Every finding on record at Ennis Care Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the inside of the microwave, cleaning the mixer beater shaft, cleaning metal storage rack where clean sheet and muffin pans where stored and were free from food debris and food particles) 2. The facility failed to ensure all items were covered and stored properly. 4.The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness and decreased quality of life.Findings included: Observation on 5/18/26 at 9:05 a.m., of clear plastic containers with lids revealed: - 1-plastic bin of corn flakes had two dates of 11/05/2019 and 3/23/26 unsure if dates indicated the receipt date, open date or discard date.- 1-plastic bin of cheerios with a date of 4/4/26 unsure if this date was the receipt date, open date or discard date.- 1-plastic bin of raisin bran with a date of 4/4/26 unsure if this date was the receipt date, open date or discard date.- 1-plastic bin of cocktail sauce packets with a date of 1/26/26 unsure if this date was the receipt date, open date or discard date.- 1-plastic container of mustard packets undated. Observation on 5/18/26 at 9:10 a.m., of multiple seasoning containers stored on a metal wire storage rack revealed: - 2.2-ounce container of ground ginger open with a date of 10/9 unsure if this date was the receipt date, open date or discard date.- 2-ounce container of ground cloves open and date not legible. - 2.12-ounce of grounded nutmeg open and date not legible. - 19-ounce container of garden seasoning open with date 7/1/25 unsure if this date was the receipt date, open date or discard date.- 16-ounce container of cayenne pepper open with date not legible.- 18-ounce container of citrus grill seasoning open and undated.- 20-ounce container of chicken seasoning open with date not legible.- 10-ounce container of poultry seasoning open and undated.- 16-ounce container of cumin ground open with a date of 1/4/25 unsure if this date was the receipt date, open date or discard date.- 19-ounce container of gardening seasoning open with a date of 8/26 unsure if this date was the receipt date, open date or discard date.- 22-ounce container of cajun seasoning open and undated. - 18-ounce container of ground black pepper open with date not legible.- 15-ounce container of ground mustard open and undated.- 16-ounce container of ground nutmeg open and undated.- 20-ounce container of onion powder open with date not legible.- 20-ounce container of chicken seasoning with a date of 4/18/25 unsure if this date was the receipt date, open date or discard date.- 6-ounce container of rubbed sage open with a date of 7/2/24 and 11/21 unsure if these dates were the receipt date, open date or discard date.- 5-pound container of cumin open with a date of 11/1/24 unsure if this date was the receipt date, open date or discard date.- 10-ounce container of bay leaf open with a date of 12/23/23 unsure if this date was the receipt date, open date or discard date.- 11-ounce container of parsley flakes open and undated. - 6-pound container of onion powder open with date of 2/20 unsure if this date was the receipt date, open date or discard date.- 28-ounce of Italian seasoning with a date of 3/3/25 unsure if this date was the receipt date, open date or discard date.- 5-pound container of baking powder open and undated- 6-pound container of garlic powder open and undated. Observation on 5/18/26 at 9:16 a.m., of industrial can-opener revealed its internal working parts, and the plastic mounting bracket, which secured it to the food prep table, were coated with a dark brown substance and food particles. Observation on 5/18/26 at 9:18 a.m., of the microwave revealed the interior of the microwave to have dried food debris on the interior top and in the corners Observation on 5/18/26 at 9:20 a.m., of food mixer revealed what appeared to be food build-up or debris on beater shaft. Observation on 5/18/26 at 9:24 a.m., of metal storage rack revealed multiple sheet pans and a muffin pan with what appeared to be a dried yellow substances, food debris, food particles on the pans, as well as along the rails and surfaces of the storage rack. Observation on 5/18/26 at 9:33 a.m., of kitchen dry storage pantry revealed: -gallon bag of vanilla wafers with an open date of 5/5/20; no use by/discard date was indicated. Observation on 5/18/26 at 9:35 a.m., of clear plastic containers with lids revealed: -22-quart plastic container of rice with a date of 5/8/26 unsure if this date was the receipt date, open date or discard date.- 22-quart plastic container of flour with a date of 1/26/26 unsure if this date was the receipt date, open date or discard date. Observation on 5/18/26 at 9:37 a.m., of refrigerator revealed: -1-gallon bag of turkey meat with a date of 5/15/26 unsure if this date was the receipt date, open date or discard date.-1-gallon of jalapeno peppers sliced with a date of 3/24 unsure if this date was the receipt date, open date or discard date.-5-pound pound of teriyaki glaze with a date of 4/29/26; unsure if this date was the receipt date, open date or discard date.-1-gallon of [NAME] hickory smoke barbecue sauce with a date of 5/11 unsure if this date was the receipt date, open date or discard date. Observation on 5/18/26 at 9:40 a.m., of freezer revealed ground meat stored in plastic wrap with a prepared date of 5/16/26; no use by/discard date was indicated. Interview on 5/20/26 at 10:50 a.m., the DM stated her expectation were that the food items would be labeled and dated upon receipt, when opened or prepared, and dated at that time with a discard date. DM stated it was everybody's responsibility for labeling and dating but that the ultimate responsibility was hers to ensure the labeling and dating was occurring. DM stated the kitchen equipment should be cleaned and sanitized after each use. DM stated it was everybody's responsibility for cleaning and sanitizing the equipment in the kitchen. DM stated cleaning duties are designated, and cleaning logs are maintained daily. DM stated it could have negatively affected the residents if food was not labeled and dated correctly and if the kitchen sanitation was not kept up and it could have affected them by causing food born illnesses. Interview on 5/20/26 at 12:20 p.m., the [NAME] A stated that all kitchen staff were responsible for labeling and dating food items upon receipt, when opened or prepared, and dated at that time with a discard date. [NAME] A stated she was trained upon hire and during in-services on labeling, dating, and sanitation. [NAME] A stated improper labeling and dating of the food items could have a negative impact on the resident health, as it may result in contaminated food and result in a resident getting sick. [NAME] A stated kitchen staff are responsible for cleaning and sanitizing the kitchen equipment after each use. Interview on 5/20/26 at 12:50 p.m., the ADM stated his expectation concerning food items were that the food items would be labeled and dated upon receipt, when opened or prepared, and dated at that time with a discard date. ADM stated all staff were responsible for labeling and dating but the DM was responsible for oversight and ensuring the labeling and dating practices are consistently followed. ADM stated all cleaning and sanitation procedures be completed routinely, equipment to be cleaned and sanitized after each use, and all cleaning logs be maintained and documented accordingly. ADM stated the DM assigned was responsible for assigning cleaning duties to dietary staff to ensure routine cleaning and sanitation task are completed. He stated it could have negatively affected the residents if food was not labeled and dated correctly and if the kitchen sanitation was not kept up and it could have affected them by causing food born illnesses and they could have gotten sick if food was not labeled correctly. Record review of date marking for food safety policy undated reflected The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food2.The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.3.The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.4.The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded.5.The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.)6.The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly.7.The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. Record review of sanitation inspection policy undated reflected It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements.3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Sanitation inspections will be conducted in the following manner:a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily.b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.5. Inspections will be conducted but not limited to the following areas:a. Dry storageb. Freezerc. Refrigeratord. Dish [NAME]. Pot washf. Main production areag. Food preparation areah. General dietary observations6. The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation and daily inspections. Managers may familiarize staff with these procedures through various means such as monthly meetings, posted memorandums, training sessions and orientation of new personnel.DM stated her expectation concerning labeling and dating of food items were that the food items would be labeled and dated upon receipt, when opened or prepared, and dated at that time with a discard date. DM stated if the food items were not labeled and dated appropriately then the facility could possibly be using expired food which could lead to food borne illness. DM stated it was everybody's responsibility for labeling and dating but that the ultimate responsibility was theirs to ensure the labeling and dating was occurring. DM H stated their expectation concerning general cleaning was that daily and weekly, deep cleaning was being completed per the cleaning schedules. DM H stated their expectation for dish washing of food production equipment was that the proper 3 step process was followed of wash, rinse, and then sanitize. DM H stated taking the temperature and the cleaning of the nourishment refrigerators responsibility was on the nursing staff.

Based on observations, interviews and record review the facility failed to ensure the resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system for three of fifteen resident rooms on the 600 hall reviewed for working call lights. The facility failed to ensure Rooms 602 A, 603 A, 603 B, and 604 B had call lights that were functioning properly. These failures posed a risk for residents' care needs not being met, potential for falls and injuries or pain.During an observation and interview on [DATE] between 11:10 am , and 11:13 am, Rooms 602 A, 603 A, 603 B and 604 B were observed to be missing call lights.*room [ROOM NUMBER] had no call light string coming out of the wall at bed 602 A,*room [ROOM NUMBER] had no call light strings for bed A or bed B , and*room [ROOM NUMBER] had no call light string coming out of the wall for bed 604 B.Housekeeper N stated she did not see any call lights strings for Rooms 602 A, 603 A, 603 B, and 604 B. She stated each bed should have its own call light in reach so residents could call for help if they needed it. She stated if residents could not call for help, they could get up and fall and hurt themselves. During an interview on [DATE] at 11:15 am, CNA I stated missing call lights had been a known issue for months on the memory care unit. CNA I stated she had access to the work order system to request repairs but had not put any workorders in. She stated she thought maintenance already knew about the call lights being missing. She stated all residents should have working call lights that are in reach. She stated missing call lights could cause problems for residents if they reach for something or if they have to go to the bathroom and cannot call for help, they could fall and get injured. During an interview on [DATE] at 11:50 am Maintenance Supervisor stated he was not aware of any current call light issues in Rooms 602 A, 603 A, 603 B, and 604 B. He stated a few months back they had an issue with a call light not working in room [ROOM NUMBER] and they had to go up in the attic to get it fixed. He stated there have not been any work orders put in recently for call lights on the 600 hall. During an interview on [DATE] at 12:02 pm, ADM stated he was not aware of the issues with call lights back on the 600 hall. He stated his expectation was that all residents would have a working call light in their room. He stated he spoke to the Maintenance Supervisor who stated there had not been any workorders generated for the rooms on the 600 hall currently missing call lights. During an interview on [DATE] at 12:34 pm, ADM stated he tested the call lights on the 600 hall and they all worked and the strings were being replaced on Rooms 602 A, 603 A, 603 B, and 604 B at this time. Review of maintenance workorders for the time period [DATE] to [DATE] reflected two work orders for the call light in room [ROOM NUMBER]. No other work orders were listed for the 600 hall call lights. Review of facility policy Call Lights: Accessibility and Timely Response dated [DATE] reflected: Policy:The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 5. Staff will ensure the call light is within reach of resident and secured as needed. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.)

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of seven residents (Resident # 5, Resident #47 and Resident #52) reviewed for activities.The facility failed to provide Resident #5, Resident #47 and Resident #52 in room activities three times per week, during the months of March 2026, April 2026 and May 2026.This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings include:1. Record review of Resident #5's face sheet, dated 05/19/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #5 had a diagnoses which included cognitive communication deficit (having difficulty with communication due to problems with thinking skills such as memory, attention, problem-solving, and organization), anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), and vascular dementia, mild, with other behavioral disturbance ( early-stage brain damage from poor blood flow that causes mild thinking problems with behaviors).Record review of Resident #5's Annual MDS Assessment, dated 01/10/2026, reflected Resident #5 had a BIMS score of 8, which indicated moderately impaired cognition. Resident #5's vision was highly impaired (object identification in question, but eyes appear to follow objects). Resident #5 was feeling down, depressed, or hopeless. The following activities were very important to Resident #5:Listening to music.Being around animals such as petsDo favorite activitiesDo things in groups of people.Go outside to get fresh air when the weather is good.Record review of Resident #5's Quarterly MDS Assessment, dated 04/13/2026, reflected Resident #5 had a BIMS score of 10, which indicated moderately impaired cognition. Resident #5's vision was severely impaired (no vision or saw only light, colors or shapes: eyes did not appear to follow objects).Record review of Resident #5's Comprehensive Care Plan, revised on 03/05/2026, reflected Resident #5 preferred to watch movies, television, listen to music and spend time on the patio and sometimes attend food related activities. (activity plan was initiated on 01/06/2025). Resident #5 had disturbed sensory perception related to impaired vision. Intervention: Do not rearrange personal belongings. Keep corridors well-lighted.Record review of Resident #5's Activity Assessment, dated 01/09/2026, reflected Resident #5 was interested in activities. She was had impaired vision. Resident #5 was interested in music. Resident #5's activity-related focuses including needs, strengths and preferences were appropriate for current care plan. She did not prefer to watch movies, going outside, attend group activities or watch television.Record review of Resident #5's Activity Progress Notes, in the electronic medical record, reflected in-room activities were not being provided for Resident #5 during the months of March 2026, April 2026, and May 2026. During an observation and interview on 05/18/2026 at 12:00 p.m., Resident #5 was in her room in bed. There was no stimulation in Resident #5's room. She stated, I cannot see to watch television, and I do not prefer to listen to the television. Resident #5 stated the activity person came to her room and put up a calendar of activities once a month and told her what was on the calendar. Resident #5 stated she did not see the activity person until it was time to receive a new calendar of activities. She denied being sad.Interview on 05/18/2026 at 12:45 p.m., the Activity Director stated Resident #5 was on the in-room activity program. She stated Resident #5 did not enjoy being out of her room. The Activity Director stated Resident #5 needed in room activities for mental stimulation and for emotional support. The Activity Director stated she had not been providing in-room activities with Resident #5. She stated she did not have an excuse of why she was not providing Resident #5 in room activities. The Activity Director stated Resident #5 was blind and could not watch television. She stated Resident #5 was not coming out of her room as much as she had been approximately 5 months ago due to her physical condition had a decline. The Activity Director stated it was her responsibility to provide activities to all residents and to know their activity preferences. She stated Resident #5 needed in room activities since March 2026. The Activity Director stated when staff entered Resident #5 room and provide ADL care this could be considered an in-room activity. She stated they did not do an actual activity with Resident #5, but they were in her room and giving care to her and she believed this would be considered an in-room activity. She stated she had been an Activity Director approximately 25 years. The Activity Director stated she documented activity participation of all residents in their progress notes in the electronic medical records.Observation and interview on 05/20/2026 at 1:45 p.m. revealed Resident #5 was lying in her bed. She stated I would listen to gospel music if I had a radio. Resident #5 stated she would love to have someone read the bible to her or listen to the bible on tapes. Resident #5 stated she did not recall if she told anyone at the facility she wanted to listen to the bible on tapes. She stated she never saw the Activity person until she would bring a new calendar at the beginning of the month. Resident #5 stated, I don't know who told you I wanted to attend activities in a group because I do not wish to do this type of activity. Resident #5 stated she did not want to attend any activities in a group of people even if they were serving food. She stated she did go outside sometimes but the Activity person quit taking her outside over the past few months. Resident #5 did not want to discuss her activities anymore.2. Record review of Resident # 47's face sheet, dated 05/20/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses which included anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), mild cognitive impairment of uncertain or unknown etiology ( noticeable decline in memory or thinking skills that is greater than expected for a person's age. The impairment is not severe enough to disrupt daily life), and legal blindness as defined in United States of America (severe vision loss- it does not mean total darkness or a complete lack of sight).Record review of Resident #47's admission MDS Assessment, dated 03/19/2026, reflected Resident #47 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #47:Listening to musicDo things in groups of peopleDo favorite activitiesGo outside to get fresh air when the weather was goodParticipate in religious services or practices Record review of Resident #47's Comprehensive Care Plan, revised on 03/20/2026 and initiated 03/13/2026, reflected Resident #47 did not have a care plan for activity preferences.Record review of Resident #47's Activity Assessment, dated 03/16/2026, reflected Resident #47 had depression. Her activity preferences were the following:Listening to musicDo things in groups of peopleDo favorite activitiesGo outside to get fresh air when the weather was goodParticipate in religious services or practicesRecord review of Resident #47's Activity Notes in the electronic medical record reflected Resident #47's activity participation was not documented.During an observation and interview on 05/18/2026 at 1:39 p.m., revealed Resident #47 was in her room sitting in her wheelchair watching television (she was watching a talk show). Resident #47 stated when she first came to the facility she did attend bingo one time, but she did not prefer group activities. She stated, I spoke with the person in activity department and asked if I could do activities in my room and for her to visit with me about 3 to 4 times a week. She stated, I thought we was in agreement for this to occur in my room, but she has not come in my room to do activities with me. She stated, I would enjoy maybe playing a game or talk about different things. Resident #47 stated she had not been offered any activity items since she was admitted in March 2026. She stated, sometimes I do become bored.Interview on 05/18/2026 at 12:45 p.m., the Activity Director stated Resident #47 spoke to her about coming in her room for activities. The Activity Director stated, when [Resident #47] was first admitted to the facility Resident #47 thought she wanted to attend group activities, however, she changed her mind and mostly wanted activities in her room. The Activity Director stated [Resident#47] wanted to play games with me during in room activity visits. She stated Resident #47 was not receiving in-room activities except when the CNAs went in the room and did ADL care. The Activity Director stated she realized now that ADL (changing briefs, giving showers, or transfers) care was not an in-room activity. The Activity Director stated, I have not provided in room activities with [Resident #47]. She stated it was a possibility if Resident #47 did not receive in-room activities she may become bored or lonely. She stated, I forgot Resident #47 requested in room activities from me. She stated she was not aware of any resident having new depression or not talking to others. 3. Record review of Resident # 52's face sheet, dated 05/20/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), personality disorder ( a lifelong, rigid pattern of thinking, feeling, and behaving that differs significantly from cultural expectations and causes major distress or functional impairment), and depression (a common but serious mood disorder that causes persistent feelings of sadness).Record review of Resident #52's admission MDS Assessment, dated 11/04/2025, reflected Resident #52 had a BIMS score of 14, which indicated her cognition was intact. Resident #42's activity preferences that were very important to her were the following:Listening to music.Be around animals such as pets.Keep up with the newsDo things with group of people.Do favorite activity.Go outside to get fresh air when the weather was good.Participating in religious services and practices.Record review of Resident #52's Quarterly MDS Assessment, dated 04/17/2026, reflected Resident#52 had a BIMS score of 15, which indicated her cognition was intact.Record review of Resident #52's Comprehensive Care Plan, dated 04/27/2026, reflected Resident #52 (date initiated on 11/11/2025) reflected Resident #52 had little interest in doing things related to change in environment and depression. Interventions: Provide a variety of activities to maintain Resident #52's interests.Record review of Resident #52's activity records in the electronic medical records reflected she did not have any in room activities during the months of March 2026, April 2026 or May 2026.During an observation and interview on 05/18/2026 at 12:15 p.m., revealed Resident #52 was sitting in her wheelchair in her room watching the news. She stated I decided several months ago I did not want to attend group activities, and I preferred the person in charge of activities to come to my room, and we do some type of activity together. She stated she discussed this with the activity person, and they were in agreement with this activity plan. She stated, the activity person did not come to her room and do any type of activity with her. Resident #52 stated sometimes she became anxious if she is around a lot of people. She denied being sad or depressed. Resident #52 asked if someone could ask the activity person to come to her room about 3 times a week and do an activity with her. Resident#52 did not reply to any other questions about activities including how she felt about not receiving activities. She stated she was tired and wanted to take a nap.Interview on 05/18/2026 at 12:45 p.m., the Activity Director stated Resident #52 was on the in-room activity program. She stated Resident #52 did request sometime in March 2026 to have in room activities three times a week. She stated she did not have an answer of why Resident #52 did not receive in-room activities. The Activity Director stated, she I do not have a reason why [Resident #52] did not receive her activity preference of having in-room activities. The Activity Director stated if a resident was not receiving activities there was a possibility a resident may become bored, lonely or depressed. She stated, It is my responsibility to ensure all residents receives activities. The Activity Director did not respond to any further questions about Resident #52 activity plan or her process to ensure residents received activities.Interview on 05/20/2026 at 11:00 a.m., the Administrator stated the Activity Director had been an Activity Director for over 25 years. He stated it was very important for the residents unable to come out of their room or unable to participate in group activities to receive activities in their room. He stated the Activity Director was over the activity department and he was her supervisor. He stated there was a possibility that a resident may become lonely if they were not receiving activities in their room. The Administrator stated he expected all activities to be documented on every resident on a daily basis to capture who was attending group activities and what the residents were doing during in-room activities. He stated he expected the participation records to be documented in the Activity Director notes in the electronic medical records.Record review of the Activity Director's personnel file reflected she began working at the facility on 01/19/2009. She had an activity director certificate with expiration date of 06/01/2026.Record review of the facility's, undated, Activities Policy, reflected Activities will be designed with the intent to :Enhance the resident's sense of well-being, belonging, and usefulness.Create opportunities for each resident to have a meaningful life.Promote or enhance cognition.Promote or enhance emotional health.Promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence.Reflect resident's interests and age.Reflect cultural and religious interests of the residents.Reflect choices of the residents.Activities refer to any endeavor , other than routine ADLs. ADL related activities, such as manicures/pedicures, hair styling, and makeovers, may be considered part of the activities program.Activities may be conducted in different ways:One-to-One programsPerson Appropriate- activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for.Program of Activities- to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 32 and Resident #43) reviewed for ADL care. The facility failed to ensure Resident #32 and Resident #43's nails were cleaned on 05/18/2026. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings include:1. Record review of Resident #32's face sheet, dated 05/19/2026, reflected a [AGE] year-old-male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #32 had diagnoses which included type 2 diabetes mellitus with diabetic chronic kidney disease and neuropathy, unspecified (body's long-term inability to properly process sugar has led to damage in two major areas: kidneys and nerves), limitation of activities due to disability (refers to the difficulty or inability an individual faces in executing everyday tasks or engaging in major life roles [like working or self-care] as a result of a physical, mental, or sensory impairment), transient cerebral ischemic attack, unspecified (pertaining to the brain and a lack of proper blood/oxygen supply. It is usually caused by a small blood clot. The exact underlying cause or specific location of the clot in the brain was not identified), and muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can). Record review of Resident #32's Annual MDS Assessment, dated 04/20/2026, reflected Resident #32 had a BIMS score of 10, which indicated his cognition was moderately impaired. Resident #32 required supervision or touching assistance with the following ADLS: Personal hygiene and upper body dressing. He required partial/ moderate assistance- helper does less than half the effort with the following: showers and lower body dressing.Record review of Resident #32's Comprehensive Care Plan, dated 05/04/2026, reflected Resident #32 had an ADL self-care performance deficit. Interventions: Bathing- check nail length and trim and clean on bath day and as necessary.Observation and interview on 05/18/2026 at 10:45 AM revealed Resident #32 was lying in bed. Resident #32's fingernails on his right hand underneath his forefinger, middle and ring fingernails had a blackish/ brownish substance. He stated he asked someone (did not recall staff name) to clean his nails. He stated the person said they would cut and clean his nails sometime next week. Resident #32 stated he asked someone on Sunday (05/17/2026). 2. Record review of Resident #43's face sheet, dated 05/19/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #43 had diagnoses which included type 2 diabetes mellitus without complications (a person has the condition characterized by high blood sugar but has not developed related health issues like nerve, eye, or kidney damage), muscle weakness (the affected muscle cannot move normally or contract with the required power, even when you try as hard as you can), and unspecified lack of coordination (a person is experiencing uncoordinated movements or balance issues, but the underlying cause or specific type of condition hasn't been definitively diagnosed yet), and moderate intellectual disabilities ( significant limitations in both intellectual functioning and adaptive daily life skills. A person would typically require ongoing support to navigate daily life).Record review of Resident #43's Quarterly MDS Assessment, dated 04/10/2026, reflected Resident #43 had a BIMS score of 3, which indicated his cognition was severely impaired. Resident #43 required partial/moderate assistance - helper did less than half the effort with personal hygiene. He was dependent on staff for lower body dressing and toileting hygiene. Resident #43 required substantial/ maximal assistance (helper does more than half the effort) with upper body dressing.Record review of Resident #43's Comprehensive Care Plan, dated 04/24/2026, reflected Resident #43 had impaired physical functioning related to limited mobility. He had bilateral hands / wrist/ feet limited range of motion. Intervention: Resident #43 required assistance from staff with personal hygiene, showers, and dressing.Observation and interview on 04/21/2026 at 10:19 AM revealed Resident # 43 was lying in bed. Resident #43's fingernails on his left and right hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #43 did not want to answer any questions.In an interview on 05/20/2026 at 9:15 AM, RN F stated the nurses were responsible for all residents with diagnosis of diabetes nail care such as trimming, cleaning, and filing. She stated the CNAs were responsible for all other residents' nail care. She stated nail care was usually completed on Sundays, as needed and during showers. RN F stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as an infection in the stomach. She stated there was a possibility a resident may have nausea and vomiting. RN F stated if a resident refused showers, nail care or any type of care the nurses documented in the nurse's progress notes. RN F stated she was in-serviced on ADL care, and all staff were to report any nail issues with the resident to the nurse. She stated, I am not aware of Resident #43 or Resident #32 refusing nail care.In an interview on 05/20/2026 at 9:15 AM, CNA K stated the nurses were responsible for diabetic nail care. She stated if a CNA observed any problems with a resident's nails the CNA was to report it to the nurse supervisor with any resident. CNA D stated the CNAs completed all nail care for residents without a diabetes diagnosis. 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 nausea and diarrhea. CNA K stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA K stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. She stated Resident #43 or Resident #32 did not refuse nail care whenever she assisted Resident #43 and Resident #32 with their ADL care which included cleaning and trimming nails. She stated she was in-service on nail care; however, she did not recall the date.In an interview on 05/20/2026 at 8:00 AM, the Director of Nurses stated the CNAs were responsible to clean and trim all residents' nails except for the residents with diabetes. She stated the nurses were responsible for nail care for diabetic residents. The DON stated the residents' nails were usually cleaned during shower days and on Sundays. She stated if a resident ingested blackish/brownish substance there was a potential the resident may experience vomiting or diarrhea. She stated it depended on the type of bacteria. The Director of Nurses stated she expected nail care to be completed as needed and on shower days. She stated anytime there was an issue with nails the staff was to report it to the nurse supervisor. The Director of nurses stated any refusal of care would be documented on the resident's care planRecord review of the facility's policy on Activities of Daily Living (ADLs), dated 05/16/2025, reflected 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.

Based on observation and interviews, the facility failed to ensure residents were treated with respect and dignity for one (Resident #47) of fifteen reviewed for respect and dignity. The facility failed to ensure Resident # 47's door was closed when she was being prepared for lift transfer exposing her lower body to the hallway. This failure could cause residents potential psychosocial harm and decreased self-worth.During an observation on 5/18/2026 at 9:20 am, CNA G and CNA H were in Resident #47's room with a mechanical lift preparing to transfer resident from her bed. Resident was lying uncovered in her bed, in a dress with her feet toward the doorway and hall. Resident #47's lower body from her upper legs to her feet were bare and visible from the hallway. During an interview on 5/18/2026 at 9:26 am Resident #47 stated she had concerns about her privacy with her body being uncovered and the door wide open. She stated anyone could walk by and see me. She stated she felt the staff did not care about her privacy and were not respecting her and this upset her. During an interview on 5/19/2026 at 11:13 am CNA G stated she was an agency CNA, and she had been trained on resident rights by the agency. She stated Resident #47 should have remained covered until they were able to get the lift completely in the room and close the door to ensure her privacy. She stated she had just recently started at the facility and did not think about the door being open and Resident #47's body being visible from the hall. She stated residents deserve privacy and dignity when care is being provided. During an interview on 5/19/2026 at 11:131 am CNA H stated she was an agency CNA, and she had been trained on resident rights by the agency. She stated she should have kept Resident #47 covered with the sheet until they had the lift in the room and they could close the door to protect her privacy. She stated they were getting ready to transfer he and then she had to use the rest room, and she walked away and did not think about Resident #47 being exposed. During an interview on 5/20/2026 at 8:55 am DON observed a picture of Resident #47 being left exposed by CNA staff and stated her expectations were: you have to cover them up - as long as you are behind closed doors it's okay to be uncovered. She further stated, You have to maintain their dignity. she stated her concerns in leaving a resident uncovered and visible from a hallway would be a dignity concern for the resident and a privacy issue. Review of facility policy Resident Rights dated 6/10/2025 reflected: Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records.a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of six residents (Resident # 4 and Resident # 47) reviewed for care plans. The facility failed to develop a comprehensive care plan to reflect Resident #4's diagnosis and triggers of PTSD (Post Traumatic Stress Disorder).The facility failed to develop a comprehensive care plan to reflect Resident #47's activity preferences of receiving in-room activities.These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial and medical needs. Findings include:1. Record review of Resident #4's face sheet, printed on 05/20/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included post-traumatic stress disorder (PTSD) with an onset date of 03/30/2026 and was categorized as During Stay, (PTSD is a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event such as abuse, accidents, or combat. People with PTSD experience severe anxiety- an emotion characterized by worried thoughts, flashbacks, and persistent feel long after the danger has passed), and bipolar disorder, current episode depressed, mild (mental health condition characterized by severe shifts in mood, energy, and activity levels. These shifts include emotional highs [mania] and emotional lows [depression]. During the episode of depression, the person is experiencing the low side of the bipolar disorder such as sadness, feeling hopelessness, lack of energy, changes in sleep [sleep too much or too little, etc.]).Record review of Resident #4's Quarterly MDS Assessment, dated 04/01/2026, reflected Resident #4 had a BIMS score of 15, which indicated her cognition was intact. She had an active diagnosis under section I Psychiatric/ Mood Disorder of PTSD.Record review of Resident #4's Care Plan, dated 03/03/2026, reflected there was not a focus area on the care plan for PTSD with related person-centered goals and interventions or possible triggers for the PTSD. 2. Record review of Resident # 47's face sheet, dated 05/20/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses which included anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), mild cognitive impairment of uncertain or unknown etiology ( noticeable decline in memory or thinking skills that is greater than expected for a person's age. The impairment is not severe enough to disrupt daily life), and legal blindness as defined in United States of America (severe vision loss- it does not mean total darkness or a complete lack of sight).Record review of Resident #47's admission MDS Assessment, dated 03/19/2026, reflected Resident #47 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #47:Listening to musicDo things in groups of peopleDo favorite activitiesGo outside to get fresh air when the weather was goodParticipate in religious services or practices Record review of Resident #47's Comprehensive Care Plan, revised on 03/20/2026 and initiated on 03/13/2026, reflected Resident #47 did not have an activity care plan.Record review of Resident #47's Activity Assessment, dated 03/16/2026, reflected Resident #47 had depression. Her activity preferences were the following:Listening to musicDo favorite activitiesGo outside to get fresh air when the weather was goodParticipate in religious services or practicesDuring an observation and interview on 05/18/2026 at 1:39 p.m., Resident #47 was in her room sitting in her wheelchair watching television (she was watching a talk show). Resident #47 stated when she first came to the facility she attended bingo one time, but she did not prefer group activities. She stated I spoke with the person in activity department and asked if I could do activities in my room and for her to visit with me about 3 to 4 times a week. She stated I thought we was in agreement for this to occur in my room, but she has not come in my room to do activities with me. I would enjoy maybe playing a game or talk about different things. Resident #47 stated she had not been offered any activity items or in-room visits since she was admitted in March 2026. She stated, sometimes I do become bored.Interview on 05/18/2026 at 12:45 p.m., the Activity Director stated Resident #47 was on the in-room activity program. She stated Resident #47 did not prefer to attend group activities. She stated anytime there was a change in the resident's activity preferences, she was expected to document on the care plan. The Activity Director stated, I did not know why an activity care plan was not documented on [Resident #47's] care plan. She stated in-room activities needed to be added to Resident #47's care plan. She stated if Resident #47 was having any type of behaviors or felt lonely the staff would not know what type of interventions to provide for Resident #47, if it was not documented on the care plan. She stated not having an activity care plan could affect the residents of not having their needs met by staff. She stated it was her responsibility to document residents activity preferences on the comprehensive care plan. The Activity Director stated Resident #47 did not have a current activity care plan. The Activity Director stated, I attend care plan meetings every week. She did not respond to any other questions about care plansIn an interview on 05/19/2026 at 2:14 p.m., the MDS Coordinator stated Resident #4 had a diagnosis of PTSD. She stated it was not documented on Resident #4's comprehensive care plan. The MDS Coordinator stated she missed documenting it on the care plan. She stated the purpose of having a Comprehensive Care Plan was to inform staff how to give the care each resident needed such as physical, behaviors, emotional, activities, type of diet and any other interventions to prevent falls or any injuries. She stated she was responsible to monitor the care plans to ensure they were correct and completed on time. The MDS Coordinator stated the information the CNAs followed on the Kardex came from the care plan. She stated if a resident needed a certain type of care or had behaviors and it was not care planned, the CNAs or nurses would not have that information to know what type of care to give the residents. The MDS Coordinator stated it was the Activity Director's responsibility to ensure the activity care plan of the residents activity preferences were documented on the care plan. She stated the IDT met once a week and discussed residents care plans due that week. She stated the Activity Director attended weekly care plan meetings.In an interview on 05/20/2026 at 8:00 a.m., the DON stated her expectation was the care plan to be reviewed during care plan meetings to ensure it was correct. She stated Resident #4's diagnosis of PTSD with interventions of Resident #4's triggers were expected to be care planned. She stated the care plan for each resident was a communication tool for all staff to know exactly what type of care and needs each resident needed. She stated anytime a mental health issue was documented on the MDS it was expected to be care planned. She stated all residents were expected to have their activity preferences documented on the comprehensive care plan. She stated if a resident was sad or had behaviors, the staff would refer to the care plan to know what their activity preferences were to re-direct the resident.In an interview on 05/20/2026 at 11:00 a.m., the Administrator stated his expectations of care plans was the IDT discussed care of each resident and if there was a change with anything which included resident preferences the care plan was expected to be revised. He stated the IDT was expected to ensure the resident's information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, activities, etc.Record review of the facility's Care Plan Policy, dated 05/05/2025, reflected the following: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 and services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two of seven residents (Resident #5 and Resident #52) reviewed for care plans.The facility failed to update the comprehensive care plan to reflect Resident #5 and Resident #52 received in room activity programs. This failure could place residents at risk for not having their needs identified and met. Findings include: 1. Record review of Resident #5's face sheet, dated 05/19/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #5 had diagnoses which included cognitive communication deficit (having difficulty with communication due to problems with thinking skills such as memory, attention, problem-solving, and organization), anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), and vascular dementia, mild, with other behavioral disturbance ( early-stage brain damage from poor blood flow that causes mild thinking problems with behaviors).Record review of Resident # 5's Annual MDS Assessment, dated 01/10/2026, reflected Resident #5 had a BIMS score of 8, which indicated moderately impaired cognition. Resident #5's vision was highly impaired (object identification in question, but eyes appear to follow objects). Resident #5 was feeling down, depressed, or hopeless. The following activities were very important to Resident #5:Listening to music.Being around animals such as petsDo things in group of peopleDo favorite activitiesGo outside to get fresh air when the weather is good.Record review of Resident #5's Comprehensive Care Plan, revised on 03/05/2026, reflected Resident #5's activity care plan was not revised to meet her current activity preferences of receiving in- room activities. Record review of Resident #5's Quarterly MDS Assessment, dated 04/13/2026, reflected Resident #5 had a BIMS score of 10, which indicated moderately impaired cognition. Resident #5's vision was severely impaired (no vision or saw only light, colors or shapes: eyes did not appear to follow objects).Record review of Resident #5's activity records in the electronic medical records reflected she did not have any in room activities during the months of March 2026, April 2026, or May 2026. During an observation and interview on 05/18/2026 at 12:00 p.m., revealed Resident #5 was in her room in bed. There was no stimulation in Resident #5's room. She stated I cannot see to watch television, and I do not prefer to listen to the television. Resident #5 stated the activity person came to her room and put up a calendar (monthly activity calendar) once a month and told her what was on the calendar. Resident #5 stated she did not see the activity person until it was time to receive a new calendar of activities. She denied being sad. She stated I prefer for someone to come to my room and read to me or talk to me about going to school, my favorite pet, my favorite memories, etc. Resident #5 stated she did discuss with the activity person wanting in room activities a few months ago around March 2026, and the activity person agreed to come to her room and do activities with her. Resident #5 stated I never received in-room activities from anyone.Observation and interview on 05/20/2026 at 1:45 p.m. revealed Resident #5 was lying in her bed. She stated I would listen to gospel music if I had a radio. Resident #5 stated she would love to have someone read the bible to her or listen to the bible on tapes. She stated she never saw the Activity person until she would bring a new calendar at the beginning of the month. The resident stated, I don't know who told you I wanted to attend activities in a group because I do not wish to do this type of activity. Resident #5 stated she did not want to attend any activities in a group of people even if they were serving food. She stated she went outside sometimes during the summer. Resident #5 stated she would have one of the nursing staff to assist her outside. 2. Record review of Resident # 52's face sheet, dated 05/20/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), personality disorder (a lifelong, rigid pattern of thinking, feeling, and behaving that differs significantly from cultural expectations and causes major distress or functional impairment), and depression ( a common but serious mood disorder that causes persistent feelings of sadness).Record review of Resident #52's admission MDS Assessment, dated 11/04/2025, reflected Resident #52 had a BIMS score of 14, which indicated her cognition was intact. Resident #42's activity preference that were very important to her were the following:Listening to music.Be around animals such as pets.Keep up with the newsDo things with group of people.Do favorite activity.Go outside to get fresh air when the weather was good.Participating in religious services and practices.Record review of Resident #52's Quarterly MDS Assessment, dated 04/17/2026, reflected Resident#52 had a BIMS score of 15, which indicated her cognition was intact. Resident #52 sometimes felt lonely.Record review of Resident #52's Comprehensive Care Plan, dated 04/27/2026, reflected Resident #52's activity care plan was not revised to meet her current activity preferences (receive in room activities).Record review of Resident #52's activity records in the electronic medical records reflected she did not have any in room activities during the months of March 2026, April 2026, or May 2026.During an observation and interview on 05/18/2026 at 12:15 p.m., Resident #52 was sitting in her wheelchair in her room watching the news. She stated I decided several months ago I did not want to attend group activities, and I preferred the person in charge of activities to come to my room, and we do some type of activity together. She stated she discussed this with the activity person and discussed my wishes of having activities in my room. She stated, the activity person had not been to my room and did any type of activity with me. Resident #52 stated sometimes she became anxious if she was around a lot of people. She denied being sad or depressed on 05/18/2026. Resident #52 stated do you think can someone ask the activity person to come to my room about three times a week and do an activity with me.Interview on 05/18/2026 at 12:45 p.m., the Activity Director stated Resident #5 and Resident #52 were on the in-room activity program. She stated all residents were expected to have their care plan revised to meet their activity preferences. The Activity Director stated she did not revise Resident #5 or Resident #52's care plan to meet their current activity preferences of receiving in-room activities. She stated she did not realize she did not revise their (Resident #5 and Resident #52's) care plan. She stated, if a resident was feeling lonely, had behavior issues or was depressed the staff would not have the information of the activities to use to help the resident.Interview on 05/19/2026 at 2:14 p.m., the MDS Coordinator stated if a resident had a change in their activity preference the activity care plan was expected to be revised. She stated the Activity Director was expected to discuss the changes with the interdisciplinary team. She stated it was very important to revise any changes with the resident to the care plan. She stated the staff would not know what type of care or activities to do with the resident if the care plan was not updated to meet their current needs and preferences. She stated in-room activities were not on Resident #5's or Resident #52's current care plan.Interview on 05/20/2026 at 8:00 a.m., the Director of Nurses stated anytime a resident's activity preference changed the care plan was expected to be revised. She stated if a resident preferred in-room activities the other staff needed to know this information to prevent the resident from becoming frustrated when staff may invite the resident to activity programs. The Director of Nurses stated the Activity Director was responsible for discussing the changes in the care plan with the interdisciplinary team and making the revisions on the care plan. Record review of the facility's Comprehensive Care Plan, dated 05/05/2026, reflected The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and when a resident experiences a status change.

Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two housekeeping carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization. Findings included:Observation on 05/18/2026 at 10:15 am revealed Housekeeping Cart #1 was located in front of Room#205 The compartment where chemicals were stored was not locked. The compartment had glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader. Housekeeper N was not standing near the housekeeping cart, and no other staff was near the unlocked housekeeping cart. Housekeeper N was mopping in Room#205, and her back was turned toward the door and unable to view housekeeping cart #1.During an interview on 05/18/2026 at 10:20 a.m., Housekeeper N stated the housekeeping cart was expected to be locked anytime housekeeper walked away from the cart. Housekeeper N stated she could not see Housekeeping Cart #1 from where she was standing in room [ROOM NUMBER]. She stated there was a possibility that if a resident drank some of the chemicals the resident may become sick with stomach issues or have an allergic reaction. She stated it was possible a resident may need to be evaluated at the hospital. She stated she did have a key to the housekeeping cart, but it was difficult to lock the cart.Interview on 05/18/2026 at 10:35 a.m., the Housekeeping Supervisor stated if a resident swallowed the chemical the nurse would not know what type of care to give the resident without knowing the name of the chemical. She stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals there was a potential for an allergic reaction, such as burning their throat, stomach and may need to be assessed at the hospital. She stated all housekeeping staff were in-serviced on locking housekeeping carts. She stated there was a possibility if a resident spilled chemical on their skin it may cause irritation to the skin. Interview on 05/20/2026 at 11:00 a.m., the Administrator stated he expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. The Administrator stated all housekeeping staff had been in-serviced on locking the housekeeping carts. The Administrator stated if a resident drank a chemical there was a possibility a resident may become ill with nausea and vomiting. He stated there was a possibility a resident may need to be transported to the emergency room for further evaluation. Record review of the Facility's Policy, not dated, on Housekeeping Cart Safety reflected All housekeeping carts must remain locked at all times when unattended. Under no circumstances should housekeeping carts be left opened or unlocked in resident care areas, hallways, or common areas. Cleaning chemicals and supplies must be secured to prevent resident access.

Based on interview, and records review, the facility failed to determine that drug records were in order and that an account of all controlled drugs is maintained and periodically reconciled for one of two medication rooms (medication room [ROOM NUMBER]) reviewed for pharmacy services. The facility failed to ensure that LPN B and LPN C completed a narcotic count for Medication room [ROOM NUMBER] refrigerator on 5/12/2026, which lead to the facility not accounting for all narcotic medications. This failure had the potential for drug diversions and medication unavailability for the therapeutic care for residents. During an interview on 5/19/2026 at 2:30 pm, LPN C stated she had worked day shift, 6 am to 6 pm on 5/12/2026 and had administered liquid narcotic medication to a resident in the afternoon around 3 or 4 pm and failed to return it to the narcotic lock box in the refrigerator in medication room [ROOM NUMBER]. LPN C stated she had an admission come on the unit, so she took the liquid narcotic and set it on the counter in Medication room [ROOM NUMBER]. She stated it was her responsibility to put the medication away and I did not secure the medication. She stated she intended to go back and put it away, but she got busy and forgot. She stated when LPN B had come on shift the evening of 5/12/2026 she had been very busy, they completed the narcotic count on the medication cart on the unit, but they failed to count the narcotic medication in the refrigerator in Medication room [ROOM NUMBER]. LPN C stated not securing the narcotic medication and not completing the narcotic count could cause medication to go missing, she could get blamed for missing narcotics, someone could get away with stealing, someone could take it that should not have it or the oncoming nurse could get blamed for stealing. She stated she had been trained in securing medications and doing narcotic counts at the beginning and end of her shifts. She stated if she had completed the narcotic count for Medication room [ROOM NUMBER] refrigerator she would have discovered she had not put the medication away properly. LPN C stated she later learned the medication was missing. During an interview on 5/19/2026 at 4:08 pm, LPN B stated he had come on shift at 6pm in the evening of 5/12/2026 and he and LPN C completed a narcotic count on the medication on the medication cart. He stated they had not gone into Medication room [ROOM NUMBER] to complete a narcotic count on the medication in the refrigerator. He stated he accepted the keys from LPN C and started his shift. He stated later in his shift, at about 3 am, he had gone into Medication room [ROOM NUMBER] and found the liquid narcotic medication sitting out on the counter and he returned it to the refrigerator. He stated he had received training on completing narcotic counts at shift change and he should have completed it with LPN C. LPN B stated by not completing the narcotic count issues could not be found and not raised, there are dishonest people and the medication could be taken. LPN B stated he later learned the medication was missing. During an interview on 5/20/2026 at 8:55 am, DON stated her expectation was that narcotic medications would not be left out and that narcotic counts would be completed at shift change. She stated medications that were left out could be diverted, could be tampered with or anyone that had access to the medication room could get the medication. She stated LPN B and LPN C should have completed their medication room [ROOM NUMBER] narcotic count and by not doing so there was a danger of diversion and not having the medication available for the patient, resulting in a missed dose. She stated they later found the missing medication behind the refrigerator in Medication room [ROOM NUMBER] and there was no effect on the resident and no missed doses. She stated the medication was replaced since it had been out of the refrigerator for some time. During an interview on 5/19/2026 at 2:52 pm, ADM stated the narcotic medication should have never been left out - it should have been stored properly. He stated the missing medication was transparent to the resident and there were no missed doses. He stated narcotic counts should always be done at shift change and if they are not completed the count could get confused, could end up passing the wrong dosage or there could be a possible diversion. Review of facility policy Controlled Substance Administration & Accountability dated 6/10/2025 reflected: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines: 9. Inventory Verification:a. An inventory count is prompted by the system each time a controlled drug or narcotic access key is accessed. This count does not require a witness.b. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on observation and interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for one of two medication rooms (medication room [ROOM NUMBER]) and one of six medication carts (medication cart #1) reviewed for storage of biologicals. The facility failed to ensure LPN C returned a liquid narcotic medication to the locked refrigerator box in Medication room [ROOM NUMBER] on 5/12/2026The facility failed to ensure Medication Cart # 1 was not left unlocked and unattended by LVN D on the 600 hall on 5/18/2026 These failures have the potential for missing medications, drug diversions and medication unavailability for the therapeutic care for residents.During an interview on 5/19/2026 at 2:30 pm, LPN C stated she had worked day shift, 6 am to 6 pm on 5/12/2026 and had administered liquid narcotic medication to a resident in the afternoon around 3 or 4 pm and failed to return it to the narcotic lock box in the refrigerator in medication room [ROOM NUMBER]. LPN C stated she had an admission come on the unit, so she took the liquid narcotic and set it on the counter in Medication room [ROOM NUMBER]. She stated it was her responsibility to put the medication away and I did not secure the medication. She stated she intended to go back and put it away, but she got busy and forgot. LPN C stated not securing the narcotic medication and not completing the narcotic count could cause medication to go missing, she could get blamed for missing narcotics, someone could get away with stealing, someone could take it that should not have it or the oncoming nurse could get blamed for stealing. She stated she had been trained in securing medications and doing narcotic counts at the beginning and end of her shifts. She stated if she had completed the narcotic count for Medication room [ROOM NUMBER] refrigerator she would have discovered she had not put the medication away properly. LPN C stated she later learned the medication was missing. During an interview on 5/19/2026 at 4:08 pm, LPN B stated he had come on shift at 6pm in the evening of 5/12/2026 and he and LPN C completed a narcotic count on the medication on the medication cart. He stated they had not gone into Medication room [ROOM NUMBER] and completed a narcotic count on the medication in the refrigerator. He stated he accepted the keys from LPN C and started his shift. He stated later in his shift, at about 3 am, he had gone into Medication room [ROOM NUMBER] and found the liquid narcotic medication sitting out on the counter and he returned it to the refrigerator. He stated he had received training on storing and securing medications and this is why he returned the liquid narcotic medication in the refrigerator. During an interview on 5/20/2026 at 8:55 am, DON stated her expectation was that narcotic medications would not be left out. She stated medications that were left out could be diverted, could be tampered with or anyone that had access to the medication room could get the medication. She stated LPN C should not have left the narcotic medication on the counter in medication room [ROOM NUMBER], it should have been properly stored and secured in the refrigerator. She stated by not doing so there was a danger of diversion and not having the medication available for the patient, resulting in a missed dose. She stated their was no impact to the resident as the medication was replaced. During an interview on 5/19/2026 at 2:52 pm, ADM stated the narcotic medication should have never been left out - it should have been stored properly. He stated the missing medication was transparent to the resident and there were no missed doses. He stated narcotic counts should always be done at shift change and if they are not completed the count could get confused, could end up passing the wrong dosage or there could be a possible diversion. During an Observation on 5/18/2026 at 9:15 am, Medication Cart #1 was unlocked and unattended on the memory care unit with three residents standing or sitting nearby. LPN D was observed to be in another resident's room and out of sight of the unlocked cart. One minute later, LPN D came out of the resident room and went to Medication Cart #1 and pushed the lock in securing the cart. During an interview on 5/19/2026 at 10:25 am, LPN D stated she usually locked her medication cart, and it is not ok to leave it unlocked and unattended. She stated she had received training on keeping medication carts locked and secured. She stated a resident could get into the cart and take something and use it. She stated she just went into the other resident's room real quick and didn't realize she had walked away and left it unlocked with other residents standing right by it. During an interview on 5/20/2026 at 8:55 am, DON stated her expectation is that medication carts would be locked and secured when they are unattended. She stated that if a cart is left open and unattended, anyone could get in the cart and take medications and potentially get sick or injured. During an interview on 5/19/2026 at 2:52 pm, ADM stated his expectation is that medication carts would be locked when the staff was not nearby to prevent anyone from getting in the cart and possibly taking medications. Review of facility policy Medication Storage dated 5/9/2025 reflected: Policy:It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines1. General Guidelines:a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.b. Only authorized personnel will have access to the keys to locked compartments.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.2. Narcotics and Controlled Substances:a. Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. b. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator.

Based on observation, 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 2 of 4 residents (Resident #4 and Resident #47) reviewed for trauma-informed care. The facility failed to ensure Resident #4 and Resident #47 had a trauma screening that identified possible triggers when Resident #4 and Resident #47 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 #4's face sheet, printed on 05/20/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included post-traumatic stress disorder (PTSD). The diagnosis for PTSD had an onset date of 03/30/2026 and was categorized as During Stay, (a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event such as abuse, accidents, or combat. People with PTSD experience severe anxiety, flashbacks, and persistent feel long after the danger has passed), and bipolar disorder, current episode depressed, mild (mental health condition characterized by severe shifts in mood, energy, and activity levels. These shifts include emotional [highs mania] and emotional lows [depression]. During the episode of depression, the person is experiencing the low side of the bipolar disorder such as sadness, feeling hopelessness, lack of energy, changes in sleep [sleep too much or too little, etc.]), and generalized anxiety disorder (a mental health condition defined by chronic, excessive, and uncontrollable worry about everyday issues).Record review of Resident #4's Quarterly MDS Assessment, dated 04/01/2026, reflected Resident #4 had a BIMS score of 15, which indicated her cognition was intact. She had an active diagnosis under section I Psychiatric/ Mood Disorder of PTSD, bipolar disorder, and anxiety. Record review of Resident #4's Care Plan, revised on 03/03/2026, reflected there was no focus area in the care plan for PTSD with related person-centered goals and interventions or possible triggers for the PTSD.Interview on 05/20/2026 at 1:00 PM, Resident #4 stated she had no concerns for nursing care in the facility. She stated the staff treated him well. Resident #4 stated no one in the facility has asked her about her PTSD and if there was anything that would trigger an episode of PTSD. She stated she preferred to speak with the social worker about her triggers.2. Record review of Resident # 47's face sheet, dated 05/20/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnosis which included post-traumatic stress disorder (PTSD). The diagnosis for PTSD has an onset date of 03/13/2026, (a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event such as abuse, accidents, or combat. People with PTSD experience severe anxiety, flashbacks, and persistent feel long after the danger has passed), anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), and schizoaffective disorder (a chronic mental health condition involves two main sets of symptoms such as: psychotic symptom- hallucinations [seeing hearing things that aren't there], mood symptoms: severe low in mood [sadness] or extreme high in mood- [very happy]).Record review of Resident #47's admission MDS Assessment, dated 03/19/2026, reflected Resident #47 had a BIMS score of 15, which indicated her cognition was intact. She had an active diagnosis under section I Psychiatric/ Mood Disorder of PTSD, schizophrenia disorder (a chronic mental health condition involves two main sets of symptoms such as: psychotic symptom- hallucinations [seeing hearing things that aren't there], mood symptoms: severe low in mood [sadness] or extreme high in mood- [very happy]), and anxiety.Record review of Resident #47's Comprehensive Care Plan, revised on 03/20/2026 and initiated 03/13/2026, reflected Resident #47 did not have a care plan related to interventions or possible triggers for the PTSD.Observation and interview on 05/18/2026 at 1:39 PM revealed Resident #47 was smiling during conversation. She denied being sad. Resident #47 stated she received good care from the staff. Resident #47 stated it would help if the facility staff knew her triggers and she would discuss it with the social worker or the person over nursing. Resident #47 stated I do not want to repeat my triggers during this interview.In an interview with the MDS Coordinator on 05/19/2026 at 2:14 PM, she stated Resident #4 should have PTSD as part of her care plan. She stated the interdisciplinary care team was responsible to ensure all problems with the residents were addressed on the care plan. The MDS Coordinator stated she was ultimately responsible to ensure the care plan was correct. She stated without updating the care plan with new resident needs or diagnoses, their care could be missed or overlooked. She reviewed Resident #4 and Resident #47's care plan. The MDS coordinator stated Resident #4's PTSD was not care planned and Resident #47 did not have triggers from PTSD on the interventions. She stated a resident with PTSD was expected to be on their care plan and have their triggers as an intervention. The MDS Coordinator stated if the triggers were not listed on the care plan it would be difficult for the staff to know how to prevent a resident from experiencing a PTSD episode such as flashbacks of the trauma situation and anxiety.Interview with the DON on 05/20/2025 at 8:00 AM, the DON stated the Interdisciplinary Team was responsible for everything related to care plans. She stated the MDS Coordinator was expected to review the care plan to verify the care plan was correct. She stated PTSD should be part of the resident's care plan with individualized goals and interventions. She stated if care plans were not updated with new diagnoses or resident needs, residents may receive incorrect care and interventions to prevent a resident from having an episode of PTSD.Interview with the Administrator on 05/20/2025 at 11:00 AM, he stated care plans should be updated with a diagnosis and triggers of PTSD. He stated not having the appropriate care plan updates and interventions could result in a resident not receiving the appropriate treatment and preventing a resident from having anxiety if PTSD triggers were not documented on the care plan.Record review of the facility's Policy on Provision of Quality of Care, dated 06/10/2025, reflected Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards or practice, the comprehensive person care plans, and the residents' choices. The following are the policy guidelines:Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being.A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan.Responsibility for interventions on the care plan will be clearly identifiedQualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices.To ensure persons are qualified, department heads, in collaboration with facility leadership and the Human Resource department, will be responsible for verifying credentials of all employees prior to hire, oversight to ensure ongoing employee competency, and education regarding areas of employee weaknesses.Policies and procedures will reflect current professional standards of practice.All employees are responsible for following established policies and procedures.Violations of policies and procedures will result in disciplinary action up to and including termination.The facility will employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of the residents' care plans.The facility will follow relevant procedures to ensure professional staff are licensed, certified, or registered in accordance with applicable state laws.

Based on interview and record review the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1(resident #1) of 5 residents reviewed for accidents and hazards.The facility failed to ensure a safe transfer with a mechanical/Hoyer lift to assist in the transfer of Resident #1 on 11/7/2025 when CNA A did not follow the protocol of having two staff to operate the Hoyer lift resulting in Resident #1 falling and sustaining a fractured right humerus (upper arm) and a closed head injury.This failure could result in serious injuries to residents and potentially death.The noncompliance was identified as PNC. The facility was provided with the IJ template on 11/18/2025. The facility had corrected the non compliance before the survey began.Findings include:Record review of Resident #1's progress notes, Facility investigation report revealed that on 11/7/2025. CNAA called for nursing assistance as Resident #1 had fallen from the Hoyer lift. Record showed that Resident #1 was found face first on the floor in a vertical position with toes touching the back legs of the lift frame. Resident was noted to have sever right arm pain to touch and a skin tear to her left arm. CNAA reported to the nurse that Resident #1 hit her face on the floor very hard. Records revealed that while LVNA assessed Resident #1 the ADONs contacted EMS, nursing administration, medical provider and the family of the residents. Records also revealed that CNA was asked to write a statement and then was escorted from the building and is no longer permitted to work within the facility.Record review of Resident #1s chart revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder, Dementia, Generalized anxiety, history of breast cancer, Cognitive communication deficit, and Major depressive disorder.Record review of the MDS dated [DATE] revealed Resident #1 had a BIMS of 03 indicating significant impairment.In an interview and observation on 11/18/2025 at 1:00 PM Resident #1 was sitting in her wheelchair at the nurse's station. The resident is pleasantly confused she was eating a sucker and talking with LVNA. Resident #1 was not able to say how her arm was broken but when asked about her arm she began stating she wanted her son. LVNA and Surveyor informed the Resident that they had both been told he was coming to see her later in the day. Resident #1's arm was in a sling for support. Resident #1 had a history of tremors in her hand and struggled to grip items. When Resident #1 dropped an item, she was not able to move to reach for it and relied on staff for assistance.Record review of the care plan for Resident #1 dated 10/2/2025 revealed the problem that Resident #1 has impaired physical functioning with interventions initiated on 1/27/2025 to utilize Hoyer lift and 2 staff for transfers. and utilizes the following for ambulation wheelchair for mobility.Record Review of the hospital ER records dated 11/7/2025 reflected Resident#1 was diagnosed with a closed head injury and a fracture to the right humerus.In an interview on 11/18/2025 at 10:00 AM with the Administrator, he stated that the agency the alleged perpetrator, CNA A worked for had been dragging their feet on giving them further information on her. He stated they were trying to obtain her competency and personnel file from the agency. He stated on 11/7/2025 CNA A decided to use the Hoyer lift by herself, and Resident #1 was fidgeting and fell face first out of the lift. He stated CNA A immediately called for the nurse to assess and they sent the resident to the hospital. He stated Resident #1 returned to the facility later that same day with a diagnosis of a broken humerus (upper arm). He stated CNA A reported other staff were busy and she should have waited but did not. He stated since the incident on 11/7/2025 the facility has in-serviced staff and had completed competency check offs for use of the Hoyer lift and all staff knew that two people were required at all times. He stated they had been attempting to obtain competency check offs for CNA A from her agency, but they had not responded. He denied requesting the info prior to employing agency staff prior to the incident on 11/7/2025. He stated the agency CNA, CNA A was asked to leave after completing her statement and had been placed on their do not return list. He stated they were no longer utilizing agency staff.In interview on 11/18/2025 at 10:53 AM with the Director of Clinical Operations, he stated following the incident on 11/7/2025 where Resident #1 fell from the Hoyer lift, Maintenance checked all equipment and made sure it was in working order. He stated they immediately in-serviced staff on abuse and neglect, safe resident handling and transfers. He stated they did competency checkoffs with therapy instruction. He stated the training was completed with all CNAs, CMAs, LVNs, and RNs. He stated going forward all agency staff, as well as employed staff, would be trained and have competency check offs where they must demonstrate proper use of the mechanical lift prior to working unsupervised.In an interview on 11/18/2025 at 12:58 PM with LVNA, she stated the policy on the use of a Hoyer lift is always 2 people to transfer a resident. She stated that she preferred to have 3 people performing lifts and transfers with the Hoyer. She stated all transfers must be a CNA, CMA, or nurse (LVN or RN). She stated that on 11/7/2025 a call came into the facility resulting in the nurses needing to check on each resident. She stated when she and other nurses were headed back towards the nurse's station CNAA stepped out and was waving calling for help and she went in the room and Resident #1 was face first on the ground the sling was still in the air attached with only 3 loops to the mechanical lift. She stated she did not move Resident #1 and secured her head until EMS arrived. She stated she could immediately see that Resident #1's right arm was broken. She stated that CNA A told her that she had moved the resident on her own as the other aide was called away. She stated that the straps and loops on the sling all appeared intact. She stated Resident #1 cannot make sudden large moves. She stated the resident does move her hands and arms on occasion. She stated in her opinion if Resident #1 had been placed on the sling appropriately she should not have fallen. She stated the front right strap was hanging down. She stated that since the incident the staff had been in-serviced on policies regarding abuse, neglect, transfers and mechanical lifts prior to returning to shift. She stated therapy trained them on Hoyer lifts and transfers and they had competency checks. She stated all staff reviewed training videos on Hoyer lifts and transfers. She stated that they have developed an additional competency check for agency staff since the incident.In an interview on 11/18/2025 at 1:27 PM with the ADON, she stated that the facility frequently in-serviced staff on abuse neglect, falls, transfers, and mechanical lifts. She stated that prior to the incident that occurred with Resident #1 they did not perform competency checks of agency staff due to the agencies claimed that they ensured agency staff were competent in skills. She stated she was not sure if the agencies provided them with proof of competencies prior to an agency staff coming to work within the facility. She stated that policy for use of the Hoyer lift required that the equipment is in working order and to always use 2 staff when lifting a resident. She stated it is her expectation that there are always at least two staff assisting to move a resident with a Hoyer lift. She stated that prior to the incident a non-related call came in that resulted in all nurses needing to check on the residents. She stated that as she was walking down the hall she saw LVN A had gone into Resident #1's room and Resident #1 was on the floor. The ADON stated CNA A, who is an agency staff, was standing next to the lift and stated she had used the lift alone. She stated once Resident #1 left with EMS she spoke further with CNA A. The ADON stated she had CNA A write a statement and asked her to leave the facility. The ADON stated that CNA A stated the resident was kicking and that the other aide had left. The ADON stated that CNA A's story was not consistent. She stated LVN A assessed Resident #1 and EMS was called to take the resident to the hospital. ADON stated that she contacted the DON and Administrator to report the incident, and she collected other statements. She stated that following the incident they did a mandatory in-service on abuse, neglect, transfers and mechanical lifts. They now have a check-off for competencies for the agency staff. She stated that the therapy department assisted in training all CNAs, CMAs, RNs, and LVNs on proper transfer and mechanical lift procedures. On the hallways there is a list of who requires a Hoyer lift and in PCC the CNAs and CMAs can see the required transfer methods ordered by physicians. She stated nurses can also see the care plan and the physician's orders on transfers.In an interview on 11/18/2025 at 2:37 PM with CNA A she stated that she was an agency aide and on 11/7/2025 she worked her 4th shift at the facility. She stated although she was aware that a mechanical lift requires two staff, she did not follow protocol. She stated she had performed the task with Resident #1 alone due to everyone being busy. She stated she should not have attempted the lift alone. She stated she had performed competencies with her agency on proper use of a mechanical lift. She stated that when she was transferring Resident #1, she was moving around, and Resident #1 fell and hit her head. CNA A stated she called for help, and the nurses came and assisted her. She stated she had not worked at the facility since the incident.Record review of facility policy, Safe Resident Handling and Transfers dated reviewed and revised 5/15/2025 revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.' Compliance guidelines include: Two staff members must be utilized when transferring residents with a mechanical lift. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. The staff must demonstrate competence in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. Resident lifting and transferring will be performed according to the resident's individual plan of care. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device.Record review of in-services completed on 11/7/2025 on safe resident handling, transfers, patients lift, abuse, neglect, and exploitation revealed all staff had been trained.Record review of a validation checklist for the mechanical lifts revealed all staff were checked for competence following the incident upon their next shift. Reviewed 47 employee Hoyer lift check off sheets dated between 11/10/2025 and 11/14/2025.Record review of logs provided revealed that Maintenance inspected the two Hoyer lifts on 11/11/2025 and ensured they were in proper working order.On 11/18/2025 at 9:38 AM Nurse Surveyor over saw the use of the mechanical lift involved a minimum of two employees and was performed in accordance with facility policy.Reviewed document the facility had developed, Competency check-off list for agency staff, to complete prior to working unsupervised. The document included: use of gait belts, mechanical lifts (require 2 persons), requesting assistance if unsure. The DON stated that this document would be used for all agency staff as they currently had chosen not to utilize agency following the incident.In an interview on 11/18/2025 at 2:26 PM with CNAB she stated she has worked several roles at the facility for over 12 years. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated she often comes in on the weekend to work extra shifts as a CNA. She stated an example of abuse or neglect would be a staff member talking badly to a resident or if a resident is sitting there and not being fed. She denied witnessing abuse or neglect in the facility. She stated if she did witness abuse or neglect, she would immediately report it to the Administrator who is the abuse coordinator. She stated when using a Hoyer lift there should always be 2 people assisting at all times. She stated if a 2nd person is not available staff should always wait for assistance and never lift a resident alone. She stated she was in the facility on 11/7/2025 but does not know the details of the incident involving resident #1. She stated all CNAs and CMA have access to transfer type orders in PCC which is their electronic medical record. She stated that since 11/7/2025 they have had multiple in-services on lifts and transfers and have been reminded that all lifts require two people. She stated they did a training with therapy on proper techniques to transfer and lift residents with the Hoyer lift.In an interview on 11/18/2025 at 3:04 PM with CNAC stated she has worked at the facility for 4 years. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated that an example of abuse or neglect would be leaving a resident wet. She denied witnessing abuse or neglect while working at the facility. She stated that if she witnessed abuse or neglect, she would immediately report it to the Administrator who is the abuse coordinator. She stated that a Hoyer lift always required 2 people. She denied any staff ever having to use a Hoyer lift alone to her knowledge she stated she always gets either a CNA, CMA or a nurse to assist or she will wait and ensure the resident is in a safe position. She stated that in PCC in the Kardex shows what type of transfer or lift is required. She stated they have a list on each hall in the linen closet that states what size sling is needed for each resident. She stated that she was working on 11/7/2025 on the memory care unit and she was not present for the incident that occurred for Resident #1 but she knows that she went to the hospital. She stated that she does occasionally get assigned to care for Resident #1. She stated she has never had an issue when transferring Resident #1 and stated she does not move around much when she is being transferred. She denied knowing CNA A. She stated that the Agency CNAs would now have a competency check-off sheet that must be completed prior to working unsupervised. She stated all staff had training with the therapy department and had to show that they were competent in the use of the Hoyer lift and transfers.In a telephone interview on 11/18/2025 at 3:18 PM CNAD she stated she has worked at the facility for over 5 years. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated an example of abuse or neglect would be a staff snatching something out of a resident's hand, not changing, feeding or bathing a resident. She denied witnessing abuse or neglect at the facility. She stated if she witnessed abuse or neglect she would secure the resident and immediately contact the Administrator. She stated if unable to reach the Administrator she will contact the DON. She stated her immediate concern is to protect her resident. She stated that when using a Hoyer lift there should always be two staff. She stated one person is controlling the lift while the other is stabilizing the resident. She stated that to her knowledge no coworkers use the Hoyer lift alone. She stated that she feels they always have sufficient staff to have a minimum of two people lifting. She stated that on 11/7/2025 she worked the 6:00am to 2:00pm. She stated that the CNAs give each other a report each shift on each resident and discuss transfers, lifts, incontinence and other things that occur with the residents they are assigned. She stated that they performed competency checks last week with the Hoyer lift after review from the therapy department and they reviewed policies on abuse, neglect, transfers and mechanical lifts.In an interview on 11/18/2025 at 3:40 PM with LVNB she stated she has worked at the facility for five years. She stated she is the MDS coordinator but has worked the floor at times. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated an example of abuse would be not providing a resident food or items they request for comfort. She denied witnessing abuse or neglect within the facility. She stated that if a resident falls or falls out of the Hoyer lift a nurse would assess them prior to moving them and typically call 911 to have them further assessed at a hospital. She stated that if she witnessed abuse or neglect, she would stop the abuse and report it to the Administrator immediately. She stated that when using a lift they must have two people at all times. She denied any knowledge of anyone using a Hoyer lift with only one person and stated there is no reason to only have one staff operating the lift. She stated the ADON and herself were here on 11/7/2025 and received a call that led to the nurses checking on each resident. She stated she was not the nurse who checked Resident #1s room and is unaware who did. She stated she and the other nurses walked back up the hall and noted that CNA A was requesting assistance and LVN A assessed the resident while she called 911 and the ADON questioned CNA A. She stated to her knowledge prior to 11/7/2025 agency staff did not have competency checkoffs within the facility that they relied on the agency to ensure their staff were competent. She stated that since 11/7/2025 they have had in-services on abuse, neglect, transfers and mechanical lifts. She stated that they had therapy department train and checkoff each staff member on transfers and mechanical lifts. She stated they watched a video on proper transfer and mechanical lifts and now they have a competency check-off sheet for all agency staff to complete prior to working alone. She stated the CNAs and CMAs can see how to transfer and or lift a resident in the electronic medical record under the Kardex. She stated that CNA A did have access to the electronic medical record as she set up access, she stated that they have a standard login for the agency staff.The noncompliance was identified as PNC. The facility was provided with the IJ template on 11/18/2025. The facility had corrected the non compliance before the survey began.

