontinent, depends on staff for all needs, emotional, Activities of Daily Living (ADL's). He had limited physical mobility, He was a smoker. He had impaired cognition function, was at risk for falls, he takes antidepressants and had chronic pain. The care plan did not address sexual behaviors. Record review of Resident #9's History & Physical dated 11/08/19 and signed by Dr. B revealed Resident #9 was in jail prior to his admission to the facility on an unrelated charge. Review of Resident #9's clinical record revealed there were no incident reports or documentation in the Progress Notes of sexual behaviors from 7/8/19 until 11/08/19. Review of Progress Notes dated 11/08/19 at 12:31 p.m. Resident #9 was observed seeking female attention but no physical contact noted, Resident #9 was placed on 1-hour observation every hour until further notice. Review of Progress Note dated 11/08/19 at 2:08 p.m. Resident #9 frequently makes inappropriate sexual comments to staff and female residents. Dr. A notified, new orders to administer [MEDICATION NAME] 5 mg per mouth every day. [MEDICATION NAME] is a hormone-suppressing drug which lowers testosterone levels thereby decreasing a man's sex drive. It is prescribed for men, so they do not think about sex as often and their sexual thoughts are not as strong as before. It is given to men who have sexual impulse disorders characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors that are considered deviant with respects to cultural norms . Reference - PubMed.gov, US National Library of Medicine, National Health Institutes of Health accessed on 1/29/20. Review of Progress Notes dated 11/08/19 MD order for Psych services/consult needed for hormone therapy evaluation only. Review of Progress Note dated 11/08/19 at 10:03 p.m. Continues on one-hour observations for inappropriate behaviors with other female residents. Resident is agitated and continues to stand by the exit door seeking exit and staff continue to redirect resident. Review of Progress Note dated 11/08/19 at 11:24 p.m.No inappropriate behaviors observe. Continues on every one-hour observation checks until further notice. [ENTITY]ts [MEDICATION NAME] 5 mg in the morning. Review of Progress Notes dated 11/19/19 at 6:00 a.m. Discontinues off one (1) hour observation checks per management, no behaviors noted or reported. Review of Resident #9's electronic Medication Administration Record [REDACTED]. It was increased to 10 mg's days later. Review of Resident #9's electronic MAR indicated [REDACTED]. Review of the Facility Provider Investigation Report dated 12/02/19 revealed the following: Resident #9 was observed undressed from the waist down lying on top of Resident #12 who was fully dressed with a shirt and pants on. When staff member walked into the room, Resident #9 stood up and pulled his pants back on his waist. Residents were immediately separated. Residents were assessed with [REDACTED]. The nurse visually assessed Resident #12's vaginal area and noted without any redness, pain or swelling. No mental distress noted for either resident. Resident #9 was placed on one on one supervision. Family, Physician, Ombudsman and Police Dept were notified of the event. Immediate Discharge notice was given to Resident #9. Police arrived at facility and placed Resident #9 in custody and subsequently took him to the County jail for violation unrelated to this event. Signed by the Director of Nurses (DON) and dated 12/03/2019. Note: He did not return to the facility after he was taken to the county jail. Review of Progress Note dated 12/12/19 at 6:44 p.m. Immediate discharge letter/notification given to Resident #9, family aware. Resident #12 Review of Resident #12's undated electronic face sheet documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED].>Review of Resident #12's Quarterly MDS dated [DATE] revealed her hearing is adequate, her speech is clear. Sometimes she is able to make herself understood and sometimes she is able to understand others. Cognitively she scored 00 on her Brief Interview for Mental Status (BI[CONDITION]) which indicates her cognitive skills for daily decision making is severely impaired. She did have [MEDICAL CONDITION] described as inattention, difficulty focusing, and easily distracted. She also had behaviors of disorganized thinking, she was incoherent and rambling at times, she would switch from subject to subject at times. She had [MEDICAL CONDITION] documented as delusional and did from time to time display verbal behaviors. Continued review of the same MDS regarding her functional status revealed Resident #12 was ambulatory without an assistive device, she was able to ambulate on and off the unit with limited supervision. She needed one-person limited assistance for bed mobility and dressing, she was set-up and supervision with transfers, walking in her room, and the corridors. She did require extensive assistance of one person for toileting, personal hygiene and bathing. Her gait was unsteady at times, but she was able to steady herself without staff assistance. She was frequently incontinent of bowel and bladder. Resident #12 Observations: 01/13/2020 4:25 p.m. Resident was observed in the secure unit, she was walking to the dining room. She was clean, well dressed, very friendly, very approachable. She was oriented to name only. 01/14/2020 10:50 a.m. Resident #12 was observed in the secure unit, she was ambulating up and down the hallway. She was clean, well groomed, she was oriented to name only, she was unable to recall the incident with Resident #9. 01/17/2020 3:10 p.m. Resident #12 was observed in the secure unit, she was up at the nurse's station. She was carrying her house slipper, she was oriented to self only. In an interview on 01/16/2020 at 10:50 a.m. with RCS D said that he was making rounds and he noticed one of the bedroom doors was closed. He said that when he opened the door Resident #9 was lying in bed on top of Resident #12. He said that Resident #12 was fully clothed but resident # 9 had his pants down past his knees. He said that Resident #9 immediately got up and started putting his pants on and he said, I didn't do nothing. He said that he separated the residents and reported the incident to the Assistant Director of Nurses (ADON). He said that the Administrator was not in the building. He said that he spoke with the DON and she asked him to write a statement. He said that Resident #9 liked females, he said that he was always trying to touch them or rub on them. He said that the room he found Resident #9 a Resident #12 was neither one of their rooms. He said that Resident #9 was very aware of what he was trying to do. He said that he did not know anything about any other incidents where Resident #9 had sexually abused another resident. RCS-D said that from time to time Resident #9 would use inappropriate language and they would have to remind him that he could not talk like that in front of the female residents. In an interview on 01/16/2020 at 10:30 a.m. with LVN G she was the charge nurse the day that Resident #9 was found in the room on top of Resident #12, but nothing really happened. She was completely clothed even if Resident #9 had his pants down. She said that Resident Care Specialist (RCS) D that reported it said that nothing happened. She said that she was unaware of anything happening between Resident #9 and Resident #19 and Resident #20. She said she didn't know anything about it that she has never heard about it, that it was never reported to her. She said that Resident #9 did like the ladies. She said that he would be seen touching the ladies, rubbing their arms, and if they were sitting beside him he would rub their thighs. She said that she would always tell him that he better stop that, or he would go back to jail. She said that he would always stop like she asked. In an interview on 01/16/2020 at 11:05 a.m. with the ADON/Nurse Manager of the Secure Unit she said that on 12/03/19 (Note:The incident occurred on 12/2/19.) that RCS D came to her and reported that while he was making his rounds that morning that he noticed the door of a room was closed, he said when he opened the door he saw the two residents lying in bed. He said that Resident #9 was laying on top of Resident #12. He said that Resident #12 was fully clothed but Resident #9 had his pants down and when he saw RCS D Resident #9 got up and while pulling up his pants he said, I didn't do anything. He said that Resident #12 did not seem upset or in any distress. She said that she did a head to toe assessment on Resident #12's vaginal area, there were no signs of trauma or penetration. She said that she reported the incident to the DON as the Administrator, who is the abuse coordinator, was out of the facility on vacation. The ADON said that she was aware that Resident #9 had displayed some inappropriate sexual behavior in the past. Particularly with the female staff. She said that Resident #9 had been started on [MEDICATION NAME] on 11/08/19. She said that Resident #9 was placed on 1:1 observation until he was discharged from the facility. She said they notified Resident #1's Primary Care Physician (PCP) was given orders to transfer him to the acute hospital for an evaluation. She said that they also called the police. She said that the ambulance came to transfer Resident #9 and the police arrived at the facility while the ambulance was still there. She said that the police arrested Resident #9, they took him out of the ambulance, and placed him in a police car and took him to the county jail on another unrelated charge. She said that Resident #9 was also issued an immediate discharge letter that same day. She said that when Resident #12's daughter was notified she said that she did not believe that it was necessary for her mother to go to the hospital for an examination because she had remained fully clothed throughout the incident. There was no direct sexual contact and no penetration, so it would just upset and confuse her mother, so she felt it just wasn't necessary. In a confidential interview on [DATE]20 at 2:29 p.m. with a staff member who wished to remain unnamed said that the RCS D actually witnessed Resident #9 laying on top of Resident #12 would not tell what happens back on the Secure Unit, he was very close with the management team. RCS D said that Resident #9 had been sexually inappropriate more than just that one time with Resident #12. They said that the DON and the ADON knew about it but did nothing about it. They said that something should have happened much sooner than it did. In a confidential interview on 01/16/20 at 4:29 p.m. with a staff member who wished to remain unnamed for fear of retaliation by the DON, said I will be fired if they find out I talked to you. They said that they have witnessed Resident #9 take Resident #20 to the room and rub her legs, he was always touching her, they had to watch him close because he touched her everywhere. They would tell Resident #9 to stop or he would go to jail. It was an ongoing problem from the time he came, the management would not do anything about it. Resident #9 had to be watched constantly. The confidential staff member said they did not actually see the incident with Resident #12 and Resident #9. They said that Resident #20 was usually Resident #9's target, that they had seen Resident #9 touching her breast and another time saw him rubbing her thigh. They said that it was reported to the DON, but nothing was done. In an interview on [DATE]20 at 3:30 p.m. with LVN A she said that the sexual assault by Resident #9 to Resident #12 should have never happened that Resident #9 had been seen sexually inappropriate with at least two other residents, Resident #19 and Resident #20 before he was found with Resident #12. She said that the DON and the ADON and most of the staff in the Secure Unit knew about Resident #9's inappropriate behavior because they had to watch him so close. She said that he had been sexually inappropriate with Resident #12 prior to this last incident. She said she did not personally witness these events, but she was sure they happened. Record review of Resident # 19's electronic medical record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of her quarterly MDS dated [DATE] revealed her hearing was adequate, her speech was clear. She rarely understands and can rarely be understood. Review of her BI[CONDITION] revealed a score of 99 which indicates her cognitive skills for daily decision making was severely impaired. She has [MEDICAL CONDITION], inattention and disorganized thinking. She does wander, continued review of the same MDS revealed her functional status as follows: Resident #19 requires extensive assist of one person for bed mobility, transfers, dressing, personal hygiene, eating, toileting personal hygiene and bathing require extensive assistance of 1-2 people. She is frequently incontinent of bowel and bladder. Review of her care plan dated 12/11/19 revealed she was a safety risk, she was dependent on staff for emotional, intellectual, physical, and social needs related to dementia. She had a cognitive communication deficit, she was dependent on staff for her ADL's. She is at risk for falls and development of pressure ulcers. There was nothing documented regarding sexual incidents. Observation/Interview on 01/13/2020 at 1:45 p.m. Resident # 19 was in the secure unit, she was sitting at the table in the dining room, she was disoriented but friendly and approachable. She was clean and well groomed. She was too disoriented to be interviewed. Record review of Resident # 20's electronic medical record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of her quarterly MDS dated [DATE] revealed her hearing is adequate, her speech is clear, she can sometimes understand, but she is rarely understood by others. Her BI[CONDITION] score was 99 which indicates her cognitive skills for daily decision making is severely compared. She has [MEDICAL CONDITION]; inattention and disorganized thinking. She has no [MEDICAL CONDITION] or behaviors documented during this assessment period. Continued review of the same MDS revealed her functional status as follows: Resident # 20 requires extensive assistance of one person for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. She is totally dependent on one person for bathing. She is always incontinent of bowel and bladder. She does not use a mobile device. She is unsteady, she can balance herself. Review of her care plan dated 11/28/19 revealed she was a safety risk related to cognitive impairment, decrease safety awareness and wandering. She was dependent on staff for all needs, emotional. She had impaired thought process. She was at risk for falls. There was nothing documented regarding sexual