Every finding on record at Epic Nursing & Rehabilitation

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved serious bodily injury, to the Administrator of the facility and other officials including to the State Survey Agency in accordance with State and law through established procedures for one of eight (Resident #1) residents reviewed for abuse and neglect. Nursing facility staff failed to report to the Administrator that Resident #1 was observed hitting another resident on 6/25/2026 at 1:30 pm. This failure could place residents at risk of not being protected from abuse, neglect, or exploitation.Findings include: Record review of Resident #1's face sheet, dated 6/26/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Epilepsy (seizure disorder), Dementia (decline in mental ability), high blood pressure, anxiety disorder, and major depressive disorder. Record review of Resident #1's admission MDS, dated [DATE], reflected he had a BIMS of 2, which indicated severe cognitive impairment. Record review of Resident #1's care plan, dated 6/26/2026, reflected a focus: Resident exhibits physically aggressive behaviors, including hitting staff and other residents, placing self and others at risk for injury with the intervention: Monitor the resident closely for signs of agitation or escalating behaviors. Identify and document potential triggers. During an interview on 6/26/2026 at 10:08 AM, CNA A stated she worked yesterday, 6/25/2026, during the day on the memory care unit. She stated she was picking up lunch trays around 1:30 PM and observed Resident #1 hit another resident. She stated Nurse A was standing right there and observed the incident. She stated she and Nurse B separated the residents and removed Resident #1 from the area. She stated she had been working on the unit for about three weeks and had never seen Resident #1 become aggressive with any of the residents. CNA A stated she received training on abuse and neglect and would consider one resident hitting another as physical abuse. She stated she should have reported it immediately to the ADM but figured since Nurse B had observed it also, Nurse B would report it to the ADM. She stated she was not aware Nurse B did not report it to the ADM. During an interview on 6/26/2026 at 12:15 PM, the DON stated she was not aware of the incident with Resident #1 until today and was not aware of any previous incidents with Resident #1 and other residents. She stated neither Nurse B or CNA A reported the incident when it happened on 6/25/2026. She stated all staff were trained to report any instances of abuse or neglect immediately to the ADM, who was the abuse coordinator. The DON stated one resident hitting another could be considered physical abuse. She stated her concern with events not being reported would be the needs of the residents may not be met. During an interview on 6/26/2026 at 12:26 PM, Nurse B stated she worked the day shift yesterday, on 6/25/2026 on the memory care unit and observed Resident #1 hit another resident on the back of the neck about 1:30 PM. She stated she separated the residents and redirected Resident #1 out of the area. She stated she assessed both residents for injuries, and none were noted. She stated it was her first day on the unit, she was busy passing medications, and she didn't think to report it to the ADM who was also the abuse coordinator. She stated she had been trained in reporting any instances of abuse or neglect immediately to the ADM and she would consider one resident hitting another as physical abuse. She stated when abuse happened I should report it right there and then. She stated not immediately reporting instances of abuse or neglect could cause it to happen again, a resident could get injured, or they could go on to other residents. During an interview on 6/26/2026 at 4:37 PM, the ADM stated he had just found out about the incident where Resident #1 hit another resident. He stated he reported the incident to the state agency and was informed neither resident was injured. He stated by incidents not being reported, he had serious concerns about residents' safety. He stated he needed to know if something was wrong so they could take care of the residents. Record review of the facility's policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, reflected: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 3. 'Immediately' is defined as:a. within two hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening condition of clinical complications for one of eight residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's FM was notified when he hit another resident on 6/25/2026. This failure could place residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.Findings include: Record review of Resident #1's face sheet, dated 6/26/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Epilepsy (seizure disorder), Dementia (decline in mental ability), high blood pressure, anxiety disorder, and major depressive disorder. Record review of Resident #1's admission MDS, dated [DATE], reflected he had a BIMS of 2, which indicated severe cognitive impairment. Record review of Resident #1's care plan, dated 6/26/2026, reflected a focus: Resident exhibits physically aggressive behaviors, including hitting staff and other residents, placing self and others at risk for injury with the intervention: Monitor the resident closely for signs of agitation or escalating behaviors. Identify and document potential triggers. Record review of Resident #1's progress notes, dated 6/25/26 to 6/26/26, reflected no entry that Resident #1's FM was contacted about the incident on 6/25/2026. During an interview on 6/26/2026 at 12:15 PM, the DON stated she was not aware of the incident with Resident #1 until today and was not aware of any previous incidents with Resident #1 and other residents. She stated she reviewed the progress notes and did not see any note that indicated Resident #1's FM was informed about the incident. She stated Nurse B should have called the family about the incident, so they were aware of the change in behavior. She stated her concern with the FM not being called was they would not be informed of changes in the resident's behaviors and their needs may not be met. During an interview on 6/26/2026 at 12:26 PM, Nurse B stated she worked the day shift yesterday, on 6/25/2026 on the memory care unit and observed Resident #1 hit another resident on the back of the neck about 1:30 PM. She stated she separated the residents and redirected Resident #1 out of the area. She stated she assessed both residents for injuries, and none were noted. She stated it was her first day on the unit, she was busy passing medications, and she did not call the FM because she had not known she was supposed to do that. During an interview on 6/262026 at 2:23 PM, the FM for Resident #1 stated she was not aware of the incident involving Resident #1 hitting another resident until she was called today. She stated it bothered her that no one called her to tell her what happened. The FM also stated if they did not call her about this incident, she was worried there may have been other issues they had not called her to discuss. During an interview on 6/26/2026 at 4:37 PM, the ADM stated he had just found out about the incident where Resident #1 hit another resident. He stated he was not aware Nurse B did not call the FM to let them know about the incident. He stated nursing staff was supposed to call the family immediately when there was a change in behavior with a resident, as it was their right to be informed. Record review of the facility's policy Resident Rights, revised February 2021, reflected: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:o. be notified of his or her medical condition and of any changes in his or her condition;p. be informed of, and participate in, his or her care planning and treatment.