Based on record review and interviews the facility failed to ensure that two (2) residents (Resident #1 and Resident #2) of six residents reviewed for transfer or discharge had the required documentation in the resident's medical record made by the physician for a safe and effective transition of care. The facility discharged Resident #1 on 3/20/2025 and Resident #2 on 3/19/2025 without physician documentation in the EMR. This failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm due to feelings of anger and sadness. The findings included: Review of Resident #1's face sheet date 5/16/2025 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses that included seizures (abnormal electrical activity in the brain), dementia (progressive memory loss disorder) Epilepsy (seizure disorder), congestive heart failure, (chronic condition in which the heart does pump blood as well as it should), mood disorder and chronic obstructive pulmonary disease (group of breathing disorders). Review of Resident #1' s annual MDS assessment dated [DATE] reflected he had a BIMS of 15 suggesting he was cognitively intact. Review of Resident #1's closed care plan dated 3/27/2025 reflected he had a problem [Resident #1] sometimes have behaviors which include: cursing at staff/other resident refuses care at times, [Resident #1] hit another resident.' Review of Resident #1's progress notes dated 3/18/2025 at 12:15 pm revealed: Resident [#1] was attempting to walk past the nurses station but was unable to move past freely due to another resident [#2] sitting in front of the nurses station in a wheelchair. Resident became frustrated; the two male residents exchanged words. Then [Resident #1] struck the other male resident [Resident #2] in the shoulder/upper arm area. The other resident responded by swinging at [Resident #1]. Review of Resident #1's progress notes dated 5/19/2025 reflected a late MD note dated 5/19/2025 with an effective date of 3/20/2025 that stated, Late entry - Resident discharged secondary to life threatening aggressive behaviors affecting the safety of other residents. Review of Resident #1's discharge notice dated 3/20/2025 related medical reason for discharge due to aggressive behaviors. Notice was signed by MD on 3/20/2025. Review of Resident #2's face sheet dated 5/16/2025 reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses that included: cerebral infarction (occurs when blood flow to the brain is blocked), dementia (progressive memory loss disorder), hemiplegia (paralysis affecting one side), a cognitive social or emotional deficit following cerebral infarction, major depressive disorder, and anxiety disorder. Review of Resident #2' s quarterly MDS assessment dated [DATE] reflected he had a BIMS of 14 suggesting he was cognitively intact. Review of Resident #2's closed care plan dated 4/2/2025 reflected he had a problem [Resident #2] sometimes has behaviors which include inappropriate verbalizations and behaviors towards staff and other residents, making sexual remarks [to] staff/residents, taking other residents belongings without permission, refuses care including showers/grooming, urinates on floor and pours urine from urinal on floor invades personal space of other residents that are [cognitively] impaired, blocks hallways so others cannot pass, giving other residents food outside their diet, [Resident #2] hit another resident. Review of progress note dated 3/18/2025 at 11:00 am s for Resident #2 revealed: [Resident #2] was seated in his wheelchair at the nurses station. He was obstructing another resident's pathway around the nurses station. The two residents exchanged words not heard by this nurse. The other resident [Resident #1] was observed striking [Resident #2] in the right upper arm. [Resident #2] was noted striking back at the other resident [Resident #1] with his right arm. Review of Resident #2's progress notes dated 5/19/2025 reflected a late MD note dated 5/19/2025 with an effective date of 3/20/2025 that stated, Late entry - Resident discharged secondary to life threatening aggressive behaviors affecting the safety of other residents. Review of Resident #2's discharge notice dated 3/19/2025 related medical reason for discharge due to aggressive behaviors. Notice was signed by MD on 3/19/2025. During an interview on 5/19/2025 at 11:24 am, FM of Resident #1 stated Resident #1 was not happy with the transfer to another facility. They stated Resident #1 enjoyed being at the facility and was his own RP. FM stated she believes Resident #1 was treated unfairly and it broke his heart to be discharged . She stated he was so sad, had tears in his eyes and was visibly upset as he liked his roommate and had a relative in the building. She stated she had gone to see him at the other facility, and he is still very sad and angry. FM of Resident #1 stated he was at another facility but did not have a phone for the surveyor to contact him. She stated they were not aware of the appeal process for the discharge and wasn't sure if Resident #1 knew he could appeal. During an interview on 5/19/2025 at 1:07 pm, FM of Resident #2 stated the facility told her they were taking Resident #2 to the hospital after the incident with Resident #1. She stated the facility sent him to a local hospital and then discharged him - she stated she asked the facility to keep him until they could find another place, but he is still at the same hospital two months later, as the hospital has not been able to find placement and the facility refuses to take him back. She stated the hospital called yesterday and is stating they are going to discharge him to a homeless shelter. FM of Resident #2 stated he is very quiet and depressed and worried because the hospital is telling him they are sending him to a homeless shelter. She stated he has vision problems since his stroke and cannot do any of his own business - FM of Resident #2 stated they handle all his paperwork, bills - any business and is worried about him being in shelter. FM for Resident #2 stated they were not aware there was an appeal process and wasn't sure Resident #2 could even navigate the appeal process if he was aware. FM of Resident #2 stated resident was still at the local hospital and did not have a phone for the surveyor to contact him. During an interview on 5/16/2025 at 1:30 pm, DON stated Resident #1 and Resident #2 had a history of going back and forth verbally, but it escalated on 5/18/2025 so both residents were issued discharge notices. She stated Resident #1 was accepted and transferred to another nursing facility but Resident #2 was taken to a local hospital. She stated after the incident, residents were separated, assessed and put on 1:1 supervision. During an interview with the ADM on 5/16/2025 at 5:15 pm he stated he checked but did not see any documentation in the EMR from the MD regarding the facility-initiated discharges of Resident #1 and Resident #2. He stated they were both discharged due to the incident on 3/18/2025. He stated he was unaware the MD had to put in a progress note regarding the reason for the discharge since they both posed a threat of harm to other residents. During an interview on 5/19/2025 at 12:13 pm, the MD stated she was aware of the incident on 3/18/2025 and approved of the discharges for both Resident #1 and #2. She stated she did not put any progress notes concerning the reason for the discharges for either resident in the EMR I failed to write a note, I apologize. She further stated, I didn't know I had to do this - I am sorry, I apologize. The MD stated she will revisit this and put this in our education slide deck for our meeting on 5/22/2025. She stated she was notified of the discharges but failed to write a note in the EMR. Review of facility incident report dated 5/16/2025 reflected Resident #1 and Resident #2 were listed under Resident to Resident Incidents with the date 3/18/2025. Review of facility self-report revealed there was a resident-to-resident incident on 3/18/2025 involving Resident #1 and Resident #2 and immediate discharged notices were issued to both residents. Resident #1 was discharged to another nursing facility and Resident #2 was discharged to a local hospital. Review of facility policy dated October 2022 entitled Transfer or Discharge, Facility-Initiated reflected: Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. the health of individuals in the facility would otherwise be endangered; Facility-Initiated Transfer or Discharge 1. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. 2. Documentation of Facility-Initiated Transfer or Discharge 1. When a resident is transferred or discharged from the facility, the following information is documented in the medical record: a. The basis for the transfer or discharge; (1) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: a) the specific resident needs that cannot be met; b) this facility's attempt to meet those needs; and c) the receiving facility's service(s) that are available to meet those needs; 3. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record: a. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; or b. The health of individuals in the facility would otherwise be endangered.

Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior of three (Residents #32, #37, #48) of five residents reviewed for safe, clean, homelike environment. 1.The facility failed to ensure the ceiling A/C vent for Resident #32's room was clean and not dusty on 03/11/25. The facility failed to ensure the leaking pipe underneath Resident #32's sink was repaired on 03/11/25 instead of the resident using a trash can to catch the water. The facility failed to ensure that the dark gray container underneath Resident #32's sink was empty on 03/11/25 that was full of water from a leaking pipe. 2. The facility failed to ensure Resident #37's fluorescent lights had a cover, exposing metal fixtures and 2 light bulbs on 03/11/2025 that was located over his bed. 3. The facility failed to ensure the hole on the bathroom wall near the toilet in Resident # 48's bathroom was sealed on 03/11/25. These failures could affect residents and place them at risk for a diminished quality of life and a diminished clean, homelike environment. Findings included: 1. Record review of Resident #32's Face Sheet, dated 03/13/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included dementia, polyneuropathy, unspecified, a condition where multiple peripheral nerves (nerves outside the brain and spinal cord) are damaged, but the specific cause is unknown, spinal stenosis is a condition where the spinal canal, the bony tunnel that protects the spinal cord and nerve roots, becomes narrowed, malignant neoplasm of the prostate (a prostate cancer, a type of cancer that starts in the prostate gland, a small gland in the male reproductive system), joint pain, and abnormalities with gait and mobility. Record review of Resident #32's Quarterly MDS assessment, dated 02/07/25, revealed the resident had a BIMS score of 15 indicating his cognition was intact. Record review of Resident #32's Care Plan, dated 02/21/25, revealed the following: Focus: Resident #32 has an ADL Self Care Performance Deficit r/t Dementia, Pain . Resident #32 is at risk for falls related to: History of falls, muscle wasting/atrophy, lack of coordination, spinal stenosis, wedge compression fracture of vertebra. Date Initiated: 02/16/2024 Revision on: 02/16/2024 Goal: Resident #32 will have no fall related injuries through the review date. Date Initiated: 02/16/2024 Revision on: 02/29/2024 Target Date: 02/26/2025 Resident #32 will have a reduced number of falls through the review date. Date Initiated: 02/16/2024 Revision on: 02/29/2024 Target Date: 02/26/2025 Resident #32 is at risk for falls related to: History of falls, Muscle Wasting/Atrophy, Lack of Coordination, Spinal Stenosis, Wedge Compression Fracture of Vertebra . During an observation and interview on 03/11/25 at 10:40 AM with Resident #32 in his room revealed the resident was alert and standing up looking at television. The A/C vent in Resident#32's bed was dusty and uncleaned. Resident #32 stated that he did not remember the last time the A/C vent in his room was cleaned by staff. He stated that he was not aware that the A/C vent in his room was dusty and not cleaned. He stated that he has been at the facility for one year. During the observation of Resident #32's room, he stated that there was a water leak in the sink in his room. He opened the 2 cabinet doors underneath the sink and pointed to a dark gray plastic container that was filled to the top with water. He stated that the white pipe underneath his sink was leaking and causing water to drip, and he decided to place the dark gray plastic container underneath his sink to hold the water from the leaking pipe. Resident #32 stated when the dark gray plastic container was filled with water, he would bend down and retrieve the container and dump the water into the toilet in his bathroom. Resident #32 stated that he has told staff and maintenance about the leaking pipe underneath his sink, but no one has repaired the leaking pipe since he has been at the facility. 2. Record review of Resident #37's Face Sheet, dated 03/13/25 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident's diagnoses included Parkinson's disease (a chronic and progressive neurodegenerative disorder that affects movement and other functions), history of repeated falls, unsteadiness on feet, polyneuropathy unspecified (a condition where multiple peripheral nerves (nerves outside the brain and spinal cord) are damaged, but the specific cause is unknown), heart disease, heart failure, and paranoid schizophrenia (a mental health condition characterized by persistent delusions and hallucinations). Record review of Resident #37's Quarterly MDS assessment, dated 02/18/25, revealed the resident had a BIMS score of 15 indicating his cognition was intact. During an observation and interview on 03/11/25 at 11:10 AM with Resident #37 in his room revealed the resident was alert and laying on his bed. Resident #37 stated that he's been at the facility for several years. Resident #37 stated that he was unaware how long he had been in his current room. During the observation of Resident #37's room, there was no cover for the fluorescent lights above his bed. Resident #37 stated that he was he did not notice that the cover for the fluorescent lights above his head was not covering the light fixture. Resident #37 stated that no staff have mentioned to him that the light cover was missing. He stated that there have not been any repairs made to the light fixture above his bed. 3. Review of Resident #48's face sheet, dated 03/13/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #48's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and borderline personality disorder (a mental health condition characterized by intense and unstable emotions, impulsive behaviors, and difficulties in relationships), osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage, the protective tissue that cushions the ends of bones within a joint, leading to pain, stiffness, and reduced movement), and Type 2 diabetes mellitus with hyperglycemia (means a person with type 2 diabetes has persistently high blood sugar levels (hyperglycemia) due to insulin resistance and/or insufficient insulin production). Record review of Resident #48's Quarterly MDS assessment, dated 02/12/25, revealed the resident had a BIMS score of 13 indicating her cognition was intact. During an observation and interview and on 03/11/25 at 11:47 AM with Resident #48 in her room revealed that she was alert and sitting in her wheelchair and was looking at television. Resident #48 stated that she had been at the facility for 1 year. During the observation of Resident #48's bathroom, the bathroom was a shared bathroom with Resident #48, her roommate and 2 residents in the room beside Resident #48 shared the same bathroom . The bathroom observation revealed there was a large sized hole in the bathroom wall behind the toilet. During interviews with Resident #48 and the other residents that share the same bathroom revealed they were unaware that there was a whole in the bathroom wall behind the toilet. All parties revealed that maintenance or staff have mentioned to them the presence of a large sized hole on the wall behind the toilet. Record Review of the facility's Maintenance Request Log at the 100 Hall's Nurses Station, revealed there was no entries regarding repairs for the rooms or bathrooms of Resident #32, Resident #37 and Resident #48. In an interview with Maintenance Supervisor on 03/13/25 at 11:07 AM, he stated that he had been employed at the facility for 1 month. He stated that he remembers an unknown staff member informing him that the pipe underneath the sink in Resident #32's room was leaking. He stated that he gave the work order for the repair for the leaking pipe in Resident #32's room to his worker, Maintenance Staff B. He stated that he assumed that Maintenance Staff B completed the work order in Resident #32's room. He stated that he did not hear anything else regarding the leaking pipe underneath Resident #32's sink, and no one has complained about the anything, therefore he assumed that the work order was done, and the repair was completed and closed. He stated that he did not follow-up on work orders that were given to Maintenance Staff B. He stated that he was unaware that the A/C vent in Resident #37's room was dusty and uncleaned. The Maintenance Supervisor stated that he was unaware that there was a hole in the wall behind the toilet in Resident #48's bathroom. He stated that it is his responsibility for ensure that the repairs are done in the facility including the exterior and interior areas within the facility, such as the residents' rooms and bathrooms including the A/C vents, and light fixtures. He stated that the risk of there being a large size hole in the wall behind the toilet in Resident #48's bathroom are that critters, such as snakes and rodents can enter from the exterior of the building into any openings or holes such as the hole in Resident's 48's bathroom wall. He stated that that residents that use that bathroom can get their foot caught in the hole, which could harm them and cause some serious injuries because of the contained area in the bathroom. He said that risk walls. The Maintenance Director stated that the risk of the leaking pipe under Resident #32's sink can cause there being stagnant water in the dark gray container underneath the sink in the resident's room which can cause some harm if the resident has any allergy issues. He stated that he has drank water from a [AGE] year old water well and he has not become sick. He stated that the light cover not being over the fluorescent lights above Resident #37's bed can become hot and can explode or pop, which can lead to the resident being harmed by being cut by the shard glass from the broken florescent lights above his head. In an interview with Maintenance Staff B on 03/13/25 at 12:25 PM, who stated that he had been employed as the Maintenance Assistant at the facility for almost [AGE] years. He stated that staff are required to complete any Maintenance Requests in the Maintenance Log in the facility's software program, such as any issues such as dusty A/C vents, repairs such as walls, leaking pipes, and light fixtures. He stated that he has not seen any requests in the Maintenance Log regarding the A/C vents, wall repair or leaking pipes, and light fixture repairs on the 100 Hallway for Resident #32, Resident #37, and Resident #48. He stated that it is the responsibility of the Nursing Staff to notify the Maintenance Departments if there is something like dust on the A/C vents, repairs such as walls and leaking pipes, wall repairs and light fixture issues/concerns in a resident's room. He stated that staff are required to complete any Maintenance Requests in the Maintenance Log in the facility's software program, such as any issues such as dusty A/C vents, repairs such as walls, leaking pipes, and light fixtures. He stated that he was unaware that the A/C vent in Resident #32's room was dusty and unclean until it was brought to his attention. He reported that the Maintenance Supervisor will give him a sheet with the open Work Orders, and he will complete the Work Orders as they are completed. Maintenance Staff B stated that the Maintenance Supervisor has never given him a Work Order for repairs for Resident #32's room. He stated the risk of the ceiling vents being unclean is that if the dust blew onto residents they could be affected and have issues breathing. He stated that he was unaware that Resident #32 had a leaking pipe underneath his sink and there was a dark gray plastic container underneath the sink to hold the water from the leaking pipe. He stated that he did not know that Resident #32 was emptying the dark gray plastic container underneath the sink for approximately 1 year according to the resident. He stated that Resident #32 can be at risk for falling trying to bend down to pick up the heavy dark gray plastic container of water and he could hurt his back and spill the water in the container and slip and fall and harm himself and be seriously injured. Maintenance Staff B stated that he was unaware that the 2 fluorescent light bulbs above Resident #37's bed did not have a halogen cover. He stated that if the fluorescent lights were to get hot and bust, it can harm Resident #37 by him being cut by broken class, which can cause injuries to different areas of the body. Maintenance Staff B stated that he was unaware that there was a large sized hole in the wall behind the toilet in Resident #48's bathroom. He stated that if there is a large hole in the wall near the toilet, it can cause rodents, snakes and other animals to enter the facility through the hole in the wall, which is nasty. He stated that the large sized hole in the wall in Resident #48's bathroom could cause harm if a snake enters the hole and anyone in the facility can be bitten by the snake. In an interview with the Operations Manager on 03/13/25 at 1:31 PM revealed that he had been employed at the facility since November 2024. He stated that he was unaware that the A/C vent cover in Resident #32's room was not dusty and unclean. Log at the Nurses Station on the 100 Hallway would be used for something such as dusty A/C vents. He stated that the responsibility of the A/C vents being cleaned falls upon the Maintenance and Housekeeping departments, not his nursing staff. DON stated that the A/C vents in a resident's room were not a risk for infection and everyone's vents in their homes, including new build homes and the State Surveyors homes were probably not dusty and clean. He stated that there was a potential for harm due to the A/C vents being harmful, but dust was in everyone's vents any place you go. He stated that going forward, he would have his staff put in any work orders regarding the cleaning or the A/C vents. He stated, he will relay to his staff, if it doesn't seem right, fix it. He stated that his expectation was that staff notify himself, management or maintenance if they observe something like the A/C vent covers needing to be cleaned or any repairs, such as repairs to pipes and walls that need to be done. He stated that the Maintenance Department uses a software system to report repairs. The Operations Manager stated that he visits with Resident #32 in his room at least once a week and he has never mentioned to him anything about having a leaking pipe underneath his sink and there being a dark gray plastic container underneath the sink that contains water that was being dumped by Resident #32 on a regular basis. He was advised that on 03/12/25 during the Resident Council Meeting, Resident #32 mentioned the issue with the leaking pipe to another State Surveyor. He stated that if Resident #32 were to spill water from the dark gray plastic container, he could slip and have falls. He stated that he did not feel that there could be any harm to a resident if there is water on the floor. He stated that he was unaware of the dusty and uncleaned A/C vent in Resident #32's room. He stated that the Maintenance Department is responsible for ensuring that the A/C vents in the residents' room are cleaned a regular basis. He stated that he felt that the dusty and unclean are vent can cause respiratory and breathing issues to anyone who is exposed to the allergens from the A/C vents. He stated that he was unaware that the halogen cover was not on the light fixture above Resident #37's bed in his room. He stated that if a light bulb gets too hot, it will burst and can hurt anyone who has access to the broken glass shards. In an interview with CNA A on 03/13/25 at 2:39 PM revealed that she stated that he had been employed at the facility for 3 years. She stated that her primary assignment was the 100 Hallway. She reported that she has not noticed that the A/C vent cover in Resident #32's room were dusty and not clean. She stated that if she was to observe the A/C vents in a resident's room not clean, she would notify Maintenance and her Charge Nurse so that the need for repair could be documented. She stated that if the A/C vents in resident's room are not cleaned on a regular basis, residents can be at risk for respiratory issues from the dust being on the A/C vent. She stated that dusty and unclean A/C vents can cause harm to anyone who has access to them breath properly. She stated that she was unaware that Resident #32 had a leaking pipe underneath his sink and there was a dark gray plastic container full of water underneath the sink. She stated that she was unaware that Resident #32 stated that he had emptied the dark gray plastic container of water out on a regular basis. She stated that Resident #32 should use his Call Light to request assistance from staff with emptying the dark gray plastic container of water. CNA A stated that Resident #32 has unsteadiness of his feet and the risk of him bending down to remove the full dark gray plastic container of water in the sink could cause harm, which can include Resident #32 slipping, and falling on any water spilled on the floor. She stated that if Resident #32 drank the stagnant water in the dark gray plastic container he can risk drinking contaminated water, which is not safe. She stated that the water in the dark gray plastic container may be brown, which is not good and can cause some health issues or concerns for the resident. CNA A stated that she was unaware that the fluorescent lights above Resident #37's bed did not have a cover over the light. She stated that without there being a halogen light cover over the fluorescent lights above Resident #37's bed, there is a risk that the fluorescent lights can get too hot and explode. She stated that without the prescience of a halogen light cover over the fluorescent lights above Resident #37's bed, he can be harms by broken glass, step on the broken glass, touch the broken glass and receive cuts. CNA A stated that she was unaware of the large sized hole in the bathroom wall behind Resident #48's toilet. She stated that the risk of there being a large sized hole in any wall could lead to any rodents or insects entering the building through the hole in the wall. She stated that harm can be cause by there being a large sized home can include rodents biting anyone in the building, which can lead to infections and illnesses. Record review of the facility's Maintenance Service policy dated 2001, revised December 2009 revealed, Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards . d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. e. Maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order. f. Establishing priorities in providing repair service . h. Maintaining the grounds, sidewalks, parking lots, etc., in good order. i. Providing routinely scheduled maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . 5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . 7. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments. 8. The Maintenance Director is responsible for maintaining the following records/ reports. k. Inspection of building; l. Work order requests; m. Maintenance schedules; . o. Warranties and guarantees. 9. Records shall be maintained in the Maintenance Director's office. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines on [DATE]. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on [DATE]. 3. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed on [DATE]. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on [DATE] at 9:15 AM, revealed the following: Dry storage area *One bag of Oreo Cookie Pieces with an expiration date, [DATE] * One bag of opened Pistachio Instant Pudding Mix * Ziploc bag dated ,d+[DATE] with an open bag of Quaker grits with no use by date * A plastic bin of what appears to be sugar not labeled * One 28oz bag of Creamy Wheat not sealed * 2 opened packs of brown gravy mix in plastic Ziploc bag not sealed * Plastic container of what appears to be Fruit Loops cereal not labeled or sealed * Plastic bin with crackers not labeled * 5 packs of instant oatmeal in a black bowl sitting on a shelf Refrigerator area *One box labeled Homestyle Fried Eggs with Cracked Black Pepper dated [DATE] contained an unsealed plastic bag of what appears to be eggs had an odor and no use by date *Jimmy Dean Turkey Sausage Patties in a plastic bag opened and not sealed Freezer area *Plastic container with frozen ground beef and other frozen meats has dried blood on the container * French Fries dated ,d+[DATE] with no expiration date *Once clear Ziploc bag with French fries dated ,d+[DATE] and ,d+[DATE] with no use by date In an interview with the Dietary Manager J on [DATE] at 9:45 AM, manager stated all staff are scheduled to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas are not expired and unsealed. DM stated she would check everything in the kitchen to ensure there were not any unopened and expired items in the dry pantry, refrigerator and freezer areas. DM stated she would throw away all expired items and unsealed items in the kitchen. She stated her expectation was for staff to throw away any items that are expired or opened in the kitchen's dry pantry, refrigerator and freezer areas and notify herself of what they found. She stated staff have received several in-services relating to food preparation, storage, and labeling and to immediately remove any expired items. She stated staff have been trained and educated when they are restocking to place the items already on the shelf in the front and the new items behind the items that were already shelved. She stated she would throw away the expired items in the kitchen and retrain and reeducate the staff via in-service trainings. In an interview with [NAME] S on [DATE] at 10:20 AM, she stated that she had been employed at the facility for 3 years. She stated that she was unaware that there were expired and unsealed items in the dry storage, refrigerator, and freezer areas. She stated that all the staff were responsible for storing the items on the shelf and checking the expiration dates on everything in the kitchen. She stated that she had taken in-service trainings on food preparation and storage and her last in-service training was about a year ago. She stated that if a staff member sees an item(s) that are expired, the staff member was to throw the item away in the trash can and then inform the Dietary Manager or Dietary Aide what they threw away. She stated that everything in the dry storage, freezer and refrigerator should be labeled and dated. [NAME] S stated that if someone ingested food that had been cross-contaminated, there was a risk that someone could die. She stated that with food in the dry pantry, refrigerator and freezer areas being unsealed and expired items can cause anyone who ingests the food to have an airborne illness and become sick which can cause them harm. In an interview with the Dietary Aide S on [DATE] at 10:28 PM, she stated that she had been employed at the facility for 1 year. She stated that she was unaware that there were expired and unsealed items in the dry storage and freezer areas. She stated that all the staff were responsible for storing the items on the shelf and checking the expiration dates on everything in the kitchen. She stated that her expectations for all staff in the kitchen is to use the First In, First Out Method, which means that kitchen staff should label the food with the dates they store them, and when staff are restocking the shelves, they are to put the older foods in front or on top so they can be used first. She stated that this system allowed the kitchen staff to find the food quickly and use it more efficiently. She stated the Dietary Manager In-Services staff on food storage, labeling and dating and removing expired items from the shelves in the dry pantry, freezer, and refrigerator areas. She stated that there are risks of airborne illness anytime someone that ingest food items from the kitchen any items that have not been label and stored properly. Record review of the facility's policy titled Food Receiving and Storage dated, [DATE] reflected, Foods shall be received and stored in a manner that complies with safe food handling practices. Procedure: Dry Food Storage: 1. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 2. Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date). Such foods are rotated using a first in -first out'' system. Refrigerated/Freezer Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by'' date, frozen, or discarded. 9. Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based on observations, interviews and record reviews, the facility failed to ensure that residents were free from abuse for one (Resident #29) of three residents reviewed for abuse and neglect. The facility failed to protect Resident #29 from abuse on 01/05/2025 when CNA E was witnessed calling Resident #29 an asshole. The noncompliance was identified as Past non-compliance. The noncompliance began on 1/5/25 and ended on 1/7/25. The failure placed residents at risk for abuse, neglect, and emotional and psychological harm. Findings included: Review of Resident #29's Face Sheet, dated 03/12/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and a subsequent admitted following a hospital stay on 09/30/2024, with diagnoses including: anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (is a mental health condition that can develop after exposure to a traumatic event. It is characterized by symptoms such as: distressing memories or flashbacks of the trauma, feelings of hopelessness or negative thoughts about oneself or others). Review of Resident #29 ' s MDS reflects a BIM ' s (Brief Interview of Mental Status) score of 10. A score of 10 indicates moderate cognitive impairment. Review of Resident #29 ' s Comprehensive Care Plan dated 07/05/2024 reflected he had an ADL (Activities of Daily Living) self-care performance deficit due to dementia and limited mobility. The plan also reflected Resident #29 was at risk of falls, and elopement. The plan does not indicate any areas of concerns for behavioral issues or concerns. Review of Resident #29 ' s nurses notes reflect RN F entered a note on 01/05/2025 that stated resident had an altercation with staff; resident verbally abused staff and attempted to assault staff member. Resident was redirected and is now calm. Administration notified. Review of Resident #29 ' s nurses note reflect a note entered on 01/06/2025 that stated [NAME] alerted that CNA E asked resident to stop being an a##hole due to resident attempting to hit CNA E as well as cursing and yelling at CNA E. Director of Operations made aware of event. DON to contact physician and make medical doctor aware as well as psychiatry. DON to ask that resident been seen my provider at next visit. Psychiatrist states that she saw resident yesterday and thought resident was doing better. DON to inform of resident behaviors. Psychiatrist states she will see resident at next visit. DON to ask that charge nurse alert Reporting Party of concern. Facility social worker also made aware of everything. Resident was asked about the event and resident did not recall this happened. At current time no concerns noted with resident nor voiced by resident. Review of Resident #29 ' s nurses note reflect a note entered on 1/6/2025 that stated Reporting Party notified of incident involving a CNA E over the weekend of 1/4 - 1/5. RP was informed of the disciplinary action taken to ensure this type of incident would not happen again. Reporting Party was in agreement of action taken and had no further complaints at this time. Review of Resident #29 ' s nurses note reflected a note entered on 1/6/2025 that stated Director of operations to call and speak with charge nurse as well as CNA E in 2 separate calls regarding occurrence with resident over the weekend. CNA E as well as charge nurse both state that resident was being very aggressive with male CNA D and was accusing male CNA D of abusing other residents. Both CNA E as well as charge nurse state that this never occurred and that no one was abused, and that resident was having a moment of paranoia/confusion/and possibly sundowning. Per charge nurse resident was hitting CNA E with clip board cursing CNA E out and had stood up and was very aggressive with CNA E to where charge nurse had to intervene. Charge nurse states that CNA E did slip up and tell resident to please stop being an as*hole but states that CNA E was also being hit. Per charge nurse resident was eventually redirected from nurse station with no further occurrence. Charge nurse states that when CNA E checked on resident shortly thereafter that resident didn ' t even seem to know anything had even occurred. Observation of Resident #29 on 03/11/25 at 1:35PM revealed he was clean, well-groomed, and appropriately dressed. He was free from any odors. There were no visible marks or bruises noted on his person. Resident #29 was alert and oriented; he was resting in his bed. During an interview with Resident #29 on 03/11/25 at 1:35PM, he stated facility staff treated him well and he felt safe at the facility. He had no concerns regarding the facility, or the care received; he reported he just returned from his mother ' s funeral today and was feeling sad. Resident #29 could not recall the specific incident between him and CNA E but said that CNA E talks to people rudely. During an interview with CNA E on 3/11/25 at 11:45AM he revealed he was gathering people to have coffee and snacks before dinner. He stated there was one resident that was combative during care, and she was amped up already. He stated hours at a time she will sit there crying. He stated he brought her to dining and Resident #29 went over to try to console her. CNA E stated Resident #29 then rolled down the hall to the nurse ' s station accusing CNA E of hurting the female resident. He stated Resident #29 stood up and started coming toward him while he was in med room (behind nurse station). CNA E stated he closed the door and Resident #29 was trying to get in the room and then Resident #29 put his weight on the door so CNA E could not get out and this lasted a few seconds. CNA E said he asked RN F for help and to make sure other residents are not around for their safety. CNA E said this happened for about an hour that Resident #29 was following him around and saying he would call the cops. CNA E stated Resident #29 was cussing at him, and CNA E said he told Resident #29 to stop acting like an asshole. CNA E said it was very heated in the moment he said that to Resident #29. CNA E said he realized he should not have said that and could have used another word or term. CNA E said Resident #29 came back and apologized about the incident. During an interview with RN F on 3/12/25 at 5:46 PM she revealed she was at the nurse desk during the incident. She stated CNA E was prepping snacks for residents and Resident #29 rolled up to the desk and was upset. She stated Resident #29 thought CNA E was abusing the residents. RN F stated Resident #29 stood up and he and CNA E were yelling at each other, and CNA E told Resident #29 to stop being an asshole. She stated they were arguing back and forth. She stated Resident #29 lunged forward pushing the door shut locking CNA E in the med room. RN F stated CNA E and Resident #29 continued going back and forth and she tried to deescalate the situation. RN F stated Resident #29 tried to hit CNA E with a clipboard. RN F stated Resident #29 tried hitting CNA E again and CNA E grabbed Resident #29 ' s hand and pushed it away. She stated Resident #29 left the nurse station and later came back and tried to call 911 to report CNA E and they took the phone away from him. RN F stated prior to this incident she had not seen signs of aggression in Resident #29 before, possibly just depression. RN F stated she immediately reported the incident to the ADON. During an interview with the social worker 01/13/25 at 10:30 AM, she revealed she completed Safe Surveys after the incident. She reported she spoke to Resident #29 who told her Oh that is the way he (CNA E) talks. She stated Resident #29 said he did not like the tone that CNA E used toward him. She said she did not know what CNA E said to the resident exactly. She said after the incident she ensured the resident was on psych services. During an interview with LVN G on 3/12/25 at 11:00 AM, she reported she had worked at the facility for 7 days and had worked with CNA E twice. She reported she had heard CNA E cussing in general conversation and to where residents were able to hear him swearing. During an interview with the Operations Manager on 1/13/25 at 2:00 PM, he stated he was informed by RN F about the incident involving Resident #29. He stated the results of his investigation were confirmed. He stated there were consistent stories given by individuals interviewed. He stated CNA E was suspended and required to take assigned trainings regarding abuse/neglect prevention, etc. prior to returning to work. The Operations Manager stated he had a one-on-one staffing with CNA E who was given a written warning. The Operations Manager reported there have been no complaints since about CNA E prior to the incident that he is aware of. The Operations Manager stated he sees CNA E often in the hallways and people have said good things about him. He stated Safe Surveys were completed throughout the entire facility. He stated Resident #29 was back to himself after the incident. The Operations Manager did not have any concerns for CNA E to continue to provide care to Resident #29 or other Residents in the facility. Review of Facility Provider Investigation Report dated 01/06/2025 reflected the following: Incident date occurred on 01/05/2025 at 3:45 p.m. At approximately 3:30 p.m. RN [NAME] witnessed CNA [NAME] using inappropriate language towards resident [NAME]. Resident [NAME] is routinely seen by psych services. Facility immediately launched investigation into the matter. Residents MD, RP, and VA notified. Alleged Perpetrator suspended pending investigation. Safe Surveys initiated. Staff in service on abuse and neglect initiated. Should be noted that the alleged victim has a diagnosis of cognitive communication deficit, altered mental status, unspecified, depressive disorder, recurrent, mild, dementia in other diseases classified elsewhere, mild, with other 07/02/2024 other diagnosis behavioral disturbance, bipolar disorder, unspecified, major depressive disorder, single episode, unspecified mild cognitive impairment of uncertain or unknown etiology. It should also be noted that alleged victim resides on the facility ' s memory care unit. In an interview with Operations Manager [NAME] and Director of Nursing [NAME] on 1/7/25, witness [NAME] (RN) was able to provide the same details of the event that the alleged perpetrator [NAME] (CNA) provided. Resident safe surveys brought forth no further concerns. (surveys attached). It is my reasonable conclusion that the allegation was confirmed. The alleged perpetrator has been consistent with his story on what happened, and the witness as well. As a result, the alleged perpetrator was suspended and assigned several healthcare academy modules (E-learning) (Certs are attached). Staff in-service completed on abuse and neglect. Alleged perpetrator was educated on appropriate topics and issued final written warning from supervisor before returning to work. Review of the following E-learning courses completed by CNA E: Completion date of 01/07/25 titled Abuse Prevention in Persons with Dementia. Completion date of 01/07/25 titled Abuse, Neglect, and Exploitation: Mandatory Reporter Completion date of 01/07/25 titled Residents ' Rights Completion date of 01/07/25 titled Mental Health: Caring for the Older Adult in Long Term Care Review of In-Service Training Report dated 01/07/2025, of all staff and departments, topic of Abuse Neglect Resident Rights. The report indicates 5 types of abuse, the abuse coordinator, and reporting abuse protocols. Review of 5 Safe Survey ' s indicated one resident responded to question #4 Have you ever heard a staff member yell at another resident? The resident responded No not really, just correction. Not abusive. Everything is being addressed the right way. Resident #29 ' s response to question #4 on the safe survey stated, just me, me and CNA E had a couple of words, but it was a misunderstanding. Review of the facilities Abuse and Neglect - Clinical Protocol, Revised March 2018, reflected Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on observation, interview, and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 3 residents (Resident #29) reviewed for Preadmission Screening and Resident Review Level I screenings. The facility failed to ensure Resident #29's Preadmission Screening and Resident Review Level One screening completed 07/02/24 and 02/11/25 on accurately reflected his diagnosis of mental illness. There was no evidence that Resident #29 was referred to a Level Two Preadmission Screening and Resident Review Screening. This failure could affect residents by placing them at risk for not receiving needed treatments and services. Findings included: Review of Resident #29's Face Sheet, dated 03/12/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and a subsequent admitted following a hospital stay on 09/30/2024, with diagnoses including: unspecified head injury, depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (is a mental health condition that can develop after exposure to a traumatic event. It is characterized by symptoms such as: distressing memories or flashbacks of the trauma, feelings of hopelessness or negative thoughts about oneself or others). Review of Resident #29's MDS Assessment, dated 02/21/24, also reflected he had diagnoses including anxiety disorder, depression, bipolar disorder, and post traumatic stress disorder. Review of Resident #29's Preadmission Screening and Resident Review Level I Screening, dated 07/02/24, reflected there was no evidence that Resident #29 had indicators of a mental illness. Review of Resident #29's Preadmission Screening and Resident Review Level I Screening, dated 11/20/24, reflected there was evidence that Resident #29 had indicators of a mental illness. Review of Resident #29's Preadmission Screening and Resident Review Level I Screening, dated 02/11/25, reflected there was no evidence that Resident #29 had indicators of a mental illness. Review of Resident #29's Behavioral health diagnostic assessment dated [DATE], reflected Resident #29 had a long history of post-traumatic stress disorder secondary to the service in the Coast Guard. The assessment also reflects that Resident #29 had a long history of depression and alcohol abuse. The report also reflects that Resident #29 reported despite past treatments including inpatient care, he continues to have difficulties with nightmares and depression. The report reflects that Resident #29 was diagnosed with Major depressive disorder and Post-traumatic stress disorder. Review of Resident #29's New Admission Worksheet dated 07/02/24 with attached hospital medical records dated 06/28/24 reflect Medical Problems list include: major depressive disorder, bipolar disorder, post-traumatic stress disorder and anxiety. Review of Resident #29's Diagnosis Report reflected he was diagnosed with Dementia on 7/2/24. Review of Resident #29's Mental/Illness/Dementia Review, Form 1012, reflected that resident does not have any mental illness. Observation of Resident #29 on 03/11/25 at 1:35PM revealed he was clean, well-groomed, and appropriately dressed. He was free from any odors. There were no visible marks or bruises noted on his person. Resident #29 was alert and oriented; he was resting in his bed. During an interview with Resident #29 on 03/11/25 at 1:35PM, he stated facility staff treated him well and he felt safe at the facility. He had no concerns regarding the facility, or the care received; he reported he just returned from his mother's funeral today and was feeling sad. He reported his wife is also at the facility and often sees her. During an interview with the MDS Coordinator on 03/12/25 at 2:03PM, she stated Resident #29's Preadmission Screening and Resident Review Level I was completed and does not indicate a mental illness because his primary diagnosis is Dementia. She reported that if a resident has a diagnosis of dementia, then they do not qualify for a level 2. She reported that Resident #29's physician signed a paper stating Resident has a primary diagnosis of Dementia (see record review of Form 1012, Mental Illness/Dementia Review) Review of the Facilities Admission Policies and Procedures, Revised March 2019, states 9. a. The facility conducts a Level I Preadmission Screening and Resident Review screen for all potential admissions, regardless of payer source to determine if the individual meets the criteria for a MD, ID, or RD. b. if the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state Preadmission Screening and Resident Review representitive for the Level II (evaluation and determination) screening process.

