Every finding on record at Elgin Nursing and Rehabilitation Center

Based on interview and record review the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident #1) reviewed for trauma-informed care. The facility failed to ensure Resident #1 had a care plan that identified possible triggers when Resident #1 had a history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization. The findings include:1. Record review of Resident #1's face sheet, dated 07/28/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included post-traumatic stress disorder chronic with onset diagnosis on 07/07/2026 (a psychiatric condition that can develop in individuals who have experienced or witnessed a traumatic, terrifying, or life-threatening event. It lingers long after the danger has passed, causing intense, disturbing thoughts and emotions that disrupt daily functioning), impulse disorder ( a mental health condition involving a repeated inability to resist harmful urges), and psychotic disorder with hallucinations (a mental health condition where individuals experience a break from reality, causing them to see, hear, smell, taste, or feel things that are not actually there).Record review of Resident #1's Quarterly MDS Assessment, dated 06/30/2026 reflected Resident #1 had a BIMS score of 9 indicating his cognition was moderately impaired. He was assessed to feeling down, depressed, or hopeless. Resident #1 assessed to have delusions (misconceptions or beliefs that are firmly held, contrary to reality). He was assessed to have a diagnosis of psychotic disorder and depression (lasing sadness, low energy, and a loss of interest in life).Record review of Resident #1's Comprehensive Care Plan, completed on 07/07/2026 and revised on 07/10/2026, reflected (problem initiated on 07/10/2026) Resident #1 was at risk for emotional and /or physical symptoms associated with distressing events and an increased inability to cope related to a diagnosis of Post Traumatic Stress Disorder. Resident had a history of incarceration, delusions ( a fixed, false belief that a person holds firmly despite clear and obvious evidence that is not true), paranoia ( an extreme and irrational mistrust or suspicion of other people, characterized by the belief that others are trying to harm, cheat, or watch you without any real proof), and longstanding mistrust of others. During periods of increased anxiety or perceived threat, resident may become verbally aggressive, make racially derogatory statements towards staff or other residents, refuse care, and exhibit escalating behaviors that may progress to physical aggression. Interventions: Administer psychiatric medications. Establish trust by being nonjudgemental and hones; offer empathy and support. Monitor for increase of paranoia, hallucinations, delusions or changes in mood. Protect other residents by redirecting or separating individuals when necessary. Provide resident with a safe means for expressing feelings, especially those of anger or aggression. Report significant behavioral changes to the interdisciplinary team and psychiatric providers. Validate the resident's emotions without reinforcing delusional beliefs. Resident #1 did not have a focus area of possible triggers for the PTSD.Interview on 07/28/2026 at 10:05 a.m. Resident #1 stated no one in the facility has asked me about if there was anything that would trigger an episode of PTSD. He stated when he heard loud noises and people talking very loud it affected him and reminded him when he was in jail. Resident #1 stated there was men that thought they were boss of him and he was not going to be bossed by a man anymore. He stated, I become nervous and mad when a man tries to boss me and when there is a lot of noises. He stated, I heard a lot of noises when I was in jail and it reminds me of when I was locked in cell and could not do anything but listen to people yelling and banging on things.Interview with the ADON on 07/28/2026 at 5:05 p.m., the ADON stated the Social Worker was responsible to ensure an assessment was completed on any resident with diagnosis of PTSD. She stated a resident's triggers were expected to be identified during the assessment. The ADON did not elaborate on any of her responses to questions. She stated Resident #1's PTSD specific triggers were not identified on the interventions of his care plan. The ADON did not respond to any further questions about PTSD care plans.In an interview with the Social Worker on 07/28/2026 at 5:15 p.m., the Social Worker stated it was her responsibility to ensure all interventions related to any psychiatric diagnosis was care planned. She stated Resident #1's PTSD was a new diagnosis, and his care plan was expected to reflect his triggers. The Social worker did not respond to any further questions about PTSD and did not elaborate on her answers to questions. She stated she was not aware of the specific triggers of Resident #1. She stated she thought documenting perceived threat was sufficient to indicate his triggers. The Social Worker stated she realized she was not specific enough and the facility staff needed to know Resident #1's triggers. She stated she was going to interview the family and Resident #1 to determine what his triggers were and would revise Resident #1's care plan to reflect his triggers. She stated it would be beneficial to all staff in approaching Resident #1 and what not to do if they were aware of what made him anxious or depressed. She stated it was a possibility with him being incarcerated could be a lot of triggers from this event in his life. In an interview with the MDS Coordinator on 07/28/2026 at 5:30 p.m., she stated Resident #1 should have PTSD triggers identified and documented in his medical record. She stated the Social Worker was responsible for ensuring the PTSD triggers was identified when she did her assessment. The MDS Coordinator stated a resident's Care plan was their Plan of care. The MDS Coordinator did not respond to any further questions about PTSD or explain the purpose of care plans.Record review of the facility's policy on Behavioral Health Sciences, dated 10/24/2022, reflected Is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. Non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being. Facility staff will implement person-centered care approaches designed to [NAME] the individual goals and needs of each resident, which includes non-pharmacological interventions to help meet behavioral health needs.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen. The facility failed to ensure meals were served in accordance with facility dining hours and endure residents were not brought into the dining room to wait for an extended period of time for their food to be served. This failure could place residents at risk of cold food, dehydration, weight loss, and quality of life. Findings included:Record review of Resident #86's face sheet, dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (an ongoing, progressive lung condition that obstructs airflow, primarily caused by smoking or long-term exposure to irritants), type 2 diabetes mellitus with diabetic chronic kidney disease (occurs when prolonged high blood sugar damages the kidney's filtering units), and abnormalities of gait and mobility (any irregular, uncoordinated, or painful walking pattern). Record review of Resident #86's care plan revealed: problem Resident #86 had a potential fluid deficit related to poor intake dated 04/01/2026 with intervention educate Resident #86 and his family and caregivers on importance of fluid intake dated 04/01/2026. Record review of Resident #86's MDS (clinical assessment to determine resident's strength and needs) dated 12/19/2025 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 11 indicating moderate cognitive issues. Record review of Resident #56's face sheet, dated 06/16/2026, revealed an [AGE] year old male who was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease ((an ongoing, progressive lung condition that obstructs airflow, primarily caused by smoking or long-term exposure to irritants), personal history of malignant neoplasm of prostate (indicates that a patient has previously been diagnosed with and treated for prostate cancer, and is currently in remission without active disease), and monoclonal gammopathy (a blood disorder where your plasma cells produce an abnormal protein called an M-protein or paraprotein). Record review of Resident #56's care plan revealed problem: Resident #86 had a problem of potential nutritional problem related to diet restriction of no added salt dated 05/11/2026 with an intervention of provide, serve diet as ordered and monitor intake and record every meal dated 05/11/2026. Record review of Resident #56's MDS (clinical assessment to determine resident's strength and needs) dated 04/23/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 9 indicating moderate cognitive issues. Record review of Resident #19's face sheet, dated 06/16/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitting on 05/03/2023. His diagnoses included cerebral infarction (occurs when a blood vessel in the brain is blocked or significantly narrowed), anxiety disorder (persistent, excessive fear or worry in everyday situations that are disproportionate to the actual threat), and spontaneous ecchymoses (unexplained bruising or blood pooling under the skin larger than 1 centimeter). Record review of Resident #19's care plan revealed problem: Resident #19 had a problem of Resident #2 experienced a 7.3 percent weight gain in 1 month dated 08/16/2025 with intervention monitor and record food intake at each meal dated 08/16/2025. Record review of Resident #19's MDS (clinical assessment to determine resident's strength and needs) dated 02/09/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 7 indicating severe cognitive issues.Record review of the facility dining hours reflected:Breakfast - 7:15 AM, Lunch - 11:30 AM, Dinner - 5:15 PM Observation on 06/14/2026 of the first lunch trays coming out of kitchen and being placed on the serving cart at 12:53 PM and 300 Hall trays beginning to be passed at 1:15 PM.Observation on 06/14/2026 at 1:00pm revealed lunch tray beginning to be served to the residents seated in the dining room. During an interview on 06/14/2026 at 1:00 PM with Resident #86 he said it bothered him that lunch was served late because he wanted food to be served punctually. Resident #86 said lunch had been served late for about a month. Observation on 06/15/2026 at 12:47 PM revealed lunch trays being checked to confirm that the resident meal tickets matched the food that was on the resident tray. No trays had been passed to any residents on any hallway at that time. During an interview on 06/15/2026 at 12:47 PM with LVN I she said she could not answer why lunch was being served late. LVN I said she did not know what was going on inside the kitchen.During an interview on 06/15/2026 at 1:15 PM with Resident #2 she said it bothered her when lunch was late because they carted her into the dining room for no reason and she just sat and waited for no reason. During an interview on 06/15/2026 at 2:00 PM with Resident #56 he said lunch was one and a half hours late and that bothered him because he was a firefighter for 29 years and things should be kept punctual and have some kind of order. During an interview on 06/16/2026 at 12:48 PM the RD said he came twice a week to the facility. The RD said that meals should be served as close to the time that it was posted to serve meals as was possible. The RD said it was a combination of all staff who were responsible for getting meals on time to the residents. The RD said it can affect residents if meals were served late because mealtimes usually cause peaks in appetite and the facility wants residents to maintain weights and appetite.During an interview on 06/16/2026 at 12:59 PM with the DM he said he had been working at the facility for almost 3 months. He said meals should go out as soon as possible according to schedule. He said lunch was scheduled to begin at 11:15 AM so lunch should be no later than 11:35 AM ish. The DM said all the kitchen staff, the CNAs and the nurses were responsible for getting the residents their meals on time. The DM said that if meals are late, snacks are late and medications are late. During an interview on 06/16/2026 at 1:06 PM with the Administrator he said his expectation was scheduled meals should be served beginning on the 100-hallway at the posted mealtimes. The Administrator said DM was responsible for making sure meals were served on time. The Administrator said he wants meals served on time because he did not want residents to get hungry and late meal affected the day and interfere with resident plans. No facility policy with the exception of the posted mealtimes.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but no less than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse or did not result in bodily injury, to the facility administrator and to other officials in accordance with State law through established procedures for four (Resident #11, Resident #60, Resident #64, and Resident #98) of 10 residents reviewed for abuse. The facility failed to report allegations of resident-to-resident abuse to HHSC when:On [DATE], when no staff was in the dining room, a resident reported to staff, Resident #64, who was blind, allegedly hit Resident #98 on the chin (no physical injuries).On [DATE] when Resident #64, who was blind, propelled his wheelchair forward and ran into Resident #2's wheelchair. Both residents pushed at each other open fisted, and Resident #2 received a small skin tear. On [DATE] CNA K witnessed a verbal and physical altercation between Resident #11 and Resident #60, no injuries. These failures could place residents at risk for delayed investigation, intervention, and abuse. Findings included:Resident #64 and Resident #98Record review of Resident #64's face sheet, dated [DATE], revealed a fifty-one-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included legal blindness (a government classification for severe vision loss), traumatic brain injury (a disruption in normal brain function caused by a bump, blow, jolt to the head, or penetrating head injury) and delusional disorders (a serious mental illness where a person experiences persistent, unshakable false beliefs (delusions) that are not based in reality). Record review of Resident #64's care plan revealed: problem of Resident #64 attempting to find his way in the dining room via using hands to pat surfaces and inadvertently came across female resident in line of path and hit/pat her in face related to blindness and anxiousness behavior of wheeling around facility randomly dated [DATE] and intervention psychiatry to address resident's increased agitation and increased wandering in wheelchair in facility (no specific destination verbalized) dated [DATE], staff to assist to and from location of choice dated [DATE], and staff to monitor resident's attempts to propel self in group setting and re-direct dated [DATE].problem Resident #64 had limited physical mobility related to blindness of both eyes, LLE contracture (chronic loss of joint mobility in your left leg, caused by the tightening of muscles, tendons, or ligaments) and impaired cognition dated [DATE] and intervention Resident #64 was extensive to total assistance by 1-2 staff for locomotion using wheelchair dated [DATE]. problem Resident #64 had a history of behavior problems (inappropriate touching of other residents, making inappropriate sexual remarks towards others, attempts to grope female staff, history of smearing bodily wastes, history of pulling penis out of brief and urinating on floor saturating clothing, history of grabbing a male resident's breast. Resident #64 had a history of TBI (damage to the brain caused by an outside physical force) psychosis and history of unsafe behaviors requiring redirection dated [DATE] and intervention 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 dated [DATE]. Record review of Resident #64's MDS (clinical assessment to determine resident's strength and needs) dated [DATE] Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 9 indicating moderate cognitive issues.Record review of Resident #98's face sheet, dated [DATE], revealed a forty-two-year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included multiple sclerosis (a chronic, unpredictable autoimmune disease of the central nervous system (brain, spinal cord, and optic nerves), paraplegia (condition characterized by the partial or complete paralysis of the lower half of the body, including both legs and often the lower trunk), and cachexia (a severe, complex metabolic syndrome characterized by extreme unintentional weight loss, including severe muscle and fat wasting).Record review of Resident #98's care plan revealed problem of a potential communication problem related to MS dated [DATE] with intervention be conscious of resident position when in groups, activities, dining room to promote proper communication with others dated [DATE] and a problem of impaired cognitive function or impaired thought processes related MS dated [DATE] and intervention cue, reorient and supervise as needed dated [DATE].Record review of Resident #98's MDS (clinical assessment to determine resident's strength and needs) dated [DATE] Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 7 indicating severe cognitive issues.Record review of TULIP reflected the facility did not report a resident-to-resident incident that occurred on [DATE] and involved Resident #64 and Resident #98.Record review of facility Incident by Incident Type report dated [DATE] to [DATE] for category of Resident-to-Resident Incidents reflected Resident #64 and Resident #98 were both involved in an incident dated [DATE]. Record review Resident #64's progress notes dated [DATE] by FDON reflected Resident #64 was in hallway propelling self in wheelchair when DON approached. DON asked Resident #64 if he had hit anyone. Resident #64 stated no. DON asked if he remembered having any physical contact with a female. Resident #64 stated no. Resident #64 also stated he was heading to dining room but did not remember being in dining room earlier. Resident #64 was calm and no aggressive movements. No visible reddened areas noted to Resident #64's fingers or hand and skin intact. Record review of facility Resident to Resident Incident Report dated [DATE] reflected Resident #68 was in hallway propelling self in wheelchair when DON approached. FDON asked if Resident #64 had hit anyone. Resident #64 said no. FDON asked if he remembered having any physical contact with a female. Resident #64 said no. Resident #64 also stated he was heading to the dining room but did not remember being in the dining room earlier. Resident #68 said I would never hit a woman, when asked if he had hit a female resident. Resident also states he does not remember hitting anyone. No injuries observed at the time of incident. IDT review - Resident #64 reportedly inadvertently hit peer in face when attempted to pass her in the dining room, feeling his way due to blindness. Resident #64 not to be left alone in group settings. Review of Incident report reflected no name of female resident. Record review of facility Resident to Resident Incident Report dated [DATE] reflected Resident #98 was sitting in her wheelchair in the dining room. Resident #98's peer had informed DON that Resident #64 hit Resident #98 in the face. Resident #98 said, [Resident #64] hit my mouth. Resident #98 denied having any pain and there was redness on face or mouth and no swelling. Resident #98 had a calm posture and denied being afraid. Resident #98 described she was just sitting there and Resident #64 hit her in the face. When Resident #98 was asked for more details Resident number 98 stated Resident # 64 came up behind her using his hands to touch/pat in a searching manner. Resident #98 said he first patted at her arms, then shoulder and then face before passing her. Resident #98 was assessed head to toe with no visible redness or to her extremities or face. Resident #98's skin was intact with no bruising or visible trauma marks. The DON assured Resident #98 he would take care of issue.Record review of Resident #98's progress notes reflected no progress not for a resident-to-resident incident.During an interview on [DATE] at 2:45 PM with Resident #98 she said a while ago she was in the dining room and was hit on the chin by Resident #64. Resident #98 said Resident #64 was an a****** and she did not want to be around him. Resident #98 said it hurt when it happened, she said she said, ow ow. She said she did not have a bruise. Resident #98 said she told a nurse about it when it happened but did not remember the name of the nurse. During an interview on [DATE] at 3:01 PM with Resident #98's RP said she was aware that Resident #98 had been hit on the chin by Resident #64. Resident #98's RP said she visited Resident #98 the day after the incident and did not see a bruise or a mark on Resident #98's chin. Resident #98's RP said Resident #64 was removed from the dining room for a period of time after the incident. The RP said she found out about the incident from Resident #98 and Resident #98 was pretty mad about it. Resident #98's RP said occasionally, the facility would try to place Resident #64 next to Resident #98 and Resident #98 requested that Resident #64 be moved. During an interview on [DATE] at 8:29 AM with FDON he said he remembered an incident in the dining room involving Resident #64 and Resident #98. FDON said he did not witness the incident, but resident (now deceased ) reported the incident to him. The FDON said there were no staff in the dining room where the event occurred because they had not begun serving the meal. The FDON said he went to check on Resident #98 to see if she was okay. The FDON said after he and Resident #98 talked he said Resident #98 told him Resident #64 was trying to get by Resident #98 and as he attempted to get by Resident #98, Resident #64 hit Resident #98 in the face. The FDON said Resident #64 did not attack Resident #98. The FDON said Resident #98 received a head-to-toe skin assessment and Resident #98 had no injuries. The FDON said Resident #98 did not say that she was afraid to be around Resident #64. The FDON said interventions were put in place for someone to be with Resident #64 when he was in his wheelchair because he was blind and had a hard time getting around. The FDON said he did not see it as an incident that was reportable because Resident #64 did not actively go after Resident #98 and they did not have an argument. The FDON said Resident #64 hit Resident #98 accidently due to his vision impairment. The FDON said when he spoke with Resident #64 about it, Resident #64 said he was not aware that he hit anyone. During an interview on [DATE] at 8:30 AM with Resident #12 she said she was in the hallway from the dining room and saw the altercation between Resident #64 and Resident #98. Resident #12 said it was a long time ago and did not know the date. Resident #12 said Resident #64 was mean to Resident #98. Resident #98 told him to stop, and Resident #64 would not stop. Resident #12 said she did not think Resident #64 hurt Resident #98 badly. Resident #12 said Resident #64 was kicking at Resident #98. During an interview on [DATE] at 9:21 AM with the PNP she said Resident #64 was chronically impulsive and delusional. The Psychiatric NP said there was a situation in the dining room a few months ago, she did not remember the date when Resident #64 reached out and accidentally hit someone. She said she was told about it but did not know the other resident involved was Resident #98. The PNP said she did not receive a call that Resident #98 was the person Resident #64 hit. She said she had no note of a call from the facility or any note that she discussed the incident with Resident #98. During an interview on [DATE] at 9:27 AM with the PNP she said she spoke with Resident #98 about the incident when Resident #64 hit her in the face when they were in the dining room. The PNP said she spoke Resident #98 about the incident and Resident #98 said the man who hit her was blind and he did hit her, but Resident #98 was mad because Resident #64 did not admit to hitting her. During an interview on [DATE] at 10:48 AM with Resident #64 he said he remembered hitting a male in the dining room but did not remember hitting anyone else. During an interview on [DATE] at 2:59 PM with the Administrator he said he did not report the incident between Resident #64 and Resident #98 to HHSC because it involved a Resident with cognitive impairment, Resident #64, and the incident did not show any intent by Resident #64 to be harmful or aggressive towards Resident #98. The Administrator said Resident #64 was going in the dining room and initially Resident #64 put his hand on Resident #98's chair and in doing so, he caught Resident #98 in the cheek. The Administrator said Resident #98 was not crying or depressed. The Administrator said he looked at the HHSC provider letter and felt that the incident did not meet the requirements to report because the incident did not involve any intent to harm. The Administrator said Resident #64 did not seek out Resident #98 to intentionally harm her and there were no physical or psychological injuries. Resident #2 and Resident #64Record review of Resident #2's face sheet, dated [DATE], revealed a sixty-eight-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life), alcoholic cirrhosis of liver without ascites (liver is scarred but can still perform its essential daily functions), and cognitive communication deficit (occurs when a person has difficulty communicating because of disruptions in brain functions like thinking, memory, or attention, rather than a physical problem with the vocal cords or a pure language impairment).Record review of Resident #2's care plan revealed problem of potential for a mood and behavior problem and the potential to be physically and verbally aggressive related to bipolar disorder, adjustment insomnia, unspecified psychosis, Dementia, depression, and poor impulse control dated [DATE] with intervention monitor resident for any signs of aggressiveness while in group activities dated [DATE].Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) dated [DATE] Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 0 indicating severe cognitive issues.Record review of TULIP reflected the facility did not report a resident-to-resident incident that occurred on [DATE] and involved Resident #2 and Resident #64. Record review of facility Incident by Incident Type report dated [DATE] to [DATE] for category of Resident-to-Resident Incidents reflected Resident #2 and Resident #64 were both involved in an incident dated [DATE]. Record review of Resident #2's progress notes dated [DATE] reflected AD reported Resident #2, and another resident had an issue in main dining room after activity had completed. Per the AD Resident #2 and Resident #64 were on opposite side of dining room from each other. Resident #64 propelled himself into Resident #2's wheelchair. Resident #2's wheelchair was bumped and both residents were moving hands around pushing at wheelchairs to move away from each other and pushing at each other's hands. Resident #2 was observed with a small skin tear to the left finger. Record review of facility Resident to Resident Incident Report dated [DATE] reflected per ADResident #64 was in the main dining room listening to music in his wheelchair. Resident #64 was legally blind and ended up attempting to wheel himself into another location. Resident #64 accidentally bumped his wheelchair into Resident #2's wheelchair and the two began pushing each other away open hands. Resident #64 unable to give description. No injuries observed at this time. Record review of facility Resident to Resident Incident Report dated [DATE] reflected AD reported Resident #2, and another resident had an issue in main dining room after activity had completed. Per AD residents were on opposite side of dining room from each other, Resident #64 who was blind, propelled self into Resident #2, witnessed by AD. Resident #2's wheelchair was bumped, both residents were moving hands around pushing at wheelchairs to move away from each other and pushing at each other's hands. Resident #2 was observed with small skin tear to left ring finger. Resident #2 unable to give descriptions. Statement by AD stated at approximately 11:00 AM on [DATE] both Resident #64 and Resident #2 were attending activities in the dining room. Resident #2 was listening to music and Resident #64 64 was across the room where residents were conducting table games. The AD said she monitored the residents during the activity, and there were no incidents between Resident #2 and Resident #64. The AD stated as she was returning residents to their rooms, the AD returned to see Resident #64 had inadvertently wheeled his chair to the side of Resident #2's chair. Resident #2 was in the same spot the AD left him and Resident #64 had navigated across the room and bumped into Resident #2's chair. The AD said neither resident was hitting the other and their fists were not closed. The AD said they were pushing away from each other's position. The AD said both residents were immediately separated and understanding Resident #64 was blind, the AD said she redirected him back to his room. The AD said she notified the ADON and administrator.During an interview on [DATE] at 8:46 AM with the FDON he said both Resident #2 and Resident #64 could be aggressive. The FDON said the incident between Resident #2 and Resident #64 was not reported because there was a staff member in the dining room with Resident #2 and Resident #64. The FDON said the residents were kind of pushing at each other and not punching each other. The FDON said the residents were pushing back to each other's wheelchair with no deliberate aggression. The FDON said if the residents do not have deliberate aggression towards each other and no deliberate injury he did not report this kind of incident to HHSC.During an interview on [DATE] at 10:42 AM with Resident #2 when asked if he was hit by another resident at the facility, Resident #2 said maybe he got hit but he did not know. During an interview on [DATE] at 11:06 AM with the AD she said Resident #2 and Resident #64 were in the dining room and an activity was breaking up and the AD was assisting residents to return to their rooms. Resident #2 and Resident #64 were separated from each other. The AD said when she returned to the dining room Resident #64, who was blind, bumped into Resident #2 and they were trying to get off of each other. The AD said Resident #2 was telling Resident #64 to get back and Resident #64 was confused and he kept pushing back. The AD said Resident #2 was aggravated and Resident #64 was upset. The AD said she knew of no injuries. She said she was trained in abuse, neglect, and exploitation and said any unwanted touching would be resident to resident altercation and should be reported to the Administrator. She said the Administrator was the abuse and neglect coordinator. The AD said it would be up to the Administrator to determine if it would be reported to the State of Texas. During an interview on [DATE] at 2:59 PM with the Administrator he said he met with the AD who depicted the incident between Resident #2 and Resident #64 as a situation where the residents were pushing their wheelchairs away from each other, did not have closed fists and were not going after each other so he did not report it to HHSC. Resident #11 and Resident #60Record review of Resident #11's face sheet, dated [DATE], revealed seventy-nine year old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life), adjustment disorder (an intense emotional or behavioral reaction to a major life stressor, like a job loss or divorce), and hemiplegia and hemiparesis (Hemiplegia refers to total or near-total paralysis, while hemiparesis refers to milder, partial muscle weakness).Record review of Resident #11's care plan revealed problem of Resident #11 had a communication problem related to aphasia (a neurological disorder caused by brain damage that impairs your ability to speak, understand, read, and write). Resident #11 was without speech. Resident #11 was usually understood and usually understood. Able to nod head, use hand gestures and use written communication dated [DATE] with intervention anticipate and meet needs dated [DATE] and Resident #11 had potential to be physically aggressive (HITTING) related to anger dated [DATE] with intervention and intervention analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document dated [DATE].Record review of Resident #11's MDS (clinical assessment to determine resident's strength and needs) dated [DATE] Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 12 indicating moderate cognitive issues.Record review of Resident #60's face sheet, dated [DATE], revealed a seventy-nine-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life), sequelae of cerebral infarction (long-term or permanent neurological, physical, and cognitive deficits that persist after an ischemic stroke), and dysarthria and anarthria (related motor speech disorders caused by brain or nerve damage that impairs the muscles controlling speech). Record review of Resident #60's care plan revealed problem of Resident #60 had potential to be physically aggressive by attempting to hit staff or other residents related to anger, dementia, history of harm to others, poor impulse control dated [DATE] with intervention separate residents dated [DATE].Record review of Resident #60's MDS (clinical assessment to determine resident's strength and needs) dated [DATE] Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 13 indicating no cognitive issues.Record review of TULIP reflected that the facility did not report a resident-to-resident incident that occurred on [DATE] and involved Resident #11 and Resident #60.Record review of facility Resident to Resident Incident Report dated [DATE] reflected CNA K alerted LVN I that Resident #11 was involved in a witnessed incident with another resident. Resident #11 was in the hallway asking to go to bed. The other resident became upset and propelled out of his room in his wheelchair yelling at Resident #11. Resident #11 approached the other resident and then the other resident used his foot to come into physical contact with Resident #11's lower extremity with minimal force due to his weakness. Resident #11 reciprocated in the same manner. This prompted the other resident to stand up and utilize his hand to come into physical contact using minimal force with Resident number 11's left shoulder. Due to a speech deficit, Resident #11 was unable to give a good description, but answered but answered LVN I's questions with yes and no answers. CNA I immediately intervened between both residents preventing any further incident and ensuring the safety of both residents. She then proceeded to separate the residents and propelled the other resident into his room and then propelled Resident #11 into his room. Once CNA K separated residents and ensured their safety she promptly approached LVN I to report incident. LVN I immediately went to perform physical assessment and skin check of each resident. Resident #11 denied any pain or discomfort related to the incident. No apparent injuries observed. No signs and symptoms of emotional distress distress observed. Administrator, DON, NP, and RP notified.During an interview on [DATE] at 3:41 PM with Resident #60 he said he had an issue with Resident #11, but now they are okay. During an interview and observation on [DATE] at 3:48 PM with Resident #11, when asked if he had an altercation with another Resident he motioned with his hands and waved for surveyor to follow him. Resident #11 rolled his wheelchair and pointed to Resident #60. During an interview by phone on [DATE] at 2:00 PM with CNA K she said Resident #60 was outside of his room and Resident #11 asked her to help him get to bed. CNA K said Resident #60 told Resident #11, don't talk to my lady and was rude to Resident #11. CNA K said Resident #11 began kicking at Resident #60 and Resident #60 called Resident #11 a mother****** and kicked back at Resident #11. CNA K said Resident #60 swung his fist at Resident #11 and hit him. CNA K said she got in the middle of the residents and separated them. CNA K said neither resident was injuried and there were no hard puches by either resident. CNA K said she notified LVN I and the residents were both assessed. CNA K said she was trained in abuse, neglect, and exploitation. CNA K said the exchanged between the residents was a resident to resident altercation. CNA K said there had been no past resident to resident issues involving Resident #11 but there had been resident to resident issues in the past involving Resident #60. During an interview by phone on [DATE] at 4:01 PM with LVN I said she worked at facility PRN and was at the nurses station when CNA K said Resident #11 and Resident #60 had a physical altercation. LVN I said CNA K was in the hallway with Resident #11 and asked CNA K for a shower. Resident #60 was in his room and came out to the hallway kicking towards Resident #11 and Resident #11 was kicking towards Resident #60. LVN I said CNA K separated them and took each resident to their room. LVN I said she assessed both residents and neither resident had complaints of pain and their skin assessment showed no marks. LVN I said neither resident had emotional distress. LVN I said she monitored both residents through the remainder of her shift. LVN I said there was minimal contact and interaction during the incident. LVN I said she filled out an incident report because it was a resident-to-resident altercation. LVN I said she received abuse, neglect, and exploitation training at the facility and the Administrator was the abuse and neglect coordinator. LVN I said it was not her call to decide when to report incidents between residents to the state. She said it was a minimal incident with no injury and no emotional harm. During an interview on [DATE] at 2:59 PM with the Administrator he said Resident #60 saw Resident #11 in the hallway and started yelling at Resident #11. The Administrator said they were kicking at each other but there was no harm and felt like they laughed it off. The Administrator said the residents were too weak to do any physical harm to each other. The Administrator said both residents were redirected back to their rooms. The Administrator said he would characterize the incident between Resident #11 and Resident #60 as a Resident-to-Resident altercation but did not feel like it rose to the level of abuse and needed to be reported. The Administrator said if there was an allegation where he felt one resident threatened another resident, for example threatening to go into another resident's room and beat them up, he would consider that abuse. He said there was no clear-cut abuse between Resident #11 and Resident #60. Review of the facility's Abuse, Neglect and Exploitation Policy dated [DATE] reflected that the facility will have written procedures to assist staff in identifying the different types of abuse -mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse-and certain resident to resident altercations. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of the facility reviewed for the pest control program.The facility failed to keep flies out of resident rooms, the facility kitchen, and the facility common areas.This failure placed residents at risk of infection, feelings of fear, anxiety, disgust, helplessness, shame, and a diminished quality of life. Findings included:Review of Resident #80's admission record, dated 06/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease (a condition that slowly damages the brain and affects thinking, memory, and the ability to do everyday tasks), contractures (when the soft tissues around a joint tighten, shorten, and lost their ability to stretch), and lack of coordination.Review of Resident #80's comprehensive MDS, dated [DATE], reflected a BIMS score was not conducted due to resident was rarely/never understood.Review of Resident #72's admission record, dated 06/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and last readmitted on [DATE]. Her diagnoses included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), and chronic diastolic heart failure (when the heart becomes stiff and cannot relax properly making it harder to fill with blood and supply the body with blood).Review of Resident #72's quarterly MDS, dated [DATE], reflected a BIMS score of 15 which indicated no cognitive impairment.Review of Resident #84's admission record, dated 06/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified asthma (chronic disease in which the bronchial airways in the lungs become narrowed and swollen and make it difficult to breathe), anxiety disorder (intense and excessive worry and fear), and chronic kidney disease (a gradual loss of kidney function over time).Review of Resident #84's quarterly MDS, dated [DATE], reflected a BIMS score of 11 which indicated moderate cognitive impairment.During an observation on 06/14/2026 at 09:17 AM, a fly was observed in the kitchen's dry goods storage area.During an observation on 06/14/2026 at 12:13 PM, four flies were observed on Resident #80's legs in the assisted dining room. Resident #80 appeared to move her legs anytime a fly moved on her bare skin. Resident #80 could not complete an interview.During an observation of dining services on 06/14/2026 at 12:49 PM a fly was observed on a dining room table and another dining room table there were two flies on it.During an observation and interview on 06/15/2026 at 09:10 AM, Resident #72 was observed with one fly flying around her head and randomly landing on objects on Resident #72's over the bed table in her room. Resident #72 stated the flies really bothered her and made her feel awful. During an interview and observation on 06/15/2026 at 10:30 AM, a fly was observed landing on the end of the straw that was in Resident #84's hydration cup in her room. Resident #84 stated the flies bother her because they bite. She stated the flies could land on your face, bite you and lay eggs or worms in the skin when they bite you. During an interview on 06/15/26 at 11:56 AM with CNA L stated flies were on the faces of the residents who were assisted with feeding in the dining room. She stated the residents did not have the capability to swat the flies away. CNA L stated it was gross that the flies were landing on the residents.During an interview on 06/16/2026 at 09:50 AM, the DON stated she was unsure what the policy for pest control was, but she knew the exterminator came into the facility to spray on an unknown frequency. The DON stated she had not received any complaints or concerns related to pest control. She stated she educated the residents during her rounds to close any open snacks to prevent any pests. The DON stated she asked residents in the dining room if they had any problems with pests and no concerns were revealed to her. She stated if a resident or staff were to express concerns with pests, she would notify the ADM and the MAIN. The DON stated all staff monitored for pests when they performed their rounds. She stated flies in the facility could cause discomfort or annoyance to the residents and it could potentially attract more pests. The DON stated the flies were in the facility due to people going in and out of the smoking door in the dining room.During an interview on 06/16/2026 at 11:27 AM, the ADM stated the policy for pest control was to have a contract in place with a pest control service, ensure the pest control service was coming as scheduled and to monitor for pests between pest control service visits. He stated staff typically would call him or the MAIN with issues that needed to be addressed. He stated cleanliness was a big part of pest control too. The ADM stated the pest control service would also come to the facility outside of scheduled times to address any issues that were reported. The ADM stated the pest control service visited the facility at a minimum once a month, but typically it was two times a month because they would call the pest control service out to address needs. He stated they had a planned visit for Friday, 6/19/2026. The ADM stated he had not received any complaints related to pests lately. He stated if he were to receive a complaint about pest control, then he would go to where the pest was located to get rid of what is attracting them, then he would notify pest control to come to the facility and perform a treatment. The ADM stated pests, including flies, could contribute to infection control and sanitation matters. He stated the primary staff who were responsible for pest control monitoring were the housekeeping and maintenance staff but ultimately it was all staff who were responsible for monitoring for potential pest issues in the facility. The ADM stated pest control was monitored during daily rounds and environmental rounds. The ADM stated there were flies in the facility due to several possible factors including: the heat, the food smells, the cooler air coming from inside the facility, when deliveries come and the doors are open, and the frequency of the in and out activity that happens around the activities planned.During an interview on 06/16/2026 at 12:26 PM, the ICP stated the policy for pest control was to have routine pest control visits, log any sightings of pests in the binder, and to have them make additional visits anytime there was a concern raised. She stated she was unsure how often pest control made their routine visits. The ICP stated she had not received any complaints related to pests or flies. She stated if she were to receive a complaint related to pest control, she would log it in the binder and notify the MAIN and the ADM. She stated if the issue could be addressed immediately then she would address the issue. The ICP stated all staff were responsible for monitoring for pests within the facility when they perform their rounds. The ICP stated having flies in the facility could make residents feel uncomfortable, give them anxiety, or could even possibly spread disease. She stated the heat was drawing the flies in anytime a door was opened they would come in.During an interview on 06/16/2026 at 12:40 PM, the MAIN stated the pest control company came out once a month routinely to perform a full service for pest control. He stated if there were concerns, he could contact the pest control company, and they would be on site within 24 hours to deal with the concern. The MAIN stated he had a few concerns raised to him about scorpions. He stated the pest control company missed the scheduled visit on 06/15/2026 due to the rain, but they were scheduled to come on 06/19/2026. He stated all staff were responsible for monitoring for pests in the facility when performing their rounds. He stated he monitored for pests when doing his maintenance and his rounds. The MAIN stated the residents may be negatively impacted because no one wants pests in their home and this is their home. The MAIN stated there were so many flies in the building because the heat and wet weather drew them in. He stated the facility had reported the flies to the pest control company for treatment and the facility had air curtains (a strong flow of air over a doorway when the door is opened to discourage pests) on the dining room doors but the flies were still able to get inside the facility.Review of facility policy titled General Kitchen Sanitation, dated 10/01/2018 reflected Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents.Procedure:.13. Have a professional pest-control program in place.Record review of Pest Control Invoices from 0131/2026 to 06/01/2026 revealed the facility had insect light tramps outside the building. The invoices also revealed the facility was not being treated inside the building for flies.

Based on observation, interview, 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 infects for 1 of 2 residents (Resident #17) observed for infection prevention.The facility failed to ensure Enhanced Barrier Precautions were followed when TN E failed to wear a gown while providing wound care to Resident #17.This failure could place residents at risk for infection, hospitalization, and decreased quality of life.Findings included:Review of Resident #17's admission record, dated 06/16/2026, reflected a [AGE] year-old female was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Her diagnoses that included: paroxysmal atrial fibrillation (intermittent episodes of rapid, chaotic electrical activity in the heart), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), and Peripheral vascular disease (a common condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping).Review of Resident #17's Comprehensive MDS, dated [DATE], reflected a BIMS score of 11 which indicated moderate cognitive impairment. Section M - Skin Conditions reflected Resident #17 had 2 unstageable pressure ulcers (a pressure wound that has its wound base covered by dead tissue).Review of Resident #17's care plan, dated 03/25/2026, reflected under Problem Resident has the need for Enhanced Barrier Precautions due to: (wound) is at risk of infection, depression, feelings of isolation, and decline in physical activity with interventions that included .Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated.Review of Resident #17's Order Summary, dated 06/16/2026, reflected the following orders: Enhanced Barrier Precautions: Use gown and gloves for high contact resident care activities for those with known to be colonized [presence of microorganisms without causing disease or triggering an immune response] or infected with a CDC targeted MDRO as well as those with increased risk of MDR. (residents with wounds or indwelling medical devices) every shift with a start date of 03/25/2026. Wound Care: Right Heel/Stage IV Pressure Injury [a pressure ulcer involving full thickness tissue loss with exposed muscle, tendon, or bone]: Cleanse with WC/NS, pat dry. Apply Collagen [a wound care dressing used to promote healing by supporting tissue growth] to wound bed, cover with foam dressing. As needed for Stage IV Pressure Injury with a start date of 06/15/2026 Wound care: Right Heel/Stage IV Pressure Injury: Cleanse with WC/NS, pat dry. Apply Collagen to wound bed, cover with foam dressing. Every day shift every Mon, Tue, Wed, Thu, Fri for Stage IV Pressure Injury. During an observation on 06/15/2026 at 09:54 AM of wound care revealed TN E did conduct hand hygiene prior to putting on gloves and starting to provide wound care to Resident #17. There was a sign indicating Enhanced Barrier Precautions and there was a supply of personal protective equipment available hanging on Resident #17's door. TN E did not put on or wear a gown while performing wound are for Resident #17. Wound care was provided to Resident #17 according to her wound care orders. TN E did perform hand hygiene after she finished the wound care for Resident #17.During an interview on 06/15/2026 at 10:18 AM, TN E stated she had been trained on the enhanced barrier precautions and providing wound care. TN E stated she forgot to put on the gown while providing care to Resident #17. She stated she was trained to wear a gown and gloves for residents with an open wound or indwelling medical device. TN E stated it was important to follow enhanced barrier precautions to protect the residents from any germs that might be on the staff's clothing. She stated by not wearing the gown she could have possibly spread infection to the resident. TN E stated the ADON and the ICP monitored to ensure enhanced barrier precautions were utilized when they did their rounds.During an interview on 06/16/2026 at 09:40 AM, the DON stated she had been trained in infection control and the use of enhanced barrier precautions. She stated the facility policy related to enhanced barrier precautions was to wear gown and gloves for any resident who has any kind of treatment, including wounds. She stated staff were expected to put on a gown and gloves prior to providing direct care. She stated if staff do not wear the gown and gloves as indicated in their policy, then bacteria could be passed on to the resident. The DON stated nursing management, primarily the ICP, monitored direct care staff for proper use of enhanced barrier precautions but she was unsure of how or how often.During an interview on 06/16/2026 at 11:14 AM, the ADM stated he had been trained in infection prevention and control and enhanced barrier precautions within the last quarter. He stated staff were expected to wear the required personal protective equipment, gown, and gloves, during direct care for any residents with the enhanced barrier precautions sign on their door. The ADM stated by not wearing a gown during direct care, the residents and/or the staff may not receive the sufficient amount of protection they required. He stated the ICP was responsible for monitoring the direct care staff and proper use of enhanced barrier precautions daily during rounds and also during weekly targeted rounds.During an interview on 06/16/2026 at 12:16 PM, the ICP stated she had received training on infection control procedures including enhanced barrier precautions. She stated enhanced barrier precautions was to protect residents from acquiring infections. She stated the policy indicated that staff providing care that required direct contact with the residents wear a gown, gloves, and, if indicated, a mask/goggles/face shield. She stated if gown and gloves were not worn, then staff were exposing themselves and the residents to possible infections and spreading of infection. She stated she was responsible for monitoring direct care staff utilize enhanced barrier precautions during random rounds. The ICP stated all staff received in-services about personal protective equipment quarterly and as needed if there is an identified concern.During an interview on 06/16/2026 at 01:50 PM, MA G stated she had received training related to enhanced barrier precautions. She stated she was trained to wear a gown and gloves when providing care to residents with the enhanced barrier precautions sign on their door. MA G stated staff were to wear a gown and gloves to prevent the spread of germs to the residents who were at a higher risk for infection. She stated the ICP was responsible for monitoring the proper use of personal protective equipment with enhanced barrier precautions when she did her rounds.During an interview on 06/16/2026 at 02:25 PM, LVN H stated she had received training related to enhanced barrier precautions and the personal protective equipment that was required to be worn during direct care with residents who have wounds or other medical devices. She stated all staff were responsible for wearing a gown and gloves when they provided direct care to the residents with the enhanced barrier precautions sign on their door. LVN H stated if a gown and gloves were not worn, then staff could bring whatever [germs] one residents had to another resident. She stated all staff were responsible for monitoring their coworkers throughout their rounds for proper use of personal protective equipment for residents that require enhanced barrier precautions.Review of facility policy titled Enhanced Barrier Precautions, dated 11/24/2025, reflected Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Policy Explanation and Compliance Guidelines: .2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following:i. Wounds (e.g., chronic wounds such as pressure ulcers, .) even if the resident is not known to be infected or colonized with a MDRO.3. Implementation of Enhanced Barrier Precautions:a. Make gowns and gloves available near or outside of the resident's room.4. High-contact resident care activities include: .h. Wound care: any skin opening requiring a dressing.