incidents. Observation/Interview on 01/13/2020 at 1:50 p.m. Resident # 20, she was in the secure unit, she was clean well groomed. She was confused and disoriented. She was friendly and approachable. She was unable to complete an interview. In an interview with the DON on [DATE]20 at 10:15 a.m. said that she was aware of the and made a self-report incident on 12/03/19 of an alleged sexual assault between Resident #9, the alleged perpetrator, (AP) and Resident #12, the alleged victim (AV). She said that while an RCS was making his rounds he discovered Resident #9 and Resident #12 laying on the bed, Resident #12 was fully clothed, and Resident #9 had his pants off and he was laying on top of Resident #12. She said she was not aware of Resident #9 sexually assaulting any other resident. She said that nothing like that had ever been reported to her or she would have self-reported it to the state. She said that Resident #12 was assessed and there were no signs of penetration. She said that Resident #12 was not taken to the hospital, she was assessed from head to toe and there was no evidence that there had been penetration during the sexual assault. She said the PCP and family was notified. She stated the nurse called the ambulance so Resident #9 could be transferred to a local hospital for an evaluation. She said she also called the police. She said when the police arrived, they took Resident #9 out of the ambulance and arrested him for parole violation and they took him to the local County jail. She said that Resident #9 had been started on the medication [MEDICATION NAME] (which is supposed to decrease his sexual urges) on 11/08/19 to be administered in the morning every day for inappropriate sexual behavior. The [MEDICATION NAME] was increased on 11/12/19 to 10 mg per day. She said that Resident #9 was lusting after the females and making sexual comments, mostly to the staff. The DON was also asked by the investigator if she was aware of the allegations of sexual abuse regarding Resident #9 and Resident's #19, and Resident #20. She said none of my staff reported any sexual incidents to me except the one I reported to the state. She said that her staff has been trained in reporting abuse and neglect, that this is discussed in every employee's orientation and multiple times throughout the year. She said that she goes over the facility policy every time that there is an allegation of abuse or neglect. She said that the staff knows that the Administrator is the Abuse Coordinator but in his absence she is the Abuse Coordinator. She said that the Administrator was on vacation during the week so she investigated and reported the sexual incident between Resident #9 and Resident #12. She said I'm having some management issues with one of the department managers, I think they are out to get me. She said that she was told by an RCS D that while he was making rounds on the skilled unit that he noticed one of the bedroom doors shut. She said he told her that it was unusual for that door to be closed so he opened the door and he saw Resident #9 and Resident #12 lying in bed. He said that Resident #9 was laying on top of Resident #12 with his pants down. He said that Resident #12 was fully clothed. She said he told her that as soon as he opened the door Resident #9 got up and while he was pulling up his pants he said, I didn't do nothing. She said the RCS D told her that neither resident was in their rooms, they were found in another resident's room. She said that the RCS and the ADON separated them immediately and reported the incident to his charge nurse. She said that Res #12 was given a head to toe assessment and there was nothing to indicate she had been raped, there was no evidence of penetration. She said that Resident #9 was placed on 1:1 observation until he could be discharged from the facility. She said that Res #12 did not show any signs that she was in any emotional distress. She said that Resident #9 was an attention seeking resident. She said that he liked the females, both resident and staff. She said that he had been seen by the staff lusting at the females and making inappropriate sexual comments toward them, mostly the staff. She said that Resident #9 likes to touch other residents, he liked rubbing their shoulders or if they were sitting down he liked to rub their thighs. She said that the staff knew to watch him closely and keep him separated from the females on the unit. She said that when it was reported to her by her staff that Resident #9's sexual behaviors were increasing she said she called Resident #9's PCP and he gave them an order to start Resident #9 on [MEDICATION NAME] 10 mg every a.m., that was on 11/12/19. She said she was not aware of any other incidents of sexual inappropriate behavior from Resident #9. She said that when this incident happened, the facility called the police and an ambulance. She said they were in the process of sending Resident #9 to the local hospital for an evaluation when the police arrived. She said that the police went into the ambulance and arrested Resident #9 and took him to the county jail, apparently, he had violated his parole. She said that Resident #12 was not sent to the hospital for any test as there was no evidence that she was raped, she was not showing any emotional or physical stress, and she has been assessed and there was no evidence of penetration. She said that she did not know anything about the allegation that Resident #9 had been sexually inappropriate with Resident #19 or Resident #20 either. She said that if anything like that happened, her staff did not report it to her. She said that this is the first she has ever heard of this. She said that she does recall that it was a very busy week for her, that the Administrator was out on vacation and she was the Abuse Coordinator in his absence. In an interview on 01/16/2020 at 1:55 p.m. with the Administrator, he said that he had been on vacation for part of the month of December 2019. He said that it was not reported to him any other incidents involving Resident #9 and any other female residents. He said that he has spoken with his DON and she said that nothing was reported to her. He said that he would be investigating the allegations that have been reported to him by the state investigators during this investigation. He said that his staff have all been in-serviced on abuse and neglect and the importance of reporting in a timely manner. He said there has been a lot of conflict with his staff over the past few months. He said that he thinks it's mostly the department managers. He said that he takes all the reported allegations very seriously and he tries to do a good investigation. He said that he was very disappointed as he thought he had a better rapport with his staff. In an interview on [DATE]20 10:10 a.m. with the DON (she has her computer to enable her to look up dates and verify information) she said that in regards to Resident #9 she was not aware of any assaults on residents to her knowledge. He did make sexual comments, to residents and staff. Immediate discharge letter was issued to Resident #9, the police were called. Resident # 9 was being transferred to the acute hospital, he was already in the ambulance when the police arrived at the facility. The police took Resident #9 out of the ambulance and arrested him on a different charge. She said that review of the MDS dated [DATE] Resident #9 had a BI[CONDITION] score of 7 (indicating Severe impairment) and review of the MDS dated [DATE] Resident #9 scored a 9 on the BI[CONDITION] interview which indicates Moderate impairment). Resident was initially admitted to the facility on [DATE] to the secure unit per family request. On 10/03/19 Resident #9 was transferred to station 2, which is an unsecure unit. Resident #9 eloped the same day and was transferred back to the Secure Unit. Resident #9 was listed on the electronic face sheet as his own responsible party. She said that the incident involving Resident #9 and Resident #12 was the only actual physical contact that was reported to her. She said that Resident #9 was heard by the staff making inappropriate sexual statements and he would look at the females with lust in his eyes. Resident #9 was able to walk but he used his wheelchair for mobility most of the time. She said that she was unaware of his wandering on the secure unit. She said that Resident # 9 was not sent to the hospital, the police arrived at the facility and took him from the ambulance, placed him in the police car and took him to the county jail. She said the ADON called Resident #12's daughter, she was not overly upset because Resident #12 was fully dressed during the incident. There was no evidence of any physical injury. She said she did not want to put her mother through that experience, she declined hospitalization . LVN G did complete a head to toe assessment on Resident #12 to include her vaginal area. There was no evidence that there was any penetration from the incident. The Administrator was notified of the Immediate Jeopardy on 1/17/2020 at 4:35 p.m. The IJ template was given to the administrator. The facility's Plan of Removal of immediate Jeopardy was accepted as being completed on 01/17/2020 at 10:35 p.m. The plan included the following: Immediate action taken: Sexual Assault Prevention Immediate Actions: Residents with cognitive impairment have the potential to be sexually assaulted. Those residents identified to be at risk were assessed by the interdisciplinary team. Care plans were updated as needed by the Interdisciplinary Team (IDT). Staff will be re-educated by Administrator, Assistant Director of Nursing and Unit Managers on the importance of reporting any acts that may be deemed of sexual nature of unwanted touching, or talking about sexual acts toward residents or staff. Staff that do not report such incidents will be immediately disciplined. Monitoring will include questioning of employees to ensure they understand the management of residents at risk for being sexually assaulted. If the staff are found to answer the questions incorrectly, they will be re-educated. If they still cannot answer the questions, they will be taken off the schedule until they can respond correctly Monitoring will occur weekly for a month, every 2 weeks x 4 weeks, then monthly x 3 months. Progress of this plan will be reported to the Quality Assessment Performance Improvement Committee weekly for 1-month, biweekly x 1 month, and monthly thereafter until substantial compliance has been achieved. The Medical Director was notified about the Immediate Jeopardy on 1/17/20 at 8:30pm. Medical Director is an active member of the Quality Assessment Performance Improvement Committee which will monitor completion and compliance of the plan. Medical Director will attend Quality Assurance Performance Improvement monthly meetings. Administrator will report progress of this plan to the Quality Assurance Performance Improvement Committee monthly meeting. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring will include questioning of employees to ensure they understand the management of residents at risk for being sexually assaulted. If the staff is found to answer the questions incorrectly, they will be re-educated. If they still cannot answer the questions, they will be taken off the schedule until they can respond correctly Monitoring will occur weekly for a month, every 2 weeks x 4 weeks, then monthly x 3 months. Monitoring the Plan of Removal conducted by the investigators 01/18/2020-01/19/2020 The 12 RCS's, 2 RN's, and 6 LVN's (all shifts) were interviewed from 01-18-2020 - 01/19/2020; They were able to define abuse, they all had knowledge of their reporting responsibilities, they were able to name the facility Abuse Coordinator and the importance of timely reporting. The Department Managers (5 managers) were interviewed from 01/18/2020 - 01/19/2020; They all had knowledge of the facility abuse policy and procedure. They were able to voice the importance of follow-up to ensure they get the proper forms completed, obtain interviews and/or witness statements, and ensure the event be documented in the resident's clinical record. They were able to voice how they would monitor and provide oversight to ensure care and services were provided. All staff interviewed were able to voice the facility Abuse policy and procedure to include; identifying, protection, investigation, their rep

Based on observation, interview, and record review the facility failed to ensure all allegatins of abuse and neglect were thouroughly investigated, report to the Administrator and State Agency, or prevent further abuse from occuring for 3 of 4 residents (Resident #12, #19, and #20) reviewed for abuse. Resident #9 had a history of [REDACTED]. No investigation was conducted on previous allegations of sexual abuse. Resident #9 had access to the alleged victims (Resident # 12, #19, #20), and the other vulnerable females living on the secured Memory Care Unit. Resident #9 was found on top of Resident #12 naked from his waist down (12/2/19). An Immediate Jeopardy situation was identified on 01/17/2020. The Immediate Jeopardy was lowered on 01/19/2020; The facility remained out of compliance at a level of no actual harm with potential for more than minimal harm, with a scope of isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure could place residents at risk for further abuse. Findings include: Record review of the facility's Abuse and Neglect policy dated July 2018 states: Any observations of abuse, neglect, or mistreatment must be reported immediately to the Administrator. The Administrator is the Abuse Prevention Coordinator. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. PREVENTION: Facility Supervisors will immediately investigate and correct reported or identified situations in which abuse is at risk of occurring. IDENTIFICATION: The facility supervisory staff will monitor all staff and residents for behavior indicative of high stress levels that may lead to abuse. INVESTIGATION: The facility will timely conduct an investigation of any alleged abuse in accordance with state law. REPORTING AND RESPONSE: STATE REPORTING OBLIGATIONS: The facility will report all allegations of abuse to the ADMINISTRATOR, STATE SURVEY AGENCY, in accordance with Federal and State Law through established procedures. Timeline for reporting: a. If the events that caused the allegation result in serious bodily injury, a report is made not later than 3 Hours after the facility is notified of the allegation. b. If the events do not involve abuse and did not result in serious bodily injury a report is made not later than 24 hours after the facility is notified of the allegation. A. Sexual Abuse Resident #9 (Closed Record) Record review of Resident #9's electronic medical record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's significant change Minimum Data Set ((MDS) dated [DATE] revealed his hearing was adequate, his speech was unclear, sometimes he has the ability to make himself understood, and can sometimes has the ability to understand others. Review of his Brief Interview for Mental Status (BI[CONDITION]) revealed he scored 9 out of 15 which indicates his cognitive skills for daily decision making is moderately impaired. He has no [MEDICAL CONDITION] or [MEDICAL CONDITION] documented during this assessment period, however it is documented that he wanders. Continued review of the same MDS revealed his functional status as follows: Resident # 9 requires extensive assistance with assist of one person for bed mobility, transfers, toileting, personal hygiene, and bathing. He requires minimal assistance of one person for walking in his room and in the corridors. He requires supervision of one person for locomotion on and off the unit. He is able to eat with set-up and supervision. Resident # 9 is frequently incontinent of bowel and bladder. He uses a wheelchair for mobility. Review of Resident #9's care plan dated 11/07/19 revealed he is incontinent, depends on staff for all needs, emotional, Activities of Daily Living (ADL's). He had limited physical mobility, He was a smoker. He had impaired cognition function, was at risk for falls, he takes antidepressants and had chronic pain. The care plan did not address sexual behaviors. Record review of Resident #9's History & Physical dated 11/08/19 and signed by Dr. B revealed Resident #9 was in jail prior to his admission to the facility on an unrelated charge. Review of Resident #9's clinical record revealed there were no incident reports or documentation in the Progress Notes of sexual behaviors from 7/8/19 until 11/08/19. Review of Progress Notes dated 11/08/19 at 12:31 p.m. Resident #9 was observed seeking female attention but no physical contact noted, Resident #9 was placed on 1-hour observation every hour until further notice. Review of Progress Note dated 11/08/19 at 2:08 p.m. Resident #9 frequently makes inappropriate sexual comments to staff and female residents. Dr. A notified, new orders to administer [MEDICATION NAME] 5 mg per mouth every day. [MEDICATION NAME] is a hormone-suppressing drug which lowers testosterone levels thereby decreasing a man's sex drive. It is prescribed for men, so they do not think about sex as often and their sexual thoughts are not as strong as before. It is given to men who have sexual impulse disorders characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors that are considered deviant with respects to cultural norms . Reference - PubMed.gov, US National Library of Medicine, National Health Institutes of Health accessed on 1/29/20. Review of Progress Notes dated 11/08/19 MD order for Psych services/consult needed for hormone therapy evaluation only. Review of Progress Note dated 11/08/19 at 10:03 p.m. Continues on one-hour observations for inappropriate behaviors with other female residents. Resident is agitated and continues to stand by the exit door seeking exit and staff continue to redirect resident. Review of Progress Note dated 11/08/19 at 11:24 p.m.No inappropriate behaviors observe. Continues on every one-hour observation checks until further notice. [ENTITY]ts [MEDICATION NAME] 5 mg in the morning. Review of Progress Notes dated 11/19/19 at 6:00 a.m. Discontinues off one (1) hour observation checks per management, no behaviors noted or reported. Review of Resident #9's electronic Medication Administration Record [REDACTED]. It was increased to 10 mg's days later. Review of Resident #9's electronic MAR indicated [REDACTED]. Review of the Facility Provider Investigation Report dated 12/02/19 revealed the following: Resident #9 was observed undressed from the waist down lying on top of Resident #12 who was fully dressed with a shirt and pants on. When staff member walked into the room, Resident #9 stood up and pulled his pants back on his waist. Residents were immediately separated. Residents were assessed with [REDACTED]. The nurse visually assessed Resident #12's vaginal area and noted without any redness, pain or swelling. No mental distress noted for either resident. Resident #9 was placed on one on one supervision. Family, Physician, Ombudsman and Police Dept were notified of the event. Immediate Discharge notice was given to Resident #9. Police arrived at facility and placed Resident #9 in custody and subsequently took him to the County jail for violation unrelated to this event. Signed by the Director of Nurses (DON) and dated 12/03/2019. Note: He did not return to the facility after he was taken to the county jail. Review of Progress Note dated 12/12/19 at 6:44 p.m. Immediate discharge letter/notification given to Resident #9, family aware. Resident #12 Review of Resident #12's undated electronic face sheet documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED].>Review of Resident #12's Quarterly MDS dated [DATE] revealed her hearing is adequate, her speech is clear. Sometimes she is able to make herself understood and sometimes she is able to understand others. Cognitively she scored 00 on her Brief Interview for Mental Status (BI[CONDITION]) which indicates her cognitive skills for daily decision making is severely impaired. She did have [MEDICAL CONDITION] described as inattention, difficulty focusing, and easily distracted. She also had behaviors of disorganized thinking, she was incoherent and rambling at times, she would switch from subject to subject at times. She had [MEDICAL CONDITION] documented as delusional and did from time to time display verbal behaviors. Continued review of the same MDS regarding her functional status revealed Resident #12 was ambulatory without an assistive device, she was able to ambulate on and off the unit with limited supervision. She needed one-person limited assistance for bed mobility and dressing, she was set-up and supervision with transfers, walking in her room, and the corridors. She did require extensive assistance of one person for toileting, personal hygiene and bathing. Her gait was unsteady at times, but she was able to steady herself without staff assistance. She was frequently incontinent of bowel and bladder. Resident #12 Observations: 01/13/2020 4:25 p.m. Resident was observed in the secure unit, she was walking to the dining room. She was clean, well dressed, very friendly, very approachable. She was oriented to name only. 01/14/2020 10:50 a.m. Resident #12 was observed in the secure unit, she was ambulating up and down the hallway. She was clean, well groomed, she was oriented to name only, she was unable to recall the incident with Resident #9. 01/17/2020 3:10 p.m. Resident #12 was observed in the secure unit, she was up at the nurse's station. She was carrying her house slipper, she was oriented to self only. In an interview on 01/16/2020 at 10:50 a.m. with RCS D said that he was making rounds and he noticed one of the bedroom doors was closed. He said that when he opened the door Resident #9 was lying in bed on top of Resident #12. He said that Resident #12 was fully clothed but resident # 9 had his pants down past his knees. He said that Resident #9 immediately got up and started putting his pants on and he said, I didn't do nothing. He said that he separated the residents and reported the incident to the Assistant Director of Nurses (ADON). He said that the Administrator was not in the building. He said that he spoke with the DON and she asked him to write a statement. He said that Resident #9 liked females, he said that he was always trying to touch them or rub on them. He said that the room he found Resident #9 a Resident #12 was neither one of their rooms. He said that Resident #9 was very aware of what he was trying to do. He said that he did not know anything about any other incidents where Resident #9 had sexually abused another resident. RCS-D said that from time to time Resident #9 would use inappropriate language and they would have to remind him that he could not talk like that in front of the female residents. In an interview on 01/16/2020 at 10:30 a.m. with LVN G she was the charge nurse the day that Resident #9 was found in the room on top of Resident #12, but nothing really happened. She was completely clothed even if Resident #9 had his pants down. She said that Resident Care Specialist (RCS) D that reported it said that nothing happened. She said that she was unaware of anything happening between Resident #9 and Resident #19 and Resident #20. She said she didn't know anything about it that she has never heard about it, that it was never reported to her. She said that Resident #9 did like the ladies. She said that he would be seen touching the ladies, rubbing their arms, and if they were sitting beside him he would rub their thighs. She said that she would always tell him that he better stop that, or he would go back to jail. She said that he would always stop like she asked. In an interview on 01/16/2020 at 11:05 a.m. with the ADON/Nurse Manager of the Secure Unit she said that on 12/03/19 (Note:The incident occurred on 12/2/19.) that RCS D came to her and reported that while he was making his rounds that morning that he noticed the door of a room was closed, he said when he opened the door he saw the two residents lying in bed. He said that Resident #9 was laying on top of Resident #12. He said that Resident #12 was fully clothed but Resident #9 had his pants down and when he saw RCS D Resident #9 got up and while pulling up his pants he said, I didn't do anything. He said that Resident #12 did not seem upset or in any distress. She said that she did a head to toe assessment on Resident #12's vaginal area, there were no signs of trauma or penetration. She said that she reported the incident to the DON as the Administrator, who is the abuse coordinator, was out of the facility on vacation. The ADON said that she was aware that Resident #9 had displayed some inappropriate sexual behavior in the past. Particularly with the female staff. She said that Resident #9 had been started on [MEDICATION NAME] on 11/08/19. She said that Resident #9 was placed on 1:1 observation until he was discharged from the facility. She said they notified Resident #1's Primary Care Physician (PCP) was given orders to transfer him to the acute hospital for an evaluation. She said that they also called the police. She said that the ambulance came to transfer Resident #9 and the police arrived at the facility while the ambulance was still there. She said that the police arrested Resident #9, they took him out of the ambulance, and placed him in a police car and took him to the county jail on another unrelated charge. She said that Resident #9 was also issued an immediate discharge letter that same day. She said that when Resident #12's daughter was notified she said that she did not believe that it was necessary for her mother to go to the hospital for an examination because she had remained fully clothed throughout the incident. There was no direct sexual contact and no penetration, so it would just upset and confuse her mother, so she felt it just wasn't necessary. In a confidential interview on [DATE]20 at 2:29 p.m. with a staff member who wished to remain unnamed said that the RCS D actually witnessed Resident #9 laying on top of Resident #12 would not tell what happens back on the Secure Unit, he was very close with the management team. RCS D said that Resident #9 had been sexually inappropriate more than just that one time with Resident #12. They said that the DON and the ADON knew about it but did nothing about it. They said that something should have happened much sooner than it did. In a confidential interview on 01/16/20 at 4:29 p.m. with a staff member who wished to remain unnamed for fear of retaliation by the DON, said I will be fired if they find out I talked to you. They said that they have witnessed Resident #9 take Resident #20 to the room and rub her legs, he was always touching her, they had to watch him close because he touched her everywhere. They would tell Resident #9 to stop or he would go to jail. It was an ongoing problem from the time he came, the management would not do anything about it. Resident #9 had to be watched constantly. The confidential staff member said they did not actually see the incident with Resident #12 and Resident #9. They said that Resident #20 was usually Resident #9's target, that they had seen Resident #9 touching her breast and another time saw him rubbing her thigh. They said that it was reported to the DON, but nothing was done. In an interview on [DATE]20 at 3:30 p.m. with LVN A she said that the sexual assault by Resident #9 to Resident #12 should have never happened that Resident #9 had been seen sexually inappropriate with at least two other residents, Resident #19 and Resident #20 before he was found with Resident #12. She said that the DON and the ADON and most of the staff in the Secure Unit knew about Resident #9's inappropriate behavior because they had to watch him so close. She said that he had been sexually inappropriate with Resident #12 prior to this last incident. She said she did not personally witness these events, but she was sure they happened. Record review of Resident # 19's electronic medical record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of her quarterly MDS dated [DATE] revealed her hearing was adequate, her speech was clear. She rarely understands and can rarely be understood. Review of her BI[CONDITION] revealed a score of 99 which indicates her cognitive skills for daily decision making was severely impaired. She has [MEDICAL CONDITION], inattention and disorganized thinking. She does wander, continued review of the same MDS revealed her functional status as follows: Resident #19 requires extensive assist of one person for bed mobility, transfers, dressing, personal hygiene, eating, toileting personal hygiene and bathing require extensive assistance of 1-2 people. She is frequently incontinent of bowel and bladder. Review of her care plan dated 12/11/19 revealed she was a safety risk, she was dependent on staff for emotional, intellectual, physical, and social needs related to dementia. She had a cognitive communication deficit, she was dependent on staff for her ADL's. She is at risk for falls and development of pressure ulcers. There was nothing documented regarding sexual incidents. Observation/Interview on 01/13/2020 at 1:45 p.m. Resident # 19 was in the secure unit, she was sitting at the table in the dining room, she was disoriented but friendly and approachable. She was clean and well groomed. She