Based on observation and interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. There were 9 errors out of 25 opportunities which resulted in a 36% percent medication error rate for 1 (Resident #28) of 4 residents reviewed for medication errors. On 3/12/25, RN C administered 9 individual medications via Gtube (surgically placed tube used to administer nutrition, fluids, and medications) to Resident #28 by pushing the medications through a syringe without an order rather than by gravity as noted in their policy. This failure placed the resident at risk of Gtube complications, aspiration pneumonia, and not receiving the therapeutic effects of medications. Findings included: Record review of Resident #28's Admission Record dated 3/12/25 reflected a [AGE] year-old male originally admitted to the facility on [DATE]. Record review of Resident #28's Quarterly MDS assessment dated [DATE] reflected he was rarely understood and rarely understood others and had severely impaired cognitive skills for daily decision making. His diagnoses included stroke; aphasia (impaired ability to communicate verbally); hemiplegia (weakness or paralysis on one side of the body); dysphagia (inability to swallow safely); non-Alzheimer's dementia; and seizure disorder. He received his calories and hydration from a feeding tube. Record review of Resident #28's Care Plan reflected the following: [Resident #28] requires tube feeding for complete nutritional needs r/t Dysphagia NPO Status. Relies solely on licensed nurse to administer all medications, nutrition and hydration needs via peg tube. Date initiated 5/18/23, Revision on 7/26/23. Interventions included: .Flush Gtube with 30 ml tap water before and after each med .Licensed nurse to crush medications and administer via Gtube; medications per order; Monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration . Record review of Resident #28's Order Summary Report dated 3/12/25 at 10:51 AM reflected the following: Enteral: if enteral feeding tube becomes dislodged, clogged or unusable for any reason and the tube is the primary source of nutrition and/or hydration contact the physician immediately to determine if iv fluids are needed every shift for dislodged clogged feeding tube. Order date 2/27/24. Flush g-tube with 30 ml tap water between each med. Order date 1/31/25. Medication orders included the following: Tricor oral tablet 124 mg give 1 tablet via G-tube one time a day Eliquis oral tablet 5 mg give 1 tablet via G-tube every 12 hours Aspirin tablet 81 mg give 1 tablet via G-tube one time a day Simethicone tablet 80 mg give 1 tablet via G-tube two times a day Furosemide solution 10 mg/ml give 4 mls via G-tube one time a day Multivitamin liquid give 15 mls via G-tube one time a day Potassium Chloride oral solution 20 mEq/15 ml give 15 mls via G-tube one time a day Keppra solution 500mg/5 mls give 5 mls via G-tube one time a day Hyoscyamine Sulfate elixir 0.125 mg/5 mls give 5 mls via G-tube one time a day Record review of Resident #28's Order Summary Report dated 3/12/25 at 3:52 PM reflected the following order had been added: Nurse may gently or slowly push the plunger into the barrel of syringe to administer medicines via G-tube. Order date 3/12/25. During an observation and interview on 3/12/25 at 7:52 AM, Resident #28 was observed in his bed. The head of his bed was elevated 30 degrees, he was awake and nodded in response to greeting and request to observe care. RN C washed her hands, put on gloves and prepared the following medications and placing them in individual medication cups: Tricor oral tablet 124 mg-crushed; Eliquis oral tablet 5 mg-crushed; Aspirin tablet 81 mg-crushed; Simethicone tablet 80 mg-crushed; Furosemide solution 10 mg/ml 4 mls poured; Multivitamin liquid 15 mls poured; Potassium Chloride oral solution 20 mEq/15 ml 15 ml poured; Keppra solution 500mg/5 mls 5 mls poured; and Hyoscyamine Sulfate elixir 0.125 mg/5 mls 5 mls poured. The medications were mixed with water to dissolve. RN C washed her hands and donned PPE. She disconnected Resident #28's tube feeding and checked for residual. Resident #28 was observed to have a large bulge in his upper right abdomen which RN C identified as a hernia (bulging of an organ or tissue through an abnormal opening). She flushed the residents Gtube with approximately 30 ml of water using the plunger of the syringe. RN C was asked about the use of a plunger and stated, they've never had us doing any by gravity here. She proceeded to slowly administer all nine medications, one at a time flushing between each medication with 30 ml of water. RN C utilized the plunger for all medications and flushes. Resident #28 was noted to cough during the medication administration. RN C stated he had a history of coughing and a large amount of secretions. She stated he was receiving medications for the secretions including the Hyoscyamine as well as a medication patch placed every three days. She elevated the head of the resident's bed higher after he began to cough. She completed the medication pass and washed her hands. During an interview on 3/12/25 at 2:53 PM, RN C stated she spoke with Resident #28's physician after the medication pass and received the order. She stated she should have gotten an order prior to using the plunger as the facility policy was to administer medications using gravity. She stated had previously spoken with the physician about Resident #28 because she had previously had difficulty passing his medications by gravity because of his hernia. She stated he would cough during the medication pass using gravity it would cause the medications to come up out of the syringe and go everywhere. She stated she had been approved to use the plunger previously but had failed to enter the order. She stated the risks of using a plunger included rupturing the tube or causing problems at the stoma (surgically created opening) site and she always went very slow when administering the medication. During an interview on 3/12/25 at 3:18 PM, the DON stated RN C had told her that morning she had used aa plunger on Resident #28's Gtube. She stated Resident #28 had a hernia and sometimes coughed during medication administration because the tube did not always flow well. She stated RN C had called the physician and obtained the order. She stated RN C should have called the physician prior to using the plunger because it was the facility's policy to use gravity for medication administration unless the physician ordered otherwise. The DON stated resident #28 had a long history of having trouble with his gtubes and was being treated by a GI specialist. She stated none of his issues were related to the use of a plunger. The DON stated the risk for using a plunger during medication administration included damage to the tube and aspiration pneumonia (an infection that occurs when something other than air is inhaled into the lungs). In an interview on 3/13/25 at 8:00 AM, LVN D stated she occasionally cared for Resident #28 and was his Charge Nurse on 3/11/25. She stated she passed his medications using gravity and had not encountered any difficulties. She stated Resident #28 had just had his gtube replace a few weeks earlier and had an upcoming follow-up appointment with his specialist in April 2025. LVN D stated the risk of using a plunger was it could be administered too fast and too much air could be inserted into his stomach. She stated the facility's policy was to use gravity unless they had a physician order. During an interview on 3/13/25 at 1:42 PM, the Medical Director stated she had spoken with RN C regarding Resident #28's Gtube medications on 3/12/25 and approved the use of a plunger for his medication administration. She stated she believed RN C had previously discussed the issue with another physician in their group on an earlier date. The Medical Director stated medications were typically administered using gravity and there were risks involves with using a plunger such as administering the medication too quickly. She stated the risk of missing the medications due to clogging or other complications was much higher than the risk of using the plunger for administration and she had approved the use. She stated she was not aware of any issues with the use of the plunger and facility staff should call her anytime they had concerns with a Gtube. Record review of the facility's policy titled, Administering Medications through an Enteral Tube, dated, Revised September 2024 reflected: Purpose The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .Steps in the Procedure .9. Dilute medication: a. Remove plunger from syringe. Add medication and appropriate amount of water to dilute. b. Dilute crushed (powdered) medication with at least 30 mL clean water (or prescribed amount). c. Dilute liquid medication with 30 mL or more (depending on viscosity) clean water. 10. Administer each medication separately. 11. Reattach syringe (without plunger) to the end of the tubing. 12. Administer medication by gravity flow, or per physician order. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly. c. Begin flush before the tubing drains completely. 13. If administering more than one medication, flush with 15 mL warm clean water (or prescribed amount) between medications. 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm clean water (or prescribed amount). 15. Quickly clamp the tubing when the flush is complete. Remove syringe .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #11) of 3 residents reviewed for care plans. The facility failed to develop interventions to address the goal on Resident #11's care plan to maintain nephrostomy tube care through the next review date. This failure could affect the facility's residents who were occasionally or frequently incontinent of bladder and/or with catheter or nephrostomy tube placement by placing them at risk of not receiving the necessary care and services to meet their needs. Findings included: 1.) Review of Resident #11's Face Sheet, dated 3/13/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, unspecified hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine), urinary tract infection, other mechanical complication of other urinary catheter, initial encounter, type II diabetes, and dementia. Review of Resident #11's Care Plan, completed on 08/11/2023, reflected she had the potential for or presence of altered nutrition and hydration due to protein calorie malnutrition, history of infections: UTI. She requires a therapeutic diet low of concentrated sweets, diet, minced and moist texture, thin (regular) 1 consistency. The goal stated Resident #1 nutrition needs will be met thru next review date. The plan also reflected a focus area station Alteration in elimination of bowel and bladder due to incontinence. Resident #11 will be free of UTI daily through next review. The plan also reflected another focus area stating, Resident #11 has potential for complications due to incontinence, frequently incontinent. Review of Resident #11's Physician Progress Note dated 03/11/2025 reflected the following: History of present illness: [AGE] year-old lady admitted to facility [NAME] on 08/08/2022 as status post admission she tried to walk a little and fell and hit her left hip. She sustained a closed displaced fracture of the femoral neck and subsequently underwent a left hip hemiarthroplasty. The patient has a past medical history significant for dementia and diabetes mellitus 2. 09/26/2023 patient returned from the ER after due to abnormal outpatient x-ray result. Patient noted to have a new left sacral fracture nondisplaced. Patient was prescribed with acetaminophen 500 mg 2 tablets twice daily and can have a dose in between as well as every 6 hours. Patient was ordered to ambulate as tolerated, follow-up with clinic or Orthopedic as needed. On October 29 (unknown year) patient was treated with Macrobid 100 mg twice daily for 10 days for ESBL E. Coli. S/P hospitalization [DATE] to 1/15/24 for pneumonia S/P hospitalization from [DATE] to 11/3/24 due to pneumonia and urinary tract infection. Imaging showed kidney stones with placement of left nephrostomy tube. Returned to facility with IV Invanz to be completed on 11/19/24. 12/27/2024 - patient readmitted after being treated at hospital [NAME] - status post left nephrostomy tube exchange, acute metabolic encephalopathy secondary to urinary tract infection, acute complicated urinary tract infection-ESBL E coli. Readmission from hospital [NAME] for blocked nephrostomy tube and discovered infection and stayed for IV antibiotics. During an observation and interview on 3/13/25 at 9:26 AM, Resident #11 was observed outside her room in her wheelchair. She was clean and well groomed. The MDS Coordinator washed her hands, donned a gown and assisted Resident #11 to bed using a gait belt. MDS Coordinator stated Resident #11 understood some English but mostly spoke Spanish. The MDS Coordinator communicated to Resident #11 using Spanish and was able to translate. LVN G washed her hands, gathered supplies and donned a gown and gloves. She stated Resident #11 had pulled the dressing off her nephrostomy tube and she was there to replace it. Resident #11's nephrostomy tube was intact and capped. It was light pink at the insertion site with no drainage or swelling. LVN G cleaned the site and replaced the dressing using sterile technique. The MDS Coordinator stated Resident #11 had a history of urinary tract infections and was found to have kidney stones, so the nephrostomy tube had been placed. She stated the resident was seen by a specialist and was expecting to have the tube removed sometime soon. During an interview with the Director of Nursing (DON) on 3/13/2025 at 1:25 p.m., she reported resident #11 has a nephrostomy tube and cannot recall the exact date she received it. She reported she checked and it is not included in Resident #11's care of plan and was not sure why. She stated she added it today after becoming aware that it was not included. After checking her notes, she reported Resident #11 went to the hospital on 10/29/24 and came back on 11/2/2024 with the tube. She reported Resident care plans are updated anytime they go to the hospital and come back so she was not sure how that happened. The DON stated there is no risk to the residents because the orders are still there, this was just missed. The DON stated the only people that see the care plan or reference it is management nurses. She stated the orders are there to treat the resident, the care plan was just missed.

Based on interview and record review, the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman, for 1 of 1 resident (Resident #1) reviewed for discharge. The facility initiated a 30-day discharge for Resident #1 on 12/10/2024 and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life. Findings included: A record review of Resident #1's face sheet undated reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosesis was were Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), dementia (memory loss), and major depressive disorder (loss of interest in activities). A record review of Resident #1's Quarterly MDS assessment, dated 09/26/2024, reflected the resident had a BIMS score of 3, which indicated severe cognitive impairment. Review of Resident #1's 30-day discharge letter dated 12/10/2024, revealed Resident #1 was given the 30-day discharge letter on the same date (12/10/2024) she was discharged to the hospital. Review of Resident #1's Discharge Planning and Summary date 12/10/2024, revealed Resident #1 was sent to the hospital for behaviors. Attempted an interview on 12/27/2024 at 10:49 a.m. left message for the local ombudsman to return call. Record review of Resident #1's chart did not reveal any notification to the Ombudsman. Record review of Resident #1's progress notes, dated 12/10/24, charted by DON reflected, discharged to hospital. During an interview on 12/27/2024 at 4:56 p.m., the SW stated she was aware a resident is given a 30 days notice prior to discharge, The SW stated she was not made aware Resident # 1 was being discharged on [DATE] until she was sent out to the hospital. The SW stated if she would have been made aware of the discharge she would have assisted in finding safe placement for Resident # 1. The SW stated she did not assist with the immediate discharge and she did not have any knowledge of. During an interview on 12/27/2024 at 6:00 p.m., the OM stated he did not contact the local ombudsman of the immediate discharge. The OM did not give a reason to why the local ombudsman was not contacted. The OM stated he thought he could issue a 30 days discharge immediately when it was behavior related. The OM stated he know to follow the provider letter when issuing 30 day discharges. Review of long-term care regulation provider letter dated 12/29/2022 reflected If a NF initiates a resident discharge, the facility must provide written notification of the discharge-in a language and manner the resident can understand-to the resident, the resident representative (if applicable), and a representative of the Long-Term Care Ombudsman Program, at least 30 days before the intended discharge date . A NF is required to provide a resident with enough preparation regarding his or her discharge so that it may be safe and orderly.

44021 Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for three of three residents (Residents #23, #34, #41, #61, #65, #66 and #179) reviewed for supervision. The resident environment did not remain free of accident hazards in addition to the supervision failure because the courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping, there were no fencing or warning signs around the affected construction areas. The courtyard also contained a laundry facility that was unlocked, with the door observed to be frequently open and lacking a self-closing mechanism. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 1. The facility failed to ensure Resident #23, and Resident #34 were adequately supervised to prevent them from leaving the secured unit unsupervised. Residents #23 and #34 had moderate/severe cognitive impairment, wandering behavior, and lacked safety awareness. On 01/29/24 at or around 3:30 PM, Residents #23 and #34 gained access to a courtyard that was currently under construction, leaving the secure unit unsupervised. The courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping, there were no fencing or warning signs around the affected construction areas. The courtyard also contained a laundry facility that was unlocked, with the door observed to be frequently open and lacking a self-closing mechanism. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 2. The facility failed to ensure Resident #179 was adequately supervised to prevent him from leaving the secured unit unsupervised. Resident #179 had severe cognitive impairment, wandering behavior, and lacked safety awareness. On 01/14/24 at or around 3:30 PM and on 01/15/24 at or around 10:25 PM, Resident #179 gained access to a courtyard under construction, leaving the secure unit unsupervised. The courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping there were no fencing or warning signs around the affected construction areas. The courtyard also contained a laundry facility that was unlocked, with the door observed to be frequently open and lacking a self-closing mechanism. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 3. The facility failed to ensure that doors on the secure unit with magnetic locking mechanisms were functioning properly allowing secure unit residents unsupervised access to a courtyard that was under construction for several weeks. An IJ was identified on 01/30/24. The IJ template was provided to the facility on [DATE] at 2:07 PM. While the IJ was removed on 02/01/24 at 4:00 PM, the facility remained out of compliance at a scope of a pattern with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and lack of safety precautions for an adjoining courtyard under a current state of construction. 4.The facility failed to properly maintain wheelchairs for Residents #41, #61, #65, and #66. These failures could place residents at risk for injury and/or death from eloping, falls, exposure to sharp debris, and possible exposure to harmful chemicals. Findings included: 1. Record review of Resident #23's quarterly MDS assessment, dated 11/13/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease, Dementia, Insomnia, Muscle Weakness, Unsteadiness on Feet, Difficulty Walking, and Other Lack of Coordination. The cognitive section C1000 of the MDS indicated Resident #23 had moderate cognitive impairment. She had symptoms which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, no psychosis, and wandering behavior. She had an unsteady gait and required a walker for mobility. Record review of Resident #23's care plan dated 01/25/24, reflected a problem identified as risk for elopement .requires secured unit related to: Wandering Risk, Alzheimer's Disease initiated on 10/10/23 which reflected, [Resident #23] will remain safe during placement at Living Center on secured unit through review date target date 04/29/24. Interventions on the care plan, dated 10/10/23 reflected Assess for risk of elopement per living center policy and Redirect [Resident #23] from doors. Record review of Resident #23's Wandering Assessment, dated 10/10/23, completed by an unknown nurse, reflected Resident #23 was admitted for High Risk for Wandering, was disorientated, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, known wanderer/history of wandering, Wander/elopement alarm not indicated. Record review of Resident #23's Quarterly Wandering assessment dated [DATE], completed by Licensed Wound Nurse, reflected Resident #23 was disorientated, Forgetful/short attention span, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, Early dementia, known wanderer/history of wandering, Wander/elopement alarm is indicated. Record review of Resident #34's quarterly MDS assessment, dated 01/10/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease, Dementia, Neurocognitive Disorder with Lewy Bodies (protein growths in brain), Muscle Wasting, Hallucinations, Unsteadiness on Feet, and Other Lack of Coordination. The cognitive section of the MDS indicated Resident #34 had severe cognitive impairment. She had symptoms which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, psychosis, and wandering behavior. Record review of Resident #34's care plan dated 01/22/24, reflected a problem identified as risk for elopement .related to: attempts to leave living center .wandering initiated on 06/22/23 which reflected, [Resident #34] will remain safe during placement at Living Center on secured unit through review date target date 12/20/23. Interventions on the care plan, dated 10/10/23 reflected Assess for risk of elopement per living center policy and Redirect [Resident #34] from doors. Record review of Resident #34's Wandering Assessment, dated 11/03/23, completed by ADON bb, reflected Resident #34 was admitted for High Risk for Wandering, could walk independently, was disorientated, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, known wanderer/history of wandering. Record review of Resident #34's Quarterly Wandering assessment dated [DATE], completed by LVN cc, reflected Resident #34 was disorientated, Forgetful/short attention span, combative, expresses fear and anxiety, does not understand surroundings, ambulates with one assist/Independent (no assist), Alzheimer's disease, dementia with psychosis, known wanderer/history of wandering, Wander/elopement alarm is indicated. In an interview on 01/29/24 at 10:00 a.m. with the Administrator revealed the facility had plumbing problems that had been addressed sometime the end of December, the Administrator stated that the construction had begun then and the trenches had been dug. The Administrator stated that would have been 4-6 weeks prior to today (01/29/24), but with he ice and the rain they had been unable to continue to correct the plumbing problems. He stated that the facility maintenance staff had covered the ditches with the plywood to make the area safer. In an interview on 01/29/24 at 4:51 PM, LVN L revealed that earlier that day Residents #23 and #34 had left the secure unit through a door that leads to the courtyard under construction. She stated that she must have had not been on that end of the hallway when Residents #23 and #34 went through the door. She stated that CNA PP had spotted the two residents in the courtyard and brought Residents #23 and #34 back to the secure unit. In an interview on 01/30/24 at 7:40 AM, CNA PP revealed she used to work on the secure unit and knows all the residents on the secure unit. She stated that sometimes the door on the secure unit (leading to the courtyard under construction) sticks and does not latch. She stated that she had just entered the courtyard from another building and saw Resident #34 holding the door open for Resident #23 so that Resident #23 could bring her walker through the door. She stated that the staff sometimes puts med carts or chairs in front of the door leading to the courtyard to deter residents on the secure unit getting outside of the unit. In an interview on 01/30/24 at 9:08 AM, with the Administrator revealed that he was aware that a couple of residents had managed to get out of the secure unit unobserved. He stated that it was his fault because he had not made sure that the door was secure as he entered the secure unit (from the courtyard entrance). He stated that he had notified all staff to be more mindful of the door not latching. He stated that the two residents (Resident #23 and #34) were found by another CNA right away. In an interview on 01/30/24 at 9:10 AM, the Maintenance Supervisor revealed that he had just found out about the door, he stated that it is not the door frame, but the door that is not hung right. In an observation on 01/29/24 at 10:45 a.m. the laundry room door was open and there was no one in the laundry. In and observation on 01/29/24 at 11:45 a.m. the laundry room door was open there was no one in the laundry. In an observation on 01/30/ 24 at 1:00 p.m. the laundry door was open and there was no one in the laundry. On 01/30/24 at 1:30 p.m. pictures were obtained of the courtyard of the ditches approximately 40 ft long and 3-4 feet deep, mounds of dirt broken pipes, debris that contained sharp edges of broken plastic pipe, broken fencing, barrels marked as hazard materials, and no protective fencing or signs indicating the hazards. In an observation and interview on 01/30/24 at 3:17 PM, it was observed that the laundry facility was located within the courtyard that was under construction courtyard that was currently under construction. The courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping, there were no fencing or warning signs around the affected construction areas. The door to the laundry facility was propped open with no automated door closing device was observed to be attached to the door. Directly inside the door to the left were numerous containers of laundry chemicals including All-purpose cleaner and degreaser, Neutralizing Sour, Chemical Alkaline Booster, Laundry Detergent and Laundry De-Stainer. All containers were observed to have warnings that denoted serious harm or injury if digested or continuous contact with exposed skin/eyes. Housekeeper EE stated that the housekeeping staff liked to keep the door open to the laundry facility because it gets very warm inside. 2. Record review of Resident #179's quarterly MDS assessment, dated 01/17/24, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's Disease, Vascular Dementia, and sleep disorder. The cognitive section C1000 of the MDS indicated Resident #179 had severe cognitive impairment. He had symptoms which included continuous inattentiveness, continuous trouble falling asleep, continuous wandering and rejection of care behaviors. Record review of Resident #179's care plan dated 01/15/24, reflected a problem identified as [Resident #179] has realized that holding the memory unit locked door for 15 seconds will release the emergency egress function of door and door will open [Resident #179] has ambulated from memory unit into courtyard X 2 but has been redirected back to memory locked unit initiated on 01/16/24. Interventions on care plan, dated 01/16/24 reflected [Resident 179] to remain 1:1 until discharge. Care Plan dated 1/15/24, reflected a problem identified as risk for elopement and required a more secured unit to ambulate safely and freely related to: Attempts to leave living center, initiated on 01/16/24. Interventions on care plan dated 01/16/24 reflected, [Resident #179] Assess for risk of elopement per living center policy and Assess for secure unit. Record review of Resident #179's Elopement Risk Assessment, dated 01/12/24, completed by an unknown nurse, reflected Resident #179 was admitted with High Risk for Elopement, could walk independently, exhibited wandering behavior, was cognitively impaired and had poor decision-making skills, had verbalized a desire to go home and had eloped/wandered from his home without supervision prior to his admission to the facility. No quarterly Elopement assessment was available as the resident was at the facility for respite care x 5 days. Record review of Progress notes from 1/14/24 at 3:30 PM and written by LVN L revealed that Charge nurse was notified resident [Resident#179] was outside of exit door. Charge nurse noted resident on the sidewalk and immediately redirected resident back to unit. Resident was calm with some confusion noted. No injuries noted. Record review of Progress notes from 1/15/24 at 10:25 PM written by LVN K revealed that .this nurse hears the door rattle from res(ident)[Resident #179] pushing it once, then followed by quiet this nurse walks out of nurses station to see res [Resident #179] running on sidewalk toward 200 hall side building, this nurse try's to follow but has to put code in door as it is locked, this nurse runs outside and catches res as res is knocking on window of other building, this nurse turns res and takes res back inside locked unit where this nurse has to put code in again to get in, res is taken to nurses station and socks are changed and DON (Director of Nursing) is notified, this nurse blocks door while waiting on staff to come and look at door as res is put on 1 on 1 monitoring as well as Q(every)15 min checks. In an interview on 01/29/24 at 3:00 PM, with LVN L revealed that Resident #179 was a very busy resident, he would only sleep for 20 minutes at a time, and he constantly wandered and checked all the exit doors all day and all night. In an interview on 01/29/24 at 4:16 PM, CNA D revealed that the door next to the nurse's station (that leads to the courtyard under construction) sometimes does not latch and that it sometimes sticks open, so the staff must make sure that they check it every time they use the door . She stated that she had reported it to a nurse a couple of months back ago. An observation on 01/29/24 at 4:20 PM, revealed that the exit door from the secure unit to the courtyard under construction was intentionally left unlatched for 1 minute, no alarm sounded to indicate the door was open. In an interview on 1/30/24 at 4:50 AM, RN V revealed that she had heard of a few instances lately of residents getting out of the secure unit and that the door leading from the secure unit to the courtyard does not close very well. She stated that it would be very helpful to have some type of alarm that goes off on the doors on the secure unit. She stated that when the facility has fire drills that the staff in the secure unit would sometimes put barriers up in front of the doors on the secure unit because the fire alarm automatically unlatches the doors. In an interview on 01/30/24 at 5:00 AM, CNA M revealed that if a resident were to get out of the secure unit unsupervised, she would immediately bring the resident back to the secure unit and inform the Charge nurse or the Administrator. In an interview on 01/30/24 at 5:11 AM, LVN GGG revealed that the door next to the nurse's station on the secure unit (leading to the courtyard) sometimes sticks open and does not latch, she stated that she had reported it a while ago but could not remember when. In an interview on 01/30/24 at 7:40 AM, CNA PP revealed that the staff working on the secure unit would sometimes put med carts or chairs in front of the exit (leading to the courtyard) next to the nurse's station on the secure unit to deter residents from getting outside of eh unit. In an interview on 01/30/24 at 7:47 AM, LVN K revealed that she had been the nurse on the night that Resident #179 got out of the secure unit. She stated that there are no alarms on the door (leading to the courtyard) but that may be a good idea. She stated that the door (leading to the courtyard) would stick open and not latch from time to time. She stated that the door did latch after Resident #179 got out of the secure unit and that delayed her getting out to him, she stated that he had made it all the way to the 200 building. She stated that she brought the resident back to the secure unit and informed the DON that the door was not working well and that she did put some chairs in front of the door until other staff arrived to fix the door. In an interview on 01/30/24 at 8:58 AM, the Administrator revealed he was aware of the door (on the secure unit leading to the courtyard) not closing properly and that the facility had put a new automatic door closer on the door to fix the problem. He stated the staff and visitors had been advised to make sure to check the door after they enter/exit to make sure that the door had latched properly. In an observation and interview on 01/30/24 at 4:08 PM, Maintenance Assistant DD toured the under construction courtyard with the Investigator. He stated the trenches in the courtyard had been started by the Administrators son the same week as Christmas around the 19th or the 20th of December, he was not exactly sure. He stated the trenches had to be dug around 3-4 feet deep to get all of the pipe out of them and put in new pipe. He stated the trenches had been dug up and then there was a freeze aound Christmas so the ground had frozen and then it rained a lot after that, that was why the trenches were still there. He identified the trenches as being 3-4 feet deep with mud at the bottom. He identified the pIles of dirt anD debris next to the trenches as being 2-3 feet tall and containing large rocks, shards of broken pipe and other debris. In an interview and observation on 01/30/24 at 6:20 PM, the Maintenance Supervisor stated that he placed a new automatic door closer on the secure unit door (leading to the courtyard) a few weeks ago. He stated he thought that Resident #179 must have got out because he had pushed on the release on the door for more than 15 seconds to disengage the lock. Maintenance Supervisor then pushed on the exit bar to the door on the secure unit leading to the courtyard for a full minute, the magnetic door latch was observed to not disengage. He then stated that the door seemed not to be seated right in the door frame and that maybe that stopped the door from latching properly sometimes. In an observation on 01/31/24 at 8:30 a.m. revealed alarms had been placed on all the exit doors of the secured unit. In an interview on 01/31/24 at 9:10 a.m. with the Administrator revealed he had the Maintenance Supervisor purchase the alarms the evening before and place them on all the exit doors, so that an alarm would sound if the doors were opened. In an interview on 01/31/24 at 12:54 PM, the Administrator revealed that he and the DON had been trained by the Regional RN for elopement, wandering and safety concerns at the facility, and that all staff had been trained. He stated that he had designated the Housekeeping Supervisor and the Maintenance Supervisor to monitor the courtyard area. In an interview on 02/01/24 at 12:55 PM, the DON revealed that the staff were educated by in-services, hands on training and on-line training and that all training was currently up to date. She stated that she thought the IJ was caused by the courtyard being dug up for several weeks and not having the trenches blocked off and marked. Secure Unit residents may have injured themselves if they got out of the secure unit unsupervised. She stated that the facility now had alarms on the doors of the secure unit and the courtyard trenches were being filled in and the debris removed. She also stated that a self-closer mechanism was going to be installed on the laundry facility door to deter residents from having access to the chemicals stored there. In an interview on 02/01/24 at 3:00 PM, the Administrator and Maintenance Supervisor revealed that they made sure that the facility would do in-servicing and education and when and how to report and identify that there may be discrepancies. The Admininstrator stated that he supervised through daily clinical meetings with the nursing department, have daily stand-up meetings with all the department heads including Maintenance and do daily advocacy rounds. I think the IJ occurred through an increase of hazards in the courtyard due to repairs. There was a missed opportunity for staff and visitors to make sure that the entrance to the secure was closed. To prevent another recurrence, the facility verified that the locks worked, the facility added alarms to the doors, staff were re-educated, to make sure that the door was checked and that the door was closed. They also stated that the facility was making sure that there were no debris or trenches in the courtyard that could (present) a hazard to residents. 4. Review of Resident #41's quarterly MDS assessment, dated 11/25/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type (Mental illness), general weakness (weakness lower limbs), and abnormalities of gait and mobility (abilities to mobilizes safely ). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #41's plan of care dated 11/25/23 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 01/29/24 at 9:30 a.m., revealed Resident #41 was sitting in her wheelchair, in the secured unit activity room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. Review of Resident #61's quarterly MDS assessment, dated 01/06/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Schizoaffective disorder (mental illness), muscle wasting (muscle deterioration), abnormalities of gait and mobility (unable to mobilize safely), and unsteadiness on feet (instability to walk ). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #61's plan of care dated 01/06/24 with updates reflected goals and approaches to include wheelchair mobility. in the secure unit activity room Observation on 01/29/24 at 9:31 a.m., revealed Resident #61 was sitting in his wheelchair in the secured unit activity room and the wheelchair's left and right armrests were cracked with exposed foam. There were no skin tears on arms. Review of Resident #65's annual MDS assessment, dated 01/28/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of Dementia (brain dysfunction) pulmonary embolism (clot in the lung), abnormalities of gait and mobility (unable to mobilize safety), difficulty in walking, and muscle weakness . Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #65's updated plan of care dated 01/28/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 9:32 a.m., revealed Resident #65 was in her wheelchair in the secured unit activity room, and the wheelchair's right armrests were cracked with the foam exposed. There were no skin tears on arms. Review of Resident #66's annual MDS assessment, dated 01/23/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Dementia (brain disorder confusion & forgetfulness), unsteadiness on feet, and lack of coordination and weakness. Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #66's updated plan of care dated 01/23/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 9:35 a.m., revealed Resident #66 was in his wheelchair, wheeling in the hallway and with no skin problems. The wheelchair's right armrest was cracked with dried food in the cracks. Review of Resident #47's quarterly MDS assessment, dated 11/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of epilepsy (seizures), abnormality of gait and mobility, and instability of left knee. Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #47's updated plan of care dated 10/08/23 with updates reflected goals and approaches to include wheelchair mobility and skin not being in contact with hard surfaces since she has thin skin and a history of skin tears on her hands. Observation on 01/29/24 at 1:45 p.m., revealed Resident #47 was in her wheelchair and had no skin problems. The wheelchair's left and right armrests were cracked with the foam exposed. Resident #47 was unable to be interviewed. In an interview on 01/29/24 at 11:00 a.m., CNA D stated when a resident's wheelchair needed repair the staff were to tell the maintenance supervisor. CNA D stated she had not reported any wheelchairs that needed repair to the maintenance supervisor. In an interview on 01/29/24 at 11:05 a.m., LVN A stated when a resident's wheelchair needed repair the staff were to report it to the maintenance supervisor, LVN A stated she thought there was maintenance log at the nurses station in the other building but there was not one at this nurse's station. In an interview on 01/30/24 at 5:00 a.m., the with Maintenance Supervisor revealed the staff tells him if equipment needs to be fixed or if a room needs repair. He stated they are supposed to use the electronic reporting system, but they do not use it. He stated to his knowledge the staff had not been trained to use the electronic reporting system, he just fixes things when he knows about it. In an in interview on 01/30/24 at 9:15 a.m., the with Administrator and Maintenance Supervisor revealed neither of them were aware of any wheelchairs that required repair on the unit. The Administrator state the staff is supposed to use the electronic reporting system. The Administrator stated he did not know when or if the staff had been in-serviced on how to use the system, the staff just usually tells them, if the wheelchairs needed to be fixed. The Maintenance Supervisor agreed with the Administrator. A review of the electronic maintenance system with the Maintenance Supervisor on 01/30/24 reflected there were no entries that indicated residents' wheelchairs needed the armrest repaired for the October-January 2024. In an interview on 02/01/24 at 1:32 PM, the Medical Director revealed that she had been informed of the IJ on 01/30/24. Record review of the facility's Policy Statement Grounds dated 05/2018 version 1.1 (H5MAPL0360) reflected 1. Maintenance shall be responsible for keeping grounds free of litter .3. Areas around buildings (i.e., sidewalks, patio, gardens, etc.) shall be maintained in a safe and orderly manner at all times. Record Review of the facility's Policy Wandering and Elopements, dated 03/2019 version 1.2 (H5MAPL0944) reflected The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while harm while maintaining the least restrictive environment for residents .1. If identified as at risk for wandering, elopement or other safety issues .to maintain the resident's safety .483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents . A review of the facility's policy and procedure Maintenance dated July 2018 reflected It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff Equipment provided by the community will be: 1. Maintained in working order. A review for the facility's policy and procedure Assist devices and Equipment dated January 2020 reflected: Our facility maintains and supervises the use of assistive devices and equipment for residents device conation. 1. certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include but limited to: .c. mobility devices wheelchairs, walkers, and canes) . 6.c. Device condition-devices and equipment are maintained on schedule and according to manufacture's instructions. Defective or worn devices are discarded or repaired . This was determined to be an Immediate Jeopardy on 01/30/24 at 2:07 PM. The Administrator was notified. The Administrator was provided with the IJ template on 01/30/24 at 2:07 PM The following plan of removal submitted by the facility was accepted on 02/01/24 at 9:52 AM and indicated the following: Plan of Removal: Immediate Corrections Implemented for Removal of Immediate Jeopardy. On January 30, 2024 at approximately 3:30 pm the following immediately corrective actions were taken: Resident #179 discharged to home (1/17) Director of Nursing and ADONs and MDSC, completed updated wander risk assessment on resident #23 and Resident #34 on (1/30). IDT reviewed interventions initiated and care plan updated r/t elopement risk (1/30). Maintenance Director installed (1/30) temporary magnet-activated alarms/chimes on all exit doors on Secure Unit until permanent alarm system can be installed by professional contractor (Contractor site survey completed 1/30 to provide quote by end of week). Maintenance Director physically inspected all Secure Unit doors/locks and tested each to make sure they're working correctly (closing properly without impediment, locking and unlocking with keypad only) - completed 1/30. Administrator verified that already existing padlocks on courtyard gates, and mag-locks on halls adjoining Secure Unit, were securely locked and functioning properly to prevent elopement from facility via this route (1/31). Life Safety team alerted Admin that trench required orange construction fencing per OSHA regulations. Fence materials were immediately purchased and installed around trench area (1/31). IDENTIFICATION OF OTHER AFFECTED: All residents on Secure Unit have the potential to be affected. Director of Nursing /designee (ADON's and MDSC) completed Wander Assessment for all 20 residents on Secure Unit in Point Click Care on 1/30/2024, and all Secure Unit residents will be reassessed Quarterly by ADON (Ongoing for duration of Secure Unit stay) Director of nursing/designee validated all residents at high risk of elopement (17 of 20 residents on Secure Unit), (score of 11 or greater), have appropriate interventions and plan of care in place per risk assessment on 1/30/2024. SYSTEMIC CHANGES AND/OR MEASURES: The Corpor [TRUNCATED]