Based on observation, interviews, and record reviews the facility failed to ensure 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 of 1 medication rooms.The facility failed to ensure that the medications and/or biologicals stored in the medication room were not expired.This failure could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication and/or treatment. Findings included:An observation of the medication storage room on 06/16/2026 at 12:10 PM with the ADON reflected:One bottle of Aspirin 81 mg enteric coated tablets with an expiration date of 03/2026Six bottles of Aspirin 325 mg tablets with an expiration date of 05/2026Ten boxes of Bisacodyl 10 mg suppositories (a medication administered in the rectum to produce a bowel movement) with an expiration date of 02/2026. During an interview on 06/16/2026 at 12:45 PM, the ADON stated it was MR F's responsibility to check the medication storage room for expired medications. She stated she was unsure how often he checked the medication storage room. The ADON stated the policy of the facility was to dispose of expired medications on their expiration date. The ADON stated the consultant pharmacist monitored to ensure all expired medications were removed monthly. She stated if a resident were to have an expired medication administered to them then the medication may not be as potent and the resident may not receive the intended effect of the medication.During an interview on 06/16/2026 at 1:39 PM, the DON stated it was the ADON and MR F's responsibility to check the medication storage room for expired medications. She stated she was unsure of how often MR F checked the medication storage room for expired medications. The DON stated it was the policy of the facility to dispose of all expired medications properly. She stated both she and the consultant pharmacist monitored monthly by doing checks of the medication storage room. The DON stated if expired medications were administered to residents, then the medication may not be as effective, and the resident may not get the therapeutic benefit from the medication.During an interview on 06/16/2026 at 2:09 PM, MR F stated he had received training in the storage of medications when he was hired for the position in 2021. He stated he was responsible for checking for expired medications in the medication storage room. MR F stated he checked the medication room multiple times weekly for expired medications. He stated the expired medications that were observed in the medication storage room may have been overlooked. He stated the facility policy for medication storage was to dispose of expired medications appropriately. He stated if a resident were to receive expired medications, then the medication may be less effective. MR F stated the pharmacy consultant came in on an unknown frequency to monitor that he had removed all expired medications from the medication storage room.During an interview on 06/16/2026 at 2:14 PM, the ADM stated MR F was responsible for ensuring all medications placed in the medication storage room were not expired. He stated the charge nurses and nurse managers were responsible for checking the medication storage room weekly for expired medications. The ADM stated the nurse or medication aide was responsible for checking the expiration date on medications as they were pulled from the medication room and disposing of the medication if the medication was expired. He stated the pharmacy consultant was responsible for monitoring that all expired medications were removed from the medication storage room monthly. He stated the policy of the facility was to remove expired medications from the shelf and destroy the medication per policy. The ADM stated if an expired medication were administered to a resident, then depending on the medication, the effectiveness of the medication could be affected. The ADM stated he was not sure why there were expired medications in the medication room, that it was a system failure.During an interview on 06/16/2026 at 2:37 PM, LVN H stated MR F, the nurses, and the medication aides were responsible for checking the medication room for expired medications when they remove anything from the medication storage room. She stated MR F checked the medication room for expired medications weekly. She stated she had seen the pharmacy consultant there about every 2 weeks, she thought, to monitor for expired medications. LVN H stated it was the policy of the facility to remove the expired medications from circulation and discard them per policy. She stated if expired medications were administered to the residents, then the effectiveness or stability of the medication could be affected.Review of facility policy titled Expiration Dating and Expired Medications, dated 10/01/2019, reflected: Policy:Drugs, which have been dispensed for individual residents, are not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy, or based on the following criteria. The Facility is to strictly adhere to the expiration date.Procedure.7. If the expiration date is expressed in terms of month and year only, the medication will not be utilized after the last day of the month.8. It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the Facility. All expired medications will be disposed of per Facility policy.9. A continuous monitoring system will be designated by the Director of Nursing to identify expired medications and remove them from the medication system.

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 set forth at S483.10(c)(2) and S483.10(c)(3), 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 2 of 14 residents (Resident #36 and Resident #68) whose comprehensive person-centered care plans were reviewed. 1.The facility failed to include Resident #36 use of smokeless tobacco in his care plan.2.The facility failed to include Resident #68 use of smokeless tobacco in his care plan. This could affect residents by failing to ensure residents received appropriate care for their health conditions.1.Record review of Resident #36's face sheet dated 06/14/2026, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cerebral palsy (a condition caused from damage or abnormal development to a part of the brain which is responsible for muscle movement and leads to movement disorders and may result in developmental delays and sensory impairments), muscle wasting and atrophy (loss of muscle tissue and strength), and hypertensive heart disease (high blood pressure).Record review of Resident #36's MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment.Record review of Resident #36's comprehensive care plan undated and accessed on 06/14/2026, revealed no use of tobacco products, goals or interventions for tobacco products listed on the care plan. 2.Record review of Resident #68's face sheet dated 06/15/2026, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: unspecified dementia, mild, with mood disturbance(group of symptoms that affect memory, thinking, and other cognitive functions), type 2 diabetes mellitus without complications(body does not produce enough insulin), muscle wasting and atrophy (refers to the loss of body mass and strength). Record review of Resident #68's MDS dated [DATE] revealed a BIMS of 06 indicating moderately impaired cognition. Record review of Resident #68's comprehensive care plan undated and accessed 06/15/2026 revealed no use of tobacco products, goals or interventions for tobacco products listed on the care plan. During an interview on 06/16/2026 at 9:00 AM, RN B and LVN A stated care plans were interdisciplinary. Surveyor asked if a resident using smokeless tobacco should be included in the care plan. RN B and LVN A both replied yes, it should have been included. During an interview on 06/16/2026 at 8:30 AM, the DON said the Resident#36 and #68 should have been assessed upon admission for tobacco use. The DON said they did an audit the day before and that was how they found out Resident # 36 and Resident #68 used smokeless tobacco.During an interview on 06/16/2026 at 9:15 AM, the Administrator stated the care plan should include everything needed to take care of a Resident. He said if a resident uses smokeless tobacco that should be care planned.Record review of the facility's policy Care Plans, Comprehensive Person- Centered dated 03/2022 revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Record review of the facility's policy Resident Smoking dated 10/24/2022. Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Policy Explanation and Compliance Guidelines:5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process.Record review of the facility's policy Comprehensive Care Plans dated 10/24/2022. Policy: It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, which includes measurable objectives and time frames to meet a resident's medical, nursing and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 14 residents (Resident #36, and Resident #68) reviewed for accuracy of assessments. The facility failed to ensure Resident #36's annual MDS, dated [DATE], accurately reflected her smoking status. The facility failed to ensure Resident #68's annual MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.Findings include: 1. Record review of Resident #36's face sheet, dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included cerebral palsy (a group of conditions that affect movement and posture), muscle wasting, unsteadiness on feet, cognitive communication deficit (problems with communication), heart failure, pain, muscle weakness, hypertension (high blood pressure), history of falling and lymphedema (localized swelling). Record review of Resident #36's annual MDS, dated [DATE], revealed Resident #36 had a BIMS score of 15, which indicated intact cognitive response. The MDS also revealed that current tobacco use was marked as no. Record review of Resident #36's care plan, dated 05/18/2026, did not reflect Resident #36's smoking status. Record review of Resident #36's Smoking Assessment on 06/15/2026, revealed Resident #15 did not have a smoking assessment completed. During an interview with Resident #36 on 06/15/2026 at 9:26a.m., he said that he was a smokeless tobacco user. He said that he had a can of snuff (finely ground smokeless tobacco) in his room. He said he used the tobacco once a day. He added that staff knew he had the snuff. Observation of Resident #36 on 06/15/2026 at 9:18a.m., revealed Resident #36 had a can of wintergreen snuff in his bedside table. 2. Record review of Resident #68's face sheet, dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #68 had diagnoses which included dementia (memory, thinking, difficulty), muscle wasting, unsteadiness on feet, cognitive communication deficit (problems with communication), kidney failure, hypertension (high blood pressure), heart failure, and major depressive disorder (mental health disorder characterized by persistent depressed mood). Record review of Resident #68's annual MDS, dated [DATE], revealed Resident #68 had a BIMS score of 11, which indicated moderate impairment. The MDS also revealed current tobacco use was marked as no. Record review of Resident #68's care plan, dated 04/02/2026, did not reflect Resident #68's smoking status. Record review of Resident #68's Smoking Assessment, on 06/15/2026, revealed Resident #68 did not have a smoking assessment completed. During an interview with Resident #68 on 06/16/2026 at 9:49a.m., he said that he was a smokeless tobacco user. He said that he uses the smokeless tobacco pouches so that he did not make a mess. He said he spits in a cup. He said no one knew he dipped and that he kept his snuff in his pocket. He said the snuff helped with his anxiety and helped keep him calm. He said he did not want the facility to take it away from him because he needed it for his nerves. During an interview with the RN B on 06/16/2026 at 10:00a.m., she said she was the MDS Coordinator. She said she was trained on the MDS. She said certain sections were done by different departments. She said she was responsible for completing the MDS after all the departments completed their section. She said information that was on the MDS were assessments, demographics, BIMS, diet, and discharge goals. She said the MDS should be completed when there was a significant change, annually, and quarterly. She said she had fourteen days from admission to complete the MDS. She said the resident's tobacco use would be put on the admission, annual and significate change MDS. She said if the resident's smoking status was not coded correctly it could affect the residents preference and comfort. She said the social worker would inform her when a resident was a smoker. She said the corporate MDS person monitored to ensure the MDS was completed correctly. She said the corporate MDS person would do regular reviews of the MDS. She said Resident #36 and Resident #68's smoking status could have been missed, or the resident may not have reported it to the facility on admission. During an interview with the SW on 06/16/2026 at 10:21a.m., she said she had been trained on the MDS. She said certain sections were done by different departments. She said the MDSN was responsible for completing the MDS after all the departments completed their section. She said information that was on the MDS were BIMS, behaviors, discharge planning, and diet. She said the MDS should be completed when there was a significant change, quarterly, discharge to the hospital, and when the resident returns from the hospital. She said she had until the assessment reference date, which was determined when the MDS coordinator opened the MDS. She said she did not know if the residents smoking status went on the MDS. She said if the resident's smoking status was not coded correctly it could affect the residents burning themselves, have issues with their tongue and gums, and their sanitation. She said the nurse would inform her when a resident was a smoker after the resident was admitted . She said the MDSN monitored to ensure the MDS was completed correctly. She said the MDSN would do regular reviews of the MDS. She said she did not know why Resident #36 and Resident #68's smoking status was not on their MDS. During an interview with the ADM on 06/16/2026 at 10:40a.m., he said he had been trained on the MDS. He said the policy for MDS was that MDS should be done on admission, change of condition and every quarter. He said the MDSN was responsible for completing the MDS accurately. He said the MDS had the resident's smoking status on it. He said if the resident's smoking status was on the MDS it would help the staff to better serve the resident's needs. He said the MDSN, and the DON monitored to ensure the MDS was correct. He said the MDSN and the DON had a consultant that came in once a month and reviewed the MDS for accuracy. He said it appeared a family member brought Resident #36 and Resident #68 smokeless tobacco and the MDSN was not made aware of it. Record review of the Smoking Residents list provided on 06/14/2026 revealed Resident #36, and Resident #68 were not on the smoking list. Record review of Smoking Residents Policy dated 10/24/2026 revealed It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and nonsmoking residents. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. Residents who smoke will be further assessed, using the Smoking Safety Screen UDA, to determine safety with smoking. Record review of the Assessment Frequency/Timeliness Policy dated 10/24/2022 revealed The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. A significant correction assessment will be completed no later than the 14th calendar day after determination that a significant error in a prior OBRA assessment occurred.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of eight residents. (Resident #9 Resident #30, and Resident #40) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #9's room was in a position accessible to the resident on 06/14/2026 and 06/15/2026.2. The facility failed to ensure the call light system in Resident #30's room was in a position accessible to the resident on 06/14/2026.3. The facility failed to ensure the call light system in Resident #40's room was in a position accessible to the resident on 06/14/2026. These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. 1. Record review of Resident #9's admission Record, dated 06/15/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #9's Diagnosis Report, dated 06/15/2026, reflected diagnoses which included schizophrenia (a chronic mental illness characterized by psychosis, disruptions in thought process), Bipolar( a mental health condition characterized by severe, dramatic shifts in a person's mood, energy, and activity levels.) hypertension (high blood pressure), type2 diabetes mellitus (body does not produce enough insulin),and anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life).Record review of Resident #9's Annual MDS, dated [DATE], reflected Resident #9 had a BIMS score of 13, indicating mild cognitively impaired. Resident #9 required supervision for toileting and transfers in and out of bed.Record review of Resident #9's, undated, Care Plan, undated and accessed on 06/15/2026, reflected Resident #9 was at low risk for falls and poor safety awareness initiated 04/22/2025 and revised 04/15/2026. An intervention included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare- free light, a working and reachable call light.During an observation on 06/14/2026 at 9:10 AM., Resident #9 was observed sitting on her recliner. Her call light cord was observed on the floor under the bed.Observation and interview on 06/15/2026 at 8:00 AM., Resident #9, was observed sitting on the edge of her bed. Her call light was observed on the floor under her bed. When asked her how she calls for assistance if she needs it she said she waits until they come in. 2. Record review of Resident #30's admission Record, dated 06/15/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #30's Diagnosis Report, dated 06/15/2026, reflected diagnoses which included hypertensive heart disease (high blood pressure), unspecified dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, history of falling (experienced one or more unintended falls in the recent past), and anxiety disorder ( a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life).Record review of Resident #30's Annual MDS, dated [DATE], reflected Resident #30 had a BIMS score of 12, which indicated mild cognitively impaired. Resident #30 requires supervision for bed mobility and transfers. Resident use a wheelchair.Record review of Resident #30's, undated, Care Plan, accessed on 06/15/2026, reflected Resident #30 was at high risk for falls and, poor safety awareness, initiated 04/25/2024 and revised on 04/23/2025. An intervention included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare- free light, a working and reachable call light.During observations on 06/14/2026 at 9:12 AM and 11:15 AM, Resident #30, was observed lying in her bed asleep. Resident #30's call light was inside a laundry basket with stuffed animals and clothing on top of it. 3. Record review of Resident #40's admission Record, dated 06/15/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #40's Diagnosis Report, dated 06/15/2026 reflected diagnoses which included Alzheimer's disease) a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, type 2 diabetes mellitus(body does not produce enough insulin), muscle wasting and atrophy (loss of muscle tissue and strength), unsteadiness on feet(feeling of wobbliness, or imbalance on feet), and history of falling(experienced one or more unintended falls in the recent past).Record review of Resident #40's Annual MDS, dated [DATE], reflected Resident #40 had a BIMS score of 15, which indicated she was cognitively intact. Resident #40 was supervision assist with her self-care needs and mobility needs.Record review of Resident #40's, undated, Care Plan accessed on 06/15/2026, reflected Resident #40 was at risk for falls and impaired mobility initiated 12/06/2024 and revision on 03/19/2026. An intervention included Be sure the resident's all light is within reach and encourage the resident to use if tor assistance as needed. During an observation on 06/14/2026 at 09:15 AM. Resident #40 was observed lying in her bed sleeping with her call light laying on the far side of the bedside table away from the resident. During an interview on 06/16/2026 at 8:15 AM, CNA D said when she puts a resident to bed, she makes sure the call light was within reach. She said if it was not within reach a resident cannot reach it and was unable to call for help. During an interview on 06/16/2026 at 8:30 AM, the DON stated her expectation was when residents were in bed, call lights should be on the bed where the resident could reach it. She stated the resident might miss an opportunity to be able to call for the nurse if the call light was not within reach. She stated all staff had been in service on call light placement. The DON stated her expectation was call lights were always within reach of the resident when they were in bed.During an interview on 03/05/2026 at 9:15 AM with the ADM, he stated he expected all staff to place the call light on the bed where it could be reached. The ADM stated the department heads have a daily morning round where they check resident rooms to make sure the call lights are in place. He said staff should be rounded every 2 hours and should automatically be checking on all call lights.Record review of the facility's policy, Call Lights: Accessibility and Timely Response, Date Implemented 10/13/2022. Policy: The purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance.Policy Explanation and Compliance Guidelines:5. Staff will ensure the call light is within reach of residents and secured, as needed.6. The Call system will be accessible to residents while in their bed or other sleeping accommodations within the residents' room.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 17 residents (Resident #15) reviewed for resident rights. The facility failed to ensure Resident #15 was treated with dignity and did not have his name written big on the back of his shirt visible to everyone.This failure could place residents at risk of feeling embarrassed or cause emotional distress. Findings Included:Record review of Resident #15's face sheet, dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included anemia (not enough healthy red blood cells), muscle wasting, unsteadiness on feet, type 2 diabetes mellitus with diabetic kidney disease (kidney damage due to diabetes), cognitive communication deficit (problems with communication), hyperlipidemia (high cholesterol), heart disease, and hypertension (high blood pressure).Record review of Resident #15's quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 10, which indicated moderate impairment.Observation in the dining room on 06/14/2026 at 12:53p.m., revealed that Resident #15's name was written big on the back of his shirt visible to everyone. During an interview with the DON on 06/16/2026 at 9:30a.m., revealed she had been trained on resident rights. She said the policy for providing the resident with dignity was providing privacy, encourage independence while also helping to keep the residents safe, treat with respect, tell them what you are going to do before treatments. She said everyone in the building was responsible for providing the residents with dignity. She said she was not sure who put the names on the resident's clothing. She said the name had always been the inner tag on the clothing. She said she had seen some hats with some names on the outside, but she did not know who did it. She said it depended on the resident and their preference on how their name on the outside of their shirt would make them feel. She said she would have to look into who monitored to ensure the residents were treated with dignity. She said she did not know why Resident #15's name was written on the outside of his shirt. During an interview with the ADM on 06/16/2026 at 10:57a.m., revealed he had been trained on resident rights. He said the policy was to inform the resident and families of their rights. He said the facility educated the staff to continually be raising awareness of the residents rights. He said management did routine rounds, and if a breach was identified during those rounds, then management was able to address the concern with education. He said there was also a grievance process where residents could make issues known and management could address those issues. He said it was a collective effort from everyone on the team to provide the residents with dignity. He said staff give the family a marker and the family would put the name on the residents clothing. He said some residents might not care about their name being on the outside of their shirt. He added if a resident did care he said the resident would let management know. He said staff knew better than putting the residents name on the outside. He said if he saw it he would likely ask about it whether it was the resident's preference or not when asked who monitored to ensure residents were treated with dignity. He said everyone had to have awareness to monitor and if a resident was uncomfortable or if the resident brought it up it should be addressed. He said he did not know why Resident #15's name was written on the outside of his shirt. He said he could make a phone call and ask around to find out why his name was on the outside of his shirt. During an interview with the ES on 06/16/2026 at 1:18p.m., she said she had been trained on resident rights. She said the policy for dignity was to make sure the resident felt comfortable and cared for. She said if staff had any issues regarding the residents they were to talk to the ADM. She said staff did put the residents name on the clothing, but she tried to encourage families to do it when the resident was first admitted or when they bring stuff in. The names should go inside the shirt on the back (gestures to upper collar of shirt near label). Same with the pants. It goes inside the pants on the back up at the top. She said if it was her and her name was written on the outside of her shirt big for everyone to see she would not like it. She said she did not know who monitored to ensure residents were treated with dignity. She also said she was not aware Resident #15's name was written on the outside of his shirt, During an interview with MA G on 06/16/2026 at 1:41p.m., she said she had been trained on resident rights. She said the policy for dignity was to provide the resident with privacy, not to talk about resident where other people could hear. She said all staff were responsible for providing the resident with dignity. She said sometimes families, or staff put the name of the resident on their clothing. She said the residents name was supposed to go inside the resident's shirt or inside the pants. She said she thought putting the resident's name on the outside of their shirt was a dignity issue and someone just might not like it. She said all staff monitored to ensure the residents were treated with dignity. She said she did not know how it was monitored. She also said she did not know why Resident #15's name was written on the outside of his shirt.During an interview with Resident #15 on 06/14/2026 at 2:02p.m., he said that staff put his name on the back of his shirt. He said staff put his name on the back of his shirt because his clothes were coming up missing. He said he would prefer his name on the inside of his shirt. He said his name on the outside did not make him feel good. He said his name on the back of his shirt where everyone could see was tacky.During an interview with LVN H on 06/16/2026 at 2:17p.m., she said she had been trained on resident rights. She said the policy for dignity was to provide the resident choices in clothing, providing privacy and participating in their treatment. She said all staff were responsible for providing the resident with dignity. She said families would put the name on the residents clothing and if not the staff would put their name on the clothing. She said the residents name was supposed to go inside the resident's shirts. She said how a resident felt about the resident's name was on the outside of his shirt depending on the resident. She said some residents might like it some might not like it. She said it was important to get the residents preference. She said everyone who interacted with the resident could monitor to ensure the resident was treated with respect. She said everyone could monitor through observations. She also said she did not know why Resident #15's name was written on the outside of his shirt. Record review of Promoting/Maintaining Resident Dignity Policy dated 01/13/2023 revealed It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