was too disoriented to be interviewed. Record review of Resident # 20's electronic medical record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of her quarterly MDS dated [DATE] revealed her hearing is adequate, her speech is clear, she can sometimes understand, but she is rarely understood by others. Her BI[CONDITION] score was 99 which indicates her cognitive skills for daily decision making is severely compared. She has [MEDICAL CONDITION]; inattention and disorganized thinking. She has no [MEDICAL CONDITION] or behaviors documented during this assessment period. Continued review of the same MDS revealed her functional status as follows: Resident # 20 requires extensive assistance of one person for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. She is totally dependent on one person for bathing. She is always incontinent of bowel and bladder. She does not use a mobile device. She is unsteady, she can balance herself. Review of her care plan dated 11/28/19 revealed she was a safety risk related to cognitive impairment, decrease safety awareness and wandering. She was dependent on staff for all needs, emotional. She had impaired thought process. She was at risk for falls. There was nothing documented regarding sexual incidents. Observation/Interview on 01/13/2020 at 1:50 p.m. Resident # 20, she was in the secure unit, she was clean well groomed. She was confused and disoriented. She was friendly and approachable. She was unable to complete an interview. In an interview with the DON on [DATE]20 at 10:15 a.m. said that she was aware of the and made a self-report incident on 12/03/19 of an alleged sexual assault between Resident #9, the alleged perpetrator, (AP) and Resident #12, the alleged victim (AV). She said that while an RCS was making his rounds he discovered Resident #9 and Resident #12 laying on the bed, Resident #12 was fully clothed, and Resident #9 had his pants off and he was laying on top of Resident #12. She said she was not aware of Resident #9 sexually assaulting any other resident. She said that nothing like that had ever been reported to her or she would have self-reported it to the state. She said that Resident #12 was assessed and there were no signs of penetration. She said that Resident #12 was not taken to the hospital, she was assessed from head to toe and there was no evidence that there had been penetration during the sexual assault. She said the PCP and family was notified. She stated the nurse called the ambulance so Resident #9 could be transferred to a local hospital for an evaluation. She said she also called the police. She said when the police arrived, they took Resident #9 out of the ambulance and arrested him for parole violation and they took him to the local County jail. She said that Resident #9 had been started on the medication [MEDICATION NAME] (which is supposed to decrease his sexual urges) on 11/08/19 to be administered in the morning every day for inappropriate sexual behavior. The [MEDICATION NAME] was increased on 11/12/19 to 10 mg per day. She said that Resident #9 was lusting after the females and making sexual comments, mostly to the staff. The DON was also asked by the investigator if she was aware of the allegations of sexual abuse regarding Resident #9 and Resident's #19, and Resident #20. She said none of my staff reported any sexual incidents to me except the one I reported to the state. She said that her staff has been trained in reporting abuse and neglect, that this is discussed in every employee's orientation and multiple times throughout the year. She said that she goes over the facility policy every time that there is an allegation of abuse or neglect. She said that the staff knows that the Administrator is the Abuse Coordinator but in his absence she is the Abuse Coordinator. She said that the Administrator was on vacation during the week so she investigated and reported the sexual incident between Resident #9 and Resident #12. She said I'm having some management issues with one of the department managers, I think they are out to get me. She said that she was told by an RCS D that while he was making rounds on the skilled unit that he noticed one of the bedroom doors shut. She said he told her that it was unusual for that door to be closed so he opened the door and he saw Resident #9 and Resident #12 lying in bed. He said that Resident #9 was laying on top of Resident #12 with his pants down. He said that Resident #12 was fully clothed. She said he told her that as soon as he opened the door Resident #9 got up and while he was pulling up his pants he said, I didn't do nothing. She said the RCS D told her that neither resident was in their rooms, they were found in another resident's room. She said that the RCS and the ADON separated them immediately and reported the incident to his charge nurse. She said that Res #12 was given a head to toe assessment and there was nothing to indicate she had been raped, there was no evidence of penetration. She said that Resident #9 was placed on 1:1 observation until he could be discharged from the facility. She said that Res #12 did not show any signs that she was in any emotional distress. She said that Resident #9 was an attention seeking resident. She said that he liked the females, both resident and staff. She said that he had been seen by the staff lusting at the females and making inappropriate sexual comments toward them, mostly the staff. She said that Resident #9 likes to touch other residents, he liked rubbing their shoulders or if they were sitting down he liked to rub their thighs. She said that the staff knew to watch him closely and keep him separated from the females on the unit. She said that when it was reported to her by her staff that Resident #9's sexual behaviors were increasing she said she called Resident #9's PCP and he gave them an order to start Resident #9 on [MEDICATION NAME] 10 mg every a.m., that was on 11/12/19. She said she was not aware of any other incidents of sexual inappropriate behavior from Resident #9. She said that when this incident happened, the facility called the police and an ambulance. She said they were in the process of sending Resident #9 to the local hospital for an evaluation when the police arrived. She said that the police went into the ambulance and arrested Resident #9 and took him to the county jail, apparently, he had violated his parole. She said that Resident #12 was not sent to the hospital for any test as there was no evidence that she was raped, she was not showing any emotional or physical stress, and she has been assessed and there was no evidence of penetration. She said that she did not know anything about the allegation that Resident #9 had been sexually inappropriate with Resident #19 or Resident #20 either. She said that if anything like that happened, her staff did not report it to her. She said that this is the first she has ever heard of this. She said that she does recall that it was a very busy week for her, that the Administrator was out on vacation and she was the Abuse Coordinator in his absence. In an interview on 01/16/2020 at 1:55 p.m. with the Administrator, he said that he had been on vacation for part of the month of December 2019. He said that it was not reported to him any other incidents involving Resident #9 and any other female residents. He said that he has spoken with his DON and she said that nothing was reported to her. He said that he would be investigating the allegations that have been reported to him by the state investigators during this investigation. He said that his staff have all been in-serviced on abuse and neglect and the importance of reporting in a timely manner. He said there has been a lot of conflict with his staff over the past few months. He said that he thinks it's mostly the department managers. He said that he takes all the reported allegations very seriously and he tries to do a good investigation. He said that he was very disappointed as he thought he had a better rapport with his staff. In an interview on [DATE]20 10:10 a.m. with the DON (she has her computer to enable her to look up dates and verify information) she said that in regards to Resident #9 she was not aware of any assaults on residents to her knowledge. He did make sexual comments, to residents and staff. Immediate discharge letter was issued to Resident #9, the police were called. Resident # 9 was being transferred to the acute hospital, he was already in the ambulance when the police arrived at the facility. The police took Resident #9 out of the ambulance and arrested him on a different charge. She said that review of the MDS dated [DATE] Resident #9 had a BI[CONDITION] score of 7 (indicating Severe impairment) and review of the MDS dated [DATE] Resident #9 scored a 9 on the BI[CONDITION] interview which indicates Moderate impairment). Resident was initially admitted to the facility on [DATE] to the secure unit per family request. On 10/03/19 Resident #9 was transferred to station 2, which is an unsecure unit. Resident #9 eloped the same day and was transferred back to the Secure Unit. Resident #9 was listed on the electronic face sheet as his own responsible party. She said that the incident involving Resident #9 and Resident #12 was the only actual physical contact that was reported to her. She said that Resident #9 was heard by the staff making inappropriate sexual statements and he would look at the females with lust in his eyes. Resident #9 was able to walk but he used his wheelchair for mobility most of the time. She said that she was unaware of his wandering on the secure unit. She said that Resident # 9 was not sent to the hospital, the police arrived at the facility and took him from the ambulance, placed him in the police car and took him to the county jail. She said the ADON called Resident #12's daughter, she was not overly upset because Resident #12 was fully dressed during the incident. There was no evidence of any physical injury. She said she did not want to put her mother through that experience, she declined hospitalization . LVN G did complete a head to toe assessment on Resident #12 to include her vaginal area. There was no evidence that there was any penetration from the incident. The Administrator was notified of the Immediate Jeopardy on 1/17/2020 at 4:35 p.m. The IJ template was given to the administrator. The facility's Plan of Removal of immediate Jeopardy was accepted as being completed on 01/17/2020 at 10:35 p.m. The plan included the following: Immediate action taken: Sexual Assault Prevention Immediate Actions: Residents with cognitive impairment have the potential to be sexually assaulted. Those residents identified to be at risk were assessed by the interdisciplinary team. Care plans were updated as needed by the Interdisciplinary Team (IDT). Staff will be re-educated by Administrator, Assistant Director of Nursing and Unit Managers on the importance of reporting any acts that may be deemed of sexual nature of unwanted touching, or talking about sexual acts toward residents or staff. Staff that do not report such incidents will be immediately disciplined. Monitoring will include questioning of employees to ensure they understand the management of residents at risk for being sexually assaulted. If the staff are found to answer the questions incorrectly, they will be re-educated. If they still cannot answer the questions, they will be taken off the schedule until they can respond correctly Monitoring will occur weekly for a month, every 2 weeks x 4 weeks, then monthly x 3 months. Progress of this plan will be reported to the Quality Assessment Performance Improvement Committee weekly for 1-month, biweekly x 1 month, and monthly thereafter until substantial compliance has been achieved. The Medical Director was notified about the Immediate Jeopardy on 1/17/20 at 8:30pm. Medical Director is an active member of the Quality Assessment Performance Improvement Committee which will monitor completion and compliance of the plan. Medical Director will attend Quality Assurance Performance Improvement monthly meetings. Administrator will report progress of this plan to the Quality Assurance Performance Improvement Committee monthly meeting. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring will include questioning of employees to ensure they understand the management of residents at risk for being sexually assaulted. If the staff is found to answer the questions incorrectly, they will be re-educated. If they still cannot answer the questions, they will be taken off the schedule until they can respond correctly Monitoring will occur weekly for a month, every 2 weeks x 4 weeks, then monthly x 3 months. Monitoring the Plan of Removal conducted by the investigators 01/18/2020-01/19/2020 The 12 RCS's, 2 RN's, and 6 LVN's (all shifts) were interviewed from 01-18-2020 - 01/19/2020; They were able to define abuse, they all had knowledge of their reporting responsibilities, they were able to name the facility Abuse Coordinator and the importance of timely reporting. The Department Managers (5 managers) were interviewed from 01/18/2020 - 01/19/2020; They all had knowledge of the facility abuse policy and procedure. They were able to voice the importance of follow-up to ensure they get the proper forms completed, obtain interviews and/or witness statements, and ensure the event be documented in the resident's clinical record. They were able to voice how they would monitor and provide oversight to ensure care and services