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received his chemotherapy medication for 17 days (07/07/23 to 07/23/23) after medication was delivered to the facility (between 06/29/23 and 07/07/23) for 1 of 9 residents reviewed for medication administration. Resident #1 should have restarted medication on 07/07/23. Medication error was discovered when FAM called to see if medication needed to be replenished and medication was started again on 07/24/23, which Resident #1 to not receive medication as ordered for 17 days. An IJ was identified on 08/09/23 at 3:30 PM. The IJ template was provided to the facility on [DATE] at 5:36 PM. While the IJ was removed on 08/11/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not IJ scoped at a pattern, due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk of complications from deterioration in health, worsening of cancer, extended recoveries, and hospitalization s. Findings included: Record review of Resident #1's admission record dated 08/09/23 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included, multiple myeloma not having achieved remission (a cancer of plasma cells, a type of white blood cell, that normally produces antibodies), dysphagia (difficulty in swallowing food or liquid), anxiety disorder (feeling nervous, restless or tense or having a sense of impending danger, panic or doom), cognitive communication deficit (difficulty with thinking or how someone uses language), diabetes (a group of diseases that result in too much sugar in the blood), and PTSD (post-traumatic stress disorder)(a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being). Record review of Resident #1's quarterly MDS assessment, dated 06/06/23, revealed a BIMS of 13, which indicated he was cognitively intact and required supervision and set-up help only with all activities except bathing which revealed he was independent with and required no setup or physical help from staff. Record review of Resident #1's physician orders dated 04/07/23 and signed by ONC, received by LVN C which revealed Lenalidomide 25 mg po daily x 21 days, then 1 week off (next cycle to start once completed prior 21 day supply and 1 week off). Record review of Resident #1's Nursing Progress Note, dated 7/23/2023 at 21:56 (9:56 PM) revealed the following: Resident's family member asked this nurse how many capsules does resident have left Revlimid 25mg. This nurse noted bottle sealed and has not been opened. RP upset d/t resident has not been getting his Revlimid medication and next dosage of 21 days is soon to come up again. This nurse noted resident's last dose of Revlimid was around 6/30/23. NP notified of missed medication video call this nurse via spruce (communication platform) new order to restart Revlimid 25mg as ordered and notify VA DR. ADON, RP, VA notified. Revlimid ID'd at 2000 (8:00 PM) with narn. Record review of Resident #1's physician orders dated 07/26/23 and signed by ONC, received by LVN C which revealed Lenalidomide 25 mg po daily x 21 days, then 1 week off (next cycle to start once completed prior 21 day supply and 1 week off). Record review of Resident #1's physician orders dated 08/09/23 revealed order for Revlimid Oral Capsule 25 MG (Lenalidomide) Give 1 capsule by mouth at bedtime for RECEIVED FROM OUTSIDE PHARMACY related to MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION until 08/14/2023 at 23:59 (11:59 PM) wear gloves with medication administration/ do not give if broken--- NOTIFY ADON/DON WHEN 7 PILLS REMAIN-- SO ORDER CAN BE DONE******** Record review of Resident #1's MAR for June 2023 revealed Revlimid Oral Capsule 25 MG was administered on June 1st and 2nd and then June 9th through 29th at 6:00 PM. Medication was administered correctly for the month of June. Record review of Resident #1's MAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 24th at 6:00 PM. Medication should have restarted on 07/07/23 through 07/27/23. Medication was missed on the days from 07/07/23 to 07/23/23 when medication error was discovered. Medication was restarted on 07/24/23 after physician was notified of error and the order was given to restart medication immediately. Record review of Resident #1's TAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 25th through 31st at 6:00 PM. Medication was continued correctly. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 1st through 8th at 6:00 PM. Medication was administered during this time. Revlimid Oral Capsule 25 MG (Lenalidomide) 1 capsule by mouth at bedtime. This medication is a chemotherapy and is used to treat multiple myeloma not having achieved remission, which is a cancer of plasma cells, a type of white blood cell, that normally produces antibodies per Google. Record review of Resident #1's care plan dated 07/25/2023 revealed resident takes cancer medication Revlimid. Cycles on medication for 21 days and off for 7 days- (Medication supplied by the VA Pharmacy/ resident's FAM brings medication to facility) Goals: Staff to assure medication is administered per orders through review period. Interventions: Monitor for adverse reactions- which include- hypersensitivity, angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes), [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucous membranes that is often a reaction to medication or an infection), toxic epidermal necrolysis (a life threatening skin disorder characterized by a blistering or peeling of the skin), Tumor Lysis Syndrome (a group of metabolic abnormalities that can occur as a complication from the treatment of cancer), hepatotoxicity (injury or impairment of the liver function caused by exposure to xenobiotics such as drugs, food additives, alcohol, chlorinated solvents, peroxidized fatty acids, fungal toxins, radioactive isotopes, environmental toxicants, and even some medicinal plants), thrombocytopenia (a low number of platelets in the blood), neutropenia, pruritis (itching), rash, fatigue, constipation, nausea. Staff to assure that medication is swallowed whole and not chewed. Staff to wear gloves with administration of this medication. During an interview on 08/09/2023 at 11:16 AM with MA E, she stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause major side effects. She stated a blood pressure medication could cause a blood pressure to rise or fall, aspirin could cause heart problems, and Depakote could cause agitation, and missing a medication could even cause death depending on the medication. She stated she was in-serviced 07/25/23 on medication administration. During an interview on 08/09/2023 at 11:44 AM with LVN A, he stated medications should be given to residents as ordered by the physician. He stated if a resident was not given medications correctly, it could potentially cause adverse reactions. He stated he was in-serviced 07/25/23 on medication administration. During an interview on 08/09/2023 at 11:55 AM with LVN B, she stated she was in-serviced 07/25/23 on medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause adverse side effects, delayed action of medication for whatever it was supposed to cure, or if it was for a preventative measure, whatever it was supposed to prevent could occur. She stated Resident # 1's medication came from the VA. She stated the FAM picked the medication up and dropped it off at the facility. She stated the medication did not come from their pharmacy, and they did not order it. She stated Resident #1 took the medication for 21 days and was off of the medication for 7 days and it continuously cycled that way. She stated she was not sure where the disconnect was or if the nurse that the FAM gave it to just forgot or what, but the resident did not get his medication started back up this last time on time. She stated she did not know exactly how many days the medication had been missed. During an interview on 08/09/2023 at 12:13 PM with MA F, she stated she was in-serviced 07/25/23 on medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause a change in resident's body or it could potentially cause harm. During an interview on 08/09/2023 at 1:16 PM with ADM and DON, they stated they had in-serviced staff 07/25/23 on medication administration. They stated medications should be given to residents as ordered by the physician. They stated if a resident was not given medications correctly, it would depend on the medication being given as to what reactions could occur. They stated if it was discovered that a medication was not given properly, the nurse should do an assessment on the resident and follow up with notifying the family and doctor. They stated Resident #1 received the chemotherapy medication from the FAM picking it up from the VA and bringing it to the facility. They stated the FAM called facility on 07/23/23 at 21:56 (9:56 PM) and spoke to a nurse and asked how many pills were left to see if he needed to re-order the medication, and that was how it was discovered Resident #1 was not currently receiving the medication. They stated that was when staff realized there was a full bottle of the medication on the medication cart. They stated Resident #1 took the medication for 21 days and off for 7 days, then it started back up and cycled routinely with that order. They stated when the FAM brought the most recent bottle of medication, resident had still not completed previous cycle of medication so nurse could not put the new cycle into the administration record. They stated they could not put the medication into the system to stop and restart the way the medication was ordered. They stated if a resident did not receive this type of medication, it could cause their blood count to be off. They stated they had in-serviced their staff on medication administration and receiving and accepting medications. They stated they had put the medication on a management board, and they discussed this medication every morning now to ensure that the dates were aligned, and the medication was available and being administered as ordered. They stated they had their clinical resource person to look into the system to see if there was any way to put it in the system with no resolution, and they had the pharmacy consultant to check for this as well. They stated if a resident did not receive this medication, it could cause his blood count to be off. They stated the VA informed them that they ran all of residents labs to check for any off blood counts and to make sure that everything looked ok or there was no changes from previous status. They stated resident went to the ONC at the VA every week and has done this throughout the time he was not receiving the medication and there were no adverse reactions. 08/09/2023 at 1:44 PM Attempted to reach the FAM, no answer, left message for return call. During an interview on 08/09/2023 at 1:47 PM with the PA, she stated there was always a potential for harm or adverse reaction with any medication that is missed or not taken. She stated any medication being missed could certainly cause side effects. 08/09/2023 at 1:56 PM Call placed to the ONC, doctor was not available to speak to surveyor. During an interview on 08/09/2023 at 1:58 PM with the PHARM, she stated the only potential thing that could have occurred would have been the progression of cancer. During an interview on 08/09/2023 at 2:14 PM with Resident #1, he stated he just got back from the VA, and he goes to the VA every week because he has cancer. He stated he liked it here and the staff all treated him well. He stated he was told about missing his cancer medication and his FAM talked to him about it also. He stated he has not had any problems or issues due to the medication being missed. He stated he did not realize he was missing any medication and he would not have known it if they did not tell him. He stated he feels safe here in the facility and he has no complaints about anything. He stated he uses a cane or walker for mobility, and he always gets to his appointments. During an interview on 08/09/2023 at 3:09 PM with LVN C, she stated they only received the chemotherapy medication orders from the new bottles of medication when Resident #'s family brought it to them. She stated the only order they had for the medication is what the medication bottle says and from the original paperwork when the resident first started the medication. An immediate Jeopardy (IJ) was identified on 08/09/2023 at 3:30 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Survey team monitored the plan of removal as follows: The Plan of Removal was accepted on 08/11/2023 at 1:50 PM and is as follows: DON assessed resident #1 on 8/9/2023 for new or worsening symptoms associated with his multiple myeloma or adverse side effects of the missed medication including increased pain or neurological symptoms. The attending physician and ONC were notified of medication error and no new orders were given with the exception of restarting medication immediately. The assessment did not reveal any obvious adverse effects related to the deficient practice. The Corporate Clinical Consultant provided education to the DON on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. DON/Designee completed education with all licensed nursing staff on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New staff, will be in-serviced during orientation period prior to working a shift. The DON/Designee completed an audit of all residents to establish which residents receive medications from outside pharmacies on 8/10/2023. 8 residents were identified through this audit. The DON/designee then conducted an audit of medication storage areas to validate that none of these residents' medications were missing and the administration record was reviewed for each resident to validate that there were no missed doses within the last 90 days on 8/10/2023. Care plans updated with directions of receiving from outside pharmacy, also initiated instructions RECEIVED FROM OUTSIDE PHARMACY No issues were identified related to missed doses or missing medication. DON/Designee completed education with all licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required licensed staff were educated on 8/10/2023 on entering orders correctly in Point Click Care for proper and error-free medication administration, and to include instructions 'RECEIVED FROM OUTSIDE PHARMACY as identification when medication is brought in from outside pharmacy, this education will be ongoing for all newly hired nurses. Sr [NAME] President of Clinical Services revised policy titled Medications Brought to the Facility by Resident/Family to having a signed receipt of accepting of the medication by licensed staff only, on 8/10/23. Director of Clinical Operations educated DON in regard to policy change. DON/Designee completed education with all licensed nursing staff informing this of this policy change. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New nursing staff and agency staff will be educated upon or upon initial shift at facility, ongoing. Education completed on 8/10/23. DON/designee completed a review of all residents to validate the availability of all medications on 8/9/2023. There were no concerns identified related to the availability of medications through this review. Director of Nursing/designee completed review of all residents to identify which medication are provided by outside pharmacy. 8 residents were identified. This review was completed on 8/9/2023. No concerns were identified related to missing medications or missed doses in the last 90 days for any of the 8 residents. The orders for the 8 residents identified were updated to reflect that meds are received from an outside Pharmacy to alert nursing staff that refills should not be requested from the house pharmacy on 8/9/2023. Corporate Clinical Consultant completed a review of the following policies on 8/10/2023: Pharmacy Services Overview, Administering Medications, Medications Brought into the Facility by Resident/Family, Accepting Delivery of Medications. Medications Brought into the Facility by Resident/Family policy was revised by Sr [NAME] President of Clinical Services to include signed acceptance receipt of medication, no other policy changes were made. Licensed nurses will communicate via 24 hour report and shift hand off of medications that were ordered and not received during shift. The Corporate Clinical Consultant completed education with the DON on 8/10/2023 on these policies and the procedure for receiving, ordering, and administering medications brought in by family or received from an outside pharmacy. The procedure is to include receipt of medication by a licensed nurse, notification of DON/designee, verification of order from the attending physician, verification of proper order entry in PCC to include notation that medication is received from and outside pharmacy, verification of proper labeling of medication container with medication and resident information, verification of quantity and type medication being delivered from outside pharmacy. The receiving nurse will be responsible for conducting the first check verification as medications are received and orders are entered and the DON/designee, will conduct the second check verification Monday-Friday in the morning clinical meeting to include needed medications for upcoming weekend, and any changes/needs from prior weekend. For after hours or weekends, the receiving nurse will contact on-call nurse manager and physician for any concerns related to supply of medications. The DON/designee completed education with licensed nurses on 8/10/2023 regarding the procedure to ensure that medications are received and administered according to ordered date, time, and frequency for residents whose medications are dispensed from an outside pharmacy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all licensed nursing staff were educated. Medications that are received from outside pharmacies will be entered with an additional note in the instruction section indicating that meds are 'RECEIVED FROM OUTSIDE PHARMACY with any additional information on the pharmacy name and/or who delivers the medication and how to obtain a refill. Communication will be shift to shift via 24 hour report, when medications are ordered or needed for licensed nurses to assure timely delivery. Education will be provided to all newly hired nurses prior to their first shift and all current staff have been educated as of 8/10/2023. DON/designee added orders with skipped days through end of calendar year, also added onto daily monitoring for review of ongoing order, on 8/10/2023. The DON/designee will conduct monitoring of new medication orders and medications stocked in medication carts/rooms/refrigerators to validate that medications received from outside pharmacies have orders entered appropriately in Point Click Care, that they are received and administered according to ordered date, time and frequency and that there is adequate stock remaining or that refill request has been initiated. Any concerns identified will be reported to the physician immediately upon identification with corrections made according to physician orders. Monitoring will occur, starting on 8/10/23, 3 times per week for 4 weeks then weekly for 2 months. Any trends identified will be reported to the QAPI Committee monthly and as needed until a lessor frequency until substantial compliance is achieved. QAPI meeting was held on 8/10/23 with the Medical Director, ADM, DON, and Nurse Management to review newly revised policy on medication brought in by family, and review and validate the plan of removal. The Administrator will be responsible for the implementation of ensuring the adequate process regarding Safe Medication Administration. The new processes/system was initiated, and all licensed nursing staff had completed education by 8/10/2023. This new process will be ongoing for new hires and agency staff prior to working a shift at the facility. All licensed nurses and medication aides were in-serviced. DON/designee used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated, completed on 8/10/23. During an interview on 08/09/2023 at 5:30 PM with the ADM, he stated there was only one resident in the facility who receives Chemotherapy. He stated there may have been others before and there were residents with a diagnosis of cancer, but none received chemotherapy now except Resident #1. On 08/09/23 at 5:36 PM Notified ADM of past non-compliance immediate jeopardy and provided ADM with immediate jeopardy template. During an interview on 08/10/2023 12:47 PM with ADM and DON, they stated the facility had a QAPI meeting the morning of 08/10/2023 with the medical director that addressed the medication error in incident but they had not had a meeting regarding medication errors in the past 3 months prior to surveyor entrance. Record review of staff in-service training report dated 07/25/2023 revealed nurses and medication aides were in-serviced on medication administration and medication orders. Record review of facility policy titled Administering Medications dated 2001 (Revised December 2012) revealed in policy statement: Medications should be given in a safe and timely manner, and as prescribed. Record review of facility policy titled Medications brought to the facility by the resident/family dated 2001 (revised April 2007) revealed Policy Statement: The facility shall ordinarily permit residents and families to bring medication into the facility. Policy Interpretation and Implementation: 3. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician, and Consultant Pharmacist, shall check to ensure that: b. The medications have been ordered by the resident's Attending Physician and documented on the physician's order sheet. Record review of facility policy titled Pharmacy Services Overview dated 2001 (revised April 2019) revealed Policy Statement: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medication and biologicals and the services of a licensed pharmacy consultant pharmacist. Policy Interpretation and Implementation: 4. Residents have sufficient supply of their prescribed medication and receive medications (routine, emergency or as needed) in a timely manner. 7. Medications are received, labeled, stored, administered and disposed of according to applicable state and federal laws and consistent with standards of practice. 9. The consultant pharmacist , in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including, (but not limited to): a. Acquisition and availability of medications: (4) Facility staff roles and responsibilities during the receipt and storage of medications; b. Medication packaging and dispensing systems; c. Administration of medication; d. Disposition of medications; e. Authorization, training, and competency of personnel; and f. Documentation of processes, as applicable. 08/11/23 10:30am DON stated that on 07/25/23, that there was an alert added to the facility's clinical white board for Resident #1's chemotherapy medication to be re-added to the facility electronic recording system. DON stated that the white board was reviewed daily by the facility's clinical team Administrator, ADON's, DON, Therapy, Social Worker). On 08/11/2023 at 1:50 PM at exit, the facility was notified that the IJ was lowered. However, the facility remained out of compliance at a severity level no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents , for one (Resident #1) of 9 residents reviewed for medication use using medications that are brought in by outside pharmacies or families, in that: 1. The facility failed to ensure Resident #1 received his chemotherapy medication for 17 days (07/07/23 to 07/23/23) after medication was delivered to the facility (between 06/29/23 and 07/07/23) for 1 of 9 residents reviewed for medication administration. Resident #1 should have restarted medication on 07/07/23. Medication error was discovered when FAM called to see if medication needed to be replenished and medication was started again on 07/24/23, which Resident #1 to not receive medication as ordered for 17 days. 2. The facility failed to have a system or policy in place with guidance for staff to check in and follow up on orders for medications brought to the facility from an outside pharmacy or family. An IJ was identified on 08/10/23. The IJ template was provided to the facility on [DATE] at 10:37 AM. While the IJ was removed on 08/11/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not IJ scoped at a pattern, due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed resident at risk of deterioration in health, worsening of cancer, extended recoveries, hospitalization s. Findings included: Record review of Resident #1's admission record dated 08/09/23 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included, multiple myeloma not having achieved remission (a cancer of plasma cells, a type of white blood cell, that normally produces antibodies), dysphagia (difficulty in swallowing food or liquid), anxiety disorder (feeling nervous, restless or tense or having a sense of impending danger, panic or doom), cognitive communication deficit (difficulty with thinking or how someone uses language), diabetes (a group of diseases that result in too much sugar in the blood), and PTSD (post-traumatic stress disorder)(a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 13, which indicated he was cognitively intact and required supervision and set-up help only with all activities except bathing which revealed he was independent with and required no setup or physical help from staff. Record review of Resident #1's physician orders dated 08/09/23 revealed order for Revlimid Oral Capsule 25 MG (Lenalidomide) Give 1 capsule by mouth at bedtime for RECEIVED FROM OUTSIDE PHARMACY related to MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION (C90.00) until 08/14/2023 23:59 wear gloves with med administration/ do not given if broken--- NOTIFY ADON/DON WHEN 7 PILLS REMAIN-- SO ORDER CAN BE DONE******** Record review of Resident #1's Nursing Progress Note, dated 7/23/2023 21:56 (9:56 PM) revealed the following: Residents son asked this nurse how many capsules does resident have left Revlimid 25mg. This nurse noted bottle sealed and has not been opened. RP upset d/t resident has not been getting his Revlimid medication and next dosage of 21 days is soon to come up again. This nurse noted residents last dose of Revlimid was around 6/30/23. NP notified of missed medication video call this nurse via spruce new order to restart Revlimid 25mg as ordered and notify VA DR. ADON, RP, VA notified. Revlimid ID'd at 2000 (8:00 PM) with narn. vs: 117/75, 74, 18, 97.5, SPO2 96% RA. Record review of Resident #1's MAR for June 2023 revealed Revlimid Oral Capsule 25 MG was administered on June 1st and 2nd and then June 9th through 29th at 6:00 PM. Record review of Resident #1's MAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 24th at 6:00 PM. Record review of Resident #1's TAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 25th through 31st at 6:00 PM. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 1st through 8th at 6:00 PM. Revlimid Oral Capsule 25 MG (Lenalidomide) 1 capsule by mouth at bedtime. This medication is a chemotherapy and is used to treat multiple myeloma not having achieved remission, which is a cancer of plasma cells, a type of white blood cell, that normally produces antibodies per Google. Record review of Resident #1's care plan dated 07/25/2023 revealed resident takes cancer medication Revlimid. Cycles on medication for 21 days and off for 7 days- (Medication supplied by the VA Pharmacy/ resident's FAM brings medication to facility) Goals: Staff to assure medication is administered per orders through review period. Interventions: Monitor for adverse reactions- which include- hypersensitivity, angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes), [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucous membranes that is often a reaction to medication or an infection), toxic epidermal necrolysis (a life threatening skin disorder characterized by a blistering or peeling of the skin), Tumor Lysis Syndrome (a group of metabolic abnormalities that can occur as a complication from the treatment of cancer), hepatotoxicity (injury or impairment of the liver function caused by exposure to xenobiotics such as drugs, food additives, alcohol, chlorinated solvents, peroxidized fatty acids, fungal toxins, radioactive isotopes, environmental toxicants, and even some medicinal plants), thrombocytopenia (a low number of platelets in the blood), neutropenia, pruritis (itching), rash, fatigue, constipation, nausea. Staff to assure that medication is swallowed whole and not chewed. Staff to wear gloves with administration of this medication. Record review of facility policy titled Medications brought to the facility by the resident/family dated 2001 (revised April 2007) revealed Policy Statement: The facility shall ordinarily not permit residents and families to bring medication into the facility. Policy Interpretation and Implementation: 3. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician, and Consultant Pharmacist, shall check to ensure that: b. The medications have been ordered by the resident's Attending Physician and documented on the physician's order sheet. During an interview on 08/09/2023 11:16 AM with MA E, she stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause major side effects. She stated a blood pressure medication could cause a blood pressure to rise or fall, aspirin could cause heart problems, and Depakote could cause agitation, and missing a medication could even cause death depending on the medication. She stated she was in-serviced regularly on abuse/neglect and medication administration. During an interview on 08/09/2023 11:44 AM with LVN A, he stated medications should be given to residents as ordered by the physician. He stated if a resident was not given medications correctly, it could potentially cause adverse reactions. He stated he was in-serviced regularly on abuse/neglect and medication administration. During an interview on 08/09/2023 11:55 AM with LVN B, she stated she was in-serviced regularly on abuse/neglect and medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause adverse side effects, delayed action of medication for whatever it was supposed to cure, or if it's for a preventative measure, whatever it was supposed to prevent could occur. She stated Resident # 1's medication came from the VA. She stated the son picked the medication up and dropped it off at the facility. She stated the medication did not come from their pharmacy, and they did not order it. She stated Resident #1 took the medication for 21 days and was off of the medication for 7 days and it continuously cycled that way. She stated she was not sure where the disconnect was, where the medication was brought in and the order was not put in the system to be administered, or if the nurse that the FAM gave it to just forgot or what, but the resident did not get his medication started back up this last time on time. She stated she did not know exactly how many days the medication had been missed. During an interview on 08/09/2023 12:13 PM with MA F, she stated she was in-serviced regularly on abuse/neglect and medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause a change in residents body or it could potentially cause harm. During an interview on 08/09/2023 at 1:16 PM with ADM and DON, they stated they were in-servicing staff regularly on medication administration. They stated medications should be given to residents as ordered by the physician. They stated if a resident was not given medications correctly, it would depend on the medication being given as to what reactions could occur. They stated if it was discovered that a medication was not given properly, the nurse should do an assessment on the resident and follow up with notifying the family and doctor. They stated Resident #1 received the chemotherapy medication from the FAM picking it up from the VA and bringing it to the facility. They stated the FAM called facility on 07/23/23 at 21:56 (9:56 PM) and spoke to a nurse and asked how many pills were left to see if he needed to re-order the medication, and that was how it was discovered Resident #1 was not currently receiving the medication. They stated that was when staff realized there was a full bottle of the medication on the medication cart. They stated Resident #1 took the medication for 21 days and off for 7 days, then it started back up and cycled routinely with that order. They stated when the FAM brought the most recent bottle of medication, resident had still not completed previous cycle of medication so nurse could not put the new cycle into the administration record. They stated they could not put the medication into the system to stop and restart the way the medication was ordered. They stated if a resident did not receive this type of medication, it could cause their blood count to be off. They stated they had in-serviced their staff on medication administration and receiving and accepting medications. They stated they had put the medication on a management board, and they discussed this medication every morning now to ensure that the dates were aligned, and the medication was available and being administered as ordered. They stated they had their clinical resource person to look into the system to see if there was any way to put it in the system with no resolution, and they had the pharmacy consultant to check for this as well. They stated if a resident did not receive this medication, it could cause his blood count to be off. They stated the VA informed them that they ran all of residents labs to check for any off blood counts and to make sure that everything looked ok or there was no changes from previous status. They stated resident went to the ONC at the VA every week and has done this throughout the time he was not receiving the medication and there were no adverse reactions. During an interview on 08/09/2023 1:47 PM with PA, she stated there was always a potential for harm or adverse reaction with any medication that is missed or not taken. She stated any medication being missed could certainly cause side effects. 08/09/2023 1:56 PM Call placed to ONC, doctor was not available to speak to surveyor. During an interview on 08/09/2023 at 1:58 PM with PHARM, he stated the only potential thing that could have occurred would have been the progression of cancer. During an interview on 08/09/2023 at 2:14 PM with Resident #1, he stated he just got back from the VA, and he goes to the VA every week because he has cancer. He stated liked it here and the staff all treated him well. He stated he was told about missing his cancer medication and his son talked to him about it also. He stated he has not had any problems or issues due to the medication being missed. He stated he did not realize he was missing any medication and he would not have known it if they didn't tell him. He stated he feels safe here in the facility and he has no complaints about nothing. He stated he uses a cane or walker for mobility, and he always gets to his appointments. During an interview on 08/09/2023 3:09 PM with LVN C, she stated they only received the chemotherapy medication orders from the new bottles of medication when the residents family brought it to them. She stated the only order they had for the medication is what the medication bottle says and from the original paperwork when resident first started the medication. 08/09/2023 Record reviewed of physician orders dated 04/07/23 and 07/26/23 and signed by ONC, received by LVN C which revealed Lenalidomide 25 mg po daily x 21 days then, 1 week off (next cycle to start once completed prior 21 day supply and 1 week off). During an interview on 08/09/2023 5:30 PM with ADM, he stated there was only one resident in the facility which receives Chemotherapy. He stated there may have been others before and there were residents with a diagnosis of cancer, but none received chemotherapy now except the one in incident. 08/09/23 Record review of facility policy titled Administering Medications dated 2001 (Revised December 2012) revealed in policy statement: Medications should be given in a safe and timely manner, and as prescribed. Record review of staff in-service training report dated 07/25/2023 revealed nurses and medication aides were in-serviced on medication administration and medication orders. 08/09/23 4:31 PM Record review of facility policy titled Accepting Delivery of Medications which is not dated revealed Policy heading: 1. All staff follow a consistent procedure in accepting medications. Policy Interpretation and Implementation 4. A nurse signs the delivery ticket, indicating review and acceptance of the delivery, and keeps a copy of the delivery ticket. Both the nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket is archived in a designated location. An immediate Jeopardy (IJ) was identified on 08/10/2023 at 10:15 AM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Survey team monitored the plan of removal as follows: The Plan of Removal was accepted on 08/11/2023 at 1:50 PM and is as follows: DON assessed resident #1 on 8/9/2023 for new or worsening symptoms associated with his multiple myeloma or adverse side effects of the missed medication including increased pain or neurological symptoms. The attending physician and ONC were notified of medication error and no new orders were given with the exception of restarting medication immediately. The assessment did not reveal any obvious adverse effects related to the deficient practice. The Corporate Clinical Consultant provided education to the DON on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. DON/Designee completed education with all licensed nursing staff on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New staff, will be in-serviced during orientation period prior to working a shift. The DON/Designee completed an audit of all residents to establish which residents receive medications from outside pharmacies on 8/10/2023. 8 residents were identified through this audit. The DON/designee then conducted an audit of medication storage areas to validate that none of these residents' medications were missing and the administration record was reviewed for each resident to validate that there were no missed doses within the last 90 days on 8/10/2023. Care plans updated with directions of receiving from outside pharmacy, also initiated instructions RECEIVED FROM OUTSIDE PHARMACY No issues were identified related to missed doses or missing medication. DON/Designee completed education with all licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required licensed staff were educated on 8/10/2023 on entering orders correctly in Point Click Care for proper and error-free medication administration, and to include instructions 'RECEIVED FROM OUTSIDE PHARMACY as identification when medication is brought in from outside pharmacy, this education will be ongoing for all newly hired nurses. Sr [NAME] President of Clinical Services revised policy titled Medications Brought to the Facility by Resident/Family to having a signed receipt of accepting of the medication by licensed staff only, on 8/10/23. Director of Clinical Operations educated DON in regard to policy change. DON/Designee completed education with all licensed nursing staff informing this of this policy change. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New nursing staff and agency staff will be educated upon or upon initial shift at facility, ongoing. Education completed on 8/10/23. DON/designee completed a review of all residents to validate the availability of all medications on 8/9/2023. There were no concerns identified related to the availability of medications through this review. Director of Nursing/designee completed review of all residents to identify which medication are provided by outside pharmacy. 8 residents were identified. This review was completed on 8/9/2023. No concerns were identified related to missing medications or missed doses in the last 90 days for any of the 8 residents. The orders for the 8 residents identified were updated to reflect that meds are received from an outside Pharmacy to alert nursing staff that refills should not be requested from the house pharmacy on 8/9/2023. Corporate Clinical Consultant completed a review of the following policies on 8/10/2023: Pharmacy Services Overview, Administering Medications, Medications Brought into the Facility by Resident/Family, Accepting Delivery of Medications. Medications Brought into the Facility by Resident/Family policy was revised by Sr [NAME] President of Clinical Services to include signed acceptance receipt of medication, no other policy changes were made. Licensed nurses will communicate via 24 hour report and shift hand off of medications that were ordered and not received during shift. The Corporate Clinical Consultant completed education with the DON on 8/10/2023 on these policies and the procedure for receiving, ordering, and administering medications brought in by family or received from an outside pharmacy. The procedure is to include receipt of medication by a licensed nurse, notification of DON/designee, verification of order from the attending physician, verification of proper order entry in PCC to include notation that medication is received from and outside pharmacy, verification of proper labeling of medication container with medication and resident information, verification of quantity and type medication being delivered from outside pharmacy. The receiving nurse will be responsible for conducting the first check verification as medications are received and orders are entered and the DON/designee, will conduct the second check verification Monday-Friday in the morning clinical meeting to include needed medications for upcoming weekend, and any changes/needs from prior weekend. For after hours or weekends, the receiving nurse will contact on-call nurse manager and physician for any concerns related to supply of medications. The DON/designee completed education with licensed nurses on 8/10/2023 regarding the procedure to ensure that medications are received and administered according to ordered date, time, and frequency for residents whose medications are dispensed from an outside pharmacy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all licensed nursing staff were educated. Medications that are received from outside pharmacies will be entered with an additional note in the instruction section indicating that meds are 'RECEIVED FROM OUTSIDE PHARMACY with any additional information on the pharmacy name and/or who delivers the medication and how to obtain a refill. Communication will be shift to shift via 24 hour report, when medications are ordered or needed for licensed nurses to assure timely delivery. Education will be provided to all newly hired nurses prior to their first shift and all current staff have been educated as of 8/10/2023. DON/designee added orders with skipped days through end of calendar year, also added onto daily monitoring for review of ongoing order, on 8/10/2023. The DON/designee will conduct monitoring of new medication orders and medications stocked in medication carts/rooms/refrigerators to validate that medications received from outside pharmacies have orders entered appropriately in Point Click Care, that they are received and administered according to ordered date, time and frequency and that there is adequate stock remaining or that refill request has been initiated. Any concerns identified will be reported to the physician immediately upon identification with corrections made according to physician orders. Monitoring will occur, starting on 8/10/23, 3 times per week for 4 weeks then weekly for 2 months. Any trends identified will be reported to the QAPI Committee monthly and as needed until a lessor frequency until substantial compliance is achieved. QAPI meeting was held on 8/10/23 with the Medical Director, ADM, DON, and Nurse Management to review newly revised policy on medication brought in by family, and review and validate the plan of removal. The Administrator will be responsible for the implementation of ensuring the adequate process regarding Safe Medication Administration. The new processes/system was initiated, and all licensed nursing staff had completed education by 8/10/2023. This new process will be ongoing for new hires and agency staff prior to working a shift at the facility. All licensed nurses and medication aides were in-serviced. DON/designee used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated, completed on 8/10/23. Monitoring was conducted from 08/10/2023 through 08/11/2023. During an interview on 08/10/2023 at 12:47 PM with the ADM and DON, they stated the facility had a QAPI meeting the morning of 08/10/2023 with the medical director included addressing the medication error in incident but they had not had a meeting regarding medication errors in the past 3 months prior to surveyor entrance. During an interview on 08/10/2023 at 12:58 PM with LVN A, he stated he had recently been in-serviced by management regarding medication administration, receiving medications, how to put the medication in the system, and when medications come in from an outside pharmacy or family. He stated the in-service taught him if the medicine comes in from an outside pharmacy or the family delivered it, to specifically make a progress note to say that the medication came in. He stated he would write that additional note in the system and label the bottle or card that comes from the pharmacy. He stated he was informed on and had reviewed the policies for medication administration, receiving medications, and receiving medications from an outside pharmacy. He stated he had never been given medication from hospice from an outside pharmacy but that always had an order prior to medication being delivered and he had to sign a receipt of delivery. During an interview on 08/10/2023 at 1:15 PM with LVN D, she stated she had recently been in-serviced by management that morning regarding medication administration, pharmacy protocols, medication coming in from the pharmacy and outside pharmacy or families protocol, and basically everything that had to do with medications coming into the facility. She stated there was a sheet that they will be signing and documenting on when receiving a medication from an outside pharmacy or family member. She stated the in-service taught her to document and double check everything and leave it in the book to refer to. She stated she would sign in any medications received from an outside pharmacy or family member and document that she received it. She stated would also check to make sure there are orders for the medications and verify that the orders have been transcribed into the MAR's or TAR's. She stated she was informed on and had reviewed the policies for incoming medications, medication administration, and signing in medications and checking orders. She stated she had not been given medication that was brought in from an outside pharmacy or family member that she can recall. During an interview on 08/10/23 at 1:31 PM with MA F, she stated she had recently been in-serviced by management regarding medications that are coming in from outside of the facility pharmacy or family members. She stated the in-service taught her that any medication given to her will go directly to the nurse and that it should be noted on the MAR's if the medication came from their pharmacy, an outside pharmacy, or family. She stated she would re-direct whoever is bringing the medication to the nurse so the nurse could sign the medications in. She stated she was informed on and had reviewed the policies for medications coming from family or other pharmacies and to check and make sure everything was correct on their MAR's. She stated she had not been given medication that was brought in from an outside pharmacy or family before. During an interview on 08/10/2023 at 1:36 PM with MA E, she stated she had recently been in-serviced by management this morning regarding family bringing in medication and pharmacy bringing in medication. She stated the in-service taught her that if a family member brings in medication that she was to re-direct them to take the medication from the nurse and if the medication comes from an outside pharmacy there was to be a note put in the system to show the medication was received. She stated she would direct family to give any medication to the nurses if they try to bring it to her. She stated she was informed on and had reviewed the policies for receiving medication from families or outside pharmacies. She stated there were 3 in-services, but she could not remember all of the exact names of the policies. She stated she had not been given medication that was brought in from an outside pharmacy or family before. She stated she had family and pharmacies try to give her medications, but she had been taught from the beginning to not accept or sign for any medications and to re-direct them to the nurse. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 9th at 6:00 PM. Medication was administered correctly during this time. On 08/11/23 at 9:30am - Monitoring visit conducted in facility. 08/11/23 Reviewed facility in-servicing for staff that covered Medications Brought to the Facility by the Residents/Family, Receiving Medication from Outside Pharmacy and Pharmacy Services Overview dated 08/10/2023. Reviewed MAR's for the sampled residents: All reviewed residents have a note added with the medication order stating the order comes from an outside pharmacy. Interview on 08/11/23 at 10:30am - DON stated that nurses and MA's are being in-serviced on the Medications Brought to the Facility by the Residents/Family policy, the procedure for Receiving Medication from Outside Pharmacy and Pharmacy Services Overview. DON stated that the facility's nurses and MA's are receiving the services prior to working their shift. DON stated some staff are receiving the training verbally and some in person to ensure all staff were trained immediately. DON stated that she asked all staff if they understood the training, and all replied yes. DON stated the facility implemented a receipt of medication brought in by the resident/family. Nurse reviewing and family member bringing medication in had to be signed and dated. DON stated there is a sticker placed on the medication that states it is from another pharmacy and a note entered with the order from other pharmacy or provided by family. DON stated that there was an alert added the facility's clinical white board for Resident #1 chemotherapy medication to be re-added to PCC. DON stated that PCC will not allow medication to be added more than 3 months at a time. DON stated that the white board is reviewed daily by the facility's clinical team Administrator, ADONs, DON, Therapy, Social Worker. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 10th at 6:00 PM. Medication was administered as ordered. Reviewed change to Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. Reviewed care plans for Resident #'s 1-9, care plans were updated to reveal medications were brought in from outside sources such as family or other pharmacies. On 08/11/23 at 11:45am - MA E stated she has been trained on Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. MA E stated she understood the training and has no issues or concerns. On 08/11/23 at 12:15pm - MA F stated she has been trained on Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. MA F stated she understood the training and has no issues or concerns. On 08/11/23 at 12:30pm - LVN G stated she has been trained on Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. LVN G stated she understood the training and has no issues or concerns. On 08/11/23 at 12:45pm - LVN H stated she has been trained on Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medicat [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for one (1) of seven (7) residents (Resident #1) reviewed for sexual abuse. The facility failed to put interventions into place when they admitted a resident (Resident #2) on 02/23/22 that had previous inappropriate sexual behaviors. As a result, Resident #2, who resided on the secured unit, was seen on video footage sexually abused Resident #1, for approximately 43 minutes on 06/19/22. An Immediate Jeopardy (IJ) was identified on 06/21/2022 at 5:15 p.m. While the IJ was removed on 6/22/22 at 6:15 p.m., the facility remained out of compliance at a scope of pattern with actual harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective actions. This failure placed female residents in the locked unit at risk of being sexually abused, contracting sexually transmitted diseases, and physical and emotional harm. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), Parkinson's disease (a chronic and progressive movement disorder), cognitive communication deficit, vascular dementia (a condition that causes problems with reasoning, planning, judgment, and memory), anxiety disorder, and recurrent depressive disorders. Record review of Resident #1's significant change MDS assessment, dated 02/02/22, reflected a BIMS of 7, which indicated a severe cognitive impairment. The assessment reflected Resident #1 had inattention and disorganized thinking fluctuations that changed in severity. Resident #1 required extensive assistance in dressing and hygiene. She required supervision to transfer, she used a wheelchair to ambulate. Record review of Resident #1's care plan, revised 02/11/22, reflected she had a terminal prognosis related to Parkinson's disease and was admitted to (hospice agency) with an intervention of working with nursing staff to provide maximum comfort for the resident. It further reflected she resided on the memory care secured unit due to aimless wandering. She had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and dementia. Record review of Resident #1's psychiatric progress note, dated 04/11/22, reflected she had neurocognitive disorders which included major and mild neurocognitive disorders due to Alzheimer's disease. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) and mild cognitive impairment. Record review of the referral documentation from Resident #2's previous facility reflected: Fax face sheet to Resident #2's facility, dated 02/22/22, reflected [Resident #2] is in need of a secured memory care unit due to wandering behaviors. Referral documentation submitted to the facility included: A MAR dated 02/01/22 through 02/28/22 that documented Resident #2 began receiving Buspirone HCL 5 mg tablet twice per day for inappropriate sexual behaviors. The first dose given to Resident #2 was the evening dose on 02/08/22. Although Resident #2 entered the previous facility on 01/25/22, the nurses notes in the referral from the previous facility to the current facility began on 02/09/22. The facility did not receive notes to determine what occurred on 02/08/22 to initiate Buspirone for inappropriate sexual behaviors. There was no evidence the current facility requested additional information regarding the diagnoses and treatment on 02/08/22. In the nurses notes provided to the facility from 02/09/22 through 02/22/22 Resident #2 was documented as going into other resident rooms daily from 02/09/22 through 02/21/22 (daily for 23 days). He was noted attempting to leave through exit doors on 02/17/22, 02/18/22 and the resident had a wander guard documented on 02/20/22 (three days). On 02/12/22 documentation included Resident has not said anything sexually inappropriate this evening. On 02/15/22 documentation included .Remains on .and Buspar 5 mg one tab BID for sexual inappropriateness and both are effective. On 02/16/22 documentation included .Easily redirected but, constant supervision is required . On 02/21/22 in addition to documentation of wandering into resident rooms Resident #2 followed a staff member into the bathroom. The staff member had completed using the restroom and nothing was seen, however, Resident #2 patted the staff member on the thigh and said she had some big thighs. Also documented was .he has to be watched continuously while awake. Record review of Resident #2's nurse's notes from the facility reflected the resident was admitted to the facility on [DATE] at 10:04 p.m. Record review of Resident #2's Admission MDS, assessment, dated 02/28/22, reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #2 was assessed as being sometimes understood and sometimes understands. His inattention and disorganized thinking comes and goes and changes within severity. He showed verbal behaviors directed at others one to three times during the look back period. It was noted wandering behaviors occurred daily. He did not use a mobility device to ambulate. Record review of Resident #2's quarterly MDS assessment, dated 03/25/22, reflected a BIMS of 4, which indicated severe cognitive impairment. Record review of Resident #2's initial care plan, dated 02/24/22, reflected there was not a plan for inappropriate sexual behaviors with staff or residents. Record review of the Physician's History and Physical, dated 03/01/22, reflected under Assessment and Plan Inappropriate Sexual Behaviors in dementia. On Buspar (Buspirone) 5 mg BID. This assessment was signed by the PA. Record review of Resident #2's physician orders reflected an order for Buspirone HCL Tablet 5 mg, revised 02/23/24, with a start date of 02/24/22, reflected the medication was for behaviors. There was no mention of the past sexually inappropriate behaviors as documented on the physician order at the previous facility. There was no order for monitoring of the behaviors documented on the Buspirone order. Record review of Resident #2's Behavior Monitoring sheets from 02/23/22 through 06/21/22 reflected the resident was not monitored for behaviors associated with the Buspirone order. Record review of Resident #2's Progress Notes reflected: 02/27/22 - Resident is seen attempting to open doors to other residents [rooms] this morning. This nurse redirected resident back to hallway and to come with this nurse to nurses desk. Written by LVN G. 02/28/22 - Resident ambulating back down hallway towards his room. Resident starts to go into others rooms and this nurse redirected resident back out of others rooms and helped resident to reoriented resident where his room is. Written by LVN G. 03/03/22 - Resident continues to go into other resident's room that are opposite gender. Redirection from nursing aide and this nurse were unsuccessful several times. Resident is able to understand he cannot go into other rooms that are females and continues to do so. Written by LVN C. 03/04/22 - Occasionally when the resident is up ambulating down the hallway the resident will look in on other residents in room and attempt to go into their rooms. This nurse and staff will redirect every episode. This nurse reeducated resident not to go into others' rooms. Written by LVN G. 03/04/22 - Resident observed trying to go into room [room # - another female resident room other than Resident #1]. Staff tried to advise resident of where his room was however resident stated, I can go wherever I want to go. Written by LVN H. 03/14/22 - This nurse was advised by an aide on the hall that the resident was trying to kiss her while assisting with shower. This nurse advised resident of inappropriate behavior. Written by LVN H. 03/16/22 - Resident [Resident #2] continues to go into Room [Resident #1's room number] and 609 [another female's room] when being redirected several times by staff to his room and verbally told what his room number is. Resident made comment to this nurse that you would be alright going with a black man. This nurse redirected resident and stated that I am his nurse and he is a resident here. Written by LVN C. 03/23/22 - Social Worker made phone call to resident's [FM], in regard to resident needing a psych consult for his behaviors. He is being verbally aggressive and threatening staff. [FM] states she agrees and gives verbal ok. There was no indication the psych consult was for entering female residents rooms or inappropriate sexual behavior. Written by the SW. 03/31/22 - This nurse was notified by aide on hall that resident was being inappropriate with her while providing incontinent care and shower. Resident rubbed aide on her bottom and stated, I don't know what to do with all this. ADON notified. Resident 2 person assist going forward. Written by LVN H. Record review of Resident #2's Care Plan, dated 03/31/22, reflected Resident #2 sometimes demonstrated sexually inappropriate behaviors exhibited by inappropriate touching, climbing into bed with female residents, and kissing female residents. Resident becomes inappropriate with staff by groping female staff members. The care plan reflected it was added by the ADON. Interventions included: To help the resident avoid situations or people that tend to trigger these behaviors. If the inappropriate behavior is displayed, to quietly attempt to re-direct him and remind him the behavior is not appropriate. To help him maintain safe hygiene with the assistance of two staff. Refer him to his psychologist/psychiatrist as needed; and Treat him with dignity and respect regardless of the behaviors. In an interview on 08/05/22 at 2:25 p.m. the MDS Nurse stated she did not put the 03/31/22 care plan in place for Resident #2 and she did not recall what occurred to initiate this care plan. She stated she was working on care plans during this time with the ADON. In an interview on 08//05/22 at 2:45 p.m. the ADON stated she did not know what occurred to initiate the care plan on 03/31/22. She stated she did read the information regarding Resident #2 being on Buspirone for inappropriate sexual behaviors but she had not known of any incidents with residents prior to 03/31/22 but had heard of incidents with female staff. She stated she did not remember anyone advising her they observed these behaviors from Resident #2. Continued Record review of Resident #2's Progress Notes reflected: 04/01/22 - This nurse notified by nurse aid that resident is going into other resident's room and slamming door and when staff is trying to redirect resident out of other resident's rooms resident is being aggressive cursing saying he is going to knock the (explicit) out of them. This nurse notified on call services regarding resident's behaviors. This nurse spoke with the PA and she gave this nurse new order for Ativan 1 mg 1 tab orally one time dose. Written by LVN C. 04/15/22 - Resident #2 was seen by psych services and a psychological evaluation was conducted. Resident #2 was referred to psychological services for Adjustment Difficulty, Agitation, Anger, Anxiety, Aggressive Behaviors, Verbal, Physical, Resistance to ADL/Meds, Restlessness, Wandering, Confusion. Patient has been threatening staff, and cussing. The evaluation reflected Resident #2 was being seen 04/15/22 for the management of psychotropic medications and side effects, and to monitor the effect of medication. The patient's psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the patient's condition, to prevent relapse or hospitalization and to improve restorative potential. Staff report frequent mood swings and emotional instability. He becomes angry and frustrated due to confusion. The psychological evaluation reflected the medication Buspar (Buspirone) for behaviors. It did not reflect inappropriate sexual behaviors. There was no plan in place on this psychological eval to address Resident #2's inappropriate sexual behaviors. Written by the NP. Record review of Resident #2's psychiatric progress note, dated 04/22/22, reflected the following: Patient has displayed symptoms such as .poor decision-making skills, sexually inappro priate behaviors There was no plan documented in the psychiatric progress note for the sexually inappropriate behaviors. Continued record review of Resident #2's Progress notes reflected: 04/23/22 through 04/28/22 - Daily Skilled Nursing notes reflected Resident #2 was frequently redirected out of other residents doorways on this 10-6 shift due to other residents are resting and resident is trying to wake other residents up. [Not all of these notes indicated who wrote them.] 04/29/22 - After resident consumed his lunch resident was pacing back and forth up and down hallway and attempts several times to go into [Resident #1's room number] room. This nurse redirected resident several times by walking him back to his room and reiterated that he cannot go into females rooms. Resident shook his head up and down and waving arms everywhere stating, I know, I know and getting upset. This nurse told resident that everyone is told that they cannot go into each other's rooms. Will continue to observe resident for any further behaviors during shift. Written by LVN C. 05/18/22 at 12:54 a.m. - Resident continues to follow patient [Resident #1's room number] into room. Staff keep redirecting resident out of room. Resident was in room earlier using restroom, staff removed him once again from [Resident #1's room number] room. Throughout shift, resident has been noted holding hands with other resident [Resident #1] and noted to be sitting in the TV room hugging. Staff has been redirecting Resident #2 throughout out shift. [It is unknown who documented this note] 05/18/22 at 12:07 p.m. - This resident keeps following resident [Resident #1's room number] back to the edge of her doorway, standing in hallway hugging on her and getting close to her. Redirection from staff multiple times unsuccessfully. Written by LVN C. 05/19/22 at 4:47 p.m. - CNA notified this nurse that at beginning of shift she noted resident and another resident in TV room close to each other. CNA states they were probably kissing. Both residents were removed from each other. [There was no documentation as to who wrote this note.] Record review of Resident #1's Progress Notes dated 05/19/22 reflected she was the resident in the TV room with Resident #2. There Record review of both of Resident #1 and Resident #2's Progress notes, dated 05/19/22, reflected the residents were observed standing in hallway hugging each other. Upon redirect the residents separated. Later Resident #1 was observed sitting in her doorway telling Resident #1 to come on in. Resident #2 was advised not to go into Resident #1's room. Resident #1 became upset. Will continue to monitor. Written by LVN H. Record review of Resident #1's Progress Notes dated, 06/19/22 at 8:47 p.m., reflected the aide (CNA F) instructed the nurse to come assess this resident (Resident #1) because another male resident (Resident #2) was in her room and it was unknown what occurred while he was there. The male resident was removed from the room and this nurse (LVN E) looked at Resident #1's body and questioned the resident. Questions were did anyone touch you? Do you know what he was doing in the room? Can you explain to me what happened while he was in the room? Resident #1 was confused and said, oh no no nothing like that. Resident #1 was assisted into bed by the nurse and while this was taking place the nurse asked the resident if she was afraid or had any problems with the male resident. Resident #1 said how could I he's so sweet. Resident #1 remained in bed since the assessment. The male resident has also remained in his bed since the incident. The male resident was questioned and asked roughly the same questions. Resident #2 stated he only touched Resident #1 on the leg around her lower knee. While the nurse was at nurse's station a call was received from Resident #1's FM. The FM was very concerned with the things that were going on in the resident's room while he [Resident #2] was in there. During the conversations with the FM, the nurse asked questions and the FM was mostly concerned with the fact that she does not want it to continue to happen and that things like this do not happen when she (Resident #1) had a roommate. The FM was very upset about the situation, but stated she understands that people on the secured unit wander. After the phone call with the FM, she is expecting a return phone call from the ADM but stated it did not have to be tonight. The ADON was informed along with the ADM. The ADM said he is going to call the FM tomorrow. The male resident (Resident #2) was placed on 15 minute checks and is in his room at the time. Written by LVN E. During a phone interview on 06/21/22 at 9:33 a.m. with Resident #1's FM, she stated she had a surveillance camera in Resident #1's room. She stated she checked in on Resident #1 on 06/19/22 around 7:50 p.m. She stated there was footage of Resident #2 going into Resident #1's room and sexually assaulting her for 43 minutes. She stated he started by kissing and embracing her. The FM stated Resident #1 had always been an affectionate person and at first was embracing him back. She stated when Resident #2 began taking off his clothes and Resident #1's pants at which point she sat in her wheelchair and no longer participated. She stated there was a point in the video when he was seen fondling her vagina and kissing her breasts. She stated he ended up laying on her bed and masturbating while she sat in her wheelchair. She stated Resident #1 had dementia and did not have the ability to consent to sexual acts. She stated Resident # 1 had a history of sexual abuse from her past and could not even imagine what she had gone through and her emotional state, although the resident would be unable to express it. She stated when she called and spoke to a nurse (LVN E) on 06/19/22, after 8:00 p.m., when she had seen the footage, the nurse told her it was too late to call the ADM and he would be calling her the next day, which she found inappropriate, but did not know the rules and did not want to cause any drama. She stated she asked the nurse why no one thought to see where Resident #2 was for 43 minutes, and the nurse told her, Well, it was close to 8:00 p.m. and everyone was in bed. The FM stated that was not true, because in the video footage, there was a resident seen opening the door and rolling herself in with her wheelchair, and then leaving. The FM stated the ADM called her the next day and she told him exactly what happened the night prior (06/19/22), and the ADM stated he wanted to see the video footage. She stated she refused to send it to him because she did not want him watching Resident #1 in that very vulnerable situation, and that it just did not feel right. She stated she would be willingly to share the footage with an investigator from the State or the police. She stated she was told by the ADM that the police were notified, but they refused to investigate because the two residents resided in the memory care unit. The FM was extremely tearful throughout the conversation and was in fear for Resident #1, especially because Resident #2 was still residing at the facility. She stated a few weeks ago, Resident #1's camera was not working for a few days. Resident #1's HA told her the resident looked at Resident #2 and stated, He molested me last night. She stated it made her cringe at the thought that this kind of assault had happened before. Resident #1's FM stated she would send the State Surveyor the footage (via e-mail) and had no problem with her reviewing it. Observation on 06/21/22 at 12:14 p.m. revealed the footage from 06/19/22, e-mailed by Resident #1's FM. The footage revealed, around 7:50 p.m., Resident #2 entered Resident #1's room, ambulating independently without a walker or wheelchair. Resident #1 had been pulling back the sheets on her bed. He walked over to her, put his hands around her waist and started kissing her. She put her hands on his shoulders for a brief moment. He then removed his shirt and tried to remove hers. He lifted it up and fondled her bare breasts while she stood there. He then pulled down her pants and brief and began fondling her vagina while she stood there. He continued to do that while he pulled down his pants and brief. Due to the video camera angle, his back side was mostly seen, so it was unable to be determined if he penetrated her, but this went on for approximately five minutes. He moved to her bed and sat down, attempted to pull her on top of him. She instead sat down on her wheelchair. He stood up, lifted her shirt, and kissed her bare breasts while she sat there. He sat back down on her bed and took off his pants and brief entirely. At about minute 34, an unknown female resident rolled her wheelchair into Resident #1's room; it was undetermined if she saw what was going on and left soon thereafter. Resident #2 laid on Resident #1's bed and spread his legs. He then masturbated himself for several minutes while Resident #1 sat in her wheelchair. During that time, Resident #1 put her brief and pants back on. When Resident #2 completed pleasuring himself, he put his brief and pants back on, walked to the door, and left. Resident #2 was in Resident #1's room for a total of 43 minutes. An aide (CNA F) soon after entered Resident #1's room and made a comment that Resident #1 was wearing the same clothes as earlier in the day. She got the nurse (LVN E) and they asked questions like What happened? and Did he touch you?. Resident #1 denied and shook her head no. Observation made on 06/21/22 at 1:23 p.m. of video footage provided by Resident #1's FM. On the morning of 06/21/22 RN D was videoed assisting Resident #1 into her bed. Resident #1 stated, There was a terrible man that came in here. RN D stated, You do not have to worry about that on my watch. Resident #1 replied, I do not like him. RN D replied back, I watch these halls like a hawk. In an interview on 08/06/22 at 10:30 a.m., Resident #1's FM stated she (Resident #1) absolutely could not make the determination to participate in sexual acts. She stated she did not believe Resident #1 understood what was happening and further stated the resident could not remember to put her pull up on after bathroom use. She stated she had financial and medical POA over Resident #1. Resident #1's FM stated on 06/19/22 she had observed, through the video surveillance in the resident's room, Resident #2 go into her room prior to this, at night, standing over her bed. She stated other men had been observed by video footage going into Resident #1's room and standing over her bed. She stated she called the facility and told them each time she did not want any men in Resident #1's room. She stated one nurse (the FM could not remember the nurse's name) said what do you want us to do separate them? We have to give them their rights. She stated when she visited Resident #1, Resident #2 tried to come in the room. She stated she told the facility staff again she did not want him in Resident #1's room. Resident #1's FM stated she had been advised by another staff member the resident told someone she was afraid (Resident #1 told the HA) of Resident #2 coming to her room again. The FM stated the video camera was broken for a short period of time, around the time Resident #1 said this. Resident #1's FM stated when she called the nurse on duty (LVN E) the night of 06/19/22 after reviewing the video footage, she stated the nurse told her she guessed she could call the administrative staff but did not know if she could reach them or not. She stated the nurse told her she would have to wait and call in the morning. The FM stated she was not okay with that but did not know the protocol. She stated she depended on the staff to tell her how they handled a situation such as this and she had no other number to call. She stated in hindsight, she wished she had called the local PD that night. Resident #1's FM stated she did talk with the ADM the next morning and advised him what she had seen on the video footage. She stated the ADM told her men have natural urges and did not believe it occurred as she said. Resident #1's FM stated if he felt that way he should not be working as an ADM. The FM stated she was fighting to get Resident #2 out of the facility. She stated she asked the ADM how he could keep Resident #2 at the facility after what occurred and he advised her they could not do anything because it's memory care. She stated the ADM told her he's not going anywhere. Record review of Resident #1's Progress Notes, dated 06/20/22, reflected: The ADM had a conversation with Resident #1's FM. The FM alleges a male resident entered her mother's room last night, took off his clothes, removed some of her Resident #1's clothes, and attempted to perform sexual acts. The ADM asked the FM to clarify what she was alleging and she responded that she was alleging sexual assault. The ADM informed the FM that the facility will need to report to police and regulatory right away. The ADM asked the FM for evidence (video), and the FM refused to send it. The FM stated she may provide the video for the police or state investigator but did not want to provide it to facility. The ADM wrote he questioned the FM if there was any point during the interaction that resident displayed she did not want the interaction to occur (pushing away or telling male resident to stop or leave). The FM said there was not; that the resident has always been very touchy-feely and she was hugging and kissing the male resident back. The ADM advised the FM per her wishes, the facility will do all they could to keep the male resident out of the resident's room, and to separate them whenever possible. The ADM asked the FM what she would like the facility to do when the resident is adamant that she wants to hold hands, kiss, or be with male resident. The FM said she did not believe the resident wanted that; the male forced himself on her. The ADM informed the FM that her mother had told staff not to redirect male resident away from her before you can't tell me what to do, He's my friend. The FM said we need to keep him out of her room. The ADM wrote he advised we will keep resident on every 15 minute checks and out of Resident #1's room. MD notified. Ombudsman notified. Police notified. Regulatory incident filed. In an interview on 08/06/22 at 11:15 a.m., LVN E stated an aide, CNA F, noticed Resident #2 came out of Resident #1's room. CNA F told her (LVN E) to go check on Resident #2 because there had been times Resident #1 was too friendly with men and they did not know what had occurred in her room. LVN E clarified Resident #1's friendliness as hand holding. She stated when she walked into Resident #1's room the resident was fully dressed and she noticed the resident had the same clothes on as she had during the day. She stated Resident #2 had the same clothes on also, with the exception, he had Resident #1's cardigan on. LVN E stated she assessed Resident #1 by looking at her neck, hair, and stomach area. She stated she raised Resident #1's shirt and lowered her pants but did not take her clothes off of her. She stated she did not assess Resident #1's groin area. She stated she did not see blood in Resident #1's groin area and did not further assess. She stated she looked for scratches, wetness on her neck, lips, face She stated she asked Resident #1 questions such as did Resident #2 touch you, did anything happen in the room. She stated she remembered Resident #1 being shocked. She stated she then assisted Resident #1 to bed for the night. LVN E stated she then went to Resident #2's room and asked him questions about what occurred in Resident #1's room. She stated she did not complete a body assessment on Resident #2. She stated she could not remember what he told her. LVN E stated Resident #2 told her he had only touched Resident #1's knee. She stated Resident #1 did not know why touching Resident #1 was wrong. She stated they put Resident #2 on 15 minute checks after she talked with the DON and ADM. LVN E stated after she assessed the residents, she went to the nurse's station and received a call from Resident #1's family member. She stated the FM told her she had seen Resident #2 on top of Resident #1 and advised her of the number of minutes he had been in her room. She stated Resident #1's FM was very upset and told her about the resident experiencing previous sexual abuse and was very upset it happened again. She stated Resident #1's FM told her Resident #2 was touching her breasts. LVN E stated Resident #1's FM might have told her Resident #2 was naked. She stated she was not sure what she was supposed to tell Resident #1's FM so she told her she needed to call the DON or ADM. She stated she told Resident #1's FM she would call DON and ADM tonight but she could not guarantee they would answer her phone call. She stated Resident #1's FM wanted her to do everything she could to keep the resident safe but she (the FM) was okay with the ADM calling her the next day. LVN E stated she reached both the DON and ADON that night and both of them told her to place Resident #2 on every 15 minute checks. She stated she told the DON and ADM what she wrote in her note. She stated she was sure she told the ADM about Resident #2 fondling Resident #1's breasts. She stated she did tell the ADM the FM was okay with him calling her the next day. She stated she thought the ADM was concerned the evening she talked with him. She stated since this occurrence there had been multiple in-depth in-services. She stated she was not sure what training she received when she first began at the facility regarding resident to resident sexual abuse. In an interview on 08/06/22 at 11:55 a.m., CNA F stated she was the aide on duty when she observed Resident #2 coming out of Resident #1's room with her (Resident #1's) cardigan on. She stated LVN E told her to watch him because he was known to go in female residents' rooms. She stated she noticed his shoes in the middle of his floor but he was not in his room. She stated she then noticed Resident #2 coming out of Resident #1's room. She stated she told LVN E to come assess Resident #1 because they did not know what occurred in the room. CNA F stated she did not know of Resident #2 to have inappropriate sexual behaviors before and there was no special monitoring of him. During a phone interview on 06/21/22 at 1:05 p.m., the EDCS from Resident #1's hospice agency stated she was made aware of the incident between Resident #1 and Resident #2 by Resident #1's FM. She stated, No, [Resident #1] absolutely did not have the ability to consent to these behaviors. During a phone interview on 06/21/22 at 1:16 p.m., Resident #1's HSW stated she was very familiar with Resident #1 as she had been seeing her at least weekly for a couple of years. She stated Resident #1 was extremely confused and only alert and oriented to self. She stated she was a social butterfly and would often reach out to grab individual's hands or to give them a hug. She stated she did not have the competency to consent to any sexual advances, and that was why she was in the secured unit. She stated she had a past of sexual assault/trauma and felt this incident would ma [TRUNCATED]