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 3 of 10 residents (Resident #8, Resident #66, and Resident #70) reviewed for ADL care.The facility failed to ensure Resident #8, Resident #66, and Resident #70 did not have long, and dirty fingernails.This failure could place residents at risk of skin tears, infection, and embarrassment.1. Record review of Resident #8's face sheet, dated 05/26/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dysphagia (trouble swallowing), muscle wasting, lack of coordination, unsteadiness on feet, pain, vomiting, hypertension (high blood pressure), and localized edema (swelling). Record review of Resident #8's quarterly MDS assessment, dated 03/19/2026, reflected a BIMS score of 15, which indicated intact cognitive response. The MDS reflected she required supervision or touching assistance from staff for personal hygiene, which indicated the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity.Record review of Resident #8's care plan, dated 01/13/2026, reflected the following: Focus: ADL self-care performance deficit requires supervision with ADL care. Resident ADL ability fluctuates related to generalized weakness.Goal: Resident will maintain ability to participate with self-care at current level.Interventions: Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use bell to call for assistance. Praise all efforts at self-care.Observation of Resident #8 on 05/26/2026 at 1:43p.m., revealed she was lying in her bed. Her nails were long and had what appeared to be dirt underneath them.During an interview with Resident #8 on 05/26/2026 at 1:43p.m., she said she had asked staff to cut her nails. She said she did not know when the last time her nails were cut. She said if her nails were cut it would make her feel much better.2. Record review of Resident #66's face sheet dated 05/26/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental function), cellulitis (bacterial infection involving inner layers of the skin), cerebral infarction (long term effects of a stroke), lack of coordination, and difficulty in walking.Record review of Resident #66's quarterly MDS assessment, dated 03/06/2026, reflected he had a BIMS score of 15 which indicated intact cognitive response. The MDS reflected he required supervision or touching assistance from staff for personal hygiene, which indicated the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Record review of Resident #66's care plan, dated 01/18/2026, reflected the following: Focus: [Resident #66] has diabetes mellitus (persistent high blood sugar).Goals: noneInterventions: Podiatry referral as needed and ordered by MD for foot/ nail care.Record review of Physician Orders dated 11/26/2025 stated May be seen by Podiatrist as needed.Record review of Resident 66's podiatrist notes revealed the last time Resident #66 saw the podiatrist was on 03/03/2026.The podiatrist note revealed the residents nails were cut and filed.Observation on 05/26/26 at 2:43 PM of Resident #66, revealed Resident #66 was sitting up in his wheelchair in his room. His fingernails were long and had a brown substance underneath them.During an interview with Resident #66 on 05/26/2026 at 1:27p.m., he did not know when staff last cut his fingernails. He said he wanted his fingernails cut and cleaned. He would not say how it make him feel with his fingernails long and dirty.3. Record review of Resident #70's face sheet dated 05/26/2026 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle wasting, muscle weakness, pain in left shoulder, embolism, and thrombosis (blood clots in blood vessels), peripheral vascular disease (abnormal narrowing of arteries), hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), and heart failure. Record review of Resident #70's quarterly MDS assessment, dated 02/27/2026, reflected a BIMS score of 05, which indicated severe cognitive impairment. [Resident #70] was dependent for personal hygiene which indicated the helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #70's care plan, dated 05/13/2026, reflected the following: Focus [Resident #70] have altered cardiovascular status related to congestive heart failure, and hypertension.Goals: [Resident #70] will be free from signs and symptoms of complications of poor circulation.Interventions: Educate on the importance of proper foot care including proper fitting shoes, wash and dry feet thoroughly, inspect feet daily, daily change of hosiery and socks. Refer to podiatrist for nail care.Record review of Resident #70's orders dated 11/20/2025 stated May be seen by Podiatrist as needed. Record review of Resident 70's podiatrist notes revealed the last time Resident #70 saw the podiatrist was on 03/03/2026.Observation on 05/26/2026 at 10:09a.m., revealed Resident #70 lying in bed with her hand in her lap talking to a family member. Her fingernails were long and had a brown substance underneath them.During an interview with Resident #70 on 05/26/2026 at 10:09a.m., she said she had been asking staff to cut her fingernails. She said no one had tried to cut her fingernails and she wanted them to be cut and cleaned. She said she did not know how it made her feel having the long nails.During an interview with CNA C on 05/28/2026 at 11:26a.m., she said she had been trained on ADL. She said the training covered what the staff were supposed to do on a daily basis for the resident such as providing care. She said the policy for nail care was on shower days the staff were to cut the residents' nails and facial hair for females. She said for males staff were to cut the nails and facial hair it they wanted the facial hair cut. She said the CNAs are responsible for cutting the residents' nails and cleaning them unless the resident was diabetic then the nurses were responsible for cutting the residents' nails. She said if the resident's nails were not cut the resident could scratch them self or feel like they are not being taken care of. She said the nurses, ADON and management monitored to ensure staff were cutting and cleaning the residents nails. She said the nurses, ADON and management monitored by observation. She said Resident #8, Resident #66 and Resident #70's nails were not cut because staff did not cut them like they should. During an interview with the ADON on 05/28/2026 at 11:39a.m., she said she had been trained on ADL care. She said the nursing staff were responsible for nail care. She added if the resident had thick nails or toenails that staff were not able to cut nurse was to notify the podiatrist. She said the nurses and CNAs were responsible for providing nail care. She said nail care was supposed to be done weekly or as needed. She said she could not say how the resident would feel about their nails not getting cut but she said she would not feel good. She said the ADON and nursing supervisor should be monitoring to ensure staff were cutting and cleaning the resident's nails. She said the ADON and nursing supervisor monitored by checking the resident's orders for nail care and by observation. She said she did not know why Resident #8, Resident #66 and Resident #70's nails were not cut. During an interview with the DON on 05/28/2026 at 2:59p.m., she said she had been trained on ADLs. She said the policy for nail care was that CNAs should clean and/or cut the resident's nails on shower day. She said if the resident is diabetic the nurse should cut the residents nails. She said the nurses and CNAs were responsible for cutting and cleaning the resident's nails. She said if staff were not cutting or cleaning the resident's nails the resident may feel unclean. She said the nurse and ADON monitored the staff to ensure they were cutting and cleaning the resident's nails. She said the nurse and ADON monitored through observations. She said she did not know why Resident#8, Resident #66 and Resident #70's nails were not cut and cleaned. During an interview with the ADM on 05/28/2026 at 1:55p.m., he said he had been trained on ADLs. He said the policy for nail care was staff were to cut and clean the resident's nails on the resident's shower days and as needed. He said the only exception was if the resident was diabetic then the nurse was to do the nail care. He said if the resident's nails were not done the resident could scratch themselves, or their nails could be dirty. He said the nurses and nursing department supervisors monitored to ensure the staff were providing nail care. He said the nurses and nursing department supervisors monitored through weekly assessments. He said he was not sure why Resident #8, Resident #66 and Resident #70's nails were not cut and cleaned. Record review of Activities of Daily Living, Supporting ADL Policy dated 02/2025 revealed Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety for 3 of 5 residents (Residents #15, Resident #35, and Resident #44) reviewed for smoking. 1. The facility failed to complete a smoking assessment for Resident #15. 2. The facility failed to complete a smoking assessment for Resident #35. 