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents, for one (Resident #10) of 1 of 23 residents reviewed for elopement risk. On 10/17/19 the facility failed to supervise and prevent Resident #10 from exiting the secure unit of the facility. Resident #10 exited the building without staff knowledge or supervision at an unknown time, without staff being aware. A staff member was driving by and reported Resident #10 was out of the facility. Staff said Resident #10 was found by a local restaurant on a busy 4-lane main road and brought back to the facility by facility staff. Resident #10 was missing for approximately 2 hours. An Immediate Jeopardy situation was identified on 01/17/2020. The Immediate Jeopardy was lowered on 01/19/2020; The facility remained out of compliance at a level of no actual harm with potential for more than minimal harm, with a scope of isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure could affect residents that were identified as elopement risks and placed them at risk of serious bodily harm, [MEDICATION NAME] physical impairment, or death. Findings include: Review of Resident #10's The Quarterly MDS dated [DATE] documents she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident# 10's BI[CONDITION] was not able to be assessed, indicating her cognition was severely impaired. The MDS did not document wandering behaviors. Resident #10's Care Plan dated 11/08/17 did not address the risk of elopement or the need for monitoring. Resident #10's Care Plan dated 11/26/19 revealed she had decreased safety awareness, wandering, behavior problems, communication problems. She was at risk for falls. She needed assistance with Activities of Daily Living. She had impaired visual function. No interventions for these were documented. Record review of the assessments on 1/17/20 for Resident # 10 revealed there was no elopement assessment documented. In an interview on 1/16/2020 at 10:20 AM RN A said Resident # 10 did elope from the Memory Care unit on 10/17/2019, in the early afternoon. Resident # 10 was outside the building at a local fast food restaurant. RN A said LVN C saw Resident # 10 outside the building and called RN A. RCS C was bringing Resident # 10 back by the time RN A got around there. LVN G was told of the elopement. RN A said the DON was pissed off and said she was not reporting the elopement. RN A said Resident # 10 did not appear to be injured. RN A said Resident # 10 was confused and disoriented. RN A provided a written statement. Record review of the statement provided by RN A dated 1/16/2020 documented LVN C called her on 10/17/2019 at 1:41 PM on her cell phone to tell her Resident # 10 was outside the building in the fast food restaurant parking lot. RN A wrote she left her office and saw several people were going after Resident # 10. RCS C actually walked resident # 10 back into the building. The DON later called her, and the DON sounded very stressed out, the Administrator was not there, and the DON said she was not going to report the elopement. RN A wrote LVN C a text and asked if the DON was pissed about Resident # 10. In an interview on 1/16/2020 at 11:07 AM in the MDS office RN A said LVN C called her when she found Resident #10 outside and said she was by a local fast food restaurant. LVN C said resident was on the sidewalk, and not at the fast food restaurant. In this interview with the investigator a loud argument began between the 2 staff regarding where Resident #10 was found. Interview with LVN C was stopped and a statement was provided by her later. Record review of the statement provided by LVN C, dated 1/16/2020 documented LVN C saw Resident # 10 outside the building on the sidewalk on 10/17/2019, when LVN C was leaving the parking lot. A time was not provided. LVN C documented calling RN A from the car, because LVN C documented she did not feel she could get Resident # 10 back in the building by herself. LVN C then documented she asked RN A to report finding Resident # 10 outside the building. In an interview on 1/16/2020 at 2:29 PM RCS L said another RCS told her Resident # 10 did leave the unit and the facility and was found at a local fast food restaurant. RCS L said RCS C was the one who brought Resident # 10 back. RCS L said the MC unit manager told them yesterday afternoon (1/15/2020) no one was to say anything about this occurring. RCS L said it was told to the AM, the SW, RCS C, RCS L and RCS D by the unit manager. RCS L said RCS D won't tell you what happens back there, never will. RCS L said Resident # 9 had been sexually inappropriate with more than just Resident # 12 that one time. RCS L said they (the management) did nothing about it, something should have been done much sooner that it was. Resident # 9 really seemed to focus on Resident #12. RCS L said another resident left the facility, and the Activity Director brought him back. In an interview on [DATE] at 11:54 a.m., RCS C said several residents had gotten out of the secure unit but not recently. She said she had brought some back but did not bring back Resident #10 when she eloped. She said had not personally been told to change her statements but heard other staff had been asked to do so. In an interview on 1/15/2020 at 4:12 p.m. and 4:40 PM the SW said she saw a CNA (name not known) bringing Resident # 10 inside the front doors of the facility. Resident # 10 was using her walker and did not appear to be injured. The CNA said Resident # 10 had got out of the MC unit and was at a local fast food restaurant. The CNA told her Resident # 10 said she was going home. The SW said she asked RN A if the DON was aware of the elopement and was told she was, but the DON had said she was not going to report it. SW said Resident #10 did elope from the unit and was found by a local fast food restaurant. The staff were told to say nothing about the elopement. The DON was notified of the elopement. Interview 1/16/2020 at 4:05 PM SW provided a written statement and said the ADON had told her and RCS L to not say anything about Resident # 10 because the DON would be in trouble. Record review of the statement provided by the SW, dated 1/16/2020 documented Resident # 10 eloped from the MC unit and the facility on 10/17/2019 in the afternoon. The SW documented she witnessed a CNA (name not known) bring Resident # 10 in the front door of the facility, Resident # 10 was using a walker and appeared uninjured. The statement documented asking if the DON was aware and being told the DON was not going to report the elopement, because she was tired of reporting things that week. The SW statement documented on 1/15/2020 the ADON ask if she knew anything about Resident # 10 eloping and the SW told the ADON what she witnessed. The statement documented the ADON then told her and another CNA standing there, to not say anything about it because the DON could get into trouble. Interview 1/16/2020 4:29 RCS K said Resident # 10 did leave the facility from the unit, LVN G said she made it to a local fast food restaurant, RCS K saw RCS C bring Resident # 10 back, and was not sure if Resident # 10 had their walker. Resident # 10 doesn't always have the walker, moves fast with or without it. Said the DON did know, RCS C told her and did not see the DON come to the unit. Record review of the nurses notes for October 2019 revealed there was no documentation of Resident # 10 eloping and there was no documented assessment for Resident # 10 when she was returned to the MC (Memory Care) unit. Observation of the secure unit on 1/13/2020 at 3:54 PM revealed there were 4 exit doors from the Memory Care unit. All the doors had number key pads, 2 of the key pads had a cover that prevented the code from being observed by bystanders. The other 2 key pads did not have a cover on them. In an observation on 1/14/2020 at 1:14 PM Resident # 10 was in the dining room, had walker, was oriented to self only. In an interview on 1/15/2020 at 10:10 AM the DON said she was not aware of any elopement by Resident # 10. Resident # 10's BI[CONDITION] was severely impaired, Resident # 10 usually used a wheelchair. In an interview on 1/15/2020 at 3:45 PM the Administrator said he has found no reports of an elopement by Resident # 10. In an interview on 1/15/2020 at 3:52 PM LVN M, MC unit nurse, said Resident # 10 watches the door would leave if she could get the code, would be able to watch and get the code but has not eloped to her knowledge. 1/16/2020 9:00 AM In an interview RCS D said the covers were put over the inside MC unit key pads the middle of last year (2019), last summer. When RCS D was asked if there was any specific reason for the covers RCS D said some of the residents can remember the code. RCS D said a couple of the residents set by the doors and watch, including Resident # 10. When ask if anyone had eloped RCS D said no. In an interview on 1/16/2020 at 9:07 AM [CONDITION] said the Administrator had ask him to put some type of barrier on the unit code pads to prevent the codes being visible, [CONDITION] said this was done several months ago. 2 of the code pads had been done. The Administrator was notified of the Immediate Jeopardy on 1/17/2020 at 4:35 p.m. The IJ template was given to the administrator. The facility's Plan of Removal of immediate Jeopardy was accepted as being completed on 01/17/2020 at 10:35 p.m. The plan included the following: PLAN OF REMOVAL Elopement: Actions for affected Resident #10 The resident resides on the Memory Care secured unit. On January 16, 2020 approximately 2pm Administrator was informed by a staff member that she knew of an elopement of Resident #10 that occurred on October 17, 2019. Immediate action taken: Elopement was self-reported to [STATE] Health and Human Services. A full investigation was initiated. Resident was assessed for physical and psychosocial well-being. Responsible party for Resident #10 was notified. All exit doors on the Memory Care unit were checked for function and found to be in working order. 2 key pads were already covered to keep residents from watching codes being entered. The remaining 2 key pads were covered to keep residents form watching codes being entered. Elopement Drills will be held on all 3 shifts throughout the weekend. Any reported elopement attempt or exit seeking behavior will be reviewed by the Interdisciplinary Team. Elopement Assessment will be updated and care plan revised with any new interventions. Assistant Director of Nursing and Unit Managers and charge nurses will complete Elopement Risk Assessments on 100% of residents residing at the facility. This will be initiated on 1/17/2020 at 6pm and will be completed by 1/17/2020 at 8:30pm. For residents identified as at risk for elopement, interventions will be reviewed, revised or initiated and care plan will be updated to reflect current interventions. Elopement Risk Notebook will be updated to include all residents identified as Elopement Risks. This notebook will be kept at the Receptionist Desk in the Lobby. Staff will be re-educated regarding the contents of this book and to use this information for an Elopement event. Administrator, Assistant Director of Nursing and Unit Managers will re-educate all staff, including all PRN and part-time staff, regarding reporting Elopement including failure to report to the Abuse Prohibition Coordinator, who is the Administrator. This re-education was initiated on 1/17/2020 and will be completed on 1/18/2020 by 2pm. Any staff member who has not completed this re-education will not be allowed to work until re-education has been completed. Monitoring will include review of chart of new admissions, readmissions and residents with change of condition to determine risk for elopement. Doors of Memory Care Unit will be monitored routinely for function. Any malfunction will be corrected to maintain integrity of the security of the unit by Maintenance Director. Documentation will be maintained in the TELS system and reported to the Administrator. Residents at risk for elopement will continued to be assessed for elopement risk quarterly, annually, and with a significant change in condition. Care Plans will be updated according to findings. Residents at risk will be monitored for their whereabouts during meal times, medication pass, and throughout the shift to ensure they remain safe within the facility. Doors found to not being working properly will immediately be secured and the Nursing Home Administrator will be notified immediately. Monitoring will include questioning of employees to ensure they understand the management of residents at risk for being sexually assaulted. If the staff is found to answer the questions incorrectly, they will be re-educated. If they still cannot answer the questions, they will be taken off the schedule until they can respond correctly. Monitoring will occur weekly for a month, every 2 weeks x 4 weeks, then monthly x 3 months. Monitoring will occur weekly for a month, every 2 weeks x 4 weeks, then monthly x 3 months. Progress of this plan will be reported to the Quality Assessment Performance Improvement Committee weekly for one (1) month, biweekly x one (1) month, and monthly thereafter until substantial compliance has been achieved. The Medical Director was notified about the Immediate Jeopardy on 1/17/20 at 8:30p.m. Medical Director is an active member of the Quality Assessment Performance Improvement Committee which will monitor completion and compliance of the plan. Medical Director will attend Quality Assurance Performance Improvement monthly meetings. Administrator will report progress of this plan to the Quality Assurance Performance Improvement Committee monthly meeting. The facility Administrator will monitor, plan, and make changes until issues are resolved. Monitoring the Plan of Removal by the investigators 01/18/2020-01/19/2020 Twelve Resident Care Specialists, 2 RN's and 6 LVN's were interviewed between 01/18/20-01/19/20 and able to correctly answer: define abuse, they all had knowledge of their reporting responsibilities, they were able to name the facility Abuse Coordinator and the importance of timely reporting. Five Department Heads interviewed btween 01/18/20-01/19/20. They all had knowledge of the facility abuse policy and procedure. They were able to voice the importance of follow-up to ensure they get the proper forms completed, obtain interviews and/or witness statements, and ensure the event be documented in the resident's clinical record. They were able to voice how they would monitor and provide oversight to ensure care and services were provided. The Administrator was able to correctly answer: -Actions taken to respond to concerns, -the investigation process and training, -Aministrator's responsibility, -how he got to the root cause of not being informed of incedents, -staff's lack of training versus the fear of retaliation, -elopements were effectively addressed, -staff's understanding of the reporting/investigative process, -which residents were high risk of elopment and how this is determined, -the location of the notebook regarding elopement risks and the person responsible for updating it. 01/18/2020 Time 4:50 p.m. Observation: All three Double doors at the entrance/exit of the secure Memory Care Unit key pad were covered. There is a sign on one set of doors to the secure unit with a sign that ask visitors and staff to use only that one set of doors for entrance and exit of the secure unit. (to be able to better monitor; to ensure no residents are slipping out of the unit as visitors and staff enter.) The code to the secure Memory Care Unit has been changed. The three doors that open into the secure unit have covers over the pads, so they are not easily seen when exiting the SU. 4:50 p.m. Observation: All doors mentioned in the POR have covers over the pads (so they are not easily visible for residents to memorize the numbers in the code) while exiting the SU. Elopement Risk Assessment was completed for Resident #10, Completed 01/17/2020, the score was 13 which places her at high risk for elopement, any assessment that is 12 or higher considered high risk for elopement. A head to toe assessment was completed on Resident #10, No skin issues noted. Reviewed the following In-services/Training: 1. Inservice/Training Dated 01/16/2020 with 76 signatures on the employee sign-in sheet. The topics covered: Purpose, Definitions, Screening, Training, Prevention, Identification, Protection, Investigation, Reporting and response - State reporting obligations, Elder Justice, Corrective action, and Documentation: This training was completed on 01/16/2020. 