Based on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 6 residents (Resident #1) reviewed for care plans.The facility failed to develop and implement Resident #1's care plan to reflect the interventions placed for monitoring after being hit by another resident after a resident-to-resident altercation that occurred on 03/14/2026.This failure could place residents at risk of not receiving required interventions to meet their current needs.Findings included:Record review of Resident #1's admission record, dated 04/16/2026, reflected a [AGE] year-old male, admitted to the facility on [DATE] and most recently readmitted on [DATE], with diagnoses that included unspecified dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about every day issues, affecting daily functioning and quality of life), impulse disorder (a group of behavioral conditions that involve the inability to control impulses and behaviors) and cerebral infarction (a disruption in blood flow to the brain leading to brain cell death sometimes causing permanent disability).Record review of Resident #1's comprehensive MDS, dated [DATE], reflected Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. Section E - Behavior reflected Resident #1 had no behaviors.Record review of Resident #1's care plan, dated 01/29/2019 and last revised 03/24/2026, reflected problem, The resident has a behavior problem AEB tearing diaper into pieces chewing on brief. Placing fingers in rectum and placing them in mouth and smelling hands and attempts to slid out of wheel chair and often laughing when he falls or is on the floor. Resident with noted sexual behaviors, fondles, touches himself and masturbates in public areas. Makes sexual comments to female staff. Exposes penis in public areas. History of entering others rooms uninvited. History of call a female resident a whore. History of inappropriate touching of another female resident. 5/22/22-Resident intentionally slide down his w/c, prefers to stand at times from w/c with interventions that included 3/14/2026: Continue to monitor for areas of concern related to contact with peer.Record review of facility incident report, 03/14/2026, reflected CNA [A] notified writer that [Resident #1] was hit in the face x2 by resident. States she saw [Resident #1] was sitting up in his wheelchair in hallway next to other resident, looking at him, before that resident proceeded to ball his fist up and hit [Resident #1] in the face. [Resident #1] was taken to dining room by CNA. Writer assessed [Resident #1], found no injuries to face or elsewhere. Questioned [Resident #1] if other resident hit him in the face, [Resident #1] states yes. Denies pain. Denies any feelings of fear or feeling unsafe. VS obtained: 114/46, 53, 97%RA, R-18, 97.4F, 1/10 pain. Reassured [Resident #1] that other resident would be kept separate and that [Resident #1] was safe. [Resident #1] smiles and states, okay, No further concerns or request. Remains sitting up in dining room watching TV, w/c brakes locked. Plan of care ongoing. The incident report had no other mentions of the plan of care.During an interview on 04/16/2026 at 06:02 PM, the ADON stated she and the DON were responsible for updating care plans. She stated care plans were reviewed during the morning meetings to ensure accuracy. The ADON stated care plans were used by the floor staff to learn how to care for the residents. She stated the care plan for Resident #1 was updated after the resident-to-resident altercation in which Resident #1 was allegedly assaulted by another resident under the problem area The resident has a behavior problem AEB tearing diaper into pieces chewing on brief. Placing fingers in rectum and placing them in mouth and smelling hands and attempts to slid out of wheel chair and often laughing when he falls or is on the floor. Resident with noted sexual behaviors, fondles, touches himself and masturbates in public areas. Makes sexual comments to female staff. Exposes penis in public areas. History of entering others rooms uninvited. History of call a female resident a whore. History of inappropriate touching of another female resident. 5/22/22-Resident intentionally slide down his w/c, prefers to stand at times from w/c. The ADON stated the problem did not relate to the incident that had occurred. She stated by not updating the care plan with a problem that related to the incident the resident could have had psychosocial distress. The ADON stated there had not been any changes in Resident #1's psychosocial status since the incident occurred on 03/14/2026.During an interview on 04/17/2026 at 10:20 AM, the DON stated she started at the facility on 03/13/2026. She reviewed the care plan for the incident and stated the care plan revision for Resident #1 for the resident-to-resident altercation should have a problem related to the incident with relevant interventions. She stated the intervention for the resident-to-resident altercation for Resident #1 should have been listed under a problem related to monitoring for psychosocial harm. She stated care plan are used by the floor staff to obtain knowledge in caring for the residents and are updated because new things come up.During an interview on 04/17/2026 at 10:51 AM, the ADM stated care plans are updated and used by the direct care staff to know how to provide care for the residents. The ADM stated care plans were updated after IDT meetings by the IDT staff. He stated Resident #1's care plan did not reflect the interventions that were place for Resident #1. The ADM stated the care plan problem should reflect the resident-to-resident altercation and the interventions that were placed. He stated not having a care plan that reflected the problem with interventions for that problem could affect the resident by not giving the staff the needed direction to provide the needed services for the resident.Review of facility policy titled Comprehensive Care Plans, dated 10/24/2022, reflected Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive care assessment.Policy Explanation and Compliance Guidelines:1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed.3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for two of five residents (Resident #1 & Resident #2) reviewed for misappropriation.The facility failed to prevent a diversion (misappropriation) of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills reported missing on 09/20/2025. Amphetamine-Dextroamphetamine is used to treat ADHD. The facility failed to prevent a diversion (misappropriation) of Resident #2's Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) Give 1 tablet by mouth three times a day for pain Active 10/24/2024, 87 tablets (a hydrocodone is pain reliever) delivered by pharmacy and 57 tablets reported missing on 09/25/2025.These failures could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.Findings included:Review of Resident #1's face sheet printed 09/29/2025 reflected a [AGE] year-old male admitted to the facility 2/17/2025. His diagnoses included multiple sclerosis, attention deficit hyperactivity disorder ADHD-(is a developmental disorder characterized by an ongoing pattern of one or more of the following types of symptoms-inattention, impulsivity, difficulty with organization, emotional dysregulation, hyperactivity) , unspecified, post traumatic disorder (is a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it) , and anxiety disorder (involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks).Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 07 indicating severely impaired cognition. Section I (Active Diagnoses reflected Anxiety disorder, Post Traumatic Stress Disorder, Section GG (Functional Abilities) reflected he required maximal assistance with hygiene and bathing and only setup with eating.Review of Resident #1's comprehensive care plan, initiated 02/17/2025, the resident had an ADL self-care deficit related to MS, Resident is at risk for emotional and/or physical symptoms associated with distressing events and an increased inability to cope related to a diagnosis of Post Traumatic Stress Disorder. Pt reports triggers are being startled from behind and loud noises.Review of Resident #1's physician order reflected an order dated 09/23/2025 for Amphetamine-Dextroamphetamine Oral Tablet 20 MG (Amphetamine-Dextroamphetamine) Give 1 tablet by mouth one time a day for ADHD - attempt GDR.Review of Resident #1's medication administration record for April 2025, reflected Amphetamine-Dextroamphetamine Oral Tablet 20 MG (Amphetamine- Dextroamphetamine) Give 1 tablet by mouth two times a day for ADHD -Start Date- 08/25/2025 5:00 PM -D/C Date- 09/23/2025 5:11 PMReview of the Provider Investigation Report dated 09/26/2025 reflected, On the morning of 9-20-2025, the Medication Aide, [MA], was distributing medications to [Resident #1], when she noticed she could not find some of the medication of Amphetamine-Dextroamphetamine. She [MA A] recalled seeing them on her cart the day before. The narcotic count completed at the beginning of the shift appeared to match the narcotics available. However, she approached the charge nurse to ask what happened to the other blister packs asking if the medications had been removed and placed on the nurse cart or possibly in the medication room. They could not be immediately found in another cart of med room. Upon review of the count sheet record and narcotic sheet by this staff, they appeared to have recently been tampered with. Specifically, you could see that the narcotic count sheet and the Narcotic Substance Record had been scratched through in a suspicious manner. At this time, they notified the Director of Nurses, who in turn notified the Administrator. Upon arrival, the Director of Nurse expanded the investigation.The facility investigation included record reviews, observations and interviews. Interviews and record reviews reflected on September 19, 2025, following the 2p-1 Op shift, there were no discrepancies identified in the narcotic sheets and blister packs. At 2pm on September 19, 2025, there was noted a total of 31 narcotic sheets reflected on the count sheets. This included 3 blister packs of Amphetamine Dextroamphetamine (one a partial, one with a count of 20 tablets and one with a count of 30 tablets. After the following 10p-6a shift, worked by [LVN B] from September 19th through 20th, 2025, it appeared the narcotic count sheet and related blister pack had been altered by pen. It appeared the blister pack and count sheets were deliberately altered to hide the missing medications. This was apparent because one can see through the scratched over numbers. In total, it appears there is one card of 20 tablets and another card of approximately 6 tables that are missing.Staff interviews did not identify an eyewitness to the medications being taken. The facility could not identify anyone with access to the carts besides those designated to be on their designated shifts. The pharmacy confirmed delivery of 10 tablets on September 16, 2025, and the additional two cards of 20 & 30 were delivered on September 18, 2025. Record review in conjunction with the questioning of [Resident #1] reflects he missed no doses. In addition, there was no time in which this medication was not available for the residents.On the evening of 9-25-2025 an additional finding was identified. [LVN B] also worked previously on Thursday, September 17, 2025, on the 2p-10p shift. A narcotic count sheet for Hydrocodone APAP-325 appeared to be altered in a similar fashion to what the facility found on the investigation of the Amphetamine-Dextroamphetamine. It is apparent white out and overmarking was used to alter each number prior to [NAME]'s shift, then the original count sheet appeared to be replaced with a copy, making the alterations less obvious but having the effect of making the count match.Initially, the facility investigation did not provide eyewitness confirmation of a specific employee taking the medications and evidence was not sufficient for employee termination.However, upon expanded review of the facility investigation and the additional findings being found similar to those of the original incident, the facility has elected to terminate [LVN B] to occur in the meeting scheduled 9-29-2025. During the period of time related to both discrepancies, [LVN B] was the nurse in possession of this cart having access to these medications and documentation. The second incident draws a clearer line to Mrs. [NAME] and the altered documentation (see attached). [LVN B] has been working under the capacity of Treatment Nurse since her hire on 4-25-2025, giving her limited and only occasional access to narcotics. However, in the last two shifts [LVN B] has had access to these medications in question, discrepancies have been identified on both occasions.Review of Resident #2's face sheet printed 09/29/2025 reflected a [AGE] year-old male admitted to the facility 08/22/2017. His diagnoses included bilateral primary osteoarthritis of the knee (is a condition where the cartilage in both knees gradually breaks down, leading to pain, stiffness, and loss of function.), chronic pain syndrome (isa condition characterized by persistent pain that lasts for at least six months), need assistance with personal careReview of Resident #2's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 12 indicating mild impaired cognition. Section GG (Functional Abilities) reflected Resident #1 had impairment on one side of both upper and lower extremities, He required moderate assistance with hygiene and bathing and only supervision with eating. other. Section J (Health Conditions) the resident did not complain about pain during the assessment period and was on a scheduled pain medication regimen.Review of Resident #2's quarterly care plan, initiated 08/28/2018, reflected Resident #2 the resident had an ADL self-care performance deficit resident has left side hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain.)related to history of CVA (Cerebrovascular Accident- It refers to a condition where blood flow to the brain is interrupted, causing brain damage.) the resident has an alteration in musculoskeletal status related to contractures of hand and leg and arthritis of bilateral knees. Resident #1 had left side hemiplegia related to history of CVA.Review of Resident #2's physician order reflected an order dated 10/23/2024 for Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) Give 1 tablet by mouth three times a day for pain.Review of Resident #1's medication administration record for September 2025, reflected Resident #2 did not miss a dose of Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen).Review of Resident #2's clinical records reflected pain assessment dated [DATE] was conducted on Resident #2 and his pain level was at 2 on the scale from 0-10, 10 being the worst pain ever. Observation on 09/29/2025 of the 200-hall nurse's narcotics book and cart, 200 and 400-halls medication aide narcotics book and cart revealed all medications and blister packets were correct per the narcotic count by the staff. During an interview on 09/29/2025 at about 11:12 am, Resident #1 stated he had not had concerns of not getting his medications. Resident #1 stated all was well. During an interview on 09/29/2025 at about 11:55 am, Resident #2 stated he did not have issues with his pain medication not being administer. Resident #2 stated his pain medication helps. Review of facility's narcotics count sheet for the 400-hall medication aide reflected on 09/07/2025 pharmacy delivered 87 pills of Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) for Resident # 2 and noted pen written on the 87 to indicate 30 pills.Review of Pharmacy consolidated delivery sheets dated 09/26/2025 reflected 90 pills of Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) delivered for Resident #2. During an interview on 09/29/2025 at about 12:15 pm, the DON stated Resident #2's had 87 pills of hydrocodone that was delivered on 09/07/2025 and 57 of those pills were missing on 09/25/2025. The DON stated there was no evidence of the count sheet. The DON stated LVN F called the pharmacy for refill of Resident #2's hydrocodone and was told it was too early to refill, refill was due 10/07/2025. The DON stated that was when they noticed someone had written on the 87 on Resident #2's narcotic sheet to reflect 30 pills were delivered. Resident #2 was running out of The DON stated the facility called pharmacy to send Hydrocodone for Resident #2 and the facility would pay, because the refill was not due until 10/7/2025. The DON stated Resident #2's hydrocodone was delivered on 09/26/2025 and never went without his pain medication. Attempted to call MA A on 09/29/2025 at 12:46 pm and MA A stated she was not in the position to talk. MA A stated she wrote a statement for the DON and the Administrator. Attempt made to 09/29/2025 at 1:21 pm, left a voice message for call back. During another interview with the DON on 09/29/2025 at 2:20 pm, she stated the MAs, and the Nurses count the narcotic sheets everyday along with the narcotics during shift change. The DON stated, whenever there was an addition to the narcotic sheet, 2 nurses' signatures were required. The DON stated whenever medication was completed or discontinued, only the Nurse Managers were required to remove the sheets and sign. The DON stated when she was made aware of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills reported missing on 09/20/2025 by LVN C, she asked both LVN C and MA A to search all carts and the medication room. The DON stated all medication carts were searched and Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills reported missing on 09/20/2025, were not found. The DON stated she went to the facility the same day and searched for Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, as well and did not see it. The DON stated she notified the Administrator and Law Enforcement was notified. The DON stated on 09/15/2025 Pharmacy sent 10 pills of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG tablets, and PARTIAL was written on the blister packet. She stated on 09/16/2025 pharmacy delivered the remaining 50 pills, a blister [NAME] of 20 pills and a blister packet of 30 pills. The DON stated the blister packets of 30 pills and the remaining of the 10 pills could not be found along with the count sheets. The DON stated count sheet inventory was tampered with to reflect less sheets. The DON stated LVN B worked as the Nurse on the evening of 09/18/2025 taking over the 200-hall medication aide cart from MA D. During an interview on 09/29/2025 at 3:02 pm, MA D stated he worked as the medication aide on the 200-hall on 09/19/2025 on the 2-10 pm shift. MA D stated he got a report from MA A who worked the 6am to 2 pm shift. MA D stated when he counted with MA A at the beginning of his shift, he remembered that the narcotic sheet was 31. MA A stated he also remembered specifically Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, blister packet of 10 pills that had PARTIAL, it was hard to miss because it was written on it boredly. MA D stated he remembered Resident #1 had 2 additional blister packets of the same medication, 1 of 20 pills and the other of 30 pills. MA D stated when he gave LVN B report the night of 09/19/2025, the medications were correct, the count sheet was correct but on 09/20/2025, Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills (blister of 20 and blister of less than 10) were reported missing. MA D stated the Mas does not remove narcotic sheet, only the DON or the ADONs. He also stated the nurses are the only ones that sign for medication from pharmacy. MA D stated he was in-serviced on drug diversion. During an interview on 09/29/2025 at 3:16 pm, LVN F stated she had worked on the 2pm -10 pm shift on the 400-hall when the 6am -2 pm nurse asked her to call pharmacy for Resident #2' Hydrocodone because the medication was running low. LVN F stated she couldn't remember the exact date, but she called the pharmacy for refill and was told by pharmacy that it was too early to refill because 29 days' worth of medication was sent on 09/07/2025. LVN F stated she later heard the medication was missing. LVN F stated they were in-serviced on drug diversion and misappropriation of property. During an interview on 09/29/2025 LVN C stated she worked the morning on 09/20/2025 on the 200-hall. LVN C stated she was approached by MA A asking about the rest of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG. LVN C stated together she and MA A looked in both medication carts and the medication was not found. LVN C stated she called the DON and was told to look in all the carts in the facility and the medication which she did but did not find the rest of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG. LVN C stated the DON later showed up to the facility and looked in all the cart but did not find the medication. LVN C stated the DON started an in-service on drug diversion, called the Administrator and Law Enforcement. LVN C stated she called Resident #1's family to notify them of the missing medication. LVN C stated Resident #1 still had 30 pills of his Amphetamine-Dextroamphetamine Oral Tablet 20 MG and did not run out completely. LVN C stated usually 2 nurses sign when narcotics were delivered, and a count sheet is added. She also stated the Nurse managers were responsible to remove the count sheets whenever a medication was completed or discontinued. LNV C stated during shift change, the off going and incoming count the narcotics to verify the count and also count the narcotic count sheets. In an interview on 09/29/2025 at 3:41 pm the Administrator stated he found out about the medication diversion on the weekend of 9/19/2025. He stated the staff had called and told him that the medication for Resident #1 documentation did not seem right. The Administrator stated the DON got to the facility before him and started an audit of all the carts in the facility while he reported the incident to the HHSC. The Administrator stated the facility started an education for staff, suspended the suspected staff, called the police, reported to the state. The Administrator stated the police did nothing because the staff in question was not seen physically with the medication, there was no eye witnessed. The Administrator stated 4-5 days into the investigation was when they found the second drug diversion for Resident #2. The Administrator stated LVN B was at the center of both incidents. The Administrator stated the facility did not drug screen any staff because by the time it was narrow down, it was late to drug screen. The Administrator stated the facility reordered both medications for Resident #1 and 2 on the facility's expense. Review of facility's in-services dated 09/20/2025 reflected an in-service titled Preventing drug diversion reflected: Nurses signature required when checking in medication from pharmacy.--Sheets to be counted each shift removal of sheet require nurse manager signature.--Narcotics counted each shift--Narcotics must be signed out from sheet and--Any discrepancies must be reported, to include tampering with documents. Review of facility's Investigation document reflected Nurses and Medication aides were given questionnaire on 09/20/2025 regarding drug diversion. Review of LVN B's statement typed by the facility dated 09/20/2025 reflected: Upon [LVN B] being suspended, she was given the opportunity to make a statement about the incident in question. The documents reflecting the medication discrepancy was reviewed with her by the Director of Nurses. [LVN B] stated she had no idea who or how this documentation was altered and stated she did not do any of it. To her knowledge, all medications were accounted for.Follow up interview with [LVN B] was conducted on 9-23-2025 again, [LVN B] reiterated she had no knowledge of the discrepancy in question. Review of MA A's statement dated 09/25/2025 reflected: Re: Missing MedicationsEmployee: [MA A], Certified Medication AideOn the morning of 9-20-2025 on the 6a-2p shift, I received the cart from, [LVN B]. Later, this morning at approximately 10:30am, I was giving the resident his first dose I noticed a discrepancy. I questioned the charge nurse of 200 Hall, [LVN C], if any medication changes were made recently or if she happened to have any additional medications for [Resident #1], specifically the Amphetamine-Dextroamphetamine in her cart. I recalled there were more of these pills the day before. I could not recall exactly how many there were previously, but there was at least a partial card appearing less than 10, and two other cards, one a count of 20 and the other a count 30. We went back to the narcotic count sheet, and they appeared to have been tampered with. It appeared they were written over or modified. At this time, I called the Director of Nurse to report the matter. Review of MA D's statement dated 09/25/2025 reflected: On 9-19-2025 following the 2:00p to 1 0:00p shift, I was competing narcotic medication count with [LVN B] and recall there were a total of 31 sheets noted. I further recall with the specific medication Amphetamine-Dextroamphetamine there was a partial blister pack of approximately less than 10 and two other blister packs including one of 20 count and another of 30 count tablets. Review of MA E's statement dated 09/25/2025 reflected: In reviewing the narcotic sheet in question for Amphetamine-Dextroamphetamine I recalled adding a sheet to the total count upon its arrival and signed accordingly. At this time, the sheet did not appear tampered with, specifically the writing over and scratching out that I currently see was not present at this time. At the time of this count, I recall a total of 31 count sheets. Review of facility's investigation document dated 09/26/2025 reflect the facility had an Impromptu QAPI to address the drug diversion. Review of LVN B's personnel file Termination notice dated 09/29/2025 reflected:LVN B has been terminated as a result of the investigation beginning 09/19/2025 and ending on 09/29/2025, regarding a drug diversion. Discrepancies were identified on 2 different occasions involving narcotics documentation and subsequent missing medication.Level three offense-falsification of any records, job resumes, or job application.Other offenses: Violation of any other policy or procedure contained in employee Manual: Narcotic Management Policy.Review of facility's policy dated 07/11/2025 titled Abuse, Neglect and Exploitation: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.Review of facility's policy dated 10/01/2019 titled Medication Policy reflected: Policy--The following procedures are designed to serve as guidelines for the facility when any type of medication diversion or tampering has occurred.Procedure--If drug diversion is suspected by a Licensed Nurse, it is his/her responsibility to report this to the Director of Nursing.If The Controlled Substances Count Is Incorrect:1. Determine if the medication was given and not charted.2. Determine if the medication may have been lost, incorrectly stored/misfiled, discarded, or sent home with a discharged patient.3. The incident must be reported to the Director of Nursing immediately. The DON will determine how the investigation is to proceed.4. Document that the individual count is correct in the controlled substances book or log to allow patient care to continue (unless medication has been tampered with*). The incorrect count should be documented on the product specific page and the shift count signature page by entering No under status of count exact yes/no.5. Sign the shift count record in the usual manner once the incorrect count has been documented. Give keys to the on-coming shift nurse.6. Working with nurse on the shift on which the count became incorrect, fills out a facility incident report. The report should summarize the events leading up to the discovery of the diversion/tampering and indicate what actions were taken to locate the medication.* If medications appear to have been tampered with:1. Telephone the dispensing pharmacy to identify medications on hand.2. Order replacement medications to allow patient care to continue.3. The Director of Nursing or designee should secure the suspected medications for further investigation. The DEA may confiscate these drugs as evidence. If this should occur, make certain that you document the type and quantity of medications being released to the DEA with witnessed signatures. Photocopy when possible. Remember that controlled medications should not be returned to the pharmacy.

Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and once developed, failed to ensure necessary treatment and services to promote healing for two (Resident #249 and Resident #40) of five residents reviewed for pressure ulcers. A) The facility failed to ensure Resident #249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2024 through 04/20/2025. Resident #249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement. B) The facility failed to ensure RN A notified Resident #249's physician on 04/20/25 at 4:20 PM when she observed a brown spot on Resident #249's sacral area. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/24/2025. The IJ template was provided to the facility on [DATE] at 2:28 PM. While the IJ was removed on 04/25/2025, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Non immediate jeopardy B) The facility failed to ensure the Treatment nurse used a cleaning technique on Resident #40's Stage 3 sacral pressure ulcer that did not cross contaminate the pressure ulcer. This failure could place residents at risk for worsening of pressure ulcers leading to discomfort, pain, and potential infections. Finding Include: A) Review of Resident #249's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses fracture of unspecified part of left femur neck (hip fracture), cognitive communication deficit, and muscle wasting and atrophy. Review of Resident #249's 5-Day MDS dated [DATE] reflected a BIMS of 13 indicating she was cognitively intake. Resident #249 was assessed to require supervision or touching assistance with toileting and partial to moderate assistance with transfers. Resident #249 was assessed to be occasionally incontinent of urine and continent of bowel. Review of Resident #249's comprehensive care plan reflected a problem dated 04/08/2025 which reflected The resident has potential impairment to skin integrity related to incontinence. Interventions included Monitor/document location, size, and treatment of skin injury. Report abnormalities . Review of Resident #249's admission nursing assessment dated [DATE] reflected she had no skin issues. Review of Resident #249 PCC skin & wound assessment dated [DATE] reflected no skin concerns noted to peri or coccyx area. Review of Resident #249's weekly skin assessments reflected no skin assessment was conducted from 04/08/2025 until 04/20/2025. Review of Resident #249's PCC skin & wound assessment dated [DATE] conducted by RN A reflected Resident #249 had no new wounds. In an interview on 04/24/2025 at 9:10 am RN A stated Resident #249 had a fall around 4:20 pm on 04/20/2025 in her bathroom. RN A stated Resident #249 went to the bathroom on her own and fell . RN A stated she conducted an assessment after the fall and did not see any injuries. She stated at that time she did not look at her sacral area closely and stated she did not smell anything like necrosis. RN A stated that around 9:45 pm a CNA came to her and reported the resident had a brown spot on her sacral area. She stated she left a note for the next shift to assess the area. Review of Resident #249's nursing progress notes reflected an entry dated 04/20/2025 at 9:50 pm CNA notified this nurse about resident having a new wound. Went to assess, noted small wound to resident's bottom with eschar area to wound bed. Skilled wound care nurse to be notified. Progress note signed by RN A. In an interview on 04/24/2025 at 3:05 pm CNA O stated she worked the evening of 04/20/2025 (2pm-10pm shift) and took care of Resident #249. She stated she helped Resident #249 into the bathroom and noticed red color spot on her bottom but denied seeing a wound or skin tear. She stated that she notified the nurse right away and the nurse whose name she does not remember came right away. In an interview on 04/24/2025 at 9:19 am the Treatment nurse stated she saw Resident #249 for wound care on 04/18/2025. She stated she did not do a full skin assessment on that day that she just looked at Resident #249's left hip incision and did not see anything else. She stated Resident #249 was on the commode when she performed the assessment and that she looked at her buttocks but did not look in depth at her sacral area. She stated she did not do treatments on residents with only surgical wounds that the floor nurses did those wound assessments. The Treatment nurse stated on 04/21/2025 that she did not assess Resident #249's skin. The Treatment nurse stated she had no idea how Resident #249's unstageable sacral pressure injury developed. In an interview on 04/24/2025 at 9:45 am the ADON stated she was working the floor on 04/21/2025. She stated on 04/21/2025 around 3:00 pm the CNAs went to lay Resident #249 down in bed and she was complaining of left hip pain. She stated they then turned Resident #249 over on her side they found a large dark area on her sacral area that had odor and covered her entire sacral area. The ADON stated she informed Resident #249's PA. Review of Resident #249's nursing progress note dated 04/21/2025 at 3:24 pm reflected Sent to (hospital) for wound care consult/patient with new sacral wound plus odorous and needs debridement . note signed by the ADON. In an interview on 04/24/2025 at 10:00 am Resident #249's PA stated she received a call from the facility on 04/21/2025 that Resident #249 had a new area to her sacrum. She stated she assessed the area and found an unstageable pressure ulcer to her sacrum that was malodorous. She stated at first, she thought that it might be an abscess, but she had not gotten the hospital paperwork yet to verify that. When asked if Resident #249 could have developed the pressure ulcer in one day since the skin assessment on 04/20/2025 reflected she did not have any skin conditions Resident #249's PA stated a pressure ulcer can develop in that time frame but not necrosis that generally takes about a week. She stated Resident #249 was [AGE] years old but can get up in a wheelchair and move around. Resident #249's PA stated she saw Resident #249 on 04/17/2025 and she complained of hip pain but no other pain. She stated she did not assess her skin at that time. When asked if not performing skin checks could be a factor in the development of the pressure ulcer, she stated it could be a factor yes. She stated, I asked the nurses how we not saw this. Resident #249's PA stated Resident #249's pressure ulcer could not have developed over night, that it was very questionable given the necrosis. Review of Resident #249's PA note dated 04/21/2025 reflected new malodorous decubitus wound .due to concern for infection, I recommend pt (patient) to go to hospital to have wound consult asap (as soon as possible) . Review of Resident #249's hospital records dated 04/21/2025 reflected This is a [AGE] year-old woman with a past medical history of hypertension (high blood pressure), hyperlipemia (high levels of fat in the blood) and hypothyroidism (decreased production of thyroid hormones) who presents from an inpatient rehab facility after having left hip surgery several weeks ago now developing sacral pain over the last week with a large sacral decubitus ulcer. The patient appears to have a central area of necrotic issue with surrounding cellulitis approximately 8 cm in diameter. She will require debridement routinely and antibiotic coverage with PT wound care for healing .8 cm in diameter necrotic decubitus ulcer with surrounding erythema .patient with possible sepsis Further review of Resident #249's hospital record reflected on 04/22/2025 she was diagnosed with sacral wound sepsis. Review of the operative report reflected preoperative diagnosis sacral pressure ulcer (unstageable) postoperative diagnosis sacral pressure ulcer (Stage IV) debridement down to and including sacral bone. Post debridement measurements 20cm x 15cm x 4cm wound vac application. With findings necrotic muscle extending to bone with copious purulence and malodorous smelling wound . Interview on 04/24/2025 at 10:55 am the DON stated when the facility was made aware of Resident #249's new pressure ulcer they sent her out to the hospital right away. She stated the facility started in-servicing staff and did a skin audit. She stated there were a lot of opportunities to see Resident #249's pressure ulcer that were missed. She stated if Resident #249's skin assessment had been done weekly it defiantly could have made a difference in the outcome if it had been caught earlier. In a follow-up interview on 04/24/2025 at 3:00 pm the DON stated that the facility regularly pulls up a list of residents' due weekly skin assessments, she stated every other day of so. She stated when they started looking into Resident #249, she found that her weekly skin assessment did not populate to alert the staff to do a skin assessment. The DON stated she did not know why the assessment did not populate. She stated the facility started training on how to complete a full and thorough skin assessment. She stated residents not being monitored and skin assessments being performed could contribute to residents having pressure ulcers not known by the facility. She stated she expected CNAs to tell nurses if a resident was not bathing and expected the staff nurses and aides to take every care opportunity to view the residents' skin for changes. In an interview on 04/24/2025 at 3:20 pm the Administrator stated he expected skin assessments to be done weekly and a thorough skin assessment be conducted. He stated if a thorough skin assessment had been conducted for Resident #249 the pressure sore would have been caught earlier. He stated if staff were charting on a skin assessment form, then a full and thorough skin assessment should be conducted. Review of the facility's undated policy Skin integrity management system reflected A head-to-toe body evaluation will be completed on every resident upon admission or readmission on the Initial Nursing Evaluation. Weekly thereafter the evaluations will be documented on the Weekly Skin Evaluation UDA. If skin is intact, no further action is required. If skin is compromised, proceed to the Weekly Wound Progress UDA. Identified skin areas will be documented on the Weekly Pressure or Non-Pressure UDA. Wound progress is to be documented each week with measurements and wound descriptions .Routine weekly checks will be completed on each resident; if skin is intact, it will be noted as such. If a new pressure injury is noted, a Weekly Pressure or Non-Pressure UDA will be started. Notification of Physician and Responsible Party will be documented in the Progress Notes. Assignments for skin evaluations will be scheduled. These assignments are to be monitored for completion . B) Review of Resident #40's face sheet dated 04/16/2025 revealed Resident #40 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit), Dysphagia (difficulty swallowing), Parkinson's Disease with Dyskinesia (a progressive disorder that affects the nervous system), Neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), and unspecified Fracture of Sacrum (a broken bone in the lower back near the tailbone). Record review of Resident #40's MDS assessment, dated 04/16/2025, reflected Resident #40 was readmitted to the facility on [DATE] following a short-term hospital stay. MDS assessment had not been completed at the time of the survey. Record review of Resident #40's care plan reflected a focus area, dated 04/23/2025, reflected The resident has stage 3 pressure ulcer to sacrum date of development 04/21/2025 r/t skin frailty, immobility and incontinence. Goal included, resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target date: 06/28/2025. Observation on 04/23/2024 at 8:18 am revealed the Treatment Nurse in Resident #40's room to provide wound care. She removed the dressing covering the wound, then provided incontinent care to Resident #40. She wiped feces off the resident's perianal area with a moist perineal wipe and used the soiled wipe to wipe the skin around the open wound. She later used clean moistened gauze to wipe the skin surrounding the wound, before using the soiled gauze to wipe the open wound bed. Interview with Treatment Nurse on 4/24/25 at 09:20 AM stated that the proper technique for performing wound care is to wipe from the inner aspect of a wound and clean outward to prevent cross-contamination of a wound. Stated, that wasn't ideal at all when informed that she wiped around the open wound when cleaning feces off the resident's skin, and then later wiped the surrounding skin before cleaning the wound bed with the same moistened gauze during wound care to Resident #40. She stated that the resident could get an infection if the wound was contaminated with feces. Interview on 4/24/25 at 02:32 pm with DON stated that her expectations for wound care technique is that the wound bed be cleaned from the center of the wound bed outward. Stated that fecal contamination of the wound could lead to a wound infection and decline of the wound. Stated that hand hygiene should be done prior to medication administration per policy. Stated that the staff could cross contaminate the resident if hand hygiene is not performed. Interview on 4/24/25 at 03:31 pm with Administrator stated that his expectation is that incontinent care be performed prior to proceeding with wound care. In a follow-up interview on 04/25/2025 at 09:40 am the Administrator stated that if there was contamination in a wound, there is a possibility that a resident may need further intervention such as antibiotics. Review of facility's policy on Infection Prevention and Control Program dated 05/13/2023, reflected All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy on Pressure Ulcer Prevention and Management dated 08/15/2022, reflected The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to .ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. The Administrator was notified on 04/24/2025 at 1:37 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 04/25/2025 at 1:15 pm. Letter of Credible Allegation For Removal of Immediate Jeopardy Attention Sir or Madam On 04/22/25 an annual survey was initiated at the facility. On 04/24/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy situation to resident health and safety. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusion set for in the verbal and written notice of immediate jeopardy and/ or any subsequent Statement of Deficiencies. The immediate jeopardy allegations are as follows. F686 Quality of Care Pressure The facility failed to ensure Resident # 249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2025 through 04/20/2025. Resident # 249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement. Resident #249 remains hospitalized . Actions for Resident Involved * On 4/24/2025 the Treatment Nurse was re-educated on completing thorough skin assessments by the Director of Nurses and suspended. Identification of Others * On 4-24-2025, the nursing facility conducted 100% head to toe assessment to ensure that residents with skin alterations were identified and documented. All skin assessments were documented on the PCC total body skin assessment form and saved in the resident's medical record. For any alterations in skin integrity, orders will be reviewed, and documentation reviewed to ensure license staff are following facility skin assessment and pressure ulcer prevention and management policy. * 3 residents were identified with newly developed rashes, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 resident identified with MASD to the sacrum, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 open blister was identified, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect the treatment. Systemic Changes/ Education On the Director of Nursing initiated education with 100% of licensed staff. Education was completed 4-24-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. * Skin Assessment Policy * A full body, or head toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include the site, type, stage, measurement, presence of exudate and amount, odor, wound bed. surrounding skin color, surrounding tissue edges, tunneling, undermining and response to treatment. * The attending physician will be notified of: * The presence of a new pressure injury or skin alteration upon identification. * The progression towards healing, or lack of healing, of any pressure injuries or skin alteration weekly. * Any complications (such as infection, development of a sinus tract, etc.) as needed. * Skin Integrity Management System * Notification of Changes Policy On 4/24/25 The Regional Clinical Specialist initiated the following education with 100% of licensed staff. Education will be completed 4-25-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training contents. * Skin Assessment Policy * A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. * The DON and/or designee will provide oversight of completion of skin assessments up-on admission/re- admission and weekly thereafter and will document on the findings on the facility clinical [NAME]-up form. * the documentation of each assessment is noted in PCC by the nurse completing assessment. The Director of Nurses/ designee will run the Total Body Skin Assessment from PCC each weekday, audit for missing assessments, and assign completion as appropriate. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include the site, type, stage, measurement, presence of exudate and amount, odor, wound bed. surrounding skin color, surrounding tissue edges, tunneling, undermining and response to treatment. * The attending physician will be notified of: * The presence of a new pressure injury or skin alteration upon identification. * The progression towards healing, or lack of healing, of any pressure injuries or skin alteration weekly. * Any complications (such as infection, development of a sinus tract, etc.) as needed. * The notification of the physician is noted in PCC and will be tracked for completion by the DON and/or designee through the review of the PCC 24 hrs. report. * Skin Integrity Management System. The documentation of this training is recorded on the facility's Inservice Training Report. * Notification of Changes Policy- The documentation of this training is recorded on the facility's Inservice Training Report. On 4-24-2025, the Regional Clinical Specialist re-educated the Director of nursing and ADONS on monitoring the skin integrity system to include completion of weekly skin assessment for each resident. Training recorded on the facility Inservice Training Report * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training content. Monitoring The Director of Nursing or designee will audit PCC total body assessment each weekday to ensure timely completion of skin assessments for each resident. o The PCC total body assessment audit will be documented on the facility's Clinical Stand-up Meeting form. The Director of Nursing and/or designee will ensure competency of the Licensed Nurses (Licensed Vocational Nurses and Registered Nurses) weekly x 4 by return demonstration of head-to-to-toe assessment and visual inspection of the resident's skin. o The verification of licenses nurse's competency will be documented on the facility Skin Assessment competency form. The Director of Nursing or designee will review the pressure ulcer log weekly following wound measurements to ensure that up-on identification of a new wound the physician was notified and that the wound assessments reflect the change in condition. o The review of the pressure ulcer log will be documented on the facility Clinical Stand-up Meeting form. o For any new admissions or resident requiring daily attention on the weekend, the on-call facility nurse manager will monitor for completion of assessment and ordered treatments. The Director of Nursing or designee will monitor compliance each weekday morning. The results of the findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed. o The compliance monitoring will be documented on the facility's monthly QAPI form. Skilled Wound Care Physician group will provide weekly review of residents with wounds. o Skilled Wound Care Physicians will provide weekly assessment and review of the residents with wounds by conducting weekly rounds. Rounds will be documented on the SWC provider Communication Log for Daily Rounds. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/ or designee reviews the documentation in PCC during the morning clinical meeting. The facility will evaluate the effectiveness of this plan during the Monthly Quality Assessment and Assurance Committee Meeting attended by at least the Administrator, Director of Nursing, Medical Director and at least three other staff members and the Infection Preventionist. The facility QAPI Committee reviews facility trends including Pressure Ulcer Reports and completion of weekly skin assessments. An Ad Hoc QAPI was conducted on 4-24-2025, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist concerning pressure ulcers and to develop the above-mentioned plan of care. We respectfully submit this action plan for the removal of Immediate Jeopardy. The Survey Team monitored the POR on 04/24/2025 through 04/25/2025 as followed: In an interview on 04/25/2025 at 1:23 pm LVN P (6-2 shift) stated she was in-serviced on skin and wound care on 4/24/2025 by the DON and the Nurse Consultant. The in-service was on wound and skin assessments and how to do assessments and notification of changes. We do weekly skin assessments on everyone in the building, on new admits, readmits and residents with change of condition. Know how to properly assess the resident. Know what to look for on a head-to-toe assessment. Know the 2 forms total body assessment do this on everyone whether they have wounds or do not have wounds. The 2nd form is what we do in iPad, and we do the wound assessment on it, and we take a picture of the wound we fill out the characteristics progress of the wound and it automatically does the measurements of the wound. Document this on a skin assessment form and it has the width length and depth for the nurse to document. The total body assessment- document skin color, temperature, moisture, condition and enter the number of wounds. I cannot recall everything on the skin assessment without looking at the form. The nurse documents the type of wound she stated LVN's could not stage a wound and would need someone else to stage such as RN or the Physician or Nurse Practitioner. If Resident has a burn put what type of degree of burn and would refer to RN or Physician for assistance if needed. Document if there was any slough if resident has staples how many does the resident have. The measurements of the wound how long the resident had the wound. Was the resident admitted with the wound. In an interview on 04/25/2025 1:48 pm LVN Q (6-2 shift) stated she was in-serviced on skin and wound care on 4/24/2025 by the Nurse Consultant and the DON did the in- service. Every time do a skin assessment do it weekly, any new admits, readmits, or change of condition. Inservice on notification of changes. I had to repeat what I learned during in-service to the DON. We have a list of who gets a skin assessment included people with wounds and without wounds every day. We must do head to toe assessment if there are some findings any bruises any skin tears pressure ulcer, we must make sure the pressure points are not red. She stated head to toe assessment was looking at the scalp, all areas of the ears, underneath both arms - arm pits, both arms, stomach area, if a female look under the breast and if a male would look under [NAME] the scrotum. I would open the buttocks area and look to determine if there was any wounds or area inside the buttocks look outside the buttocks, especially the sacral area. If have any fat rolls anywhere on the body look under the fat rolls. Would look at the thighs, both upper and lower leg extremity, look at ankles, heels, underneath the feet and in between toes. Would follow the skin assessment and document any findings of the skin assessment of the resident on the skin assessment. If find a pressure ulcer I will do skin assessment on IPAD we can take picture of the wound, I would look first photo how it looked and if needed to take another photo would take another photo. After the picture is taken on the IPAD it directs you what to do next. And you would click on options and the IPAD would measure the wound. You would point the iPad to the head of the resident and take picture and it would show you the measurements of where the wound was located. When you take a picture it gives option where it says where is the position where the head of the patient point the camera to the wound it tells where is the location of the wound and click on it and it gives you a diagram of the person it has option to rotate to get the actual site of the wound it will ask all characteristics of the wound such as is it draining, does it have an odor s/s of infection and gives the option it gives to measure but as an LVN cannot stage. I would call the doctor and get orders and treat per doctor order. Notify the doctor notify the DON notify family I have to make sure to document progress notes and on the skin assessment and care plan it. In an interview on 04/25/2025 at 2:15 pm LVN R (6-2 shift) stated she had been in-service on 4/24/2025 by DON and Nurse consultant. She stated she had to repeat what was covered during the in-service to the DON. We went over the head-to-toe assessment and the wound care assessment and notification of changes. We are to do weekly skin assessments and we have a list of skin assessments due every day. Also, we do skin assessments on any new admit, readmit and any resident with a change of condition even if we had already completed a skin assessment on that resident for the week we would do a new skin assessment. First Check in hair and scalp, behind ears and in ears, check in the nose, check arm pits, and stomach chest area. If a female check underneath the breast, check boney prominences check the back and coccyx, need to spread the buttocks cheeks, and check the entire bottom, if male check underneath the scrotum. Check the entire body. The assessments- skin and wound use the iPad take picture of the wound and it automatically prompts you what to do it will measure the wound on the IPAD and report exactly where the wound is located. She stated LVNS did not stage a wound. There would be a diagram of a picture of a body and the where the wound was found on the body would be located on the diagram. She stated If I found a new wound I would assess it- if there was drainage, measurement, any eschar, bleeding and what was listed on the skin assessment you would check if there were any black areas in the wound. I would document it and notify the doctor, the DON, the ADON and the family. I would document if there was a new physician order and do the treatment to the skin concern and then I would do a nurses note, skin assessment, wound assessment, change of condition nurses note and write it on the care plan information of the wound and physician order. I would complete a skin assessment form. We do skin assessments every week, on admission, readmission and when change of condition - on every resident if they do or do not have an existing skin concern. In an interview on 04/25/2025 at 2:32 pm LVN S, 6-2 shift DON and Nurse Consultant did in-service on 4/24/2025. We are to complete skin assessments on every resident weekly and in-service on notification of changes. I had to repeat what was told to us during the in-service I repeated to the DON. We are given