3. The facility failed to complete a smoking assessment for Resident#44. This failure placed all residents at risk for serious injury, harm, due to staff not knowing if the resident was safe or needed assistance to smoke.Findings included: 1. Record review of Resident #15's face sheet, dated 05/26/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had a diagnosis which included nicotine dependance (chronic addiction in which the brain adapts to regular nicotine exposure causing cravings, withdrawal symptoms, and difficulty quitting), lack of coordination, hypokalemia (low potassium), bipolar (extreme mood swings), and dementia (severe) with other behavior disturbance (memory, thinking, difficulty). Record review of Resident #15's annual MDS, dated [DATE], revealed Resident #15 had a BIMS of 12, which indicated moderate cognitive impairment. The MDS also revealed that current tobacco use was marked as no. Record review of Resident #15's care plan, dated 05/13/2026, reflected the following: Focus: Tobacco use.Goal: Will quit smoking/using tobacco by next review date.Interventions: Assess smoking safety quarterly and as needed. Monitor clothing for burn holes. Provide safe metal containers for extinguishing cigarette butts.Record review of Resident #15's Smoking Assessment on 05/27/2026, revealed Resident #15 did not have a smoking assessment completed. 2. Record review of Resident #35's face sheet, dated 05/26/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #35 had a diagnosis which included lack of coordination, type 2 diabetes mellitus without complications (high blood sugar), muscle wasting, mild intellectual disability (a neurodevelopmental condition characterized by below average intellectual functioning), cognitive communication deficit (problems with communication), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Record review of Resident #35's annual MDS, dated [DATE], revealed Resident #35 had a BIMS of 0, which indicated severe cognitive impairment. The MDS also revealed that current tobacco use was marked as yes. Record review of Resident #35's care plan, dated 01/07/2026, reflected the following: Focus: The resident is a smoker.Goal: The resident will not suffer injury from unsafe smoking practices through the review date. The resident will not smoke without supervision through the review date.Interventions: Instruct resident about the facility policy on smoking: locations, times, safety concerns. Observe clothing and skin for signs of cigarette burns.Record review of Resident #35's Smoking Assessment on 05/27/2026, revealed Resident #35 did not have a smoking assessment completed. 3. Record review of Resident #44's face sheet, dated 05/26/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #44 had a diagnosis which included respiratory failure, lack of coordination, muscle wasting, muscle weakness, nicotine dependance (chronic addiction in which the brain adapts to regular nicotine exposure causing cravings, withdrawal symptoms, and difficulty quitting), hyperthyroidism (excessive production of thyroid hormones), and anemia (not healthy red blood cells. Record review of Resident #44's admission MDS, dated [DATE], revealed Resident #44 had a BIMS of 15, which indicated intact cognitive response. The MDS also revealed that current tobacco use was marked as yes. Record review of Resident #44's cancelled care plan, dated 05/04/2026, reflected the following: Focus: The resident requires staff supervision when using tobacco products. Goal: I will follow tobacco policy of facility without injuring myself or others.Interventions: I require the facility staff to keep all tobacco and fire-starting materials for safety. My smoking supplies are stored in smoker's box with facility staff to issue to me during supervised smoking times.Record review of Resident #44's Smoking Assessment on 05/27/2026, revealed Resident #44 did not have a smoking assessment completed. Observation of smoking on 05/27/2026 at 09:08a.m., revealed Resident #44 was outside smoking with staff present.During an interview with the ADON on 05/28/2026 at 11:44a.m., she said she had been trained on how to complete the smoking assessment in the computer. She said a smoking assessment should be done on admission and quarterly. She said normally the Social Worker was responsible for doing the smoking assessments, but the facility did not have a full-time social worker. She said the nurses do the smoking assessments on admission. She said she would do the smoking assessment if she was the nurse at the time the resident was admitted . She said if a resident did not have a smoking assessment the resident could be smoking unsafely, or staff would not know if the resident needed a smoking apron. She also said if a staff member was not familiar with the resident the staff member would not know what the resident's needs were when smoking. She said management would monitor to ensure a smoking assessment was completed on all residents who smoked. She said management monitored by going into the system and looking to see if the smoking assessments had been done. She said she did not know why Resident #15, Resident #35 and Resident #44 did not have a smoking assessment completed During an interview with the DON on 05/28/2026 at 1:05p.m., she said she had been trained on completing the smoking assessments. She said the smoking assessment contained information about the resident such as if the resident had to be supervised while smoking or if the resident needed a smoking apron. She said the smoking assessment should be done on admission, quarterly or if the resident had a change in condition. She said the nursing department was responsible for completing the smoking assessment. She said if the resident did not have a smoking assessment the resident could be at risk of burning themselves or their clothing. She said the DON/ADM monitored to ensure the smoking assessments were done. She said the DON/ADM monitored by checking to see if each resident who smoked had a smoking assessment. She said when the DON/ADM checked for the smoking assessment they would also see when the resident was due for another assessment. She said she thought she had done Resident #15, Resident #35 and Resident #44's smoking assessment.During an interview with the ADM on 05/28/2026 at 1:47p.m., he said he had been trained on completing the smoking assessments. He said the policy was to ask the resident if he/she smoked when they were being admitted to the facility. He said if the resident smoked the smoking assessment should be done on admission before the resident started smoking. He said the nurse was responsible for doing the smoking assessment. He said if the resident did not have a smoking assessment the resident could burn themselves. He said the nursing management monitored to ensure the residents had smoking assessments. He said the nursing manager monitored by checking the computer to see if there was a smoking assessment completed. He said he did not know why Resident #15, Resident #35 and Resident #44 did not have a smoking assessment completed. Record review of the Smoking Policy- Residents dated 10/2022 revealed This facility shall establish and maintain safe resident smoking practices. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker or smokeless tobacco user, the evaluation will include current level of tobacco consumption, method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe), desire to quit smoking, if a current smoker; and ability to smoke safely with or without supervision (per a completed Smoking Assessment). The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Smoking Assessment. A resident's ability to smoke or chew tobacco safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure CK B wore a hair net on his beard.2. The facility failed to ensure CK B washed his hands when changing tasks.3. The facility failed to ensure DA A washed hands when changing tasks. These deficient practices could place residents at risk for food borne illness. During an observation on initial tour of the kitchen on 05/26/2026 at 9:11 a.m., it was revealed that CK B failed to use a hair net to cover facial hair while preparing puree food. During a kitchen observation on 05/26/2026 at 10:55 a.m., it was revealed that CK B failed to wash hands prior to pureeing ham. CK B failed to wash hands after returning to the food preparation area from loading the pureed ham food canister in the oven. It was observed that CK B failed to wash hands before preparing puree of turnip greens or upon completion of the puree preparation. During an observation in the facility kitchen on 05/26/2026 at 11:45 a.m., it was revealed that DA A wash hands prior to loading lunch trays into the meal cart. DA A delivered a meal cart to the secure unit and she failed to wash hands upon re-entry of the kitchen at 12:10 