2. Inservice/Training dated 01/18/2020 at 4:30 p.m. with [AGE] employee signatures covering the following topics: Incident/Accident Report for Resident, Risk Management Information System, Four-point plan 01/19/2020; Interviews with 6 LVN's, 2 RN's, 10 RCS from both stations and the Memory Care Unit. That covered all shifts to include the weekend staff. 1. 01/18/2020 - 01/19/2020 Interviews with 4 department managers, they were able to answer all questions. They were aware of the Elopement book, they knew how to use it and knew where it was located. 2. 01/18/2020 at 4:25 p.m. Electronic Review (Part of Monitoring) 3. Residents at risk for abuse/neglect/sexual assault dated 01/17/2020; All residents residing on the secure unit were assessed (36 residents) Electronic Record Review for Resident Elopement Risk Assessments All residents residing on the Secure Unit (36 residents) Residents on 200 Hall (24 residents reviewed) Residents on 300 Hall (7 residents reviewed) Assessments completed. Electronic Record Review Completed, All residents identified for at risk for elopement had their Care Plans updated. The Immediate Jeopardy was lowered on 01/19/2020; The facility remained out of compliance at a level of no actual harm with potential for more than minimal harm, with a scope of isolated due to the facility's need to complete training of all staff and monitor the plan of removal.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being for one (Resident #1) of five residents reviewed for diabetic care and services. The facility failed to provide Resident #1, who had a [DIAGNOSES REDACTED]. The failure resulted in Resident #1 developing a diabetic ulcer to sole of his right foot, which could increase the chances of infection, complications, and possibly amputation. The failure could affect the four residents, who required an extra-long mattress. Findings included: Resident #1's MDS assessment, dated 08/17/15, reflected the resident was a [AGE] year-old male, admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident was cognitively intact, required the extensive physical assistance of one person with bed mobility, and had functional limitation in range of motion with his lower extremity on one side. The resident was 77 inches tall (6 feet 5 inches) and had no diabetic ulcers. Review of Resident #1's History and Physical dated 08/18/15 reflected the resident had a below-the-knee amputation to his left leg. Resident #1's Comprehensive Care Plan, dated 08/18/15 reflected: Focus: (Resident #1) potential for pressure ulcer development r/t Immobility . Goal: Resident #1 will have intact skin, free of redness, blisters or discoloration by/through review date .Target Date: 11/18/15. Interventions: .Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date Initiated: 08/18/2015. Resident #1's Comprehensive Care Plan, dated 09/23/15 reflected: Focus: (Resident #1) has diabetic ulcer to right foot, plantar area r/t (related to) Immobility. Goal: (Resident #1's) diabetic ulcer will show signs of healing and remain free from infection by/through review date .11/18/15. Interventions: .Footboard of bed removed to prevent pressure on heel. Date Initiated: 10/01/2015. Low air loss mattress. Date Initiated 10/01/2015 . The Skin-Weekly Non-Pressure Condition Record, dated 09/23/15, reflected Resident #1 had a diabetic ulcer to his right foot/plantar (the sole), which he acquired at the facility. The wound bed was described as red with moderate serous drainage and an no odor. No measurements of the ulcer were documented. The interventions included the use of a low air loss mattress and a heel protector. The Wound Care Special Initial Evaluation, dated 09/28/15, reflected Resident #1 had a diabetic wound on his right, plantar foot with wound duration of a least one day. The Wound Care Physician assessed the wound to measure 3.0 cm x 3.0 cm x 0.2 cm with moderate serous exudate (drainage), and 100% yellow necrotic (dead) tissue. The Wound Care Physician debrided (removed) the muscle and necrotic tissue. An interview on 11/16/15 at 11:15 a.m. with Resident #1 revealed the facility caused the sore on his foot. He stated his right foot was dead and had no feeling except for an occasional sharp pain, for about three years. He explained that the sore on his foot was caused when his foot rubbed against the footboard of his bed, and the facility did not remove the footboard. Resident #1 stated, I can't leave here till my foot is healed. An observation on 11/16/15 at 11:15 a.m. revealed Resident #1 in bed with an air mattress on the bed. The bed did not have a footboard in place. An observation on 11/17/15 at 2:24 p.m. revealed the diabetic ulcer on Resident #1's right foot was clean and there was no drainage. LVN C measured the ulcer, and it was approximately 1.0 cm x 1.0 cm x < 0.5 cm. An interview on 11/18/15 at 10:00 a.m. with LVN A revealed she took care of Resident #1 when he was on Hall 300. LVN A stated Resident #1 was admitted to the facility with a [MEDICAL CONDITION] and a feeding tube. She stated he could make his needs known, and he never complained that his foot touched the foot board. LVN A stated, once the CNA noticed the spot on the resident's foot, wound care was started immediately. When asked if the footboards on the beds were removable, LVN A stated some of the footboards could be removed and Resident #1's footboard could come off. When asked if she removed the footboard on Resident #1's bed, LVN A replied, No. An interview on 11/18/15 at 11:00 a.m. with the ADON revealed Resident #1 was alert and oriented and could make his needs known. The ADON stated, We were constantly pulling him up (in bed). She stated extenders were put on his bed, to make the bed longer, and they ordered the resident an extra-long bed. An interview on 11/18/15 at 8:35 a.m. with the DON revealed they tried using extenders on Resident #1's bed initially to make the bed longer and on 09/23/15 they removed the foot board from the resident's bed. When asked under what circumstances the facility provided extra-long beds for residents, the DON stated an extra-long bed was provided if a resident was greater than six feet tall. An interview on 11/18/15 at 8:45 a.m. with the Health Information Coordinator revealed she ordered an extra-long bariatric bed for Resident #1 on 09/23/15. She stated they did not need a physician order [REDACTED]. She stated there were currently four residents with extra-long beds. When asked about bed extenders, the Health Information Coordinator stated the Maintenance Supervisor handled those. An interview on 11/18/15 at 3:30 p.m. with the Maintenance Supervisor revealed he did not know if the facility owned bed extenders or extra-long beds. He stated he had only been at the facility for a few months. The facility did not have a policy and procedure related to the use of extra-long beds. The American Podiatric Medical Association released the following information, which was retrieved on 12/02/15, from http://www.apma.org/Learn/FootHealth.cfm?ItemNumber=981: Diabetic Wound Care A [MEDICAL CONDITION] is an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot. .Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States, and approximately 14-24 percent of patients with diabetes who develop a foot ulcer will require an amputation .Research has shown, however, that development of a foot ulcer is preventable. Causes .Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes. .Because many people who develop foot ulcers have lost the ability to feel pain, pain is not a common symptom. .There are several key factors in the appropriate treatment of [REDACTED]. .Taking the pressure off the area . A list of residents, who required the use of special beds and/or mattresses was provided on 11/18/15, and the list reflected a total of four residents required the use of an extra-long mattress.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #1) of one resident reviewed for pain management. Resident #1's physician ordered a hospice evaluation for pain management on 12/15/10 after he spoke with Resident #1's guardian, who was in agreement with the physician's plan of care. Nursing staff contacted the physician due to the resident's increasing pain, but did not follow a physician's orders [REDACTED]. The ADM did not contact hospice for an evaluation until 01/10/11 (27 days later). The resident continued to receive physical therapy from 12/15/10 through 01/10/11, which caused the resident to have increased pain, which was not relieved. This failure could affect the facility's 11 residents currently receiving pain medication and placed them at risk for unrelieved pain, which could cause a decrease in their quality of life, to eat less, and withdraw from activities. Findings included: The Face Sheet dated 12/15/09 reflected Resident #1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The hospital's Physician Discharge Note/Orders dated and signed by the physician on 11/20/10 reflected Resident #1 was hospitalized from [DATE] through 11/22/10. Resident #1's readmission physician orders [REDACTED]. On 11/23/10 the resident was evaluated and therapy orders were written for PT 5 times a week through 01/30/11 and OT 5 times a week through 01/30/11. ST evaluated the resident and orders were written for ST 5 times a week through 01/22/11. A progress note from Physician E dated 12/08/10 reflected the following, "R (right) foot dry gangrene. Skin - dry gangrene worsening, Pain- Due to gangrenous toes." The note further reflected the physician left a message for Resident #1's guardian to discuss options. A progress note from Physician E dated 12/15/10 reflected the following, "F/U (follow-up) Dry Gangrene Rt. Foot. Some agitation due to pain, toes hurt to light touch. Awake in bed and looks uncomfortable. Pain in rt. foot with touch (any). 1) I discussed options surgical vs non-surgical __ (with) guardian ...today. Risks of surgery and risks of non-surgery approaches reviewed. Based on this discussion ____ (guardian) agreed to hospice referral at this time & no intention for hospitalization if/when need arises. 2) Pain (foot). May need more routine dosing of [MEDICATION NAME] ([MEDICATION NAME] an opioid [MEDICATION NAME]) & possibly [MEDICATION NAME] ([MEDICATION NAME]) if [MEDICATION NAME] ineffective." Resident #1's physician wrote an order dated 12/15/10, which reflected the following. "The patients Guardian ________ (guardian's name) has requested ________ (name of hospice) Hospice consultation for dry gangrene right foot/end stage [MEDICAL CONDITION] and pain management. Increase [MEDICATION NAME] 10/325 mg dosing frequency to 1 po qid (by mouth four times a day) routinely for pain." A progress note from Physician F dated 01/10/11 reflected the following,"Gangrene R (right) foot. Pt. good candidate for hospice care. End-stage [MEDICAL CONDITIONS]. ______ (Hospice Name) Hospice consult requested by ______ (physician) on 12/15/10. Received a call from nursing staff last week about patient. The Administrator hasn't called the hospice until today. ______ (Physician) spoke with ______ (guardian) explains in detail the risks of surgery & risks of non surgery. ______ (guardian) agreed to place the patient under hospice care. Spoke to ______ (Administrator) he says that pt. is getting benefits from PT (physical therapy). It's clear from clinical exam that pt. has end-stage [MEDICAL CONDITION] and gangrene. She will not improve despite the PT and she has very low potential for any rehab. __________ (Administrator) says that her Medicare is going to run out this week and he is planning to call hospice next week (01/16/11). I personally spoke to _______ (physician) today and he agrees that this looks to be a case of Medicare fraud. ________ (Administrator) claims the responsibility of not calling the hospice until now. _______ (Administrator) was again told by me to initiate hospice today." On 02/10/11 at 11:30 AM, when the surveyor entered the facility the ADM stated he knew what the investigation was about and proceeded to give a statement. He stated they (the facility) had received an order for [REDACTED]. The ADM continued that three weeks later the resident's physician came in the building and was upset she (Resident #1) had not been placed on hospice. The ADM was asked if he had spoken to the Guardian. He stated he had, and she had agreed to keep Resident #1 on therapy. He assumed at that time they no longer had a valid order after the Guardian agreed not to put her on Hospice. On 02/10/11 at 11:46 AM, an interview was conducted with ADON A. She stated in December 2010 an order was received to put Resident #1 on hospice. She stated the ADM was going to contact the Guardian, and while she could not recall for sure, she thought for about a month, nothing was done about the hospice order. She stated the leadership group would meet regularly, and she would periodically ask what was happening with the Hospice order for Resident #1. She stated she would be told, "They would talk about it after meeting," or "She needed to stay on Medicare." She stated she was never made aware whether the Guardian had been contacted. ADON A stated this continued until one day when she was off, a charge nurse called the physician and asked for additional pain medication for Resident #1, because she was hurting, and her current pain medications were not effective. She was told by her nurses Physician F wanted her sent to the hospital, but when ADON A returned the next day, Resident #1 was still in the building. On 02/10/11 at 12:00 PM, ADON B was interviewed. She stated she was not really aware of the situation with Resident #1. She did recall ADON A bringing Resident #1 up in some stand-up meeting. ADON B said ADON A would say, "She needs to be on Hospice." ADON B stated she could not recall the group's response to ADON A's statement. On 02/10/11 at 12:30 PM, the Director of Rehabilitation was interviewed regarding Resident #1's therapy. She stated she was aware of the physician order [REDACTED]. On 02/10/11 at 1:00 PM, the DON was interviewed. She stated Resident #1 had been bedfast since July or August 2010. She stated Resident #1 would get