Based on observation, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 of 8 Residents (Resident # 22, Resident # 50, and Resident # 74) reviewed for ADLs. The facility failed to ensure Resident #22, Resident #50, and Resident #74 nails were trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Record review of Resident #22's face sheet, dated 04/23/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behaviors ( person presented signs of loss of memory, language, problem-solving and other thinking abilities without behaviors), type 2 diabetes mellitus with diabetic neuropathy, unspecified ( a chronic disease characterized by high blood sugar levels, primarily due to the body's inability to effectively use or produce enough insulin- neuropathy causes pain, numbness, and tingling in different parts of the body), and multiple sclerosis (progressive disease involving damage to the nerve cells in the brain and spinal cord, whose symptoms may include numbness, impaired speech and of muscular coordination, blurred vision , and severe fatigue). Record review of Resident #22's Quarterly MDS Assessment, dated 04/09/2025, reflected Resident #22 had a BIMS score of 4 indicating her cognitive status was severely impaired. Resident #22 was totally dependent on staff for personal hygiene, showers, and oral hygiene. She required substantial /maximal assistance (helper does more than half the effort) with upper and lower dressing, and toileting hygiene. Review of Resident #22's Comprehensive Care Plan, completed on 04/04/2025 , reflected Resident #22 had an ADL self-care performance deficit related to decreased mobility, contractures, and chronic pain. Interventions: Resident #22 required extensive assistance by 1-2 staff with personal hygiene. Observation and interview on 04/22/2025 at 9:45 AM revealed Resident #22 was in her room lying in bed. Her nails on her right hand were not smooth around the edges and had a blackish/brownish substance underneath her middle, ring, and fore fingernails on her right hand. Resident #22 also had a blackish/brownish substance on the tip of her middle and ring finger on her right hand. She was not interviewable. Record review of Resident #50's face sheet, dated 04/23/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mild cognitive impairment of uncertain or unknown etiology ( a condition where an individual experiences memory or thinking problems that are noticeable but not severe enough to interfere with their daily activities, and the specific cause of these problems was unclear or has not been determined, altered mental status, unspecified ( confusion, disoriented and change in alertness, but without a clear diagnosis), vitamin D deficiency ( causes issues with bones and muscles, can lead to brittle bones, muscle weakness, and pain. Can result from lack of sunlight exposure or insufficient dietary intake), and anxiety disorder (excessive fear, worry that is not warranted to the situation). Review of Resident #50's Quarterly MDS assessment dated , 03/31/2025, reflected Resident #50 had a BIMS score of 15, which indicated her cognition was intact. Resident #50 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or as needed) with personal hygiene, upper and lower body dressing, showers, and toileting. Review of Resident #50's Comprehensive Care Plan, completion date of 04/21/2025, reflected Resident #50 had an ADL self-care performance deficit related to decreased mobility and poor strength. Interventions: Bathing/Showering: Check nail length and trim, clean on bath day and as needed. Report any changes to the nurse. Resident #50 required one staff assistance to provide shower and toileting. Resident #50 was total dependent on staff for personal hygiene. Observation and interview on 04/22/25 at 09:58 AM revealed Resident #50 was lying in bed in her room. Her nails on her right and left hands were not smooth around the edges and there was a blackish/brownish substance underneath her middle and fore fingernails on her right hand. She stated she asked someone over the weekend to file and clean her nails and the person stated they would sometime during the week. Resident #50 stated she did not recall the staff's name. She stated she believed the staff worked in nursing but did not recall if the staff was a CNA or a Nurse. Resident #50 stated she did not recall seeing a name badge on the staff's clothes. Review of Resident #74's face sheet, dated 04/23/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #74 had a diagnosis which included type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma ( severe complication characterized by extremely high blood sugar, severe dehydration, and altered consciousness- a temporary change from a person's normal mental state), vascular dementia, mild, with anxiety ( primarily caused by problems with blood vessels in the brain, due to stroke or mini-strokes- anxiety is a feeling of worry , nervousness, or unease, typically a current event or something with an uncertain outcome), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side ( and age -related physical debility ( can include muscle weakness- decrease strength or ability to perform task, fatigue, low physical activity). Review of Resident #74's Quarterly MDS Assessment, dated 02/13/2025, reflected Resident #74 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #74 required supervision or touching assistance (helper provides verbal cues and/or touching/ steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or as needed) with personal hygiene, showers, and toileting hygiene. She required setup or clean-up assistance (helper sets up or cleans up and resident completes the activity) with eating, oral hygiene, upper and lower body dressing, and putting on and talking off footwear. Review of Resident #74's Comprehensive Care Plans with a completion date of 03/03/2025 reflected Resident #74 had an ADL self-care performance deficit related to hemiplegia (a condition characterized by paralysis- the loss of ability to move- on one side of the body) Intervention: Resident #74 required extensive assistance by one staff with bathing or showering. She required limited assistance by one staff for personal hygiene and oral hygiene. Observation and interview on 04/22/2025 at 10:58 AM revealed Resident #74 was in her room lying in bed, on her right hand underneath her middle and ring fingernails was blackish/brownish substance. Resident #74 had rough edges around her fingernails on her right hand and had blackish/brownish substance underneath her middle and fore fingernails on her left hand. Resident #74 stated she did not like her nails to be dirty. She stated she did not remember if she asked someone to help her with her nails. Resident #74 stated her nails had been dirty and rough for the past 4 or 5 days. In an interview on 04/24/2025 at 9:35 AM, CNA I stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA I state the residents' nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA I stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given nail care to Resident #22, Resident #74, and Resident #50 and they did not refuse nail care. She stated if any resident refused nail care, she reported it to the nurse and the nurse would document the refusal in nurses' notes. In an interview on 04/24/2024 at 10:25 AM, LVN B stated the nurses were responsible for filing and trimming all residents' nails and the CNAs was responsible to clean all residents' nails except the residents with diagnosis of diabetes. She stated nail care on residents was completed weekly by the nurse. She stated this usually occurred on Sundays. LVN B stated CNAs were to clean underneath residents' nails as needed. She stated it depended on what type of bacteria was underneath the residents' nails if a resident became ill such as stomach issues. LVN B stated she was not a physician and was unable to answer what type of illness a resident may receive if the resident swallowed some type of bacteria. LVN B stated she had trimmed and cut residents' nails. She stated she was not aware of Resident #43 or Resident #59 refusing nail care. She stated the nurses documented in nurses' notes anytime a Resident refused any type of care including nail care. LVN B stated if a resident's nails were not trimmed properly and were jagged, there was a possibility the resident may scratch themselves, staff or other residents and cause a skin tear. She stated the nurse supervisor was responsible for monitoring the CNAs and nail care. In an interview on 04/24/2025 at 10:45 AM, the Director of Nurses stated she expected the nurse on duty to do all nail care on a resident. She stated the nurse or CNA can clean resident's nails. The Director of Nurses stated if a resident nails was not smooth around the edges of the nails, there was a potential the resident may scratch themselves or another resident and cause a skin tear. She stated also the resident may scratch their eye and may cause issues such as a tear on the eyeball. She stated the CNAs were expected to check resident's nails on shower days and report to the nurse supervisor if a resident nails needed to be trimmed, filed or any issues the CNA observed with the Residents fingernails. She stated if a resident had a blackish/brownish substance on tip of their finger or underneath their nails it was a possibility a resident may ingest the blackish/brownish substance and become ill such as vomiting and/or diarrhea. She stated if a resident refused nail care or any type of care the nurse was to document the refusal in the nurses' notes. In an interview on 04/24/2025 at 10:55 AM, CNA H stated the CNAs were responsible for cleaning the resident's nails and the nurses was responsible for cutting and filing all residents' nails. CNA H stated residents' nails were usually cleaned on their shower days or when needed. She stated if a resident's nails were dirty, nail care was expected to be completed immediately. CNA H stated if any staff observed resident's nails needed to bet cut or filed, the staff was to report the observation to the nurse supervisor. CNA H stated if a resident had nails not trimmed or was rough on top of the nail, there was a possibility a resident may scratch themselves and develop a skin tear. CNA H stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as vomiting and being nauseated. CNA H stated she had been in-serviced on cleaning, filing, and trimming residents' nails. CNA H stated she did not remember the date of the in-service. CNA H stated she was not aware of Resident #50, Resident #74, or Resident #22 refuse nail care. CNA, H stated she worked at least 1-2 times a week on the halls where Resident # 22, Resident # 50, and Resident # 74 resided. In an interview on 04/24/2025 at 11:18 AM, ADON stated the nurses completed all nail care on residents except cleaning resident's nails. She stated the Nurses were responsible to complete nail care such as trimming, filing, and cleaning once a week or as needed. ADON stated if staff observed a resident's nails needed to be trimmed or filed, the staff was to report it to the nurse supervisor. She stated the nurse or CNA can clean resident's nails but ultimately it was the CNAs responsibility during showers and/or as needed. ADON stated if a CNA noticed any concerns of a resident's nails, the CNA was expected to report any concerns to the nurse. She stated the nurse was expected to assess the residents nail, document concern in the nurses note and call the physician and the family, if needed. ADON stated if a resident had blackish substance underneath their nails there was a possibility a resident may become ill such as nausea or diarrhea depending on the type of bacteria. ADON stated if a resident had rough edges around their nails, it was a possibility the resident may scratch themselves and develop an infection or a skin tear. She stated she was not aware of Resident #50 or Resident #74 or Resident #22 refusing nail care. ADON stated any refusal of nail care would be documented in the nurses' notes. She stated the nurse supervisors were responsible for monitoring the CNAs and nail care. The ADON stated the ADON and DON was responsible to monitor the nurse supervisors . Review of the facility's Activities of Daily Living (ADLs) Policy, dated 05/26/2023, reflected The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide K wore a beard guard when standing over clean dishes in the dishwashing room. 2. The facility failed to ensure Dietary [NAME] M used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 04/22/2025 at 9:10 AM, Dietary Aide K was not wearing a beard guard when standing in the dishwasher room over clean dishes. His beard growth was approximately 10 inches. Interview on 04/22/2025 at 9:15 AM, Dietary Aide K stated he was expected to wear a beard guard anytime he was in the kitchen area. He stated if hair fell on to plates and the hair transferred to residents' food there was a possibility a resident may become ill with some type of stomach issues (when asked what type of stomach issues he did not respond to the question). He stated germs were located on hair. Dietary Aide K stated he had been in-service on wearing beard guards. He stated it was in February 2025 or March 2025. He did not recall the exact date. 2. Observation on 4/22/2025 at 9:25 AM, Dietary [NAME] M was not wearing gloves. He touched the right side of his shirt with his middle finger, ring finger and fore finger on his right hand. Dietary [NAME] M touched the area of a large cooking spoon where the cook later used when stirring food for lunch without sanitizing his hands. He removed gloves from the glove box when his right middle, ring and fore fingers touched the Touchette's (area of the glove for the fingers), and he did not sanitize or wash his hands. Dietary [NAME] M continued to do food preparation with the gloves on his hands. Interview on 04/22/2025 at 9:30 AM, Dietary [NAME] M stated he did not wash or sanitize his hands when he touched inside the serving spoon and did use the serving spoon in the pots on the stove when placing potatoes in the pots. He stated he did not wash his hands prior to placing new gloves on both hands. Dietary [NAME] M stated he did touch his shirt. He stated his shirt was considered contaminated and if he touched anything contaminated, he was to wash his hands immediately. He stated there was a possibility germs from his shirt may cross contamination. Dietary [NAME] M stated germs may transfer to the food from his hands. He stated if a resident ate food with germs on it there was a possibility a resident may become ill with stomach problems such as vomiting. He stated he had been in-service on hand hygiene but did not remember the date of the in-service. Interview on 4/24/25 at 8:30 AM Dietary Manager stated hair nets or cap and beard guard on facial hair are required for all staff while in the kitchen. Dietary Manager stated it could negatively affect a resident if hair restraints are not worn by a resident receiving food with hair in it. Dietary Manager stated it was her responsibility to ensure beard restraints were worn by the male staff in the kitchen. Dietary Manager did not answer why dietary aide did not properly wear a beard guard while in the kitchen even though he had facial hair. She stated all staff were to wash hands after touching anything. Interview on 04/24/25 at 12:30 PM the Administrator stated his expectation was that hair restraints were to be worn by all staff in the kitchen. The ADM stated if hair restraints are not worn there was a possibility a hair may fall into food. He stated there was a possibility if a resident ingested a hair the resident may become ill with some type of stomach issues. The Administrator stated he was not a nurse and did not know the extent of stomach illness getting into the food. The ADM stated all kitchen staff are responsible for wearing hair restraints and that ultimately the DM was responsible for ensuring hair restraints are worn by all staff in the kitchen. Record review of the Facility's Policy on Employee Sanitation, dated 05/10/2018 reflected: 1. Hair restraints, such as hats, hair coverings or nets, caps and beard/moustache restraints or other effective hair restraints are worn to keep hair from contacting food and food-contact surfaces. 2. Hand washing: a. Immediately before engaging in food preparation including working with exposed food, clean equipment, utensils, and unwrapped, single-service and single-use articles. b. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure Dietary [NAME] L followed the puree recipe for biscuits and added apple juice instead of water or stock to the bread puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings include: Observation on 04/23/2025 at 10:20 AM, revealed Dietary [NAME] L placed 6 biscuits into the puree blender. She did not measure apple juice and poured apple juice on top of the biscuits and began to puree the biscuits. The biscuit puree was very thin almost liquid form. Dietary [NAME] L continued to add the apple juice. There was a recipe for puree fish hanging on the top shelf for the Dietary [NAME] L could review when she pureed the fish. However, there was not a recipe for puree biscuits. Interview on 04/23/2025 at 10:30 AM, Dietary [NAME] L stated she always used apple juice when she purees bread. She stated she had puree bread so many times she did not need to review the recipe. Dietary [NAME] L stated the recipe was in a manual in the manager's office on a shelf toward the back of the kitchen. She stated she did not measure the apple juice and did not know how much apple juice was needed to puree biscuits. Dietary [NAME] L stated there were six residents on the puree diet. She stated she was recently in-service on how to puree food and she did have training on pureeing food. She did not recall the date. Review on 04/23/2025 at 10:35 AM, of the biscuit puree recipe reflected food thickener bulk use 1 tablespoon plus 3/4 teaspoon for 5 servings. Water or stock use 1/2 cup plus 2 tablespoons. Prepare slurry (a mixture typically made from a thickening agent, such as flour or cornstarch, which is used to thicken food). Process until smooth using 1 oz of slurry per biscuit. Chill and hold at 41-degree Fahrenheit or below for service. Interview on 04/23/2025 at 10:50 AM, the Dietary Manager stated stock was the same as apple juice . She stated the Dietary [NAME] L did not prepare the puree biscuit correctly. She stated she was expected to follow the recipe and to measure the apple juice and Dietary [NAME] L did not do either one of these instructions. She stated she had in-service the staff few months ago on how to puree food and Dietary [NAME] L was in the in-service. Interview on 04/23/2025 at 11:50 AM, the Dietary Consultant stated all cooks were expected to follow all recipes including puree recipes. She stated the apple juice was not appropriate to use when pureeing biscuits or any type of bread. Dietary Consultant stated gravy would have been the better option to use when puree biscuits and use thickener if needed. She stated when pureeing any type of food, the cooks were expected to use the spoon test to place the puree food on back of the spoon and if it did not fall into the bowl, it was at the correct consistency. She stated Dietary [NAME] L will be re-educated on how to puree food correctly and will observe Dietary [NAME] L when she pureed food. She stated she was a new consultant to this facility and will ensure all dietary staff was re-educated on puree food. In an interview on 04/24/2025 at 10:00 AM, the Administrator stated he expected the cooks to follow the recipe when preparing puree food or any type of food. He stated there was a possibility if the puree food was not the correct consistency, a resident may aspirate when eating the puree food. The Administrator stated the Dietary Manager was responsible to monitor the kitchen and the kitchen staff and he was responsible for monitoring the Dietary Manager. Review on 04/24/2025 the facility in-service training, dated, 03/20/2025, reflected puree consistency in-service was given to all dietary staff including Dietary [NAME] L. Dietary Manager and Dietary Consultant gave the in-service. Requested a policy on preparing puree diets on 4/23/2025 at 10:50 AM, Dietary Manager stated they referred to the puree recipe for their policy.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #70, Resident #85, and Resident #247) reviewed for rights. The facility failed to ensure LVN N and CNA B knocked on Resident #70, Resident #85, and Resident #247's doors when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #70's Face Sheet dated 04/23/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #70's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental function), urinary tract infection, constipation, need for assistance with personal care, type 2 diabetes mellitus without complications (high blood sugar), dementia (memory, thinking, difficulty), schizophrenia (mental disorder), depression, insomnia (difficulty sleeping), chronic pain, history of falling, lower back pain, hypertension (high blood pressure), gastroesophageal reflux disease without esophagitis (reflux), and vision loss. Record review of Resident #70's Quarterly MDS assessment dated [DATE] revealed Resident #70 had a BIMS score of 03 indicating severe cognitive impairment. Review of Resident #85's Face Sheet dated 04/23/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #85's diagnoses included sepsis (a life-threatening complication of an infection), muscle wasting, unsteadiness on feet, lack of coordination, cognitive communication deficit (problems with communication), pain, hyperlipidemia (high cholesterol), hypertension (high blood pressure), and gastroesophageal reflux disease without esophagitis (reflux). Record review of Resident #85's Quarterly MDS assessment dated [DATE] revealed Resident #85 had a BIMS score of 08 indicating moderate cognitive impairment. Review of Resident #247's Face Sheet dated 04/23/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #247's diagnoses included urinary tract infection, anemia (not enough healthy red blood cells), hyperlipidemia (high cholesterol), depression, kidney failure, weakness, adult failure to thrive, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), and age-related debility. Record review of Resident #247's Quarterly MDS assessment dated [DATE] revealed Resident #247 had a BIMS score of 14 indicating intact cognitive response. Observation of hall 100 on 04/22/2025 at 11:57 am revealed that CNA B did not knock on Resident #70's door before entering the room. Observation of hall 100 on 04/22/2025 at 11:58 am revealed CNA B did not knock on Resident #85's door before entering the room. Observation of hall 100 on 04/22/2025 at 12:fpm revealed CNA B did not knock on Resident #247's door before going into the room. Observation on 100 hall on 04/23/2025 at 08:46 am revealed that LVN A did not knock on Resident #85's door before entering the room. An interview with Resident #70 on 04/23/2025 at 9:06 a.m., revealed that he did not want to talk to the surveyor. Resident #70 just looked at surveyor. An interview with Resident #85 on 04/23/2025 at 1:2 revealed that she was good and was just watching television. She would not answer questions about staff knocking. An interview with Resident #85's FM on 04/23/2025 at 1:45 p.m., revealed that staff knock at times and there were times that the staff do not knock. He said that he did not care if staff knocked because the door made a lot of noise, and he could hear the staff coming in. He said that staff not knocking did not upset him. During an attempted interview with Resident #247 on 04/23/2025 at 1:46 p.m., she said that staff never knock before going into her room. She said that it would make her happy if anyone who came into her room would knock first. She said that she did not get upset when staff did not knock. During an interview with LVN N on 04/23/2025 at 1:20 p.m., she said she had been trained on resident rights. She said the policy for knocking was that staff were supposed to always knock before entering, introduce themselves and tell the resident what they were going to do. She said that all staff were required to knock before entering the resident's room. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel like staff are intruding on their privacy. She said that the charge nurse or management monitor to ensure staff were knocking on the residents' doors. She said that the charge nurse or management monitored by observations. She said she realized she did not knock once she entered the room. She said she normally did knock but got distracted by the aides. During an interview with CNA B on 04/24/2025 at 11:26 am revealed that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to always knock before entering. She said that all staff were required to knock before entering the resident's room. She said that knocking was for the resident's privacy and dignity. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel like they do not have any privacy or respect. She said that the charge nurse monitor to ensure staff were knocking on the residents' doors. She said that the charge nurse monitored by observations. She said she was not sure why she did not knock on the residents doors before entering. An interview with the DON on 04/24/2025 at 11:30 a.m., revealed she and staff had been trained on resident rights. She said the policy was that staff were to knock on the door and that she was not sure if there was a policy. She said that staff were to knock except if it was an emergency such as the resident on the floor. She said it was important for staff to knock because it was the resident's right. She also said that if staff did not knock on the door, it might bother some residents but others it may not bother it would depend on the resident. She said that all management was responsible for monitoring to ensure staff were knocking. She said that management monitored it by doing observations. She said some of the staff were students and are still learning but for the ones who were not students, she said she did not know why they did not knock. An interview with the ADM on 04/24/2025 at 11:35 a.m., revealed that he and staff had been trained on resident rights. He said the policy was to knock on the door, pause wait for a response and then enter. He said that it was important for staff to knock on the residents' door for their privacy. He said the resident may feel like their privacy is being invaded, could hurt their dignity and cause the resident to feel disrespected. He said the only time staff did not need to knock on the resident's door was in the event of an emergency. He said that the charge nurse was to monitor to ensure that staff were knocking on the door. He said the charge nurses monitored knocking by observation of the halls. He said he did not know why staff were not knocking on residents' doors before entering . Record review of Promoting/Maintaining Resident Dignity Policy dated 1/13/2023 revealed it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity. Staff were to maintain resident privacy.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #40 and Resident #1) of 18 residents reviewed for infection control practices. 1. The facility failed to ensure the Treatment nurse used a cleaning technique on Resident #40's Stage 3 sacral pressure ulcer that did not cross contaminate the pressure ulcer. 2. The facility failed to ensure that MA C performed hand hygiene prior to medication administration for Resident #1. The failure related to wound care technique could place residents at risk for healthcare associated cross contamination leading to worsening of pressure ulcers discomfort, pain, and potential infections. The failure with hand hygiene prior to medication administration could place the residents at risk for healthcare associated cross contamination and possible infections related to the contamination of the environment and oral medications. Findings included: Review of Resident #40's face sheet dated 04/16/2025 revealed Resident #40 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit), Dysphagia (difficulty swallowing), Parkinson's Disease with Dyskinesia (a progressive disorder that affects the nervous system), Neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), and unspecified Fracture of Sacrum (a broken bone in the lower back near the tailbone). Record review of Resident #40's MSD assessment, dated 04/16/2025, reflected Resident #40 was readmitted to the facility on [DATE] following a short-term hospital stay. MDS assessment had not been completed at the time of the survey. Record review of Resident #40's care plan reflected a focus area, dated 04/23/2025, reflected The resident has stage 3 pressure ulcer to sacrum date of development 4/21/25 r/t skin frailty, immobility and incontinence. Goal included, resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target date: 06/28/2025. Observation on 04/23/2024 at 8:18 AM revealed the Treatment Nurse in Resident #40's room to provide wound care. She removed the dressing covering the wound, then provided incontinent care to Resident #40. She wiped feces off the resident's perianal area with a moist perineal wipe and used the soiled wipe to wipe the skin around the open wound. She later used clean moistened gauze to wipe the skin surrounding the wound, before using the soiled gauze to wipe the open wound bed. Interview with Treatment Nurse on 4/24/25 at 09:20 AM stated that the proper technique for performing wound care is to wipe from the inner aspect of a wound and clean outward to prevent cross-contamination of a wound. Stated, that wasn't ideal at all when informed that she wiped around the open wound when cleaning feces off the resident's skin, and then later wiped the surrounding skin before cleaning the wound bed with the same moistened gauze during wound care to Resident #40. She stated that the resident could get an infection if the wound was contaminated with feces. Interview on 4/24/25 at 02:32 PM with DON stated that her expectations for wound care technique is that the wound bed be cleaned from the center of the wound bed outward. Stated that fecal contamination of the wound could lead to a wound infection and decline of the wound. Stated that hand hygiene should be done prior to medication administration per policy. Stated that the staff could cross contaminate the resident if hand hygiene is not performed. Interview on 4/24/25 at 03:31 PM with Administrator stated that his expectation is that incontinent care be performed prior to proceeding with wound care. Stated his expectation was that hand hygiene should be performed prior to medication administration. Follow-up interview on 04/25/2025 at 09:40 AM with Administrator stated that if there was contamination in a wound, there is a possibility that a resident may need further intervention such as antibiotics. Stated that there is a possibility of cross contamination if staff did not wash or sanitize hands prior to administering medications to a resident. Stated that the resident has a potential to develop stomach issues such as nausea and vomiting, depending on the type of bacteria. Review of facility's policy on Infection Prevention and Control Program dated 05/13/2023, reflected All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy on Pressure Ulcer Prevention and Management dated 08/15/2022, reflected The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to:ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. Record review of Resident #1's face sheet, dated 04/23/2025, reflected Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with a diagnosis of Seizures, Vascular Dementia (dementia related to the blood vessels of the brain), Anxiety, and transient cerebral ischemic attack (a brief stroke-like attack wherein symptoms resolve withing 24 hours). Record review of Resident #1's MDS assessment, dated 02/20/2025, reflected Resident #1 had a BIMS score of 12, indicating moderate cognitive impairment. Record review of Resident #1's care plan reflected a focus area, dated 03/03/2025, The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia. Interventions indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness. Observation on 04/23/25 at 09:43 AM revealed MA C did not perform hand hygiene when entering the Resident's room prior to administering oral medications to Resident #1. Interview with MA C on 4/24/2025 at 9:48 AM stated that she did not perform hand hygiene prior to administering medications to Resident #1. Stated that normally she would clean from the inner part of the wound to the outer surrounding skin. Stated that the resident could possibly get an infection if hand hygiene was not performed prior to medications. Review of the facility's policy on Infection Control, dated 05/13/2023, reflected Hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's policy on Medication Administration, dated 10/01/19, reflected, Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and medications given via enteral tubes.