p.m. At 12:21 p.m., DA A was observed placing covers on the food plates while working on the food line and she failed to wash hands upon entry to the kitchen. During an interview on 05/26/2026 at 9:11 a.m., DM stated she had worked at this facility for 1 year and she has obtained a Manager Food Handler Certificate. DM stated there are a total of 13 kitchen staff including herself (DM) and the RD and each staff member has a current Food Handler Certificate. She stated that the Food Handler certification training includes training on kitchen sanitation and hand sanitation. She stated each staff member had also been in-serviced last week on hand hygiene. She stated staff are trained to use hand hygiene frequently. DM stated it is her expectation that staff will hand sanitize between tasks. During an interview on 05/26/2026 at 9:29 a.m., CK B stated he had been working at this facility for 7 months and he had been trained on proper hand sanitation. CK B stated proper hand sanitation means that all the kitchen staff are supposed to wash hands after touching food. CK B stated that all staff should wash hands to prevent germs from affecting everyone's health. CK B stated all staff are to wear hair restraints on their head to prevent hair from falling into the resident's food. During an interview on 05/26/2026 at 11:45 a.m., DA A stated she had been trained on proper hand hygiene and hand-washing technique. DA A stated the last in-service training was 1 week ago. She stated, we are to wash our hands in the designated hand-washing sink between each task. DA A said, the purpose of handwashing is to prevent cross contamination. During a phone interview on 05/27/2026 at 2:04 p.m., RD revealed that the facility has a contract for Dietary Services with the company she works for. RD stated, she enters the facility 1 time per month. RD stated some of her duties are to work with the DM and to educate the staff on sanitation. She said she will prepare a report showing findings and she will give recommendations to the facility's DM. RD stated she was not aware that kitchen staff were not using proper hand sanitation techniques. She said, staff are required to wash hands and to use proper hand sanitation between tasks. She said that she will make sure that hand sanitizing training is done as soon as possible for the kitchen staff. During an interview on 05/28/2026 at 1:18 p.m., DON stated she has worked at this facility for 6 months and she has been trained in hand sanitation techniques. She stated that staff should use hand sanitation when they enter the kitchen and they should wash their hands again between tasks. She stated gloves should be worn when preparing or cooking food. She stated the purpose of hand hygiene is to prevent foodborne illness. DON stated it is her expectation that all kitchen staff wear proper hair covering for head and facial hair. She stated, Residents could be exposed to illness if proper sanitation is not conducted in the kitchen. DON did not know why [NAME] was not wearing a facial hair restraint. During an interview 05/28/2026 at 1:35 p.m., ADM stated he had training in kitchen sanitation and hand hygiene. He stated, I am the one who does in-service training for the staff on hand hygiene. He stated, staff are to wash hands between every change of station. He said the purpose of hand sanitation in the kitchen is to prevent infection and contamination. He said, staff or resident could get sick due to transmission of germs if staff do not follow the hand sanitation policy. ADM stated staff are supposed to wear hair nets, and beard nets. ADM stated DM and myself are responsible for kitchen sanitation. Record Review of Facility's Food Preparation and Service policy, revised November 2022 revealed:Policy StatementFood and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation General GuidelinesFood preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food Preparation Area 4. Appropriate measures are used to prevent cross contamination. 5. Handwashing sinks are located near food preparation and clean dish areas and are separate from ware washing sinks. Food Distribution and ServiceFood and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents.8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Record Review of Facility's Handwashing/ Hand Hygiene policy, dated October 2023 and updated 01/2025 revealed:Policy statementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and ImplementationAdministrative Practices to Promote Hand HygieneAll personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.5. Environmental measures are being taken to reduce contamination associated with sinks and sink drainage, including:hand washing sinks that are constructed and installed according to health department codes.Indications for Hand Hygiene1. Hand hygiene is indicated:a. immediately before touching a resident Washing Hands1. Wet hands first with warm water, then apply an amount of product recommended by the manufacturer to hands.2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.3. Rinse hands with water and dry thoroughly with a disposable towel.4. Use towel to turn off the faucet.5. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis.Applying Alcohol-Based Hand Rubs1. Apply generous amount of product to palm of hand and rub hands together.2. Cover all surfaces of hands and fingers until hands are dry.3. Rub hands together in the same way as if were using soap and water.4. Allow the sanitizer to dry (This should take around 20 seconds).5. Follow manufacturers' directions for volume of product to use.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for residents that included the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of the resident's admission for 1 (Resident #44) of 4 residents reviewed for care plans. The facility failed to complete a baseline care plan within 48 hours of Resident#44's re-admission date of 05/02/26. This failure could result in residents not receiving prescribed care while in the facility.Findings included: Record review of Resident #44's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. She was diagnosed with chronic respiratory failure (a long-term condition where the lungs cannot maintain adequate oxygen levels or remove carbon dioxide effectively, often requiring ongoing treatment and oxygen support), muscle wasting and atrophy (muscle weakness), hypothyroidism (underactive thyroid gland, often treated with medication and measured with blood work), anemia (low blood cell count), chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), , lack of coordination, arthritis, nicotine dependence, systemic inflammatory response syndrome (a clinical condition characterized by an exaggerated inflammatory response of the body to a harmful stressor, which may be infectious (like bacteria or viruses) or non-infectious (such as trauma, burns, surgery, or cancer), and anxiety disorder. Record review of Resident #44's Nursing Home Comprehensive MDS, dated [DATE] reflected that this admission assessment was the first assessment since the most recent admission. Section A reflected an entry date of 05/02/26, and type of entry was a reentry from the original admission date of 03/23/26. Record review of Resident #44's Quarterly MDS, dated [DATE], reflected a BIMS Score of 15, indicating no impaired cognition. Section GG reflected Resident #44 used a manual wheelchair, required setup or clean-up assistance for meals and oral hygiene, and partial/moderate assistance for other activities of daily living. Record review of Resident #44's Inactivation Request MDS, dated [DATE] reflected 3. Inactivate existing record. Record review of Resident #44's Nursing Home Discharge MDS, dated [DATE] reflected in Section A this was an unplanned discharge, which was from 03/23/26 - 04/30/26, and Resident #44 was discharged to Home/Community. Section GG reflected Resident #44 required verbal cues and touch assistance for bed mobility, bed to wheelchair, toilet and shower transfers, and setup or clean-up assistance for her daily living activities. Record review of Resident #44's Discharge Summary reflected a discharge date of 04/30/26 at 6:00 PM, against medical advice, to home in a family vehicle with no home health care services arranged. Resident #44 and her RP did not want to sign the discharge summary. Record review of Resident #44's Care Plan Report dated 05/02/26 reflected Resident #44's focus areas, goals, and interventions/tasks had been initiated on 04/01/26, revised and cancelled on 05/04/26. Record review of Resident #44's Progress