Based on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) out of five residents reviewed, in that: The facility failed to adequately put procedures in place after being told Resident #1, who resided in the locked unit of the facility, was seen on video footage being sexually assaulted by Resident #2 for approximately 43 minutes on 6/19/22. On 6/21/22 at 5:15 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 6/22/22 at 6:15 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. This failure placed residents in the locked unit at risk of being sexually violated, at risk of sexually transmitted diseases, and physical and emotional harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS of 8, indicating a mild cognitive impairment. It further reflected she utilized a wheelchair. Review of Resident #1's care plan, revised 2/11/22, reflected she had a terminal prognosis related to [CONDITION(S)] disease and was admitted to (hospice agency) with an intervention of working with nursing staff to provide maximum comfort for the resident. It further reflected she resided on the memory care secured unit due to aimless wandering. Additionally, it reflected she had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and dementia. Review of Resident #1's psychiatric progress note, dated 4/11/22, reflected she had neurocognitive disorders including major and mild neurocognitive disorders due to Alzheimer's disease. Review of Resident #1's nursing progress notes in her EMR reflected the following: 6/19/22 8:47 PM - Aide instructed nurse to come assess this resident (Resident #1) because another male resident was in her room and we were unaware of what happened while he was in there . Resident #2 was questioned and stated he only touched her on the leg around her lower knee. While nurse was at the nurse's station, she received a call from (Resident #1's) FM and she was concerned with the things that were going on in her mother's room while Resident #2 was in there. 6/20/22 10:15 AM - (Administrator Note) Conversation with (Resident #1')s FM: She alleges that male resident entered Resident #1's room last night, took off his clothes, removed some of Resident #1's clothes, and attempted to perform sexual acts. Administrator asked [family member] to clarify what she was alleging and she responded that she was alleging sexual assault . ADM asked her for the evidence (video), and [family member] refuses to send. ADM questioned if there was any point during the interaction that resident displayed that she did not want interaction to occur (pushing away or telling male resident to stope or leave) Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 4, indicating a severe cognitive impairment. It further reflected he was rarely understood and rarely able to understand others. Additionally, it reflected that he did not use any assistive devices to ambulate. Review of Resident #2's care plan, revised 3/31/22, reflected he sometimes demonstrated sexually inappropriate behaviors exhibited by: inappropriate touching, climbing into bed with female residents, and kissing female residents with an intervention of helping him to avoid situations or people that tended to trigger those behaviors. Review of Resident #2's psychiatric progress note, dated 4/22/22, reflected the following: Patient has displayed symptoms such as . poor decision-making skills, sexually inappropriate behaviors Review of #2's nursing progress notes in his EMR reflected the following: 3/16/2022 9:23 PM - (Resident #2) continues to go into room [number] (Resident #1's room) and [room number] when being redirected several times by staff to his room and verbally told his room number is [number]. 4/29/22 1:39 PM - After resident consumed his lunch, (Resident #2) was pacing back and forth up and down hallway and attempts several times to go into [room number] (Resident #1's room). This nurse redirected resident several times by walking him back to his room and reiterated that he cannot go into females' rooms. Resident shook his head up and down and waving arms everywhere stating, I know, I know. 5/19/22 9:14 PM - (Resident #2) observed in hallway hugging (Resident #1). This nurse was able to redirect resident, however, moments later resident was observed by staff member standing in (Resident #1's) doorway. Staff member tried to redirect resident to his room when he was noted to become agitated. 6/19/22 8:41 PM - New order for q15 minute monitoring related to sexual allegations. 6/20/22 1:42 PM - (Resident #2) continues on monitoring due to inappropriate behavior with another resident. 6/20/22 4:11 PM - (Resident #2) walking from dining room and female resident from room [number] reached out to him and they held hands. 6/20/22 5:00 PM - (Resident #2) walking up to nurse's station. A female resident sitting in her wheelchair at nurse's station and Resident #2 reached out for her hand and started talking to her. Female resident did not pay attention to resident and did not talk to him or touch his hand. During an observation on 6/21/22 at 1:10 PM revealed Resident #2 ambulating independently without a walker or wheelchair down the hall of the locked unit by himself. He was a bigger gentleman, over six feet tall. He did not respond to the Surveyor when she spoke to him. During a phone interview on 6/21/22 at 9:33 AM with Resident #1's FM, she stated she had put a surveillance camera in Resident #1's room, since she lived far away and wanted to be able to check on her. She stated on 6/19/22 around 7:50 PM, there was footage of Resident #2 going into Resident #1's room and for 43 minutes he sexually assaulted her. She stated he started kissing and embracing her. She stated Resident #1 had always been an affectionate person and at first was embracing him back. She stated when Resident #2 began taking off his clothes and her pants was when she sat in her wheelchair and no longer participated. She stated there was a point in the video when he was seen fondling her vagina and kissing her breasts. She stated he ended up laying on her bed and masturbating while she sat in her wheelchair. She stated Resident #1 had dementia and did not have the ability to consent. She stated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated when she called and spoke to a nurse on 6/19/22 after she saw the footage, the nurse told her it was too late to call the ADM and he would be calling her the next day, which she found inappropriate, but did not know the rules and did not want to cause any drama. She stated she asked the nurse how no one thought to see where Resident #2 was for 43 minutes, and the nurse told her, Well, it was close to 8:00 PM and everyone was in bed. The FM stated that was not true, because in the video footage, there was a resident seen opening the door and rolling herself in with her wheelchair, and then leaving. She stated the ADM called her the next day and she told him exactly what happened the night prior (6/19/22), and the ADM stated he wanted to see the video footage. She stated she refused to send it to him because she did not want him watching Resident #1 in that very vulnerable situation, and that it just did not feel right. She stated she would willingly share the footage with an Investigator from the State or the police. She stated she was told by the ADM that the police were notified, but they refused to investigate because the two residents resided in the memory care unit. She was extremely tearful throughout the conversation and was in fear for Resident #1, especially because Resident #2 was still residing there. She stated a few weeks ago, Resident #1's camera was not working for a few days. Resident #1's hospice aide told her that Resident #1 looked at Resident #2 and stated, He molested me last night. She stated it made her cringe at the thought that this kind of assault had happened before. Resident #1's FM stated she would send the Surveyor the footage (via e-mail) and had no problem with her reviewing it. Observation on 6/21/22 at 12:14 PM revealed the footage from 6/19/22, e-mailed by Resident #1's FM. The footage revealed, around 7:50 PM, Resident #2 entered Resident #1's room, ambulating independently without a walker or wheelchair. Resident #1 had been pulling back the sheets on her bed. He walked over to her, put his hands around her waist and started kissing her. She put her hands on his shoulders for a brief moment. He then removed his shirt and tried to remove hers. He lifted it up and fondled her breasts while she stood there. He then pulled down her pants and brief and began fondling her vagina while she stood there. He continued to do that while he pulled down his pants and brief. Due to the video camera angle, his back side was mostly seen at this point, so it was unable to be determined if he penetrated her, but this went on for several minutes. He moved to her bed and sat down, attempting to pull her on top of him. She instead sat down on her wheelchair. He stood up, lifted her shirt, and kissed her bare breasts while she sat there. He sat back down on her bed and took off his pants and brief entirely. At about minute 34, a resident rolled in her wheelchair into Resident #1's room; it was undetermined if she saw what was going on and left soon thereafter. Resident #2 laid on Resident #1's bed and spread his legs. He then masturbated himself for several minutes while Resident #1 sat in her wheelchair. During that time, Resident #1 put her brief and pants back on. When Resident #2 completed pleasuring himself, he put his brief and pants back on, walked to the door, and left. Resident #2 was in Resident #1's room for a total of 43 minutes. An aide soon after entered Resident #1's room and made a comment that Resident #1 was wearing the same clothes as earlier in the day. She got the nurse and they asked questions like What happened? and Did he touch you?. Resident #1 denied and shook her head no. Observation made on 6/21/22 at 1:23 PM of video footage of Resident #1 from the morning of 6/21/22 revealed RN D assisting Resident #1 into her bed. Resident #1 stated, There was a terrible man that came in here. RN D stated, You do not have to worry about that on my watch. Resident #1 replied, I do not like him. RN D replied back, I watch these halls like a hawk. During a phone interview on 6/21/22 at 1:05 PM with the EDCS from Resident #1's hospice agency, she stated she was made aware of the incident between Resident #1 and Resident #2 by Resident #1's FM. She stated, No, [Resident #1] absolutely did not have the ability to consent to these behaviors. She stated she would have the SW contact the Surveyor, who knew Resident #1 more intimately as she saw her weekly. During an observation and interview on 6/21/22 at 1:12 PM with Resident #1 revealed she was in her wheelchair in the hall, dressed appropriately and was clean. She was alert and oriented to self only. She was pleasantly confused, and it was difficult to follow a conversation with her. However, she did deny feeling unsafe at the facility. During a phone interview on 6/21/22 at 1:16 PM with Resident #1's HSW, she stated she was very familiar with Resident #1 as she had been seeing her at least weekly for a couple of years. She stated Resident #1 was extremely confused and only alert and oriented to self. She stated she was a social butterfly and would often reach out to grab individual's hands or to give them a hug. She stated she did not have the competency to consent to any sexual advances, and that was why she was in the secured unit. She stated she had a past of sexual assault/trauma and felt this incident would make her trauma ten times worse. She stated the that this a huge incident that would affect her peace of mind as she was completely violated and disrespected. She stated she was very concerned for Resident #1's emotional health and well-being. She stated it was a blessing she had a camera in her room so that Resident #2 could be caught and stopped from hurting and/or violating Resident #1 or any other residents that resided on the locked unit. She stated she was enraged that the resident (Resident #2) was still residing there and felt like Resident #1 would not be safe until she was moved out of the facility. She stated she was currently working on finding alternate placement. During an interview on 6/21/22 at 1:23 PM with CNA A, he stated he had heard multiple versions of what happened between Resident #1 and Resident #2. He stated he did know Resident #2 had gone into Resident #1's room for a period of time. He stated Resident #1 definitely did not have the ability to consent to any sexual advances. He stated the charge nurse, RN C, was completing the Q15 checks. He stated he had not ever seen Resident #2 being sexually inappropriate to any of the residents, but he rarely worked on the locked unit. During an interview on 6/21/22 at 1:28 PM with MA B, she stated she had never seen Resident #2 being sexually inappropriate to any of the residents. She stated she had heard three different stories of what happened on 6/19/22 involving Resident #1 and Resident #2. She stated neither of those residents (Resident #1 and Resident #2) could make consent to that and it was absolutely inappropriate. She further stated, I would not want it to happen to my parents! She stated the intervention they were doing to prevent it from happening again was just constantly making sure they were apart from each other. During an interview on 6/21/22 at 1:40 PM with RN C, she stated she had heard that Resident #2 had gone into Resident #1's room. She stated Resident #1 absolutely did not have the capacity for consent. She stated the only sexually inappropriate behaviors she had witnessed by Resident #2 was that he liked to grab residents' hands. She stated she was completing Q15 checks and just keeping them on opposite sides of the unit. She stated it was frustrating because they had all worked so hard to ensure something like that did not happen. During a phone interview on 6/21/22 at 2:17 PM with Resident #1's HA, she stated she came to the facility to bathe Resident #1 three times a week. She stated about a month ago her video camera in her room was not working. She stated during that time, she arrived at the facility and sat down at a table where Resident #1 was eating breakfast. She stated Resident #1 nodded towards Resident #2 and stated, He molested me last night. She stated she had not notified anyone at the facility because she had dementia and thought maybe she was remembering when she was sexually assaulted in her past. During an interview on 6/21/22 at 2:42 PM with the ADM and DON, they were asked what they were doing to ensure the safety of all the residents in the locked unit from Resident #2. The ADM stated as soon as he was notified about what Resident #1's FM had alleged on the night of 6/19/22, they put him on Q15 minute checks, notified the police, and made a self-report to HHSC. He stated he felt like they did exactly what they should have done. The Surveyor informed them she had watched the video footage and Resident #1 was sexually violated/assaulted by Resident #2 for 43 minutes. They stated they were not sure if it was true because the FM would not send them the video footage, so they did not have the proof. They stated the FM had a tendency to exaggerate. The ADM stated now that he knew it was true, he would be more aggressive in keeping the residents safe by working on an immediate discharge. Review of a facility Abuse, Neglect, and Resident Rights in-service, dated 3/21/22, reflected the staff was in-serviced by the ADON on who the Abuse Coordinator (the ADM) was, the five types of abuse, and reporting abuse allegations. Review of a facility Abuse, Neglect, and Resident Rights in-service, dated 4/8/22, reflected the staff was in-serviced by the ADON on who the Abuse Coordinator was, the five types of abuse, and reporting abuse allegations. Review of a facility Abuse, Neglect, and Resident Rights in-service, dated 6/9/22, reflected the staff was in-serviced by the ADON on who the Abuse Coordinator was, the five types of abuse, and reporting abuse allegations. Review of the facility's Abuse Prevention Program Policy, updated 2021, reflected the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to . verbal, mental, sexual, or physical abuse . As part of the resident abuse prevention, the administration will: 1. Protector our residents from abuse by anyone including, but not limited to: .residents . . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Identify and assess all possible incidents of abuse. . 8. Protect residents during abuse investigations. Definitions: . 3. Sexual Abuse is defined as non-consensual contact of any type with a resident. Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of the facility's Resident Rights Policy, revised December 2016, reflected the following: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: . c. be free from abuse, neglect The ADM and DON were notified on 6/21/22 at 5:15 PM that an Immediate Jeopardy had been identified due to the above failures. The IJ template was provided to the ADM and DON on 6/21/22 at 5:15 PM. A Plan of Removal was accepted on 6/22/22 at 5:03 PM which reflected: Summary of Details which lead to outcomes : On 06/21/22 an abbreviated survey was initiated at [Facility name and address]. 06/21/22, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F600 -Abuse/Neglect/Exploitation The facility failed to protect one resident on the memory care unit by providing adequate supervision or intervention to prevent abuse by Resident #1. Resident #1 resides on the secure unit of the facility with 27 other memory care residents. On 6/19/22 around 7:00 PM, video surveillance caught footage of R1 (male; Resident #2) entering R2's (female; Resident #1's) room. He undressed R2 and himself. He is seen fondling her vagina and kissing her breasts. He then masturbated in front of her. The [family member of Resident #1] contacted the facility to notify them of the incident. R2 was put on Q15 checks. On 6/20/22 the ADM spoke to [Resident #1's family member] who refused to send him the video footage. He did contact the police who came out and told him that they would not investigate due to the residents residing in the memory care unit. I interviewed multiple individuals - her hospice SW and aide and several facility staff members who all stated R2 did not have the capacity to give consent. I interviewed R2, who I wound to be alert to person only. She was pleasantly confused. R2's hospice aide stated a few weeks ago her (Resident #1/R2) camera was broken and R2 looked at R1 and stated, he molested me last night. She did not report this to the facility. She believed it may have been her dementia and the fact that she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] the facility). R1's care plan, dated 3/31/22, reflected he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/21/22 at 2:42 PM with the ADM and DON, they stated had they had proof R1 had actually crossed the line with R2, they would have taken more aggressive action before learning that Surveyor had watched the video. Identify residents who could be affected The failure to effectively supervise or to put interventions in place for Resident #1 resulted in Resident #2 being sexually violated. Problem 1: The facility needs to take immediate action to ensure the safety of all residents residing on the memory care unit by preventing further abuse by Resident #1. 1.The facility needs to have policies and procedures in place to ensure the residents on the secure unit are protected from further abuse. Action Taken: o Once the facility was made aware of the alleged allegation by Resident #2's family (6/20/2022), Resident #1 was placed on Q15 minute checks, pending the investigation. The facility was not provided the video surveillance taken from the family placed in room camera at the time of the allegation. o Administrator reported the allegation on 6/20/2022 after speaking with the family to local authorities as well as HHSC. o The Director of Nursing/designee completed an assessment on Resident #1, to assess for psychological and physical harm, no injury noted. Care plan updated. Attending physician and resident representative notified (6/20/2022). o The Director of Nursing/designee completed an assessment of Resident #2 to assess for psychological and physical harm, no injury noted. Care plan updated. Attending physician and resident representative notified (6/20/2022). o The Administrator/Designee immediately initiated staff interviews of all staff who worked the unit at the time of the allegation to verify that all applicable events have been reported (6/20/2022). o The Administrator immediately initiated Abuse and Neglect in-service including the prohibiting abuse/those at risk, definition of abuse, timely reporting, and comprehensive investigation of any allegations of abuse. The Administrator will ensure education will be provided for 100% of all staff before the next shift scheduled, new employees will also receive education upon hire, staff will not be permitted to work with residents until complete. This process is on-going.( 6/20/2022). o The Administrator/Designee will validate that Abuse and Neglect training is provided to hospice, agency, and other applicable contract staff prior to beginning of next shift (6/21/2022). o The Administrator/Designee initiated Safe surveys on memory care neighborhood of residents who can be interviewed which did not reveal any other allegations or concerns, to include: any inappropriate touching, unwanted advances (6/21/2022). o The Director of Nursing/designee will conduct a record review of residents who are not able to be interviewed to assess for any signs and symptoms related to abuse including changes in behavior/withdrawal from normal activities, decreased appetite, etc. Initial review of all non-verbal residents completed 6/21/2022. (6/21/2022). o Director of Nursing/Designee requested from resident physician to have psychology services see Resident #2 regarding potential side effects from the event (6/20/2022) . On 6/21/22 at approximately 2:40 p.m. the facility was made aware of the content of the video confirming the allegation, provided to the state, facility placed Resident #1 on a 1: 1 continuous care and started the process for an immediate discharge. o On 6/21/2022 at approximately 5: 15pm, Resident #1 was safely discharged home with family. o Regional Director of Clinical Operation provided in service and education to Administrator and Director of Nurses that all allegations are to be comprehensively investigated as stated (6/21/2022). o Administrator/DON will review all admissions with IDT, including screening records and history for inappropriate and unwanted signs of sexual behaviors. Potential admissions with history of sexual behaviors that have not been resolved will not be admitted . If resident begins to exhibit inappropriate or unwanted sexual behaviors, resident will be placed on 1: 1 observation until a resolution of behaviors occurs up to and including discharge to another safe appropriate facility. This will be an ongoing process. o DON/Designee will complete secure unit assessments on residents within the memory care neighborhood, on admission/update current residents, monthly x3 months, then quarterly thereafter to include monitoring for exhibits of sexual behavior. (6/22/2022) Monitoring: The Administrator/designee will conduct Safe Surveys/assessments for residents residing in the Memory Care Neighborhood daily for 5 days and then 3 times a week times 30 days to validate that they are safe and free from potential abuse. The Administrator will report any identified concerns to the Quality Assurance Performance Improvement Committee as needed and monthly until a [NAME] frequency is deemed appropriate. Involvement of Medical Director The Medical Director, [Doctor's name] was notified of the Immediate Jeopardy on 6/21/22. The Administrator in collaboration with the Inter-disciplinary team and Medical Director will review the Abuse and Neglect policy and validate that all policies and procedures involving Abuse and Neglect meet federal, state, and local regulations. Involvement of QA On 6/21/22 an Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Administrator and Inter-Disciplinary team reviewed the abuse and neglect policy and process to ensure practice is to act upon all allegations as if they are true and accurate until proven otherwise. Who is responsible for implementation of process? The Administrator, Director of Nursing and Assistant Director of Nursing will be responsible for implementation of ensuring the adequate process regarding Abuse and Neglect. The New Process/ system will be started on 6/21/22. Please accept this letter as our plan of removal for the determination of lmmediate Jeopardy issued on 6/21/22. The Surveyor monitored the Plan of Removal from 6/21/22 - 6/22/22 as follows: Interviews were conducted on 6/22/22 from 4:13 PM - 4:34 PM with one nurse, one MA, and three aides working on the locked unit. All staff members stated they had been in-serviced on abuse and neglect were able to name the ADM as their Abuse and Neglect Coordinator, describe the five types of abuse and neglect, and give examples of identifying abuse with dementia and non-verbal residents. Review of the facility's Abuse and Neglect In-service, dated 6/20/22, reflected the staff were in-serviced on types of abuse and identifying abuse with residents with dementia or non-verbal, which reflected: How to identify abuse in a patient with dementia or who is on-verbal: - Withdrawal from normal activities - Decrease in appetite - Change in behavior -Unexplained injury to include bruising Types of Abuse: Sexual Abuse - Including inappropriate advances, unwanted touching, fondling - bruises, bleeding Physical Abuse - unexplained injuries, unusual bruising Exploitation - withdrawal, missing items Neglect - weight loss, bed sores, long fingernails/soiled Emotional - odd behavior, withdrawal from activities. Review of the facility's (hospice agency) Abuse and Neglect Policy, reflected the HA was in-serviced on abuse and neglect, specifically on reporting allegations of abuse or neglect on 6/22/22. Review of Resident #2's nursing notes in his EMR, on 6/22/22, reflected the following: 6/21/22 2:44 PM - Resident is placed 1:1 due to new evidence - Charge Nurse is aware to place resident on 1:1 at this time. 6/21/22 4:55 PM - DON/ADM spoke with Resident #2's RP in regard to resident behavior regarding other female resident - ADM to issue an immediate discharge due to behaviors . Resident discharged home with his [family member] at this time. During an observation and interview on 6/22/22 at 2:50 PM with the RNC she showed the Surveyor that they updated the Secure Unit Assessment (for future residents) to include the question: Does resident have a significant behavior problem, for example, sexual inappropriateness, unwanted touching, physical aggression, etc., that seriously disrupts the rights of other residents? She also showed the Surveyor that they manually added the above question to the current residents' assessments that resided in the locked unit. She stated they started the Safe Surveys the day before, 6/21/22. She stated that will include completing the surveys for five days, then three times a week for 30 days, and then quarterly. She stated they created Safe Survey forms; one for verbal residents and one for non-verbal residents. She showed the Surveyor their binder that was tabbed by each day in which the Safe Surveys would be stored to ensure they were completed per their POR. Review of the facility's Safe Survey for verbal residents, on 6/22/22, reflected the following questions (answers were appropriate, no residents had concerns): 1. How is your overall care? 2. Do you feel safe at the facility? 3. Do you feel like you can report issues that you may have? 4. Have you experienced ay inappropriate touching by staff and/or other residents? 5. Have you had any unwelcome advances by staff and/or other residents? 6. Do you feel like you have been abused? Review of the facility's Safe Survey for non-verbal residents, on 6/22/22, reflected the following questions (answers were appropriate, no residents had concerns): 1. Has resident had any noted changes in behaviors that resulted in medication changes? 2. Has resident had any recent changes in appetite/weight loss? 3. Has resident had a decline in participation with activities? Review of the facility's updated New Admission Worksheet (referral form), as of 6/22/22 reflected the following question was added: Does resident have any history of inappropriate or unwanted signs of sexual behavior? If so, explain in detail. (NOTE: If behavior is not resolved, referral will be denied). During an interview on 6/22/22 at 5:05 PM with the ADM, DON and the RNC, they were asked how they were ensuring all staff were in-serviced before working the floor, the DON stated she has been in-servicing staff over the phone and also as they walk in the facility before their shift. She stated they have notified all hospice agencies they must in-service all of their staff members and send proof of the in-service. The ADM stated he was responsible for ensuring the Safe Surveys were being done as described in their POR. He stated the binder would be kept in his office and each day he will ensure each resident was screened. The ADM [TRUNCATED]