Based on record review and interviews, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for one (Resident #84) of 10 residents reviewed for care plans, in that: 1. The facility failed to ensure Resident #84's comprehensive care plan included a smoking plan. This failure could place the residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #84 Face sheet, dated 4/24/2025, reflected he was a [AGE] year-old man, who was admitted to facility on 12/30/24 with diagnoses of centrilobular emphysema (lung disease with damage to the air sacs), respiratory failure, obstructive pulmonary disease (chronic progressive lung disease), type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), unsteadiness on feet, cognitive communication deficit (problems with communication), and muscle wasting and atrophy. Record review of Resident #84 Quarterly MDS dated [DATE] , indicated he had a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. Records review of Resident #84's comprehensive care plan dated 3/25/2025, reflected the resident's diagnoses with a focus on interventions that were actively being completed to support residents' health. Smoking was not reflected on care plan. In an observation and interview with Resident #84 on 4/22/2025 at 10:10 AM, resident was observed lying in his bed with oxygen. Resident stated that due to him being on antibiotics changed his smoking schedule. He stated he goes after the other residents, and when he goes out to smoke, he smokes alone. Resident stated if the state surveyors observed him by himself, the reason was due to him being on the antibiotics for his blood issues. In an observation and interview with Resident #84 on 4/23/2025 at 9:13 AM. Resident was sitting up in a chair, he stated he had just come from smoking. Resident was observed to be clean and neat in appearance . Records review revealed a smoking safety screen for Resident #84 was completed on 1/6/2025. In an interview on 4/24/2025 at 1:44 PM, Social Worker (SW) stated she has worked at the facility for four years. SW stated she has been trained on the smoking policy. SW was asked to explain the smoking policy. She stated all residents must be supervised unless they sign themselves out to smoke away from the facility property. SW was asked if smoking should be included on a care plan for a resident that smokes, SW stated yes, it should be on the care plan. SW was asked, what could be a potential outcome if smoking was not on the care plan. SW stated there could be a possible accident. SW was asked had Resident #84 signed himself out to smoke, SW stated he had in the past, but she did not know of anytime recently. SW stated she was not aware of Resident #84 smoking alone. SW stated Resident #84 was not supposed to smoke unsupervised. SW was asked why smoking was not included on the care plan for resident 84, SW stated it should be on the care plan. SW was told that smoking was not reflected on resident 84 care plan. In an interview on 4/24/2025 at 3:30 PM, Director of Nursing (DON ) stated, she was aware of the facility's smoke policy. DON stated residents have smoke times assigned and they must be supervised while smoking. DON was asked who was responsible for developing the care plan, DON stated the nursing team. DON was asked should smoking be included on a resident's care plan if they were a smoker, DON stated yes. DON was asked what potential outcomes could be when smoking is not reflected in the care plan, DON stated it can lead to opportunities for accidents. She stated that she was not aware of him smoking alone. Record review on 4/24/2025 of facility's Comprehensive Care Planning Policy dated 10/24/22 reflected the following: a) Care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B )resident's goals for admission, desired outcomes, and preferences for future discharge. b) Resident specific interventions that reflect the resident's needs and preference and align with the resident's cultural identity, as indicated.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #1) reviewed for pain management. The facility failed to ensure Resident #1 received scheduled hydrocodone as ordered from 03/29/24 to 03/31/24. This failure placed residents at risk of increased pain and decreased quality of life. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including pain in left shoulder, contracture of left elbow, hip, and knee and right elbow, hip, and knee, osteoarthritis, generalized anxiety disorder, chronic pain syndrome, and rheumatoid arthritis. Review of the admission MDS assessment for Resident #1 dated 03/12/24 reflected a BIMS score of 15, indicating she was cognitively intact. It reflected she was on a scheduled pain regimen. It reflected she had not experienced pain in the five days prior to the assessment. It also reflected she was taking opioid pain medication . It reflected she required total or substantial assistance in all ADLs except eating and oral hygiene, with which she required only partial assistance. Review of the care plan for Resident #1 dated 02/29/24 reflected the following: The resident is on pain medication therapy HYDROcodone-Acetaminophen Oral Tablet 10-325 MG) r/t chronic pain. The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Monitor/document/report PRN adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinary retention. Review of physician orders for Resident #1 dated 02/28/24 reflected the following: HYDROcodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 2 tablet by mouth two times a day for chronic pain. Review of the March 2024 MAR for Resident #1 reflected the 09:00 AM and 09:00 PM administrations were marked 9, indicated on the MAR key by 9=Other / See Progress Notes. These administrations were signed by MA B. Review of the progress notes for Resident #1 from 03/29/24 to 03/31/24 reflected the following notes: 03/29/24 01:02 PM Note Text: (np) called and updated to reorder norco 10-325mg to pharmacy. 03/31/24 03:12 AM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period. 03/31/24 05:56 AM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period PRN Administration was: Effective Follow-up Pain Scale was: 0. 03/31/24 10:54 AM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period. 03/31/24 03:09 PM Acetaminophen Oral Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever 2 tabs to = 650mg, to not exceed more than 3 grams from all sources in a 24hr period PRN Administration was: Effective Follow-up Pain Scale was: 0. 03/31/24 08:44 PM HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 2 tablet by mouth two times a day for chronic pain. Pending delivery from the pharmacy. Review of administrations from the facility emergency kit reflected Resident #1 was given 2 tablets of hydrocodone at 09:40 PM on 03/28/24 and that LVN A signed out the dose. There were no other administrations recorded for her after that. Review of pain assessments for Resident #1 from 03/29/24 to 03/31/24 reflected she was assessed three times per day (day shift, evening shift, and overnight shift) for pain and reported a pain level of 0 each time, indicating she was in no pain. The dayshift and evening shift assessments for 03/30/24 and 03/31/24 were conducted by LVN A. Observation and interview on 04/04/24 at 02:06 PM revealed Resident #1 laying in bed under blankets. She was calm and stated she was comfortable. She stated she had experienced an issue with her pain medications the previous weekend from Friday 03/29/24 to 03/31/24. She stated her usual hydrocodone was white, and on Thursday night 03/28/24, she received a dose that was blue. Resident #1 stated she thought it was unusual, but it did not concern her. She stated she looked up the number printed on the pills that evening and saw they were hydrocodone, so she took them. She stated the following morning, 03/29/24, she should have received another dose, but MA B told her the pills had not arrived from the pharmacy. She stated she went through the whole weekend with MA B telling her the pills were not available. She stated she started to feel poorly; her legs were irritated, and she was sweaty. She stated she was always in pain due to her rheumatoid arthritis, and she had been on the hydrocodone for [AGE] years. She stated the medications did not do a lot for her pain, but she was used to having them. She stated she felt strange, so she did not know if she was going through withdrawal. She stated the nurse came in and checked her vital signs, which were fine. Resident #1 stated she did not say anything to the nurse about the missing medication, because Resident #1 figured if MA B knew, the nurse must have known. Resident #1 stated all day Sunday she was very hot and sweaty, and finally she asked LVN A what was going on with her hydrocodone. Resident #1 stated LVN A then reached out and took care of the issue, and the hydrocodone came in that night. Resident #1 stated she received a dose around 10:00 PM on Sunday night 03/31/24. An interview was attempted on 04/04/24 at 02:23 PM with MA B. A voicemail was left but no return contact occurred as of 04/11/24. During an interview on 04/04/24 at 03:40 PM, LVN A stated she conducted several pain assessments for Resident #1 from 03/29/24 to 03/31/24, and Resident #1 never communicated that she was in pain. LVN A stated she did not see any nonverbal signs of pain during that time: no tremors, sweating, nausea, or anything that would indicate distress. LVN A stated LVN A had called the NP on the night of 03/28/24 and requested the hydrocodone be refilled. LVN A stated she also pulled a hydrocodone from the emergency kit that evening for Resident #1. LVN A stated she did not work on Friday 03/29/24. LVN A stated when she returned on 03/30/24, she assumed the medication had arrived, because Resident #1 did not complain, and the medication aide did not report any unavailable medications to her. LVN A stated it was not until late Sunday morning that Resident #1 told LVN A she had a bad night the night before and told her she had not received her hydrocodone since the previous Thursday night 03/28/24 that LVN A realized the medication was still unavailable. LVN A stated she called the pharmacy and learned they had not received the request from the weekday NP yet. LVN A stated she then called the on call NP who sent a triplicate request form to the pharmacy, and the medication was delivered later that night. LVN A stated the administration record reflected that Resident #1 was administered Tylenol on 03/30/24 and 03/31/24. LVN A stated she did not know why the nurse on duty 03/30/24 had not administered any doses of the medication from the emergency kit. LVN A stated she did not, because she did not know the medication was unavailable until mid-day 03/31/24. During an interview on 04/04/24 at 04:14 PM, the ADON stated the IDt had been aware Resident #1's hydrocodone had not come in during their morning meeting on 03/29/24, and she had asked LVN C to follow up with the pharmacy and the NP to find out what was going on. The ADON stated she did not find out if LVN C followed up or what the result was, and the ADON was just now finding out that Resident #1 went without her hydrocodone all weekend. The ADON stated they ensured residents had the medications they needed for pain management, because they had and emergency kit. The ADON stated they pulled reports that let them know if something was missing, but because it was the weekend, there was no one present to pull the report. She stated they had no process during the weekend to oversee if medications were unavailable and relied on the staff to report verbally so they could get the medications that were needed. She stated she and the DON were both responsible for ensuring the residents had their scheduled medications available. The ADON stated without available hydrocodone, a resident could go with uncontrolled pain. During an interview on 04/04/24 04:45 PM, the DON stated the first point of contact/responsible person for ensuring residents had their pain medications available was the charge nurse. The DON stated the managers reviewed a report each weekday morning to address any issues or missing medications, but on weekends, it was up to the charge nurses on duty to monitor that system. She stated she ensured the staff were compliant with their system by training them to communicate when something is wrong. The DON stated the staff knew they had to give the medications and follow orders, and if the medications were not available, they knew they had to communicate directly for each missed administration. She stated it was also their policy to reorder medications well ahead of time: the aides needed to let the nurses know to reorder, and the nurses needed to do the reordering. The DON stated Resident #1's hydrocodone was scheduled, and there must have been a communication lapse from MA B to the nurses on duty those days. The DON stated a potential negative outcome of the failure was residents would be uncomfortable and would not feel very comfortable. Review of in-services from January 2024 to March 2024 reflected the following: Medication Administration 03/07/24 Medication Administration 03/14/24 Medication Administration 03/19/24 Medication Administration 03/26/24 Review of the facility policy dated 08/15/22 and titled Pain Management reflected the following: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Review of facility policy dated 10/24/22 and titled Medication Administration reflected the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of facility policy dated 10/01/19 and titled Ordering and Receiving Medications from Pharmacy reflected the following: It will be the responsibility of the facility to re-order the medication to avoid any lapse in therapy. And Controlled substances are re-ordered a five-day supply remains to allow for transmittal of the required written prescription to the pharmacist.

Based on observation, interviews and record reviews it was determined the facility failed to ensure the facility remained free of accidents and hazards as possible for three of six residents (Resident #1, #3 and #4) and two of three housekeepers reviewed for accidents and hazards. A. The CNA A failed to ensure Resident #1 was provided the required level of assistance of two staff during incontinence care and repositioning, resulting in the resident falling and sustaining a mildly displaced fracture of the proximal fibula (right lower leg) and distal tibia (right ankle). B. Housekeeper B and Housekeeper C failed to lock in the housekeeping cart which contained chemicals and left the cart unattended. These failures placed resident at risk for decline in health status, injuries, and hospitalization s. The findings included: A. Review of Resident #1's face sheet dated 08/23/2021 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Contractures on Left and Right Hips, Muscles, Left Elbow, Left Wrist, Right and left hand, Right and left Ankle and Left Knee. [CONDITION(S)] and Dysphagia following unspecified [CONDITION(S)] Disease, Chronic Pain and Unspecified Sequelae of Unspecified [CONDITION(S)] Disease. Review of Resident #1's Quarterly MDS dated [DATE] reflected the resident didn't have speech and was rarely/ never understood or understands. She had poor short- and long-term memory recall and her daily decision-making ability were severely impaired. The MDS also indicated Resident #1 was totally dependent and required the physical assistance of at least two with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Her range of motion had impairment on both sides (upper and lower extremities). Review of Resident #1's Comprehensive Care Plan dated 06/08/2021, reflected resident had an ADL self-care performance deficit related to impaired mobility, contractures, chronic pain and impaired cognition. The comprehensive care plan indicated bed mobility the resident required extensive to total assistance by two staff for repositioning and dressing, hygiene, and transfers with mechanical lift. The comprehensive care plan indicated Resident #1 was at high risk for falls related to poor positioning in chair and bed, impaired cognition and decreased in mobility. The resident needed a safe environment with the bed in a low position. According to the care plan, Resident #1 had an alteration in musculoskeletal status related to contractures of bilateral upper and lower extremities and staff should be educated on safety measures to reduce risk of falls. Review of Resident #1's The Kardex is the information from the care plan and informs staff of care needed by each resident for August 2021 reflected Resident #1 required extensive to total assistance by two staff for the following: repositioning and turning in bed every two hours and as necessary, dressing, personal hygiene, toileting, and transfers. Review of facility investigation report related to the incident involving Resident #1 dated 08/16/2021, reflected on 08/16/2021 at approximately 5:30 AM, CNA A reported to LVN D that when giving incontinent care to Resident #1, CNA A turned the resident towards her- and the air mattress raised up and Resident #1 began coming off the bed. CNA A was not able to push her over onto the bed, so she leaned Resident #1 against her body and eased her onto the floor. LVN D reported CNA A came to her for help with Resident #1. LVN D found resident in sitting position on the floor close to the bed. Care plans reviewed Resident #1 required two person assist with care. CNA A did not follow policy on bed mobility and transfers. Review of facility investigation report related to the incident involving Resident #1 dated 08/16/2021 reflected CNA A written statement stated, As I was changing Resident #1 I turned her towards me and her mattress leaned up and I try to push her back and she tighten up and tense up toward me. I couldn't get her back the other way, so I just let her lean on me and sat her on the floor. Review of facility investigation report related to the incident involving Resident #1 dated 08/16/2021, reflected LVN E written statement stated, I was assigned on 300 hall 10-6 shift. 5:30 AM, CNA A came at the nurse's station and reported to me that Resident #3 was on the floor and she needed help to put her back to bed due to her mattress leaned up and resident turned toward her (CNA A), she ( CNA A) had to ease resident down and sat her on the floor. I went with her to assess Resident #1 and she was in sitting position close to the bed and bed was on lowest position. When I asked CNA A is the bed low when you sat he down she said no the bed was a little high. Observed an open area to right big toenail and left forehead was a little red. Notified Director of Nurses, Nurse Practitioner and Responsible Party and gave report to on coming nurse to monitor resident. Review of Physician Assistant's Progress Note Dated 08/16/2021 reflected Resident #1 was examined during morning rounds. According to the progress note, a small hematoma was noted to the left side of the forehead and distortion was noted to the right lower leg with [CONDITION(S)]. Resident was noted to have facial grimacing to the right lower leg was tender to touch. The note indicated Resident #1 is total assist and is unable to move upper or lower extremities. According to the note when the air mattress slides down, the patient certainly could have sustained injuries as she is bedbound quad status with severe lower extremity contractures. The note indicated a Stat x-ray of tibia/fibula ordered. Review of Resident #1's Radiology report dated 08/16/2021 reflected, Mildly displaced fracture of the smaller bone below the knee and the large bone below the knee are noted, likely acute. In an interview on 08/31/2021 at 9:00 AM CNA F stated she followed the Kardex when giving care to residents. She had been in serviced on how to use the Kardex prior to 8/16/2021 and either on 8/16/2021 or day after she couldn't recall exact date. In an interview on 08/31/2021 at 9:10 AM CNA G stated the CNA's had been instructed to follow the Kardex on every resident when providing care. Staff was in serviced in August 2021 on how to use the Kardex, how to transfer a resident with two staff assistance. She was in serviced before August 2021 on how to transfer residents and to follow the Kardex and understood all the types of assistance a resident would need with transfers. All nursing staff had access to the Kardex. In an interview on 08/31/2021 at 11:00 AM the ADON stated Resident #1 required two person assist with all her care including repositioning, dressing, grooming, bathing, hygiene, toileting, and transfers. The CNA's had been in serviced in 2021, prior to the incident, on following the Kardex but she could not recall the exact date. CNA A did not follow the Kardex or follow the protocol for repositioning a resident in the bed. The Kardex is a source of information for staff to follow what is documented on the care plan for each resident. When the staff was in serviced on 08/24/2021, the nursing staff attended the in-service knew to follow the Kardex when giving care. There wasn't a direct answer from the CNA A why she didn't ask for assistance. The nursing staff received in services on 8/16/2021 related to abuse and neglect, positioning and transferring, two-person bed mobility and was demonstrated how to transfer residents. In an interview on 08/31/2021 at 12:15 PM the Administrator stated CNA A did not follow the correct protocol of repositioning Resident #1 or giving her care on the date 08/16/2021. It was determined CNA A did not ask for assistance when giving care to resident. Resident #1 is a two person assist during all care. After the investigation, it was very clear CNA A was at fault and the injury of Resident #1 occurred after CNA A didn't follow residents needs for care. The DON and ADON in serviced staff on following Kardex and the information provided on the Kardex. On 8/16/2021 in-service on two-person bed mobility, abuse and neglect and positioning and transferring residents was given to the nursing staff. I am not certain why CNA A didn't ask for assistance. It wasn't clear in her interview and her written statement. In an interview on 08/31/2021 at 1:25 PM Resident #1's Primary Care Physician stated Resident #1 required more than one person to assist her. The PCP stated Resident #1 had contractures and needs two people to assist with all her care and needs. The PCP stated if one person assisted her, it could result in an injury. In an interview on 08/31/2021 at 2:45 PM Health Care Nursing Services Consultant stated all staff were to follow what was documented on the Kardex. CNA A didn't need to move or reposition Resident #1 alone. She was to have another staff with her when giving care to Resident #1. It is expectation for all CNA's to follow the Kardex information. If a CNA had questions about any type of care of a resident, they are to ask their nurse supervisor. Review of Facility policy on moving a resident up in bed dated 07/15 reflected if the resident is unable to assist you: one person stands on each side of bed. Position lift sheet from under the resident's thigh to about the shoulders. Roll both sides of the lift sheet toward the resident's body. Stand straight and turn slightly toward the head of the bed. Keep your feet flat on the floor approximately 12 inches apart. The foot nearest the head of the bed should be turned in that direction. Grasp the rolled lift sheet on both sides of the resident at the thighs and shoulders. On the count of 1, 2,3 go lift the resident toward the head of the bed. Facility policy on Kardex and ADL care was not provided at time of exit. Inservice's on Kardex and ADL care prior to 08/16/2021 was not provided at time of exit. B. Review of Resident #3's face sheet dated 08/31/2021 reflected she was[AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease, [CONDITION(S)] with Hallucinations due to known Physiological Condition, Mood Disorder, Major Depressive Disorder, [CONDITION(S)] and Chronic Obstructive Pulmonary Disease, unspecified. Review of Resident #3's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 0, which indicated her cognition status was severely impaired. According to the MDS Resident #3 had a behavior of wandering. Review of Resident #3's Comprehensive Care Plan dated 07/09/2021 reflected Resident #3 The resident had history of disorganized thinking related to impaired cognition and it was difficult to redirect her. The care plan also indicated the resident had potential fluid deficit related to a preference to drink water out of bottles. Review of Resident #4's face sheet dated 08/31/2021 reflected [AGE] year-old-female admitted to the facility on [DATE] with the following diagnoses: Peripheral Vascular Disease, Other Psychoactive Substance Abuse, Peripheral Vascular Angioplasty status with Implants/ Grafts, and Chronic Obstructive Pulmonary Disease. Resident #4's Admission MDS dated [DATE] reflected the resident had BIMS score of five indicating severe cognitive impairment. She was not steady with walking, moving from seated to standing position, turning around and surface to surface transfer but was able to stabilize without staff assistance. Resident #4's Comprehensive Care Plan assessment dated [DATE] reflected resident had impaired cognitive function. Resident required to be cued, reorient, and supervised as needed. Present one thought, idea, question, or command at a time. Observation on 08/31/2021 at 8:50 AM revealed Housekeeper B was in room #102 mopping approximately 10 minutes. She could not view the housekeeping cart was located in the hall beside room #102. Her back was turned to the hallway. The housekeeping cart had a compartment with a lock to store chemicals. The compartment was opened approximately 5-7 inches and was facing the hallway with chemicals accessible. The compartment had one yellow colored chemical and one green colored chemical in 2 different plastic bottles with the same label. Both bottles had label [NAME] Dual Action Floor Cleaner. The