Notes dated 04/25/26 reflected, This nurse was notified by another staff nurse LVN that this resident told her she wanted to go home and to pack her stuff and leave AMA. This nurse approached resident's room and asked resident why she was wanting to go home, resident stated, I want to go home, I'm tired of the rules and regulations. Resident #44 was educated on the risks of leaving against medical advice. This nurse notified the DON and Administrator. MD/NP on call notified as well. Observation on 05/26/26 at 10:35 AM revealed Resident #44 sitting in her bed typing on her phone. She appeared clean and well-groomed, and her room was free from odors. Interview on 05/27/26 at 09:35 AM revealed Resident #44 stated she had left the facility against medical advice on 4/30/26. She stated she was tired of all the bullshit in the facility and wanted to live with her family member. She stated she returned to the facility on 5/02/26. During an interview on 05/28/2026 at 12:48 PM the MDS Coordinator stated she had been trained on care plans. She said she was not sure how long she had to do the care plan. She said she was responsible for completing the care plans. She said the care plan had information about the resident such as the resident's smoking status, ADL, medications, and behaviors. She said she monitored to ensure every resident had a care plan. She said she monitored by completing the MDS; the MDS would trigger her to go in and complete a care plan. The MDS Coordinator said Resident #44 left the facility AMA on 04/30/2026. She said Resident #44 changed her mind and returned to the facility on [DATE] She stated she did not realize that she had to do another care plan. During an interview on 05/28/2026 at 1:11 PM. the DON said she had been trained on a care plan. She said that if it was a baseline care plan the facility had 24 hours to complete it. She said the IDT team and the MDS was responsible for the care plan. She said if there was not a care plan it could put the resident at risk of not getting the proper care the resident needed. She said the DON, ADM, and MDS regional monitored to ensure the care plans were done. She said they monitored their dashboard in the electronic medical records. She said Resident #44 did not have a care plan because when the resident left on 03/31/2026 her profile was deleted on the nursing side. During an interview on 05/28/2026 at 1:28 PM the ADM stated he had been the Administrator at this facility since November 2025. He stated he had been trained in care plans, which covered doing an initial care plan that included resident medications, preferences, family involvement, what time they like to get up, go to bed, what they like and dislike eating, and discuss this information with the IDT. The ADM stated he was a nurse and received training on care plans since 2010 and had additionally received training with the regional department when taking the job as Administrator. He stated the Policy and Procedure on Care Plans included conducting an initial care plan on admission within 48 hours, change of condition, and quarterly care plans. The IDT, the resident and family/RP were to be involved in the care plan process. The MDS nurse and the Social Worker were responsible for Care Plans. He further stated since they currently do not have a Social Worker, the MDS nurse was responsible. The ADM stated the Care Plan had important information about the residents' care, behaviors, how they eat, and patient care. The initial care plan should be completed within 48 hours. The initial care plan not being completed on time could affect the residents by staff not knowing know to provide care. N, The Regional MDS and I are responsible for monitoring the completion of the initial care plan, and on Thursdays the IDT holds a meeting that includes the DON with MDS nurse. He stated Resident #44 did not have a care plan. He stated Resident #44 went left the facility and went home AMA (against medical advice) and found that she could not take care of herself. Resident #44 had been discharged for 72 hours. Her family member could not take care of her, and after 72 hours Resident #44 started calling the DON. The ADM stated he had not been aware that when a resident left the facility AMA that the facility had to do a whole admission that included the initial care plan if the resident returned to the facility. Review of the facility's Policy & Procedures on Care Plans, Comprehensive Person-Centered, dated March 2022, reflected, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. participate in the planning process.b. identify individuals or roles to be included.c. request meetings.d. request revisions to the care plan.e. participate in establishing the expected goals and outcomes of care.f. participate in determining the type, amount, frequency, and duration of care.g. receive the services and/or items included in the plan of care; andh. see the care plan and sign it after significant changes are made.5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences.6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.(2) any specialized services to be provided as a result of PASARR recommendations; and(3) which professional services are responsible for each element of care.c. includes the resident's stated goals upon admission and desired outcomes.d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are:a. provided by qualified persons.b. culturally competent; andc. trauma informed.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition.b. when the desired outcome is not met.c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment.13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 3 residents (Resident #15, and Resident #67) reviewed for accuracy of assessments. The facility failed to ensure Resident #15's annual MDS, dated [DATE], accurately reflected her smoking status. The facility failed to ensure Resident #67's admission MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.Findings include: 1. Record review of Resident #15's face sheet, dated 05/26/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had a diagnosis which included nicotine dependance (chronic addiction in which the brain adapts to regular nicotine exposure causing cravings, withdrawal symptoms, and difficulty quitting), lack of coordination, hypokalemia (low potassium), bipolar (extreme mood swings), and dementia (severe) with other behavior disturbance (memory, thinking, difficulty). Record review of Resident #15's annual MDS, dated [DATE], revealed Resident #15 had a BIMS of 12, which indicated moderate cognitive impairment. The MDS also revealed that current tobacco use was marked as no. Record review of Resident #15's care plan, dated 05/13/2026, reflected the following: Focus: Tobacco use.Goal: Will quit smoking/using tobacco by next review date.Interventions: Assess smoking safety quarterly and as needed. Monitor clothing for burn holes. Provide safe metal containers for extinguishing cigarette butts.Record review of Resident #15's Smoking Assessment on 05/27/2026, revealed Resident #15 did not have a smoking assessment completed. 2. Record review of Resident #67's face sheet, dated 05/26/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #67 had diagnoses which included parkinsonism (syndrome characterized by tremors and postural instability), signs and symptoms involving cognitive functions and awareness (changes in mental ability including memory loss, concentration and impaired decision making), polyneuropathy (damage affecting the nerves roughly the same area on both sides of the body), and schizophrenia (mental health condition that affects everything from how you think, how you feel and how you behave). Record review of Resident #67's admission MDS, dated [DATE], revealed Resident #67 had a BIMS of 03, which indicated severe cognitive impairment. The MDS also revealed current tobacco use was marked as no. Record review of Resident #67's care plan, dated 01/05/2026, reflected the following: Focus: SmokerGoal: Will have no complications from smoking through next review. Will present no hazards through the next review.Interventions: Assess smoking safety quarterly and as needed. Encourage resident to participate in activities.Record review of Resident #67's Smoking Assessment, dated 03/14/2026, revealed Resident #67 required supervision when smoking. During an interview with the MDS LVN on 05/28/2026 at 12:40p.m., she said she was trained on the basics of the MDS. She said she was responsible for completing the MDS. She said information that was on the MDS were