Based on interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was transferred, according to his care plan, with a mechanical lift and two staff from his wheelchair to his bed which resulted in a fracture to his right shoulder. This failure placed residents at risk of accidents, injuries, and a diminished quality of life. The findings were: Review of the face sheet dated [DATE], indicated Resident #1 was 73- years- old, admitted on [DATE] with diagnoses including [CONDITION(S)] (kidney transplant failure), delusional disorders, mood disorder due to known physiological condition, pressure ulcer of sacral region, stage 4, peripheral vascular disease (circulatory problem in which narrowed arteries reduce blood flow to your limbs, diabetes, [CONDITION(S)] heart disease, and [CONDITION(S)] [CONDITION(S)] (irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart. A-fib increases the risk of stroke, heart failure and other heart-related complications). Hospital Discharge Summary dated [DATE] revealed Resident #1 expired on [DATE] for diagnosis unrelated to injury. Review of the quarterly MDS assessment dated [DATE], indicated Resident #1 was cognitively intact with a BIMS of 15, hard of hearing, was understood, and he usually understood others. He required extensive assist for bed mobility and was dependent on two staff for assistance with eating, transfers, dressing, personal hygiene, and bathing. Review of the care plan dated [DATE], indicated Resident #1 had an ADL self-care performance deficit related to [CONDITION(S)] (paralysis of one side of the body), limited mobility, limited range of motion, musculoskeletal impairment, and stroke. Interventions included transferring: resident requires mechanical lift (used to move a person who is unable to stand on their own or whose weight makes it unsafe to move or lift them manually) with 2 staff assistance for transfers. Review of a hospital radiology report dated [DATE] revealed a Resident #1 had a displaced oblique fracture (break that is on the angle of a bone) through the proximal right humeral (upper arm bone) diaphysis just below the surgical neck with surrounding soft tissue swelling (Enlargement of organs, skin, or other body parts caused by a buildup of fluid in the tissues). Review of a written statement dated [DATE] the day after the incident, by CNA A revealed after Resident #1 ate in the dining room he told CNA A he, Wanted to lie down because his bottom was in pain for being up so long. There was no immediate help around me, and he was complaining of his bottom so I went ahead and transferred him. During an interview on [DATE] at 11:14 AM, the Administrator stated on [DATE], Resident #1 ate lunch in the dining room and was up in his wheelchair for 2.5 hours. The Administrator stated CNA A transferred the resident by herself, from his wheelchair to the bed without using the mechanical lift, to help relieve his pain. CNA A chose to transfer Resident #1 by herself because it was after lunch and her coworkers were busy helping other residents and she did not want Resident #1 to continue to be in pain. The Administrator stated on [DATE] at 8:00 AM she learned at 7:00 AM that Resident #1 complained of right shoulder pain at 6:40 AM. She said the wound care nurse assessed the resident and noted his right shoulder had swelling extending from clavicle to the mid-section of his upper arm, close to his bicep. The Administrator stated Resident #1's right upper arm had slight bruising to under the arm area that was visible from the front of his arm. She stated Resident #1 was unable to raise his arm. The Administrator stated Resident #1 was sent to the ER for further assessment and x-rays. She stated CNA A was suspended pending an investigation. The Administrator interviewed Resident #1 upon returning to the facility from the ER that same morning. Resident #1 told the Administrator that he believed the injury occurred the prior afternoon when CNA A transferred him by herself. She stated upon completion of the investigation CNA A was written up as a result for failing to follow the resident's plan of care and transferring Resident #1 by herself. The Administrator indicated she made a self-report to the state agency. During an interview on [DATE] at 12:00 PM, the DON stated CNA A knew the way she transferred Resident #1 was not the proper way and was re-educated by the DON regarding safe transfers prior to returning to work. The DON stated CNA A and remaining direct care staff were re-educated regarding proper transferring and on the Abuse & Neglect Policy and Procedures, given a pre-test and post-test regarding safe transfers, and given a skills check off including a return demonstration on how to perform a safe transfer. During an interview on [DATE] at 9:00 AM, CNA A revealed having worked at this facility for the past year. CNA A stated, I transferred the resident because of pain on his bottom and he has sacral wound. CNA A revealed she got the Resident #1 up with another CNA's assist using a mechanical lift before Resident #1's care plan meeting started at 10:00 AM. CNA A revealed he was fed lunch by staff at 12:00 PM, he finished eating between 12:30 PM - 12:45 PM and then Resident # 1 began complaining of pain to his bottom. CNA A revealed she took Resident #1 to his room, gave call light to him, and told Resident #1 she would be back to transfer him back to bed after staff picked lunch trays up. CNA A stated, I peeked out of his room to see if another staff member was in the hallway that could help, but I didn't see anyone. CNA A stated, I self-transferred him around 1:30 PM from the geri chair (geriatric chair - large, padded chair with wheeled base, designed to assist seniors with limited mobility) to the bed. I put both my arms under his underarms, stood him up, then pivoted him to the bed. CNA A stated this was the only time she had transferred Resident #1 by herself and without a mechanical lift. CNA A stated, The policy with this resident was to always use a hoyer lift, a sling, and two staff to transfer. I knew he was a hoyer lift (mechanical lift) and that he was not okay to transfer him by myself, but I tried to help him because he complained of a lot of pain. After he laid down, he said he was ok. CNA A revealed she went home at the end of her shift and no one knew she self-transferred Resident #1 without using a hoyer lift. CNA A revealed she was off work the next day and the DON called her at home and asked if she transferred Resident #1 the day prior. CNA A stated, I told the DON I transferred him by myself with my two arms lifting him under his arms, stood him up, and pivoted him to the bed to lie down. CNA A revealed the DON informed her Resident #1 complained of pain to the wound care nurse, said the pain was from the self-transfer by CNA A, and described CNA A. CNA A stated she came in later that same day, was reprimanded for the improper transfer, reeducated on performing proper transfers and abuse and neglect, and signed a write-up (disciplinary document). CNA A stated, The ADON had all staff complete a pre-test and post test on abuse and neglect and proper transfers and complete a skills check off with another staff member to demonstrate we could do a proper transfer. During an interview on [DATE] at 9:50 AM, the Wound Care Nurse revealed she went into Resident #1's room around 6:30 AM to let him know she was going to complete wound care treatment to sacral wound, and he let her know he was having pain that bothered him throughout the night. The Wound Care Nurse stated they discussed where the pain was, assessed him, and observed swelling and discoloration to his shoulder through the underarm. The Wound Care Nurse stated she immediately called the DON on her cell phone to inform her that Resident #1 was going to be sent out to the local VA hospital for evaluation and treatment. The Wound Care Nurse stated, I went back to the resident to investigate more before he was transferred from the facility and he told me he was being transferred by a CNA and that the pain started immediately after the transfer. He gave a description on how the transfer occurred and description of the CNA. The Wound Care Nurse stated Resident #1 was transferred to the local VA hospital, the hospital called back later to inform her that Resident #1 had a fracture, and the Wound Care Nurse notified the DON and Administrator immediately. During an interview on [DATE] at 10:10 AM, the ADON revealed staff asked her in the past for assistance with transfers but she was not asked the day of the improper transfer. The ADON stated she is the facility educator and reeducated staff verbally and with written documentation on abuse and neglect and proper transfers on Friday the day the incident was discovered involving Resident #1. The ADON stated she developed pretest and posttest on abuse and neglect and proper transfers and administered them to all nursing staff starting the following Monday and then nursing staff completed a skills check off with return demonstration of proper transfers using a mechanical lift, stand-up lift, and gait belt. During an interview on [DATE] at 10:40 AM, the DON stated, After CNA A told me she knew she screwed up by putting the resident in bed by herself and without using the hoyer lift because he was in pain, she said she told CNA A that was no excuse because you still have to do it the right way and follow protocol.

Based on interview and record review the facility failed to promptly notify the physician of critical laboratory results for 1 of 13 residents reviewed for laboratory services. (Resident #2) The facility did not promptly notify the physician of Resident #2's critical laboratory results. LVN H was notified of the critical laboratory findings on [DATE] at 9:35 a.m. The physician was not notified until [DATE] at approximately 2:00 a.m. Resident #2 was sent to the hospital and expired on [DATE] at 3:28 p.m. This was determined to be past non-compliance that existed from [DATE] and was corrected on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for infection, injury, and death. Findings included: Consolidated physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The order indicated the resident had a midline catheter (a catheter inserted inside a major vein) with a dressing change to be completed weekly. The MDS dated [DATE] indicated Resident #2 sometimes understood others and was sometimes understood. The MDS indicated Resident #2 was totally dependent on staff for ADLs. The MDS indicated Resident #2 had an active [DIAGNOSES REDACTED]. The care plan dated [DATE] indicated Resident #2 had impaired cognition with episodes of confusion and lethargy. The care plan indicated Resident #2 had impaired skin integrity with multiple wounds and had a PICC (peripherally inserted central catheter) to her right upper extremity and [MEDICAL TREATMENT] port to right chest wall. The care plan indicated Resident #2 had osteo[DIAGNOSES REDACTED]. A Lab Services Report dated [DATE] indicated bloodwork was collected [DATE] at 5:45 a.m., received [DATE] at 6:54 a.m., and results were reported to LVN H on [DATE] at 9:35 a.m. The report indicated Resident #2's WBC (white blood cells) were critically high at 29.50 (normal reference 4XXX,[DATE].0). The report indicated Resident #2's previous WBC count was 19.85 (high) on [DATE], and 14.48 (high) on [DATE]. A hospital discharge summary dated [DATE] indicated Resident #2 was admitted [DATE] at 5:34 a.m., and died [DATE] at 3:28 p.m. with the final [DIAGNOSES REDACTED]. During an interview on [DATE] at 7:39 p.m., LVN H said she could not remember if she had taken the call for Resident #2's critical laboratory values on [DATE]. She said she believed LVN B had discussed the critical laboratory values with the physician. During an interview on [DATE] at 1:00 p.m., LVN B said she did not notify the physician of the critical laboratory values on [DATE]. During an interview on [DATE] at 1:55 p.m., LVN C said she noticed the critical laboratory values around 2:00 a.m. and called ADON [NAME] and then notified the physician. She said she received a new order to send Resident #2 to the hospital. During an interview on [DATE] at 10:03 a.m., The DON said Resident #2 was critically ill. She said LVN C discovered the critical laboratory values early in the morning of [DATE] and notified ADON E. She said ADON [NAME] instructed LVN C to notify the physician and send Resident #2 to the hospital. During an interview on [DATE] at 11:08 a.m., the physician assistant said he did not receive notification of Resident #2's critical laboratory value until [DATE] at approximately 2:00 a.m. The physician assistant said he should have been notified of the critical laboratory values immediately. A Notification of Change Policy dated [DATE] indicated .The facility will immediately inform the resident and consult with the resident's physician for a significant change in the physical, mental, or psychosocial status of a resident . It was determined these failures placed Resident #2 in an Immediate Jeopardy situation from [DATE] through [DATE]. The facility took the following actions to correct the non-compliance on [DATE]: The DON in-serviced staff on notification of critical laboratory values and when to notify the physician. On [DATE], the investigator determined interventions were completed by: Sixteen nurses were interviewed and said they received training prior to the investigators entrance regarding physician notification of critical laboratory values and when to notify the physician.