up in a Geri-chair approximately once a week. The DON stated the facility received an order for [REDACTED]. She stated over the next few weeks, she was never told if the ADM had spoken to the Guardian. She stated it was usually the nurse, who would have made the contact and received the permission from the family. She stated she never saw any documentation the Guardian had accepted or declined hospice. "We were waiting on ______ (ADM) to tell us he had gotten approval," the DON said. The DON was asked if she notified Physician E, and she stated, "If he had wanted more pain meds, he could have ordered it." She was asked, "But didn't he order Hospice to manage her pain?" and she stated, "He was here every week." The DON, who was currently writing a written statement, was asked to clarify in her statement what she meant by saying the physician could have ordered more pain meds. and she said, "I'm not gonna write that." The DON continued by stating Physician F came in the building on 01/10/11 and wrote a second order for Hospice, and "despite our policy," she called and ordered Hospice. The DON was then asked if she thought Physician E had intended therapy services to continue once the hospice order was written on 12/15/10, and she stated it was not, but no one attempted to clarify the order. On 02/10/11 at 1:45 PM, the Director of the Guardian Services Agency was interviewed. The Director stated the Guardian in charge of Resident #1 no longer worked for the agency. She stated in the front of every chart was a contact sheet, and the facilities were told if they did not receive a call back from the Guardian, they could contact the alternate or herself (the Director). "We are available 24 hours a day. Saying you could not reach the guardian, no way, that is not an excuse," she said. When asked if the Guardian would have refused Hospice services for Resident #1, she stated, "That would have been a situation she would have discussed with me, and we did not discuss that." On 02/10/11 at 2:00 PM, Charge Nurse LVN C was interviewed. She stated Resident #1 was a bedfast resident, who had been on Hospice prior to this last hospitalization in November 2010. She also stated she had been on routine pain medications prior to her hospitalization , but when she returned, the order was written as needed. LVN C stated Resident #1 would have bad days and better days, but her pain appeared to be getting worse. She stated the physician had ordered Hospice for pain management and changed her pain medications to routine four times a day. "Her pain kept getting worse. It really bothered me. It tore me up," stated LVN C. She stated ADON A and the DON knew. She stated therapy was working with her every day, which made her pain worse. "I would ask them, why are y'all doing this to her.?" LVN C stated one day Resident #1 had been to therapy, and she really appeared to be hurting, and her pain medications were not relieving her pain. LVN C stated she called Physician F, and he wanted to know why hospice was not managing her pain. When he was told Hospice had not been consulted, he said to send her to the hospital. LVN C stated she told the DON and LVN D, and they did not want to send her to the hospital, so the physician was called back. LVN C stated they asked if they got a Hospice referral for Resident #1, could they keep her in the facility, and he agreed. LVN C stated that was on 01/06/11, and when she returned to work on 01/10/11, Resident #1 was still in the facility, and hospice still had not been consulted. On 02/10/11 at 2:15 PM, the Guardian was interviewed regarding Resident #1. She stated she had a conversation with Resident #1's physician (Physician E), and together they agreed the resident should be placed on Hospice. She stated she had spoken regularly to the ADM, because she had several residents on the facility's secured unit. The Guardian stated she never would have held up Hospice services if her doctor ordered it. "That is not what we do, that was why I spoke to the doctor to see what he thought was best," stated the Guardian. She was asked specifically if she refused Hospice Services and she said, "No." She further stated she recalled the ADM making a statement regarding Resident #1 having some skilled days left, but she did not understand that to mean Hospice would not be started. On 02/10/11 at 5:00 PM, the ADM was interviewed regarding Resident #1. He stated a Hospice Evaluation order was written, and in a meeting with his department heads, they discussed the resident. He stated his question was, since she was receiving therapy for her contractures, and she could not be on both (Medicare) Part A and Part B, was there any benefit (to keeping her on therapy). He said he spoke to the Guardian within a day or two and suggested, based on her therapist and his opinion, Resident #1 was benefiting from therapy, and in order to put her on Hospice, therapy would have to be stopped. He told her she could refuse to put her on Hospice, and she stated, "I'm fine with that." He said he told her, "She (Resident #1) was almost off Medicare anyway, and at that point, we will not have a choice." "I think there was a benefit to her," he said, "I don't think there was caused anymore pain than was necessary." The ADM further stated no one in his staff shared concerns about her pain medications. He stated he told the staff the Guardian had not refused therapy. When asked if any staff shared concerns about the Hospice order, he stated, "No, because at that point we had no valid Hospice order." The ADM continued by stating, Physician F came in the building and "blew a gasket," and he was not going to change his mind (about the order for Hospice). So the ADM stated he called the Guardian back, and this time she agreed to Hospice. On 02/11/11 at 9:00 AM, an interview was conducted with the facility's Clinical Regional Director. She stated regarding the order for Hospice dated 12/15/10, "We would have expected the doctor's order to be followed or dc'd (discontinued) after the physician was contacted." On 02/11/11 at 9:40 AM, CNA G was asked about Resident #1. She stated Resident #1 was a bedfast, total care resident. She stated she would "jump back" or retract her leg whenever her leg was touched. She also stated Resident #1 would moan, grimace, and rub her leg. CNA G stated she thought these behaviors were due to pain, because the resident could not tell you she was hurting, and she (CNA G) would report this to the charge nurse. On 02/11/11 at 9:50 AM, CNA H was interviewed regarding Resident #1. She stated Resident #1 would moan and grimace or hold onto her right leg. She interpreted these behaviors as being in pain, and she would report them to her charge nurse. She stated the charge nurse would call and try to get the resident more pain medications. "At first it (pain meds) would take care of it (the pain), but towards the end, it did not," stated CNA H. She was then asked what she meant by toward the end. CNA H was then asked if Resident #1 was still attending therapy, and she stated, "Yes." On 02/11/11 at 10:50 AM in an interview, the Medical Director stated when asked, specifically about the Hospice order written on 12/15/10 for Resident #1, "The physician's orders [REDACTED]. It's about money," stated the Medical Director. On 02/11/11 at 11:10 AM, the DON was interviewed regarding the nurse's note dated 01/06/11 where it indicated Physician F ordered Resident #1 be sent to the hospital for pain control. The DON stated they got Physician F to agree they would send Resident #1 to the hospital or have Hospice come for an evaluation. The DON was then asked if either of the physician orders [REDACTED].#1 and said, "She did not appear to be in as much pain as described." She stated she spoke with therapy, and they had started a second modality on her (Resident #1), so she decided not to follow the physician orders. On 02/11/11 at 11:30 AM, LVN D was interviewed. She stated LVN C had come to a meeting and told her and the DON about the order to send Resident #1 to the hospital for pain control. She said the physician had said to send her to the hospital or get her on hospice. "We did not want to do that yet," she stated, "So we decided we would call the Guardian." When asked if they spoke to the Guardian, she stated, "It was a few days, because she was changing jobs." She further stated, "As far as sending her to the ER (emergency room ), we just didn't see then need." LVN D was then asked about her ability as a nurse to ignore a physician order. LVN D stated, "If I feel the doctor is incorrect, then I am not going to follow the order. This was not a life or death situation." The symptoms of dry gangrene according to MayoClinic.com (<http://www.mayoclinic.com/>) include: When gangrene affects your skin, signs and symptoms may include: A blue or black discoloration of your skin. Severe pain followed by a feeling of numbness. A foul-smelling discharge leaking from a sore. According to Medline plus http://www.merckmanuals.com/home/print/sec03/ch034/ch034b.html Occlusive [MEDICAL CONDITION] Occlusive [MEDICAL CONDITION] may result from gradual narrowing or sudden blockage of an artery. When an artery narrows, the parts of the body it supplies may not receive enough blood. An inadequate blood supply is called ischemia. Ischemia may develop suddenly or gradually. When an artery is suddenly or completely blocked, the tissue it supplies may die. Symptoms vary depending on which artery is affected, how completely the artery is blocked, and whether the artery is gradually narrowed or suddenly blocked. Usually, about 70% of the artery's interior has to be blocked before symptoms occur. Gradual narrowing of an artery may result in less severe symptoms than sudden blockage-even if the artery eventually becomes completely blocked. Symptoms may be less severe because gradual narrowing allows time for nearby blood vessels to expand or new blood vessels (called collateral vessels) to grow. Thus, the affected tissue can still be supplied with blood. If an artery is suddenly blocked, there is no time for collateral vessels to develop, so symptoms are usually severe. Arteries of the Legs and Arms: Sudden, complete blockage of an artery in a leg or an arm may cause severe pain, coldness, and numbness in the affected limb. The person's leg or arm is either pale or bluish (cyanotic). No pulse can be felt below the blockage. The sudden, drastic decrease in blood flow to the limb is a medical emergency. The absence of blood flow can quickly result in loss of sensation in or paralysis of a limb. According to Symptoms of Dry Gangrene | eHow.com <http://www.ehow.com/about_ 94_symptoms-dry-gangrene.html> http://www.ehow.com/about_ 94_symptoms-dry-gangrene.html#ixzz1EFgsOmha <http://www.ehow.com/about_ 94_symptoms-dry-gangrene.html> The onset of pain from the gangrene varies from patient to patient. One patient may have a constant feeling of numbness, and another may exhibit constant pain in the region. It is important to have the disease treated before pain, deformation and loss of function is damaged irrevocably. The pain that accompanies gangrene is constant and will restrict the patient's ability to move, walk and bandage the infected area properly. Review of a list of residents dated 02/11/11 provided by the ADON revealed there were 11 residents on pain medications.

Based on interview and record review, it was determined the facility failed to ensure the Administrator and the DON managed the facility's resources effectively and efficiently to attain or maintain the highest practicable physical well-being for one (Resident #1) of one resident reviewed for pain. The Administrator and the DON failed to ensure hospice services were provided according to the physician's orders [REDACTED]. The DON failed to follow a direct order from the physician to send Resident #1 to the hospital for pain control. Resident #1 was diagnosed with [REDACTED]. Resident #1 suffered pain following the therapy sessions, which on 01/06/11 was unrelieved with her routine pain medications. LVN C notified the physician and was directed by the physician to send the resident to the hospital for pain control or to have hospice evaluate the resident. LVN C informed the DON and LVN D of the physician's orders [REDACTED]. These failures resulted in a 27-day delay in Resident #1 receiving hospice services and caused Resident #1 to have unrelieved pain from a combination of the dry gangrene and therapy services. This failure could affect the facility's 11 residents currently receiving pain medication and placed them at risk for unrelieved pain, which could cause a decrease in their quality of life, to eat less, and withdraw from activities. Findings included: The Face Sheet dated 12/15/09 reflected Resident #1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The hospital's Physician Discharge Note/Orders dated and signed by the physician on 11/20/10 reflected Resident #1 was hospitalized from [DATE] through 11/22/10. Resident #1's readmission physician orders [REDACTED]. On 11/23/10 the resident was evaluated and therapy orders were written for PT 5 times a week through 01/30/11 and OT 5 times a week through 01/30/11. ST evaluated the resident and orders were written for ST 5 times a week through 01/22/11. A progress note from Physician E dated 12/08/10 reflected the following, "R (right) foot dry gangrene. Skin - dry gangrene worsening, Pain- Due to gangrenous toes." The note further reflected the physician left a message for Resident #1's guardian to discuss options. A progress note from Physician E dated 12/15/10 reflected the following, "F/U (follow-up) Dry Gangrene Rt. Foot. Some agitation due to pain, toes hurt to light touch. Awake in bed and looks uncomfortable. Pain in rt. foot with touch (any). 1) I discussed options surgical vs non-surgical __ (with) guardian ...today. Risks of surgery and risks of non-surgery approaches reviewed. Based on this discussion ____ (guardian) agreed to hospice referral at this time & no intention for hospitalization if/when need arises. 