assessments, demographics, BIMS, diet, and smoking status. She said the MDS should be completed when there was a significant change, annually, and quarterly. She said she had fourteen days from admission to complete the MDS. She said there was a question on the MDS about the resident's tobacco use and if the resident was a smoker, it would be checked yes. She said if the resident's smoking status was not coded correctly she did not know how it would affect the resident. She said staff would inform her when a resident was admitted that the resident was a smoker. She said there was a person in corporate that monitored to ensure the MDS was completed correctly. She said the corporate person would access the resident's cart remotely and look at the MDS once in a while. She said she did not know how she missed Resident #15 and Resident #67's smoking status not being correct. During an interview with the ADM on 05/28/2026 at 1:51p.m., he said he had been trained on the MDS. He said the policy for MDS was that MDS should be done on admission, change of condition and every quarter. He said the MDS LVN was responsible for completing the MDS accurately. He said the MDS had the resident's smoking status on it. He said if the smoking status was not correct on the MDS the resident would not be able to smoke when they wanted to smoke. He said the DON, ADM and the MDS Regional person monitored to ensure the MDS was correct. He said the DON, ADM and the MDS Regional person monitored by doing IDT meetings weekly on Thursdays to ensure everything was on the MDS. He said he did not know why the Resident #15 and Resident #67's smoking status was not correct on their MDS. Record review of the Smoking Residents list provided on 05/26/2026 revealed Resident #15, and Resident #67 were smokers. Record review of the Comprehensive Assessments Policy dated 02/2025 revealed Comprehensive assessments are conducted to assist in developing person-centered care plans. Significant Correction to Prior Comprehensive Assessment (SCPA) - The SCPA is a comprehensive assessment for an existing resident that must be completed when the IDT determines that a resident's prior comprehensive assessment contains a significant error. It can be performed at any time after the completion of an admission assessment. A significant error is an error in an assessment where the resident's overall clinical status is not accurately represented (example: miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and the error has not been corrected via submission of a more recent assessment. A significant error differs from a significant change because it reflects incorrect coding of the MDS and NOT an actual significant change in the resident's health status.

Based on interviews and record reviews, the facility failed to use services of a Registered Nurse for at least 8 consecutive hours, 7 days a week from 3/30/2026 to 5/7/2026 For one of one nursing facility reviewed for RN coverage. The facility failed to have RN coverage on 3/30/2026, 4/8/2026, 4/13/2026, 4/17/2026, 4/22/2026, 5/1/2026, 5/6/2026, and 5/7/2026. This failure could place residents at risk of not receiving adequate care and services from an RN, and decreased quality of life.During a record review on 5/8/2026 at 5:16 pm with the ADM present, of Daily timecard, period: 3/22/26 to 5/8/26, reflected no time entries for an RN for 3/30/2026, 4/8/2026, 4/13/2026, 4/17/2026, 4/22/2026, 5/1/2026, 5/6/2026, and 5/7/2026. During an interview on 5/8/2026 at 5:16 pm, ADM stated there were no entries on the Daily timecard report for RN coverage 3/30/2026, 4/8/2026, 4/13/2026, 4/17/2026, 4/22/2026, 5/1/2026, 5/6/2026, and 5/7/2026. During an interview on 5/8/2026 at 1:44 pm, the DON stated they have sufficient staffing to meet the needs of the residents. She stated the facility has had about a dozen gaps in RN coverage since March 2026. She stated their full-time wound care RN left in March, and they have been actively trying to hire an RN or use agency nurses but cannot get nurses to come out here to cover in this area. She stated her average daily census is 68. The DON stated she was aware the DON hours could not be included as RN coverage if the facility's average daily census was over 60. She stated she was aware the facility had previously been cited by the state agency in the Fall of 2025 for not having RN coverage. During an interview on 5/8/2026 at 3:39 pm, the ADM stated he was aware of issues with RN coverage at the facility. He stated he did not really have concerns because the DON is still on call 24 hours a day, 7 days a week and they have telehealth options for MD and NP coverage if needed. He stated that lack of RN coverage could maybe affect the residents' care with assessments of things like that. He stated he has not had any complaints from family members or residents about not having an RN available. He stated to his knowledge, care to the residents has not been affected. He stated the DON, who is an RN, is very hands-on, and all the nursing staff pitch in to take care of the residents. He acknowledged that the DON is the only RN in the building at times. He stated that their corporate RN also comes in to check in and see how things are going. During an interview on 5/8/2026 at 4:03 pm, the RNC stated he did not normally cover this building but was here today since the state agency was in the building. He stated his understanding was that the average daily census was 68 for this facility and he was aware the DON hours could not be included as RN coverage if the facility's average daily census was over 60. He was not aware of the current issues related to RN coverage for this facility. He stated his concerns with not having RN coverage wound be staff would not have access to an RN for coverage, there might be situations where you need RN insight and they may not have it. He stated this could potentially affect residents in assessments or in higher clinical care. During an interview on 5/8/2026 at 5:25 pm, the ADM said the average daily census was 68. Review of the Daily Staffing Sheet for 5/1/2026 to 5/7/2026 reflected RN coverage was being provided by the DON on 5/1/2026, 5/6/2026 and 5/7/2026. Review of facility policy Staffing, Sufficient and Competent Nursing, revised August 2022, reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 1.Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including:a. assuring resident safety;b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident;c. assessing, evaluating, planning and implementing resident care plans; andd. responding to resident needs.2. A licensed nurse is designated as a charge nurse on each shift.A .A licensed nurse may be a licensed practical nurse (LPN), licensed vocational nurse (L VN), or registered nurse (RN).b. A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care.c. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.3.A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or not later than 24 hours if the events that cause the allegation do not involve abuse to the Administrator for 3 of 7 residents (Resident #1, Resident #2, Resident #5) reviewed for Abuse and Neglect.[KS1] [LP2] The facility staff failed to immediately report abuse and neglect to the Administrator when: 1) Resident #1 was observed engaging in sexual activity with Resident #2 on 9/24/2025.2) Resident #2 was observed engaging in inappropriate behavior with Resident #1 on 9/18/2025 and 9/24/2025.An Immediate Jeopardy (IJ) was identified on 9/29/2025. The IJ template was provided to the facility on 9/29/2025 at 2:00 pm. While the IJ was removed on 10/3/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.3) The BOM confessed to the Marketing Director that she had taken Resident #5's credit card and spent $3700 for personal useThis failure placed residents at risk of not being protected from abuse, neglect, or exploitation.Findings included: 1.) Resident #1 Review of Resident #1's face sheet dated 9/26/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Anemia (low blood iron level), Insomnia (problems falling and staying asleep), Hypokalemia (low blood levels of potassium), and acute respiratory failure. Review of Resident #1's admission MDS assessment dated [DATE] reflected she had a BIMS score of 4 suggesting severe cognitive impairment. Review of the behavior section revealed no behaviors were noted. Review of Resident #1's progress notes on 9/18/2025, reflected no mention of her being found in bed with Resident #2 on 9/18/2025. Review of Resident #1's progress notes dated 9/25/2025 at 4:14 am by LVN E reflected: CNA reported that this resident was lying in bed with female resident [Resident #1] sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #1's care plan (the only care plan in the EMR) on 9/26/2025, reflected the focus area initiated on 9/11/2025:I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition.with interventions Administer meds per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. 