Based on interview, and record review, the facility failed to ensure the physician was consulted when there was a change of condition for 1 of 13 residents reviewed for notification of changes.(Resident #1) The facility did not notify the physician when Resident #1 had a change in condition. Resident #1 complained of chest pain, nausea, shortness of breath, and experienced increased restlessness, anxiety, falls and heart rate starting [DATE]. Resident #1 was found face down on the floor without a pulse or respirations and was pronounced dead on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents who experience a change of condition at risk for harm, deteriorating health or death. Findings included: Consolidated physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. A physician order [REDACTED].#1 would receive [MEDICATION NAME] (anti-nausea medication) 4mg PRN (as needed) per MD protocol. The most recent MDS dated [DATE] indicated Resident #1 understood others and made herself understood. The MDS indicated her cognition was intact and she required extensive assistance for ADLs. The MDS indicated the resident had [DIAGNOSES REDACTED]. The most recent care plan updated [DATE] indicated Resident #1 was at risk for alteration in fluid balance related to her history of [MEDICAL CONDITION]. The care plan indicated staff would notify the physician of changes as needed. The care plan indicated Resident #1 was at risk for falls related to her history of falls and attempting to self-transfer. The care plan indicated staff would rule out medical complications [REDACTED]. The care plan indicated staff would notify the physician of falls as needed and attempt to identify the root cause for falls. The care plan indicated Resident #1 experienced pain in her back and shoulders related to her [DIAGNOSES REDACTED]. A nursing note dated [DATE] at 3:19 p.m., indicated Resident #1 reported I do not feel well. A nursing note dated [DATE] at 4:30 p.m., indicated Resident #1 was found trying to get out of bed unassisted. The note indicated Resident #1 complained of right shoulder pain and Bio freeze (pain relief gel) was administered as ordered. A nursing note dated [DATE] at 8:01 p.m., indicated Resident #1 complained of nausea and a standing order was written for [MEDICATION NAME] 4 mg as needed per physician protocol. The note indicated the medication was administered. A nursing note dated [DATE] at 9:00 p.m. indicated Resident #1 was found in floor with a bruise noted to left side of her back. The note indicated the resident's blood pressure was ,[DATE], pulse was129 (normal ,[DATE]) and temperature-97.5. The note indicated neurological checks were initiated. An incident report dated [DATE] (for the 9:00 p.m. fall) indicated Resident #1 was found face down on the floor with a reddish-purple bruise on the right side of her back. The report indicated an assessment and vital signs were immediately obtained and the Resident #1's blood pressure was ,[DATE], pulse 129, temperature 97.5. A fall investigation worksheet completed on [DATE] indicated Resident #1 was oriented with no behaviors observed prior to the fall at 9:00 p.m. The investigation worksheet indicated Resident #1 did not have a history of attention seeking by sitting herself on the floor, no history of throwing herself on the floor, and no history of rolling out of bed on the floor. A fall investigation summary dated [DATE] at 9:00 p.m. indicated resident lying on floor face down. Bruise to right side of back. Vitals obtained and stable. MD notified. A nursing note dated [DATE] at 3:33 a.m., indicated Resident #1 fell on [DATE] at 10:30 p.m. The note indicated there were no signs of pain or distress and respirations were even and unlabored. The note indicated the resident's blood pressure was ,[DATE], pulse 104, respirations 20 and temperature 97.3. The note did not indicate the physician was notified. A nursing note dated [DATE] at 11:36 a.m. indicated Resident #1 was found by the housekeeper on her hands and knees in the floor. The note indicated the resident's respirations were even and unlabored and her blood pressure was ,[DATE], pulse 98, respirations 16, and temperature 97.8. The note did not indicate the physician was notified. A nursing note dated [DATE] at 1:38 p.m. indicated Resident #1 was found at 12:20 p.m. face down next to the bed. The note indicated the resident was unresponsive with no pulse or respirations. The note indicated CPR was initiated and 911 was called. The note indicated the nurse verified Resident #1 was a DNR (do not resuscitate), life saving measures were stopped and Resident #1 was pronounced dead at 12:36 p.m. by RN A. During an interview on [DATE] at 11:42 a.m., the complainant said he heard Resident #1 complain to facility staff on the evening of [DATE] sometime before dinner that she could not breathe, and her chest was hurting. The complainant said Resident #1 kept saying my chest is hurting to the staff. The complainant could not recall the names of the staff. The complainant said the staff gave her a pill but they would not send her out. During an interview on [DATE] at 4:43 p.m., LVN G said she cared for Resident #1 on the evening of [DATE]. She said Resident #1 was more restless that evening than usual. She said Resident #1 kept trying to get up out of bed, appeared anxious and complained of being short of breath. LVN G said she put oxygen on Resident #1 and the resident continued to complain of shortness of breath. LVN G said Resident #1 could not catch her breath so she attempted to raise the head of Resident #1's bed but Resident #1 did not want to sit up. LVN G said she did not recall if Resident #1 had complained of pain. LVN G said Resident #1 complained of nausea so she initiated the nausea protocol and administered [MEDICATION NAME] 4mg. LVN G said she did not notify the physician of Resident #1's nausea or shortness of breath. LVN G said she did not notify the physician of Resident #1's increased pulse of 129 on [DATE] at 9 p.m. LVN G said she could not recall if she had notified the physician of Resident #1's falls. LVN G said she could not remember if she checked the oxygen saturation or listened to heart and lung sounds of Resident #1. During an interview on [DATE] at 11:36 a.m., ADON F said she notified the physician of Resident #1's fall on [DATE] at 9:00 p.m. via text message. She said she could not remember if the physician responded. ADON F said Resident #1 had just fallen so it made sense that her pulse was elevated (129). ADON F said she notified the physician of the fall only, not the increase in Resident #1's pulse. ADON F said the charge nurse should always notify the physician when a resident fell . ADON F said changes in residents' condition should be relayed to the physician. During an interview on [DATE] at 3:00 p.m., RN A said she cared for Resident #1 the day she expired ([DATE]) during the day shift. She said Resident #1 had increased restlessness that day and the night before. She said Resident #1 kept getting up over and over and had to be assisted back to bed by staff multiple times. RN A said Resident #1 had fallen getting out of bed that morning as well as a couple of times during the night. She said Resident #1 would occasionally try to get out of bed unassisted, but not at the frequency she exhibited on [DATE] and [DATE]. RN A said she did not notify the physician when Resident #1 fell on [DATE] at 11:36 a.m. RN A said she could not remember if Resident #1 complained of pain. RN A said Resident #1 was started on oxygen on the night shift because of shortness of breath. She said Resident #1 complained of being short of breath throughout the morning. She said she did not notify the physician of Resident #1's shortness of breath. RN A said she thought she took Resident #1's oxygen saturation level, but she could not remember what it was, and she forgot to document it. RN A said she did not know why she did not address Resident #1's shortness of breath and did not administer the as needed order for breathing treatment (Duo-Neb nebulizer treatment) for shortness of breath. RN A said she did not remember if she listened to heart and lung sounds of Resident #1. RN A said she notified ADON D of the falls. She said ADON D could authorize the facility to send the resident out to the emergency department immediately and she was aware of Resident #1's condition but ADON D did not tell her to send the resident out. RN A said she should have notified the physician of Resident #1's increased restlessness, fall and shortness of breath. RN A said the facility had standing orders and protocols from the physician to address different symptoms. She said it was not required to notify the physician when these standing orders were initiated unless the treatment was not effective. During an interview on [DATE] at 1:00 p.m., LVN B said she observed Resident #1 on the morning of [DATE] before she passed away. LVN B said she walked past Resident #1's room and noticed Resident #1 was trying to get out of bed. She said she went into the room and assisted the resident back to bed. LVN B said she later observed Resident #1 on the floor on [DATE] and went into the room to assist her back into the bed. She said Resident #1 complained she could not breath and was short of breath. LVN B said Resident #1 was wearing oxygen both times she observed her, and she did not normally use oxygen. LVN B said she was not taking care of Resident #1 that day ([DATE]) but she discussed Resident #1 being short of breath with RN A, who was the resident's nurse. LVN B said RN A was aware Resident #1 complained of being short of breath. During an interview on [DATE] at 1:55 p.m., LVN C said she was familiar with Resident #1 and worked the day Resident #1 died . LVN C said Resident #1 would complain of pain to her neck and shoulder occasionally. LVN C said Resident #1 had never complained of shortness of breath or nausea when she cared for her in the past. LVN C said the facility had standing protocols from the physician for nausea and shortness of breath. She said nursing staff were not required to notify the physician when they initiated these protocols with standing orders. During an interview on [DATE] at 8:14 a.m., ADON D said Resident #1 was alert and oriented and able to make her needs known. ADON D said she was not aware Resident #1 complained of chest pain or being short of breath. She said Resident #1 had not complained to her. ADON D said RN A should have reported any change of condition to the physician and nursing staff should have been monitoring Resident #1's oxygen saturation and documenting in the MAR indicated [REDACTED]. ADON D said she was called to the room when Resident #1 was found on the floor face down on [DATE]. She said she rolled her to her back and noted Resident #1's lips were blue. ADON D said she initiated CPR and was informed Resident #1 was a DNR and life saving measures were stopped. She said the resident was pronounced dead by RN A. During an interview on [DATE] at 11:08 a.m., the physician assistant said he had not been notified of Resident #1's vital signs on [DATE] at 9:00 p.m. He said he should have been notified immediately of Resident #1's elevated pulse of 129. The physician assistant said he had not been notified of Resident #1's complaints of nausea, shortness of breath or changing vital signs. The physician assistant said he had not been notified of Resident #1's fall on [DATE] at 11:36 a.m. The physician assistant said he should always be notified when a resident fell . The physician assistant said he would have expected facility staff to notify him immediately of Resident #1's change in condition. During an interview on [DATE] at 9:05 a.m., The DON said she was not working the day Resident #1 expired. The DON said she reviewed the chart and Resident #1 complained of feeling bad off and on for a few months. The DON said Resident #1 would have increased physical complaints when she was in a depressive state. The DON said nausea was not new for Resident #1 and the resident would utilize the anti-nausea medication with her pain medication to knock her out. The DON said they offered to send Resident #1 to the emergency room the day before she expired ([DATE]) because she complained of not feeling well and Resident #1 declined. The DON said she had forgotten to chart that information. The DON said nursing staff should notify the physician if a resident had a change in condition. A Notification of Change Policy dated [DATE] indicated .The facility will immediately inform the resident and consult with the resident's physician for a significant change in the physical, mental, or psychosocial status of a resident . A Policy for Physician notification/protocol Usage dated [DATE] indicated .It is the facility mission to have all needs of the resident met by timely implementation of any health concerns. We will have standing protocols for physicians .Physicians will give us written and signed protocols to be used. Each nurse will refer to the protocols for common needs of the resident. The nurse needs to contact the physician at any time the timeliness and urgency of the residents needs change. Nurses' judgement must be used. If the protocol is used, then when the physician comes in he will be notified by the items in his box. Nurse can communicate the situation to the nurse administration regarding the resident .Nurses must write a telephone order for the protocol used. Notify the PA's by using the communication box .[MEDICAL CONDITION]/[MEDICAL CONDITION]/URI/PNA-If a resident has abnormal lung sounds, wheezing or new shortness of breath order chest x-ray and call results to the PA. If wheezing or short of breath, order nebulizer treatments .chest pain-new onset, give [MEDICATION NAME] 0.4 mg/SL every 5 minutes up to 3 doses and notify physician, if no reply in timely fashion, send to ER .Nausea-[MEDICATION NAME] 4 mg tab every 6 hours as needed .Oxygen parameters-O2 at 2 liters/min via nasal cannula for O2 saturation less than 90% O2 up to 4 liters via nasal cannula. For acute respiratory distress if unable to raise oxygen level after this call physician and send to ER. The administrator and DON were notified on [DATE] at 3:32 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:35 p.m. and included: All residents will be assessed for change of condition by nursing administration/charge nurses by [DATE] at 8:00 p.m. Findings will be reported to DON/ADON responsible party and physician. Resident chart will be placed in focused charting The DON will in-service all current employees by [DATE] at 9:00 p.m. on Interact 4.0(stop and watch, SBAR procedures, acute transfer form, hospital reconciliation, return to facility), definition of a fall, when to fill out an incident report, recognizing change in condition and when to notify the physician. This training will be included in all orientation training going forward. Nursing administration/designee will monitor personnel to ensure staff are following the plan of removal by reviewing the 24 hour report, daily rounds, reviewing lab results, reviewing SBARs, and monthly QA review of outcomes of change in condition by the medical director, administrator, DON and interdisciplinary team. The investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by: *Sixteen nurses were interviewed and said they had been in-serviced on change of condition and physician notification. They said the stop and watch forms would be filled out by anyone noticing a change in a resident's normal behavior, appearance, symptoms etc. The form would be given to the charge nurse and the DON. The charge nurse would immediately assess the resident and complete the SBAR and notify the physician of any changes. The physician would be notified immediately when a new standing protocol is initiated. *Thirteen CNAs were interviewed and said they had been in-serviced on the stop and watch forms and resident change in condition. They said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance or anything different than usual. The staff indicated these forms were to be given to the charge nurse immediately and copied for the DON. *One medication aide was interviewed and said she had been in-serviced on the stop and watch forms and resident change in condition. She said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance or anything different in the resident. She said these forms were to be given to the charge nurse immediately and copied for the DON. The charge nurse was to assess the resident and notify the physician of any change in condition. *Five training nurse aides were interviewed and said they had been in-serviced on the stop and watch forms and resident change in condition. They said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance. The said the forms were to be given to the charge nurse immediately and copied for the DON. *Two support staff were interviewed and said they had been in-serviced on the stop and watch forms and resident change in condition. They said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance or anything other than usual. They said the forms are to be given to the charge nurse immediately and copied for the DON. *Stop and watch forms were placed at the nursing station and linen closets *The DON provided a summary of 98 residents assessed for change of condition. Three issues were reported. No major issues found. On [DATE] at 8:20 a.m., the administrator and DON were informed the IJ was removed; However, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 13 residents reviewed for quality of care. (Resident #1) The facility did not thoroughly assess, provide interventions, and treatments for Resident #1 when she complained of chest pain, nausea, shortness of breath, and experienced an increase in restlessness, anxiety, falls, and heart rate starting [DATE]. Resident #1 was found face down on the floor without a pulse or respirations and was pronounced dead on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious illness and death. Findings included: Consolidated physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 understood others and made herself understood. The MDS indicated her cognition was intact and she required extensive assistance for ADLs. The MDS indicated the resident had [DIAGNOSES REDACTED]. The most recent care plan updated [DATE] indicated Resident #1 was at risk for alteration in fluid balance related to her history of [MEDICAL CONDITION]. The care plan indicated staff would notify the physician of changes as needed. The care plan indicated Resident #1 was at risk for falls related to her history of falls and attempting to self-transfer. The care plan indicated staff would rule out medical complications [REDACTED]. The care plan indicated staff would notify the physician of falls as needed and attempt to identify the root cause for falls. The care plan indicated Resident #1 experienced pain in her back and shoulders related to her [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. Nursing notes dated [DATE] and [DATE] indicated no oxygen saturation levels were documented for Resident #1. A nursing note dated [DATE] at 3:19 p.m., indicated Resident #1 reported I do not feel well. A nursing note dated [DATE] at 4:30 p.m., indicated Resident #1 was found trying to get out of bed unassisted. The note indicated Resident #1 complained of right shoulder pain and Bio freeze (pain relief gel) was administered as ordered. A nursing note dated [DATE] at 8:01 p.m., indicated Resident #1 complained of nausea and a standing order was written for [MEDICATION NAME] (an anti-nausea medication) 4 mg as needed per physician protocol. The note indicated the medication was administered. A nursing note dated [DATE] at 9:00 p.m. indicated Resident #1 was found in the floor with a bruise noted to left side of her back. The note indicated the residents blood pressure was ,[DATE], pulse was 129 (normal 60 -100) and temperature-97.5. The note indicated neurological checks were initiated. An incident report dated [DATE] (for the 9:00 p.m. fall) indicated Resident #1 was found face down on the floor with a reddish-purple bruise noted to the right side of her back. The report indicated an assessment and vital signs were immediately completed and Resident #1's blood pressure was ,[DATE], pulse 129, temperature 97.5. A fall investigation worksheet completed on [DATE] indicated Resident #1 was oriented with no behaviors observed prior to the fall at 9:00 p.m. The investigation worksheet indicated Resident #1 did not have a history of attention seeking by sitting herself on the floor, no history of throwing herself on the floor, and no history of rolling out of bed on the floor. A fall investigation summary dated [DATE] at 9:00 p.m., for Resident #1 indicated resident lying on floor face down. Bruise to right side of back. Vitals obtained and stable. MD notified. A nursing note dated [DATE] at 3:33 a.m., indicated Resident #1 fell on [DATE] at 10:30 p.m. The note indicated there were no signs of pain or distress and respirations were even and unlabored. The note indicated the residents blood pressure was ,[DATE], pulse 104, respirations 20 and temperature 97.3. The note did not indicate the physician was notified. A nursing note dated [DATE] at 11:36 a.m., indicated Resident #1 was found by the housekeeper on her hands and knees in the floor. The note indicated the resident's respirations were even and unlabored and her blood pressure was ,[DATE], pulse 98, respirations 16, and temperature 97.8. The note did not indicate the physician was notified. A nursing note dated [DATE] at 1:38 p.m., indicated Resident #1 was found at 12:20 p.m. face down next to the bed. The note indicated the resident was unresponsive with no pulse or respirations. The note indicated CPR was initiated and 911 was called. The note indicated the nurse verified Resident #1 was a DNR (do not resuscitate), life saving measures were stopped and Resident #1 was pronounced dead at 12:36 p.m. by RN A. During an interview on [DATE] at 11:42 a.m., the complainant said he heard Resident #1 complain to facility staff on the evening of [DATE] sometime before dinner that she could not breathe, and her chest was hurting. The complainant said Resident #1 kept saying my chest is hurting to the staff. The complainant could not recall the names of the staff. The complainant said the staff gave her a pill but they would not send her out. During an interview on [DATE] at 4:43 p.m., LVN G said she cared for Resident #1 on the evening of [DATE]. She said Resident #1 was more restless that evening than usual. She said Resident #1 kept trying to get up out of bed, appeared anxious and complained of being short of breath. LVN G said she put oxygen on Resident #1 and the resident continued to complain of shortness of breath. LVN G said Resident #1 could not catch her breath so she attempted to raise the head of Resident #1's bed but Resident #1 did not want to sit up. LVN G said she did not recall if Resident #1 had complained of pain. LVN G said Resident #1 complained of nausea so she initiated the nausea protocol and administered [MEDICATION NAME] 4mg. LVN G said she did not notify the physician of Resident #1's nausea or shortness of breath. LVN G said she did not notify the physician of Resident #1's increased pulse of 129 on [DATE] at 9 p.m. LVN G said she could not recall if she had notified the physician of Resident #1's falls. LVN G said she could not remember if she checked the oxygen saturation or listened to heart and lung sounds of Resident #1. During an interview on [DATE] at 11:36 a.m., ADON F said she notified the physician of Resident #1's fall on [DATE] at 9:00 p.m. via text message. She said she could not remember if the physician responded. ADON F said Resident #1 had just fallen so it made sense that her pulse was elevated (129). ADON F said she notified the physician of the fall only, not the increase in Resident #1's pulse. ADON F said the charge nurse should always notify the physician when a resident fell . ADON F said changes in residents' condition should be relayed to the physician. During an interview on [DATE] at 3:00 p.m., RN A said she cared for Resident #1 the day she expired ([DATE]) during the day shift. She said Resident #1 had increased restlessness that day and the night before. She said Resident #1 kept getting up over and over and had to be assisted back to bed by staff multiple times. RN A said Resident #1 had fallen getting out of bed that morning as well as a couple of times during the night. She said Resident #1 would occasionally try to get out of bed unassisted, but not at the frequency she exhibited on [DATE] and [DATE]. RN A said she did not notify the physician when Resident #1 fell on [DATE] at 11:36 a.m. She said she did not notify the physician of Resident #1's shortness of breath. RN A said she could not remember if Resident #1 complained of pain. RN A said Resident #1 was started on oxygen on the night shift because of shortness of breath. She said Resident #1 complained of being short of breath throughout the morning. RN A said she thought she took Resident #1's oxygen saturation level, but she could not remember what it was, and she forgot to document it. RN A said she did not know why she did not address Resident #1's shortness of breath and did not administer the as needed order for breathing treatment (Duo-Neb nebulizer) for shortness of breath. RN A said she did not remember if she listened to heart and lung sounds of Resident #1. RN A said she notified ADON D of the falls. She said ADON D could authorize the facility to send the resident out to the emergency department immediately and she was aware of Resident #1's condition but ADON D did not tell her to send the resident out. RN A said she should have notified the physician of Resident #1's increased restlessness, fall and shortness of breath. During an interview on [DATE] at 1:00 p.m., LVN B said she observed Resident #1 on the morning of [DATE] before she passed away. LVN B said she walked past Resident #1's room and noticed Resident #1 was trying to get out of bed. She said she went into the room and assisted the resident back to bed. LVN B said she later observed Resident #1 on the floor on [DATE] and went into the room to assist her back into the bed. She said Resident #1 complained she could not breath and was short of breath. LVN B said Resident #1 was wearing oxygen both times she observed her, and she did not normally use oxygen. LVN B said she was not taking care of Resident #1 that day ([DATE]) but she discussed Resident #1 being short of breath with RN A, who was the residents nurse. LVN B said RN A was aware Resident #1 complained of being short of breath. During an interview on [DATE] at 8:14 a.m., ADON D said Resident #1 was alert and oriented and able to make her needs known. ADON D said she was not aware Resident #1 had complained of chest pain or being short of breath. She said Resident #1 had not complained to her. DON D said RN A should have reported any change of condition to the physician and nursing staff should have been monitoring Resident #1's oxygen saturation and documenting in the MAR indicated [REDACTED]. ADON D said she was called to the room when Resident #1 was found on the floor face down on [DATE]. She said she rolled her to her back and noted Resident #1's lips were blue. ADON D said she initiated CPR and was informed Resident #1 was a DNR and life saving measures were stopped. She said the resident was pronounced dead by RN A. During an interview on [DATE] at 11:08 a.m., the physician assistant said he had not been notified of Resident #1's vital signs on [DATE] at 9:00 p.m. He said he should have been notified immediately of Resident #1's elevated pulse of 129. The physician assistant said he had not been notified of Resident #1's complaints of nausea, shortness of breath or changing vital signs. The physician assistant said he had not been notified of Resident #1's fall on [DATE] at 11:36 a.m. The physician assistant said he should always be notified when a resident fell . The physician assistant said he would have expected facility staff to notify him immediately of Resident #1's change in condition. During an interview on [DATE] at 9:05 a.m., the DON said she was not working the day Resident #1 expired. The DON said she reviewed the chart and Resident #1 had complained of feeling bad off and on for a few months. The DON said Resident #1 would have increased physical complaints when she was in a depressive state. The DON said nausea was not new for Resident #1 and the resident would utilize the anti-nausea medication with her pain medication to knock her out. The DON said they offered to send Resident #1 to the emergency room the day before she expired ([DATE]) because she complained of not feeling well and Resident #1 declined. The DON said she had forgotten to chart that information. The DON said nursing staff should notify the physician if a resident had a change in condition. A Policy for Physician notification/protocol Usage dated [DATE] indicated .It is the facility mission to have all needs of the resident met by timely implementation of any health concerns. We will have standing protocols for physicians .Physicians will give us written and signed protocols to be used. Each nurse will refer to the protocols for common needs of the resident. The nurse needs to contact the physician at any time the timeliness and urgency of the residents needs change. Nurses' judgement must be used .[MEDICAL CONDITION]/[MEDICAL CONDITION]/URI/PNA-If a resident has abnormal lung sounds, wheezing or new shortness of breath order chest x-ray and call results to the PA. If wheezing or short of breath, order nebulizer treatments .chest pain-new onset, give [MEDICATION NAME] 0.4 mg/SL every 5 minutes up to 3 doses and notify physician, if no reply in timely fashion, send to ER .Nausea-[MEDICATION NAME] 4 mg tab every 6 hours as needed .Oxygen parameters-O2 at 2 liters/min via nasal cannula for O2 sats less than 90% O2 up to 4 liters via nasal cannula. For acute respiratory distress if unable to raise oxygen level after this call physician and send to ER . The administrator and DON were notified on [DATE] at 3:32 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:35 p.m. and included: All residents will be assessed for change of condition by nursing administration/charge nurses by [DATE] at 8:00 p.m. Findings will be reported to DON/ADON responsible party and physician. Resident chart will be placed in focused charting The DON will in-service all current employees by [DATE] at 9:00 p.m. on Interact 4.0(stop and watch, SBAR procedures, acute transfer form, hospital reconciliation, return to facility), definition of a fall, when to fill out an incident report, recognizing change in condition and when to notify the physician. This training will be included in all orientation training going forward. Nursing administration/designee will monitor personnel to ensure staff are following the plan of removal by reviewing the 24 hour report, daily rounds, reviewing lab results, reviewing SBARs, and monthly QA review of outcomes of change in condition by the medical director, administrator, DON and interdisciplinary team. The investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by: *Sixteen nurses were interviewed and said they had been in-serviced on change of condition and physician notification. They said the stop and watch forms would be filled out by anyone noticing a change in a resident's normal behavior, appearance, symptoms etc. The form would be given to the charge nurse and the DON. The charge nurse would immediately assess the resident and complete the SBAR and notify the physician of any changes. The physician would be notified immediately when a new standing protocol was initiated. *Thirteen CNAs were interviewed and said they had been in-serviced on the stop and watch forms and resident change in condition. They said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance or anything different than usual. The staff indicated these forms were to be given to the charge nurse immediately and copied for the DON. *One medication aide was interviewed and said she had been in-serviced on the stop and watch forms and resident change in condition. She said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance or anything different in the resident. She said these forms were to be given to the charge nurse immediately and copied for the DON. The charge nurse was to assess the resident and notify the physician of any change in condition. *Five training nurse aides were interviewed and said they had been in-serviced on the stop and watch forms and resident change in condition. They said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance. The said the forms were to be given to the charge nurse immediately and copied for the DON. *Two support staff were interviewed and said they had been in-serviced on the stop and watch forms and resident change in condition. They said they were to fill out the stop and watch form for any noted change in a resident's normal behavior, actions, appearance or anything other than usual. They said the forms are to be given to the charge nurse immediately and copied for the DON. *Stop and watch forms were placed at the nursing station and linen closets *The DON provided a summary of 98 residents assessed for change of condition. Three issues were reported. No major issues found. On [DATE] at 8:20 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 13 residents reviewed for elopement. (Resident #3) The facility did not monitor Resident #3 who was a new admission hourly per facility policy. Resident #3 was last seen at the facility at approximately 2:30 p.m. and the facility did not notice he was missing until approximately 7:30 p.m. The resident was found by local law enforcement at a convenience store approximately 1.5 miles from the facility. This was determined to be past non-compliance that existed from 5/19/19 and was corrected on 5/20/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for severe injury or death. Findings included: Consolidated physician's orders [REDACTED].#3 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan dated 5/17/19 indicated Resident #3 was confused, independent with transfers, walking, and locomotion. The care plan indicated he had a history of [REDACTED]. An elopement/wandering risk assessment dated [DATE] indicated Resident #3 was not an elopement risk. A 72-hour Adjustment to the Facility monitoring sheet initiated 5/17/19 at 8:00 p.m. for Resident #3 indicated the resident would be monitored hourly for 72 hours. On the day of his elopement (5/19/19), the monitoring sheet indicated RN K signed off that Resident #3 was okay at 6:00 a.m. through 10:00 p.m. An incident report dated 5/19/19 at 7:30 p.m., indicated Resident #3 was not in his room and all staff members were notified of a missing resident. The report indicated a full facility search was initiated and Resident #3 was not found. The report indicated the DON and police were notified and the police called back and informed the nurse Resident #3 had been picked up at a convenience store and taken to the address Resident #3 had provided (his previous home address). The report indicated Resident #3 returned to the facility and a full assessment was completed, fluids and snack were offered, a wander guard was placed on his left ankle, and the resident was placed on every 15-minute checks. A witness statement dated 5/19/19 by MA N indicated MA N observed Resident #3 at approximately 2:30 p.m. standing in his room, looking out the door, and speaking to his roommate. The statement indicated MA N went back to his room at approximately 3:00 p.m. to obtain vital signs and Resident #3 was not in his room. The statement indicated MA N went back at approximately 7:00 p.m. to give Resident #3 medications and the resident was still gone and she reported to the charge nurse. A nursing note dated 5/19/19 at 9:54 p.m. indicated the nurse was notified at 7:30 p.m. by a medication aide Resident #3 was not in his room. The note indicated all staff were notified of the missing resident and a full facility search was initiated. The note indicated the DON and police were notified and the police informed them Resident #3 had been picked up at a convenience store and per Resident #3 he was lost. The note indicated the police took Resident #3 to his previous residence (address provided by Resident #3). The note indicated the DON picked Resident #3 up and returned him to the facility where a full assessment was completed. The note indicated Resident #3 was given fluids, a wander guard was placed on his left ankle and fifteen-minute checks were initiated. A safety device sheet dated 5/20/19 indicated Resident #3 had a wander guard applied for elopement risk. The MDS dated [DATE] indicated Resident #3 usually understood others and was sometimes understood. The MDS indicated he required limited assistance with ADLs and had behaviors of wandering. The MDS indicated the resident had moderate cognitive impairment. A care plan dated 5/23/19 indicated Resident #3 had impaired cognition, was at risk for falls, and was placed on the secure unit due to wandering and risk for elopement. During an interview on 6/19/19 at 5:26 p.m., RN K said she was extremely busy on 5/19/19. RN K said she last observed Resident #3 in the dining room at lunch. She said they noticed the resident was missing at approximately 7:30 p.m. when the medication aide was looking for him to give his evening medications. RN K said she notified all staff of the missing resident and they began a search in the building and around the premises. She said Resident #3 was not located so she notified the DON and was instructed to call the police. RN K said the police called right back and informed her Resident #3 was found approximately 1.5 miles down the road at a convenience store and they had taken him to an address he provided (his previous home address). RN K said she notified the DON and the DON went to get the resident. RN K said she did a full assessment on Resident #3 and he had no injuries. RN K said they applied a wander guard and placed Resident #3 on every 15-minute checks. RN K said she held herself responsible, but she was stretched too thin that day. During an interview on 6/18/19 at 4:18 p.m., CNA L said she was working the evening Resident #3 eloped. CNA L said she never saw him on her on her 2 p.m. to 10 p.m. shift. She said Resident #3 was new and she did not know what he looked like and had never worked with him. CNA L said she made her rounds when she came in at approximately 2:00 p.m. She said Resident #3 was not in his room at that time. CNA L said she passed ice at approximately 3:00 p.m. and Resident #3 was not in his room at that time. CNA L said she received report at shift change that Resident #3 roamed the halls, so she was not alarmed when he was not in his room. CNA L said she assumed Resident #3 was walking around and someone else had seen him. CNA L said the medication aide was looking for him and that was when the nurse was notified Resident #3 had not been seen. CNA L said this was after dinner because Resident #3 was not in the dining room for dinner either. During an interview on 6/18/19 at 5:01 p.m., TNA M said she worked the 2:00 p.m. to 10:00 p.m. shift the evening Resident #3 eloped. TNA M said she did not know Resident #3 because he was new. She said she did her rounds at the beginning of the shift but did not see Resident #3. TNA M said she did not report to anyone that she had not seen Resident #3. During an interview on 6/17/19 at 10:03 a.m., the DON said Resident #3 admitted late on a Friday (5/17/19). She said he walked the halls but did not attempt to go out or exit seek. The DON said he was noticed missing around 7:30 p.m. on 5/19/19. She said the police were notified and called back to report they had found him at a convenience store down the road and had taken him to his home address. The DON said she went to Resident #3's home to pick him up and his neighbors were with him. She said he was not in any distress and no injuries were noted. The DON said a wander guard was applied as soon as they returned to the facility and Resident #3 was placed on 15-minute checks. The DON said she in-serviced staff on the elopement process and monitoring residents. The DON said Resident #3 was moved to the secure unit 3 days later because he was observed unscrewing screws on the patio door trying to get out. During an interview on 6/20/19 at 2:12 p.m. the DON said they had a checklist for new admissions. She said every new admission was put on hourly monitoring for 72 hours to make sure they were adjusting. The DON said the charge nurse was responsible for the hourly monitoring. The DON said RN K admitted to not actually seeing Resident #3 but marking the monitoring sheet that she had. The DON said she re-educated all nurses on the admission monitoring and following procedure. The DON said RN K resigned during the investigation. During an observation of the road from the facility to the convenience store on 6/20/19 at 2:28 p.m. the road led to an intersection where the resident would have turned left. The highway was busy with traffic and the resident would have crossed another intersection and a railroad crossing before arriving at the convenience store approximately 1.5 miles from the facility. An Admissions Protocols Process indicated .To ensure all residents are admitted with the respect and dignity that each individual deserves while maintaining continuity of care from home, hospital, or other entity .Do complete head to toe assessment of resident and complete nursing and risk assessment. If elopement risk, then place a wander guard on resident .Place on 1-hour monitoring for first 72 hours for proper care and risk of changes in condition related to facility admission . It was determined these failures placed Resident #3 in an Immediate Jeopardy situation from 5/19/19 to 5/20/19. After Resident #3 eloped on 5/19/19 the facility implemented the following interventions: *On 5/19/19 the DON in-serviced staff on the elopement process, hourly monitoring, new admissions, and following procedure. *On 5/19/19 2 CNAs and a MA received counseling for not following protocol and alerting the nurse when Resident #3 was not in his room at the time of rounds. On 6/19/19, the surveyor determined interventions were completed by: Six nurses were interviewed and said they received training prior to the investigator's entrance on elopement process, hourly monitoring, new admissions, and following procedure for a missing resident. The nurses were able to answer questions appropriately regarding the process of initiating hourly rounding on a new admission, what to do if a resident was reported missing, when to initiate a search for a missing resident and how to ensure hourly rounding was completed. Eight CNAs were interviewed and said they received training prior to the investigator's entrance on the elopement process, proper rounding and following the procedure for a missing resident. The CNAs were able to appropriately answer questions regarding making rounds, locating residents during rounds, when to notify the charge nurse if a resident was not located during rounds and when to initiate a search for a resident that could not be located.

Based on observation, interview and record review the facility failed to ensure the PICC line site was maintained consistent with professional standards of practice and in accordance with physician orders [REDACTED]. (Resident #2) The facility did not change Resident #2's PICC line dressing weekly as ordered by the physician. Resident #2's PICC line dressing was not changed as scheduled on [DATE], [DATE] and [DATE]. Resident #2 was admitted to the hospital and died with [DIAGNOSES REDACTED]. This was determined to be past non-compliance that existed from [DATE] and was corrected on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents with PICC lines at risk for serious infection and death. Findings included: Consolidated physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].#2 would have dressing changes to midline (a catheter placed in a major vein so that medication or nutrients can be injected directly into the bloodstream) weekly and as needed. The MDS dated [DATE] indicated Resident #2 sometimes understood others and was sometimes understood. The MDS indicated Resident #2 was totally dependent on staff for ADLs and had an active [DIAGNOSES REDACTED]. The MDS indicated Resident #2 received treatment with IV medications. The care plan with an onset date of [DATE] indicated Resident #2 had impaired cognition with episodes of confusion and lethargy. The care plan indicated Resident #2 had impaired skin integrity with multiple wounds and had a PICC (peripherally inserted central catheter) to her right upper arm and a [MEDICAL TREATMENT] port to her right chest wall. The care plan indicated Resident #2 osteo[DIAGNOSES REDACTED] wound infection. The care plan did not address care or dressing changes of the PICC line. A laboratory services report dated [DATE] indicated bloodwork was collected [DATE] at 5:45 a.m. The report indicated Resident #2's WBC (white blood cells) were critically high at 29.50 (normal reference 4XXX,[DATE].0). The report indicated Resident #2's previous WBC count was 19.85 (high) on [DATE], and 14.48 (high) on [DATE]. A grievance report dated [DATE] indicated the family of Resident #2 complained her PICC line dressing was dated [DATE] and had not been appropriately changed. The grievance report summary indicated LVN H had signed Resident #2's MAR indicated [REDACTED]. The report indicated Resident #2's PICC line dressing was not changed on [DATE] and LVN J said she did not change the dressing on [DATE] because Resident #2 went out to [MEDICAL TREATMENT]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A hospital discharge summary dated [DATE] indicated Resident #2 was admitted on [DATE] at 5:34 a.m. and died on [DATE] at 3:28 p.m. with the final [DIAGNOSES REDACTED]. During an interview on [DATE] at 3:53 p.m., LVN J said Resident #2 went to [MEDICAL TREATMENT] on [DATE], so she did not change the PICC line dressing. LVN J said Resident #2 was upset when she returned from [MEDICAL TREATMENT] and she believed Resident #2 refused the PICC line dressing change by her body language. She said Resident #2 did not verbally refuse the PICC line dressing change. LVN J said she was pretty sure she passed the information on to the next shift Resident #2 needed her PICC line dressing changed. LVN J said she could not remember who she passed the information to. During an interview on [DATE] at 7:39 p.m., LVN H said she was busy on [DATE] when Resident #2 required a PICC line dressing change. She said she marked that she had completed the change in the MAR, but she did not have time to get to it. LVN H said she told the oncoming shift the dressing change had not been completed. She said she could not remember who she told. LVN H said she did not flush the PICC line or look at the PICC line site on [DATE]. During an interview on [DATE] at 1:55 p.m., LVN C said she flushed Resident #2's PICC line and noticed the dressing was in very bad shape. She said she could not remember the date she noticed the dirty dressing or the date on the dressing, but it was disgusting. LVN C said the port did not have a cap on it and was exposed to air. She said the dressing was peeling up on all sides and was a grayish black color. She said the dressing had lint on the underside. LVN C said she changed the dressing at that time. During an interview on [DATE] at 10:03 a.m., the DON said Resident #2 received IV antibiotics for osteo[DIAGNOSES REDACTED] through the PICC line. She said Resident #2's PICC line dressings were scheduled to be changed once a week on [DATE], [DATE], and [DATE]. She said on [DATE] she was informed Resident #2's PICC line dressing had not been changed since [DATE]. The DON said LVN H admitted to not changing the PICC line dressing on [DATE]. The DON said LVN H was suspended and later resigned. During an interview on [DATE] at 11:08 a.m., the physician assistant said the improper care of the PICC line could have caused an increase in Resident #2's white blood cell count. He said the improper care of the PICC line could have caused the [MEDICAL CONDITION] in Resident #2's right upper extremity. He said he would expect staff to follow Resident #2's orders and complete PICC line dressing changes and care as ordered. An undated Peripherally Inserted Central Catheter Care and Maintenance procedure guide indicated .the purpose was to safely care for, maintain, and monitor PICC lines .catheters should be covered with a transparent film dressing. The transparent dressing, injection port, and extension tubing are changed every 7 days and PRN .Extreme care is required during dressing change procedures so as not to pull out the catheter and to maintain sterility .follow sterile central line dressing change procedure . The website www.registerednursern.com/picc-line-dressing-change-clinical -nursing-skills/ accessed on [DATE] indicated .A PICC line is a soft plastic tube that is inserted into a large vein right above the patient's heart. The PICC line must always remain sterile so that the patient does not run the risk of getting an infection. The PICC line dressings should be changed at least once a week. If the dressing becomes loose, wet, or dirty the dressing must be changed more often to prevent infection. The PICC line dressing must be inspected on a daily basis .When changing a PICC line dressing put on a pair of sterile gloves .Do not touch the outside of the package or anything other than the contents of the package once the gloves are on the hands .Infections are the biggest complication so it is important to monitor the dressing and change the PICC line dressing whenever it gets dirty, loose or wet . It was determined these failures placed Resident #2 in an Immediate Jeopardy situation from [DATE] through [DATE]. The facility took the following actions to correct the non-compliance on [DATE]: The DON in-serviced staff on PICC line dressing changes and assessments of all in house PICC lines. The PICC line policy was reviewed and all PICC line dressing changes were moved to Mondays on the 10:00 p.m. - 6:00 a.m. shift. On [DATE], the investigator confirmed interventions were completed by: *Sixteen nurses were interviewed and said they received training prior to the surveyor's entrance regarding appropriate PICC line care and dressing change schedule. All nurses indicated PICC line dressing changes were due every Monday on the 10:00 p.m. - 6:00 a.m. shift. *Two residents receiving PICC line services were reviewed and dressings were being changed and documented as ordered by the physician.