compartment also had a bottle of Virex II 256, but information explaining the chemical had faded and was not legible. In the housekeeping cart was an uncovered 2-quart water/ tea pitcher with a chemical in it not labeled. In an interview on 08/31/2021 at 8:55 AM Housekeeper B stated she did not speak English. In an interview on 08/31/2021 at 8:56 AM CNA C interpret the conversation with Housekeeper B stated she could not see the housekeeping cart from the room. She stated her cart lock wasn't working and the locks on all the housekeeping carts had been broken or not working for months. Housekeeper B confirmed chemicals were to be stored in locked compartments and labeled. Housekeeper B was not able to identify if the chemicals were correctly labeled and identified the yellow substance in the tea/water pitcher as toilet bowl cleaner. She stated a resident could have an illness or go to a hospital if chemical was swallowed. Observation on 08/31/2021 at 9:06 AM revealed Housekeeper D was in the dining room mopping. She could not view the housekeeping cart when entered the dining room at 9:04 AM. She was approximately 15 feet away from the cart and was not facing the cart. The housekeeping cart had a compartment with a lock to store chemicals. The compartment was completely opened, and chemicals were accessible. The compartment contained one bottle of Peroxide Multi Surface Cleaner. One bottle of Good Sense 7 Cleaner label partly missing and was faded and illegible. One bottle of Bio Enzymatic Odor Eliminator. Also observed in the housekeeping cart on the bottom shelf was a 2-quart tea/ water pitcher uncovered and without a label that was half full of a yellow liquid. Observation on 08/31/2021 at 9:08 AM revealed Resident # 3 speaking to Resident #4 as she was pointing and attempting to assist self from chair in the dining room, less than 4 feet from the housekeeping cart, stated I would like to have some of that lemonade. Resident #4 stated to Resident #3 I can't get that lemonade for you I am going to smoke. Ask someone else to get it for you. In an interview on 08/31/2021 at 9:10 AM Resident #3 stated, I don't need a cup. I will drink that lemonade from the pitcher. Yes, that is lemonade can't you see it. If my knees wouldn't hurt, I would have walked to get it myself. I was almost out of my chair when my knees started hurting. In an interview on 08/31/2021 at 9:15 AM Housekeeper D stated she didn't speak English. In an interview on 08/31/2021 at 9:50 AM had CNA C interpret conversation with Housekeeper D stated the yellow liquid in the tea pitcher was toilet bowl cleaner. A resident can get very sick from drinking any of these chemicals. All chemicals are to be locked but we can't lock them in our carts. The locks on all carts needs to be repaired they don't lock. Housekeepers had been informed the chemicals on the carts are to be locked. She reported this to Housekeeping Supervisor. In an interview on 08/31/2021 at 9:19 AM the Housekeeping Supervisor stated the chemical in the plastic tea pitcher was toilet bowl cleaner. She stated all the bottles on the housekeeping cart needed to be re-labeled as they did not have all the information on all the bottles and need new labels on the bottles. She stated they reuse all the chemical bottles and if they were not using the chemical originally contained in the bottle they would put a different chemical in that bottle and replace a label on top of the label already on the bottle. The Housekeeping Supervisor identified the green chemical in the bottle [NAME] Dual Action Floor Cleaner as the correct chemical. The yellow chemical in the other bottle labeled [NAME] Dual Action Floor Cleaner was either toilet bowl cleaner, virex or peroxide. Housekeeping Supervisor stated all chemicals are to be in the original bottle and labeled. She stated there were no documentation on if the bottles were washed prior to using it for a different chemical. If the bottles are not washed properly or have the appropriate label this could cause harm to staff and residents if used incorrectly or if chemicals are combined. Resident #3 did tell surveyor she thought it was lemonade. The Housekeeper Supervisor stated if she had drunk the chemical in the tea pitcher, she could have become sick and possibly have to go to the hospital. She confirmed information was not available for that chemical. The Housekeeping Supervisor confirmed all the housekeeping carts locks were not working on 08/31/2021, but carts continued to be used. She denied housekeepers had reported the locks not working on the housekeeping carts. In an interview on 08/31/2021 at 12:15 PM the Administrator stated all chemicals were to be stored in a locked area and stored in the original container with the correct label. The Administrator stated no chemicals should be stored in a tea pitcher, and It was dangerous if the housekeepers didn't know the exact chemical being used in a resident's room. Any resident could become seriously ill and cause physical harm if it was on their skin or if swallowed. He wasn't aware of the broken locks on all the housekeeping carts. All the housekeeping carts are being repaired with new locks. In an interview on 08/31/2021 at 2:00 PM the Director Manager over Housekeeping stated all chemicals were to be locked in the housekeeping cart. The Manager confirmed the locks on the housekeeping carts were not currently working. The housekeepers were expected to pour the chemicals in the correct container with the correct label, and a tea pitcher wasn't considered an appropriate container. The Manager identified the yellow liquid in the tea pitcher as peroxide and not toilet bowl cleaner using the smell and color of the chemical. The Manger stated they did not have toilet bowl cleaner in the facility. The Manager stated, it would be difficult for the housekeepers to know which safety data sheet to view if an accident happened with the chemical in the tea pitcher. The Manager stated the facility didn't use virex and identified the chemical in the virex bottle on the housekeeping cart as peroxide. The Manager stated it could be harmful to residents and to the housekeepers if using wrong chemical on surfaces in a resident's room and a resident could become sick or have skin issues if they had contact with certain chemicals. According to the Manager the green liquid chemical in the [NAME] Dual Action Floor Cleaner was the correct chemical but the yellow liquid chemical in the [NAME] Dual Action Floor Cleaner was the wrong chemical for that bottle. The locks for the housekeeping carts had been ordered. Record Review of the Product Specification Document of Peroxide Multi Surface Cleaner and Disinfectant provided by the Director Manager over Housekeeping reflected Do not ingest. Do not get in eyes, on skin, or on clothing. Do not breathe dust/ fume/ gas/ mist/ vapor/ spray. Use only with adequate ventilation. Keep out of reach of children. Store in suitable labeled containers. Storage temperatures 0 degrees Celsius to 50 degree Celsius. If swallowed or inhaled get medical attention immediately. Cause severe skin [CONDITION(S)] and eye damage. May cause an allergic skin reaction. Toxic if inhaled. Record Review of the Safety Data Sheet Quik Fill 35 [NAME] Dual Action Floor Cleaner provided by the Director Manager over Housekeeping reflected Skin corrosion or irritation, serious eye damage or eye irritation and specific target organ toxicity (single or repeated exposure). Inhalation- respiratory irritation, cough. Causes serious eye damage, severe skin [CONDITION(S)], digestive tract [CONDITION(S)]. Store in suitable labeled containers. Keep out of reach of children. Storage temperature 10 degrees Celsius to 45 degrees Celsius. Record Review on 08/31/2021 of the Safety Data Sheet Bio-Enzymatic Odor Eliminator provided by the Director Manager over Housekeeping reflected Keep out of reach of children. Get medical advice if you feel unwell. Store in suitable labeled containers. Storage temperatures 0 degrees Celsius to 45 degrees Celsius. Record Review on 08/31/2021 of the Protocol of Proper Chemical Use dated 06/2016 reflected Avoid old bottles for new chemicals. Even though the bottle may appear dry, a residue of previous chemical often remains and could cause a chemical reaction. Each housekeeping cart has a lockbox. All chemicals are to be stored in the lock box. Do not leave your cart unattended. Always make sure that all bottles have proper labels. Never use a chemical for something other than what it is intended. Never mix chemicals. Record Review on 08/31/2021 of the Protocol for Stocking A Cart dated 06/2016 reflected Store chemicals in lock-box when not using them. Bottles must be labeled with the appropriate OSHA approved label. Must be locked up when not in use.

Based on observation, interview, and record review the facility failed to ensure that each Resident receives adequate supervision to prevent accidents for 1 of 8 Residents (Resident #1)when they: 1. Failed to adequately supervise Resident #1 who voiced a verbal threat of suicide on [DATE]. 2. Failed to provide a psychological assessment for Resident #1 in a timely manner(15 days) following a verbal threat of suicide 3. Failed to adequately communicate to direct care staff and social service that Resident #1 had verbalalized a threat of suicide. Resident #1 was found by her roommate on [DATE] with a plastic bag over her head. Resident #1 was sent to a local hospital emergency room and later admitted to the Intensive Care Unit (ICU) where she died on [DATE]. This deficient practice resulted in an Immediate Jeopardy (IJ) on [DATE] at 11:15 AM. While the IJ was removed on [DATE] at 4:15 PM, the facility remained out of compliance at a Severity of Actual Harm with a Scope of Isolated that is not IJ due to lack of time to monitor the Plan of Removal for effectiveness. The deficient practice to ensure adequate supervision allowed Resident #1 to attempt self injury that resulted in death. Findings include: During an observation on [DATE] at 2:45 PM revealed Resident #1 at the local hospital. Resident #1 was non-responsive. During an interview on [DATE] at 2:50 PM, the local hospital Registered Nurse (RN) stated Resident #1 was placed on comfort care and was not expected to live. During a telephone interview on [DATE] at 2:00 PM with the hospital nursing staff. The Nurse stated Resident #1 died on [DATE]. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 13 (cognitively intact). Review of Resident #1's nurses notes dated [DATE] reflected -11:00 AM-Resident voiced ideation of suicide. Stated she was going to kill herself if she did not get out of here. Resident placed on 15 minute checks. Physician notified, order received for psyche evaluation. Notified second contact. The contact stated it was normal if things weren't going the way she wanted. Resident has taken pills numerous times before. Resident placed on 15 minute checks. Review of Resident #1's medical record revealed no further notations of the monitoring for suicidal ideation. Review of Resident #1's medical record reflected a physician order for a psychiatric evaluation dated [DATE]. Review of a physician order [REDACTED]. (Resident refuses psychiatrist) Review of Resident #1's Care Plan dated [DATE] reflected the following: Resident #1 with history of depression. Resident with little interest. Resident with history prior to admission of suicide ideation. Daughter states when she doesn't get her way, she will make remarks, but has never gone through with a plan.- Will show no signs/symptoms of depression while on medication within next 90 days.- Encourage Resident to be out of room as much as possible. Encourage socialization with other Residents. Encourage attendance to group activities. Give routine medication per orders. Monitor for side effects of medication." The Care Plan did not have documentation of the implementation of the 15 minute monitoring checks due to the ideation of suicide voiced on [DATE] Review of a facility report titled Nursing Assessment for Physician Calls and dated [DATE] reflected the following: Time 3:45 AM-informed Medical Director (MD) patient was found with plastic bag over face-no respirations or pulse-Cardio-Pulmonary Resuscitation (CPR) and bagging started. Emergency Medical Service (EMS ) called. Pulse was found and transported to the hospital. ( Name of family notified:) own responsible person (RP) Second contact neighbor notified. " Resident's roommate out in hall yelling "she's trying to kill herself. " Ran to room- found Resident in her bed on back with a plastic trash bag over her head. No response when name called.- felt for pulse; none found but skin still very warm. Bag ripped open and CPR started. 911 called. CPR and the bag continued until EMS arrived at approximately 4:10 PM. Taken by ambulance to hospital." During an interview on [DATE] at 11:45 AM, Resident #5 stated her roommate (Resident #1) had told her that she had attempted suicide in the past. Resident #5 recalled the evening of [DATE] and Resident #1 asking her you know what to do if I die tonight, right ? Resident #5 stated she told everyone she knew she was worried about Resident #1. Resident #5 stated she could not recall who she had told or what the response was. During an interview on [DATE] at 7:00 AM, the Administrator stated that on [DATE], Resident #1's roommate was screaming help, she tried to kill herself. Licensed Vocation Nurse (D) responded and began CPR. EMS was contacted and Resident #1 was transferred by ambulance to the local hospital. The Administrator stated, Resident #1 was last seen at 2:00 AM during rounds by CNA Y who reported both Resident #1 and Resident #5 were asleep when she looked into the room. The Administrator stated Resident #1 had verbalized she wanted to die on [DATE] and a Psychological evaluation was ordered. The Administrator stated 15 minute monitoring checks were implemented. The Administrator stated he had been unable to locate the monitoring logs. The Administrator stated the facility had an interim Social Worker at the time of the incident and does not know why a visit was not documented in the medical record. Review of Resident #1 ' s current medical record reflected no social service notes for [DATE] concerning the [DATE] incident. During an interview on [DATE] at 7:10 AM, the Director of Nurses (DON) stated he did not know where the August monitoring log was. The DON stated Resident #1 refused to see a psychiatrist, but agreed to talk to a Psychologist. The first meeting was held on [DATE]. Review of Resident #1's current medical record did not reflect any notation of psychiatric services from [DATE] to [DATE]. Review of Resident #1's Psychiatric New Patient Referral Checklist dated [DATE] reflected the following presenting problems: sadness/depression, suicidal thoughts, and social withdrawal. The Progress note reflected the following: Assessment: "Resident #1 is intelligent, logical, independent spirit. Understandable emotional reaction to loss of independence." Behaviors/symptoms targeted during session: adjustment issues; anger, anxiety, and noncompliance. Review of Resident #1's psychiatric progress notes dated [DATE] reflected; Resident seemed happy to meet with clinician. Attempts to plot against staff, and against her family, Probably longtime passive-aggressive style. During an interview on [DATE] at 8:30 AM, the Psychologist stated his understanding was Resident #1 was referred to his services due to her voicing suicide ideation. The Psychologist stated the staff reported to him, Resident #1 was not adjusting to placement, was angry, demanding, and resisting therapy- voicing vague self harm statements in a manipulative manner. The psychologist stated when a Resident voices suicidal ideation, he would expect the facility to provide a sitter or at the least, 15 minute checks. The psychologist stated he did not know if that was followed through. The psychologist stated he did not see 15 minute checks in Resident #1's plan of care. If an active suicide ideation is voiced, it should be reported and an evaluation done immediately. The psychologist stated he felt the facility obviously did not do enough to protect Resident #1. On [DATE], the Administrator and the DON presented a Monitoring Log form for the month of September. Review of the log revealed it was complete for the month with initials on [DATE] up to 6:00 AM. During an interview at this time, the DON stated he was still unable to locate an August Monitoring log and did not know why staff were documenting 15 minute checks after the time the Resident had been transported to the hospital. During an interview on [DATE] at 7:50 AM, Certified Nurse Aide Y (CNA) stated she was never informed that Resident #1 had ever voicing suicidal ideation. CNA Y stated she was never informed to conduct 15 minute checks on Resident #1. CNA Y stated Resident #1 always said I want to go home. When asked by the surveyor where the bag may have come from, CNA Y stated she thought maybe from the trash can. CNA Y stated there are generally several trash bags layered into the basket. When a soiled brief is discarded, the bag is taken out and thrown away. CNA Y stated Resident #1 often got up on her own to use the bathroom. She stated that on [DATE] that she had last seen both Resident #1 and Resident #5 during 2:00 AM rounds. Both residents were asleep in their room. During an interview on [DATE] at 8:20 AM, CNA X stated she does not remember ever being informed Resident #1 required 15 minute checks or had voiced suicidal ideation. CNA X stated she was aware of Resident #1's roommate (Resident #5) having a past history of suicide attempts. CNA X stated Resident #1 continuously said I want to go home. During an interview on [DATE] at 9:00 AM, LVN D stated she had no idea Resident #1 had voiced ideation of suicide. LVN D stated Resident #1 continuously voiced wanting to go back to home in community. LVN D stated she recalls seeing the bag covering Resident #1's head, it appeared to have something white tied at the neck, but she looked quickly and could not be sure. LVN D stated all trash cans in Resident rooms had plastic trash bags in them. During an interview on [DATE] at 9:11 AM, the Social Worker (SW) stated her first day of employment was [DATE]. The SW stated no one had informed her Resident #1 had voiced ideation of suicide, only that she wanted to go back to her home in the community. The SW stated if she had been aware of the situation, she would have asked Resident #1 directly and then initiate the suicide protocol for suicidal ideation. The SW stated had she known, she definitely would have pulled the chart, made sure Resident #1 was receiving psychiatric services and continued to touch base until the Resident received needed services. During an interview on [DATE] at 10:30 AM, CNA W stated she had not been informed Resident #1 had voiced suicidal ideation and had never been instructed to provide 15 minute checks. CNA W stated she knew Resident #1 wanted to go home. CNA W stated she recalls being told a couple of weeks ago to keep an eye on a Resident in that room she assumed it was her roommate.(Resident #5) During an interview on [DATE] at 10:35 AM, CNA V stated she had no idea Resident #1 could have been suicidal. CNA V stated all she told me is she wants to go home. CNA V stated a couple of weeks ago the nurse told her to keep an eye on Resident #1's roommate (Resident #5) because she had suicidal thoughts. CNA V stated she was not instructed to document 15 minute checks. CNA V stated Resident #1 started to improve and then recently began to decline, not wanting to eat. CNA V stated she reported this to the nurse.CNA V stated extra trash bags are kept in the receptacles in the room. During an interview on [DATE] at 9:00 AM, LVN D stated she had last seen Resident #1 between 3:15 AM and 3:30 AM when she conducted rounds. LVN D stated she conducted round every 15 to 30 minutes by walking down the hall. LVN D stated she was monitoring Resident #1 for behaviors. LVN D stated she was not told Resident #1 had voiced suicidal ideation. LVN D stated the monitor log documented behavior at the top and was not specific. LVN D stated when she monitors residents for behaviors she just checks to ensure the resident is asleep. She stated that she filled out the monitoring log until 6:00 AM on the day of the incident because she was coming into her busy time and that she does not conduct 15 minute monitoring checks the last two hours of her shift. During the last two hours of the shift the CNAs make rounds and to be honest that ' s what is considered monitoring. During an interview on [DATE] at 1:00 PM, the Regional RN stated that the nurses are responsible for conducting the 15 minute checks and signing off that they were completed. The Regional RN stated this information should be communicated on the 24 hour report. Review of the 24 hour reports indicated no notation of the suicidal ideation. On [DATE] at 11:15 AM, the Administrator, DON, and Corporate Nurse were informed that an Immediate Jeopardy existed due to the failure to adequately supervise to prevent Resident #1 from attempting suicide. On [DATE] at 4:15 PM, the facility provided the surveyor with a written plan of removal, which reflected the following: Facility ' s Response to Resident Expressing Suicidal Ideation 1. Communications / Notifications: When a Resident presents suicidal ideation the following people will be immediately notified: the charge nurse or supervisor, facility Administrator, Director of Nurses (DON), Social Worker (SW), the Resident ' s Primary Physician, the Resident ' s responsible party, the nursing staff and the Social Service Consult group. The DON, SW or designee will conduct the PHQ-9 (Mood and Behavior Assessment) to determine if the Resident is expressing suicidal ideation and will notify the primary physician to obtain a referral for a psychiatric / psychological consult based on the assessment. The mental health officer and/or police will be contacted for consultation. The charge nurse will make and entry on the 24 hour report when a Resident verbalized suicidal ideation. The Resident Care Team (Certified Nurse Aides (CNAs), Charge Nurse, housekeeping, dietary and other staff) will be educated on the process for monitoring of Residents with suicidal ideation. 2. Interventions / Assessments A staff member will remain with the Resident until the nurse supervisor/charge nurse arrives to perform a physical assessment and interview the Resident. An Incident Report, including physical assessment, will be completed by the charge nurse and/or nurse management. Geriatric Depression Scale will be completed by the Social Worker and/or Assessment Nurse. The Resident and the facility will enter into " No Suicidal Contract. " Monitoring will be implemented by nursing staff (to include Nurses (Registered and Licensed), CNAs and Certified Medication Aides (CMAs)) every 15 minutes or one-to-one if situations indicates. Monitoring will be recorded by facility staff on designated monitoring sheets. An initial Care Plan will be developed by the Interdisciplinary Team and subsequent revisions. The Resident will be referred to a psychologist and / or psychiatrist for services. The SW or Social Services Consultant will follow up with the psychologist or psychiatrist within 24 hours to secure and appointment. If an appointment cannot be made within 24 hours the administrator or designee will contact the medical director for consultation. If a Resident exhibits the ability to execute a suicide plan, efforts will be made will be made to obtain an order to admit the Resident to an inpatient psychiatric setting. If the Resident or family denies consent for psychological/psychiatric treatment following suicidal ideations, the following will occur: The Resident/ or responsible party will be requested to complete a " Refusal of Treatment " acknowledgement. The facility will notify the mental health officer or police department for immediate intervention as well as the ombudsman office for consultation. Documentation of the suicidal ideation will be recorded in the Resident ' s record. Medication review will be conducted by the pharmacy for recommendations. 3. Prevention Measures A psychosocial Assessment to include identification of a history of suicidal activity and Mood Assessment will be completed within 14 days of admission of a new Resident and a suicide prevention plan will be implemented if assessment is positive for suicidal ideation. An initial care plan will be developed by the IDT and subsequent revisions will be made to the care plan as needed. The facility will restrict the Resident ' s access to items that might have the potential to be used to cause harm against self, including search of the Resident ' s room for such items. 4. Education / In-services The facility staff, including CNAs, charge nurses, housekeeping, facility managers and other staff as identified will be in-serviced on the following: a) Identification of the Resident having expressed suicidal ideations. b) What signs and symptoms to monitor. c) How to intervene. d) How to promote Resident safety. e) Reporting expectations. The DON, SW or designee will counsel and educate staff on potential negative outcomes of suicidal ideations, and educate the Resident and the responsible party on available services of the psychological well being of the Resident. 5. Monitoring The Administrator, DON, SW or designee will review the Facilities Response to Resident Expressing Suicidal Ideations on a daily basis to ensure compliance during their daily start up meeting. The surveyor confirmed the facility had started to implement the plan of removal and that inservices were conducted with all staff. The Plan of Removal was accepted at 4:20 PM on [DATE]. While the IJ was removed on [DATE] at 4:15 PM, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to put policies into place. Per administrator the facility census was 111.