2.) Resident #2 Review of Resident #2's face sheet dated 9/26/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affects movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and Benign Prostatic Hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2's progress note dated 9/18/2025 at 2:30 pm by LVN C reflected: In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's progress note dated 9/25/2025 at 4:14 am by LVN E reflected: CNA reported that this resident was lying in bed with female resident sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. During an interview on 9/26/2025 at 2:39 pm, CNA B stated she was working Wednesday night on 9/24/25 and about 7:30 pm she discovered Resident #1 and Resident #2 in Resident #2's room. Resident #2 was sitting in his wheelchair and was naked from the waist down with Resident #1 on top of him also naked from the waist down and they were engaged in sexual activity. She stated she separated and redirected residents and took the female resident across the hall to her room and helped her put her clothes back on. She called LVN E, the charge nurse, and told her what happened. She stated she had not thought it was abuse at the time because both residents had dementia and did not really know what they were doing. She had no suspicion of ANE because the residents were confused. She stated she did not call the ADM because she reported it to LVN E and thought she would. She stated she has had training on ANE and all incidents of ANE are to be reported immediately to the ADM. She did not do that and now she realizes it was ANE and should have been reported. She thought because they were confused it could not be ANE. During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025. She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg. She stated Resident #2 wasn't trying to engage in anything. She further stated she had no suspicion of ANE because she did not see him try to grab at nothing try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time. She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that. She stated she did not report the incident as ANE because they weren't naked and didn't have their hands in each other pants - nothing like that going on, they were fully clothed and weren't trying to do anything. LVN C further stated she notified the DON but was not sure if the DON notified the ADM. During an interview on 9/26/2025 at 3:28 pm, LVN E stated she had been working the evening of 9/24/2025 and received a call from CNA B around 7:30 - 7:45 pm about two residents found having sex. She stated she went to the memory care unit and assessed both residents and did not find any physical injuries. She stated she called the ADON around 9:20 pm and told her what happened. The ADON told her to do an incident report. There was no discussion about ANE or reporting to the ADM. She referred to the DON. She called the DON and told her what happened, and the DON told her to complete a head to toe assessment, put a progress note in the system and notify families. She stated there was no discussion or guidance from the DON to call the ADM or notify the abuse coordinator about the incident, so she was not sure how to handle it. She stated she did not have any suspicion of ANE because neither the ADON nor DON discussed it with her, so she did not think there was any ANE. She stated she has had multiple in-services on ANE and they were supposed to report all incidents of ANE to the ADM who is the AC. She did not report it because no one said it was ANE. During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together. She stated it was her expectation that staff would follow the facility policy and report any ANE to her immediately. She stated she was aware of the incident on 9/24/2025; but she had not been notified until the next morning when she came into work and immediately began an investigation and reported it to the state agency. She stated staff should have notified her the night before right after it happened and not waited until the next day. During an interview on 10/1/2025 at 12:07 pm, the ADON stated LVN E called her on 9/24/2025 about 9:22-9:25 pm and told her about the incident with Resident #1 and Resident #2. She stated she told LVN E to separate the residents, assess them and notify the DON. She stated she had not discussed the possibility of ANE or reporting to the ADM with LVN E at that time; she just told her to call the DON and get guidance. She stated she had been trained to report any ANE immediately to the ADM and is not sure why this was not reported. The ADM was notified on 10/01/25 at 4:53 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 10/02/25 at 4:53 pm. Plan of Removal Immediate Jeopardy F609On 09/26/2025 an abbreviated survey was initiated. On 09/26/202the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: 1-F609 The facility staff failed to immediately report suspicion of abuse and neglect to the Abuse Coordinator for Resident #1 and Resident #2 when both residents had been observed engaging in sexual activity on the memory care unit on 9/24/2025 at about 7:30 pm.2-- Resident #5 free from misappropriation when the Business Office Manager took his benefits card and spent $3,700.Action (Immediate): 1-Resident 1 and Resident 2 were immediately separated from each other. Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker. The social worker performed trauma informed care assessment. No adverse findings noted. Medical Director was notified, and orders obtained for psychiatric services. Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented. Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity. 2- The Business Office Manager was immediately terminated from employment at the facility on 9/17/25, and the local police department was notified on 9/17/25 of the misappropriation of resident funds.Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing Action: (Identification) 1--All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors. If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately. Zero out of 60 incident reports reviewed showed no adverse/inappropriate behavior. Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart. Daily audits will be conducted for behavioral events for 14 days, then weekly x 30 days.2-- 2- On 9/18/25 The Regional Business Office director completed an audit for 70 residents' trust funds based on the immediate jeopardy, with no discrepancies noted. Start Date: 9/26/2025Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing Action: (Prevention) 1--Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations. Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.2--One-time weekly audits over the next 30 days by the Regional Business Office Manager. --One-time weekly Resident Funds Management Service audits over the next 30 days by the Regional Business Office Manager. If a discrepancy is found, it will be investigated by the regional business office manager, facility administrator, and Regional VP of Operations. This began on 9/19/25. Start Date: 9/26/2025 Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing Action: (Prevention) 1. Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator) 2. Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. All Facility staff will complete them prior to working their next shift. New employees and agency staff will be educated upon hire and/or prior to working a shift. Knowledge will be verified via test and verbal discussion with affirmative feedback. 2-- Staff that handle resident funds will undergo retraining on financial policies, ethical standards, and proper fund management procedures. Start Date: 9/26/2025 Completion Date: 10/1//2025Responsible: Administrator and/or Director of Nursing Action: (Monitoring) 1--The resident will be monitored for aggressive/inappropriate behaviors. When no longer exhibiting aggressive/inappropriate behavior that warranted the 1:1 observation the Interdisciplinary Team and Physician will collaborate for the discontinuation of 1:1 observation. 