2) Pain (foot). May need more routine dosing of [MEDICATION NAME] ([MEDICATION NAME] an opioid [MEDICATION NAME]) & possibly [MEDICATION NAME] ([MEDICATION NAME]) if [MEDICATION NAME] ineffective." Resident #1's physician wrote an order dated 12/15/10, which reflected the following. "The patients Guardian ________ (guardian's name) has requested ________ (name of hospice) Hospice consultation for dry gangrene right foot/end stage [MEDICAL CONDITION] and pain management. Increase [MEDICATION NAME] 10/325 mg dosing frequency to 1 po qid (by mouth four times a day) routinely for pain." A progress note from Physician F dated 01/10/11 reflected the following,"Gangrene R (right) foot. Pt. good candidate for hospice care. End-stage [MEDICAL CONDITIONS]. ______ (Hospice Name) Hospice consult requested by ______ (physician) on 12/15/10. Received a call from nursing staff last week about patient. The Administrator hasn't called the hospice until today. ______ (Physician) spoke with ______ (guardian) explains in detail the risks of surgery & risks of non surgery. ______ (guardian) agreed to place the patient under hospice care. Spoke to ______ (Administrator) he says that pt. is getting benefits from PT (physical therapy). It's clear from clinical exam that pt. has end-stage [MEDICAL CONDITION] and gangrene. She will not improve despite the PT and she has very low potential for any rehab. __________ (Administrator) says that her Medicare is going to run out this week and he is planning to call hospice next week (01/16/11). I personally spoke to _______ (physician) today and he agrees that this looks to be a case of Medicare fraud. ________ (Administrator) claims the responsibility of not calling the hospice until now. _______ (Administrator) was again told by me to initiate hospice today." On 02/10/11 at 11:30 AM, when the surveyor entered the facility the ADM stated he knew what the investigation was about and proceeded to give a statement. He stated they (the facility) had received an order for [REDACTED]. The ADM continued that three weeks later the resident's physician came in the building and was upset she (Resident #1) had not been placed on hospice. The ADM was asked if he had spoken to the Guardian. He stated he had, and she had agreed to keep Resident #1 on therapy. He assumed at that time they no longer had a valid order after the Guardian agreed not to put her on Hospice. On 02/10/11 at 11:46 AM, an interview was conducted with ADON A. She stated in December 2010 an order was received to put Resident #1 on hospice. She stated the ADM was going to contact the Guardian, and while she could not recall for sure, she thought for about a month, nothing was done about the hospice order. She stated the leadership group would meet regularly, and she would periodically ask what was happening with the Hospice order for Resident #1. She stated she would be told, "They would talk about it after meeting," or "She needed to stay on Medicare." She stated she was never made aware whether the Guardian had been contacted. ADON A stated this continued until one day when she was off, a charge nurse called the physician and asked for additional pain medication for Resident #1, because she was hurting, and her current pain medications were not effective. She was told by her nurses Physician F wanted her sent to the hospital, but when ADON A returned the next day, Resident #1 was still in the building. On 02/10/11 at 12:00 PM, ADON B was interviewed. She stated she was not really aware of the situation with Resident #1. She did recall ADON A bringing Resident #1 up in some stand-up meeting. ADON B said ADON A would say, "She needs to be on Hospice." ADON B stated she could not recall the group's response to ADON A's statement. On 02/10/11 at 12:30 PM, the Director of Rehabilitation was interviewed regarding Resident #1's therapy. She stated she was aware of the physician order [REDACTED]. On 02/10/11 at 1:00 PM, the DON was interviewed. She stated Resident #1 had been bedfast since July or August 2010. She stated Resident #1 would get up in a Geri-chair approximately once a week. The DON stated the facility received an order for [REDACTED]. She stated over the next few weeks, she was never told if the ADM had spoken to the Guardian. She stated it was usually the nurse, who would have made the contact and received the permission from the family. She stated she never saw any documentation the Guardian had accepted or declined hospice. "We were waiting on ______ (ADM) to tell us he had gotten approval," the DON said. The DON was asked if she notified Physician E, and she stated, "If he had wanted more pain meds, he could have ordered it." She was asked, "But didn't he order Hospice to manage her pain?" and she stated, "He was here every week." The DON, who was currently writing a written statement, was asked to clarify in her statement what she meant by saying the physician could have ordered more pain meds. and she said, "I'm not gonna write that." The DON continued by stating Physician F came in the building on 01/10/11 and wrote a second order for Hospice, and "despite our policy," she called and ordered Hospice. The DON was then asked if she thought Physician E had intended therapy services to continue once the hospice order was written on 12/15/10, and she stated it was not, but no one attempted to clarify the order. On 02/10/11 at 1:45 PM, the Director of the Guardian Services Agency was interviewed. The Director stated the Guardian in charge of Resident #1 no longer worked for the agency. She stated in the front of every chart was a contact sheet, and the facilities were told if they did not receive a call back from the Guardian, they could contact the alternate or herself (the Director). "We are available 24 hours a day. Saying you could not reach the guardian, no way, that is not an excuse," she said. When asked if the Guardian would have refused Hospice services for Resident #1, she stated, "That would have been a situation she would have discussed with me, and we did not discuss that." On 02/10/11 at 2:00 PM, Charge Nurse LVN C was interviewed. She stated Resident #1 was a bedfast resident, who had been on Hospice prior to this last hospitalization in November 2010. She also stated she had been on routine pain medications prior to her hospitalization , but when she returned, the order was written as needed. LVN C stated Resident #1 would have bad days and better days, but her pain appeared to be getting worse. She stated the physician had ordered Hospice for pain management and changed her pain medications to routine four times a day. "Her pain kept getting worse. It really bothered me. It tore me up," stated LVN C. She stated ADON A and the DON knew. She stated therapy was working with her every day, which made her pain worse. "I would ask them, why are y'all doing this to her.?" LVN C stated one day Resident #1 had been to therapy, and she really appeared to be hurting, and her pain medications were not relieving her pain. LVN C stated she called Physician F, and he wanted to know why hospice was not managing her pain. When he was told Hospice had not been consulted, he said to send her to the hospital. LVN C stated she told the DON and LVN D, and they did not want to send her to the hospital, so the physician was called back. LVN C stated they asked if they got a Hospice referral for Resident #1, could they keep her in the facility, and he agreed. LVN C stated that was on 01/06/11, and when she returned to work on 01/10/11, Resident #1 was still in the facility, and hospice still had not been consulted. On 02/10/11 at 2:15 PM, the Guardian was interviewed regarding Resident #1. She stated she had a conversation with Resident #1's physician (Physician E), and together they agreed the resident should be placed on Hospice. She stated she had spoken regularly to the ADM, because she had several residents on the facility's secured unit. The Guardian stated she never would have held up Hospice services if her doctor ordered it. "That is not what we do, that was why I spoke to the doctor to see what he thought was best," stated the Guardian. She was asked specifically if she refused Hospice Services and she said, "No." She further stated she recalled the ADM making a statement regarding Resident #1 having some skilled days left, but she did not understand that to mean Hospice would not be started. On 02/10/11 at 5:00 PM, the ADM was interviewed regarding Resident #1. He stated a Hospice Evaluation order was written, and in a meeting with his department heads, they discussed the resident. He stated his question was, since she was receiving therapy for her contractures, and she could not be on both (Medicare) Part A and Part B, was there any benefit (to keeping her on therapy). He said he spoke to the Guardian within a day or two and suggested, based on her therapist and his opinion, Resident #1 was benefiting from therapy, and in order to put her on Hospice, therapy would have to be stopped. He told her she could refuse to put her on Hospice, and she stated, "I'm fine with that." He said he told her, "She (Resident #1) was almost off Medicare anyway, and at that point, we will not have a choice." "I think there was a benefit to her," he said, "I don't think there was caused anymore pain than was necessary." The ADM further stated no one in his staff shared concerns about her pain medications. He stated he told the staff the Guardian had not refused therapy. When asked if any staff shared concerns about the Hospice order, he stated, "No, because at that point we had no valid Hospice order." The ADM continued by stating, Physician F came in the building and "blew a gasket," and he was not going to change his mind (about the order for Hospice). So the ADM stated he called the Guardian back, and this time she agreed to Hospice. On 02/11/11 at 9:00 AM, an interview was conducted with the facility's Clinical Regional Director. She stated regarding the order for Hospice dated 12/15/10, "We would have expected the doctor's order to be followed or dc'd (discontinued) after the physician was contacted." On 02/11/11 at 9:40 AM, CNA G was asked about Resident #1. She stated Resident #1 was a bedfast, total care resident. She stated she would "jump back" or retract her leg whenever her leg was touched. She also stated Resident #1 would moan, grimace, and rub her leg. CNA G stated she thought these behaviors were due to pain, because the resident could not tell you she was hurting, and she (CNA G) would report this to the charge nurse. On 02/11/11 at 9:50 AM, CNA H was interviewed regarding Resident #1. She stated Resident #1 would moan and grimace or hold onto her right leg. She interpreted these behaviors as being in pain, and she would report them to her charge nurse. She stated the charge nurse would call and try to get the resident more pain medications. "At first it (pain meds) would take care of it (the pain), but towards the end, it did not," stated CNA H. She was then asked what she meant by toward the end. CNA H was then asked if Resident #1 was still attending therapy, and she stated, "Yes." On 02/11/11 at 10:50 AM in an interview, the Medical Director stated when asked, specifically about the Hospice order written on 12/15/10 for Resident #1, "The physician's orders [REDACTED]. It's about money," stated the Medical Director. On 02/11/11 at 11:10 AM, the DON was interviewed regarding the nurse's note dated 01/06/11 where it indicated Physician F ordered Resident #1 be sent to the hospital for pain control. The DON stated they got Physician F to agree they would send Resident #1 to the hospital or have Hospice come for an evaluation. The DON was then asked if either of the physician orders [REDACTED].#1 and said, "She did not appear to be in as much pain as described." She stated she spoke with therapy, and they had started a second modality on her (Resident #1), so she decided not to follow the physician orders. On 02/11/11 at 11:30 AM, LVN D was interviewed. She stated LVN C had come to a meeting and told her and the DON about the order to send Resident #1 to the hospital for pain control. She said the physician had said to send her to the hospital or get her on hospice. "We did not want to do that yet," she stated, "So we decided we would call the Guardian." When asked if they spoke to the Guardian, she stated, "It was a few days, because she was changing jobs." She further stated, "As far as sending her to the ER (emergency room ), we just didn't see then need." LVN D was then asked about her ability as a nurse to ignore a physician order. LVN D stated, "If I feel the doctor is incorrect, then I am not going to follow the order. This was not a life or death situation." The symptoms of dry gangrene according to MayoClinic.com (<http://www.mayoclinic.com/>) included: When gangrene affects your skin, signs and symptoms may include: A blue or black discoloration of your skin. Severe pain followed by a feeling of numbness. A foul-smelling discharge leaking from a sore. According to Medline plus http://www.merckmanuals.com/home/print/sec03/ch034/ch034b.html Occlusive [MEDICAL CONDITION] Occlusive [MEDICAL CONDITION] may result from gradual narrowing or sudden blockage of an artery. When an artery narrows, the parts of the body it supplies may not receive enough blood. An inadequate blood supply is called ischemia. Ischemia may develop suddenly or gradually. When an artery is suddenly or completely blocked, the tissue it supplies may die. Symptoms vary depending on which artery is affected, how completely the artery is blocked, and whether the artery is gradually narrowed or suddenly blocked. Usually, about 70% of the artery's interior has to be blocked before symptoms occur. Gradual narrowing of an artery may result in less severe symptoms than sudden blockage-even if the artery eventually becomes completely blocked. Symptoms may be less severe because gradual narrowing allows time for nearby blood vessels to expand or new blood vessels (called collateral vessels) to grow. Thus, the affected tissue can still be supplied with blood. If an artery is suddenly blocked, there is no time for collateral vessels to develop, so symptoms are usually severe. Arteries of the Legs and Arms: Sudden, complete blockage of an artery in a leg or an arm may cause severe pain, coldness, and numbness in the affected limb. The person's leg or arm is either pale or bluish (cyanotic). No pulse can be felt below the blockage. The sudden, drastic decrease in blood flow to the limb is a medical emergency. The absence of blood flow can quickly result in loss of sensation in or paralysis of a limb. According to Symptoms of Dry Gangrene | eHow.com <http://www.ehow.com/about_ 94_symptoms-dry-gangrene.html> http://www.ehow.com/about_ 94_symptoms-dry-gangrene.html#ixzz1EFgsOmha <http://www.ehow.com/about_ 94_symptoms-dry-gangrene.html> The onset of pain from the gangrene varies from patient to patient. One patient may have a constant feeling of numbness, and another may exhibit constant pain in the region. It is important to have the disease treated before pain, deformation and loss of function is damaged irrevocably. The pain that accompanies gangrene is constant and will restrict the patient's ability to move, walk and bandage the infected area properly. Review of a list of residents dated 02/11/11 provided by the ADON revealed there were 11 residents on pain medications.