2--Weekly and as needed reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager. Start Date: 9/26/2025Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing/IDT/Physician The surveyor monitored the POR as follows: Record Review of abuse, neglect, exploitation Inservice completed by 10/03/25In an interview with CNA F on 10/03/25 at 12:00pm she stated she completed her abuse, neglect, exploitation in-service this morning and was given a test after completion. CNA F was able to provide types of abuse including physical, sexual, financial, and gave examples such as stealing a resident's money. CNA F Knew to report immediately if ever witnessed to the ADM.In an interview with RN G on 10/03/25 at 12:15pm she stated she was given in-service this morning over abuse, neglect, and exploitation. RN G knew to contact the ADM immediately if she ever witnessed and ANE. RN G knew types of abuse such as taking funds, sexual abuse, and talking bad to residents. RN G knew the signs of abuse/neglect and gave examples of not changing the residents and not caring for them.In an interview with CNA H on 10/03/25 at 1:42pm she stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test. CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call lights, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. CNA H stated she was aware she needed to report any ANE immediately to her Administrator.In an interview with MA I on 10/03/25 at 2:03pm she stated she received her in-service on 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. MA stated she knew to report and ANE immediately to the ADM.In an interview with HK J on 10/03/25 at 2:36pm she stated that she received the in-service over abuse, neglect, and exploitation today. HK J knew to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money).In an interview with the DM on 10/02/25 at 2:53pm she stated that she just had her inservice over exploitation in the DON's office. The DM stated taking a resident's magazine would be exploitation. The DM knew to report immediately to the ADM if she witnessed any abuse or neglect.In an interview with the DA on 10/02/25 at 3:07pm she stated she was in the DON's office just a while ago for in-service. The DA knew to report abuse, neglect, and exploitation to the ADM immediately. The DA gave an example of exploitation such as stealing money from a resident. While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to evaluate the effectiveness of the corrective systems.Additional Findings included:3.) Resident #5Record review of Resident #5's admission record dated 10/02/25 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses including: major depressive disorder (sadness), cognitive communication deficit (inability to communicate effective), and hypertension (high blood pressure).Record review of Resident #5's Quarterly MDS assessment, dated 09/23/25, revealed the resident had a BIMS score of 0 indicating the resident had severe cognitive impairment. Record review of Resident #5's care plan, dated 09/29/25, revealed Resident #5 was care planned for visually impaired and requires secure storage of personal items/medications in a lock box to ensure safety and prevent misuse or loss.An attempted interview with the BOM was made 10/02/25 at 4:30pm, 10/03/25 at 11:49am, and 10/03/25 at 3:37pm. Voice message was left and the BOM did not return call prior to facility exit 10/03/25.In an interview with the Marketing Director on 10/01/25 at 10:44am she stated that the BOM confessed to her on 9/16/25 around 6:00 PM that she took Resident #5's credit card and used it for her personal use. The Marketing Director stated the BOM stated that she had used $2000 and then stated $3000. The Marketing Director told the BOM that once she used the card she could not stop. The Marketing Director stated the BOM gave her the office key and stated she was not coming back to work because the police would be there. The Marketing Director stated she did not immediately report the incident to the ADM because she was still trying to process what the BOM just told her. The Marketing Director stated she reported to the ADM around 9:00am on 9/17/25. The Marketing Director stated it was expected for her to report to the abuse coordinator immediately after the BOM told her.In an interview with the ADM on 10/03/25 at 12:40pm she stated the Marketing Director did not contact her until the next day (could not recall the exact time, around 10:30am), after the BOM told her that she took Resident #5's credit card and used it for her personal use. The ADM stated it was expected for the Marketing Director to report to her immediately once she found out about the incident and not the next day.Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, reflected: Reporting Allegations to the Administrator and Authorities1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility;b. The local/state ombudsman;c. The resident's representative;d. Adult protective services (where state law provides jurisdiction in long-term care);e. Law enforcement officials;f. The resident's attending physician; andg. The facility medical director.3. Immediately is defined as:a. within 2 hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse and neglect for three residents (Resident #1, Resident #2 and Resident #4) of seven reviewed for abuse. The facility failed to:1) Ensure Resident #1 did not engage in sexual activity with Resident #2 on 9/24/2025.2) Ensure Resident #2 did not engage in inappropriate behavior on 9/18/2025, 9/19/2025 and 9/24/2025.3) Ensure CNA D did not grab Resident #4's wrist forcefully and shake her arm in the presence of therapy staff on 9/3/2025. On 9/26/2025 at 6:40 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/3/2025, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of abuse, injury, and psychosocial harm. Findings included: 1. Review of Resident #1's face sheet, dated 9/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), anemia (low blood iron level), insomnia (problems falling and staying asleep), hypokalemia (low blood levels of potassium), and acute respiratory failure. Review of Resident #1's admission MDS assessment, dated 9/5/2025, reflected she had a BIMS score of 4 suggesting severe cognitive impairment. Review of Resident #1's progress notes for the date of 9/18/2025, reflected no mention of her being found in bed with Resident #1 on 9/18/2025 Review of Resident #1 's progress note dated 9/25/2025 at 4:14 am, by LVN E reflected: CNA reported that this resident was lying in bed with female resident [Resident #1] sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #1's care plan dated 9/26/2025 (the only care plan in the EMR) on 9/26/2025, reflected the focus area initiated on 9/11/2025: I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition with interventions to Administer meds per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. 2. Review of Resident #2's face sheet, dated 9/26/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), Parkison's disease (progressive neurological disorder that affect movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and benign prostatic hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2's progress note, dated 9/18/2025 at 2:30 pm, by LVN C, reflected: In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's progress note, dated 9/25/2025 at 4:14 am, by LVN E, reflected: CNA reported that this resident was lying in bed with female resident sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. During an interview on 9/26/2025 at 2:39 pm, CNA B stated she worked Wednesday night on 9/24/25 and about 7:30 pm she discovered Resident #1 and Resident #2 in Resident #2's room. Resident #2 was sitting in his wheelchair and was naked from the waist down with Resident #1 on top of him also naked from the waist down and they were engaged in sexual activity. She stated she separated and redirected residents and took female resident across the hall to her room and helped her put her clothes back on. She called LVN E, the charge nurse, and told her what happened. She stated she had not thought it was abuse at the time because both residents had dementia and did not really know what they were doing. She had no suspicion of ANE because the residents were confused. She stated she did not call ADM because she reported it to LVN E and thought LVN E would call and report this to ADM. She stated she was trained on ANE and all incidents of ANE were to be reported immediately to the ADM. She stated- she did not do that and now she realizes it was ANE and should have been reported. She thought because they were confused it could not be ANE. During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025. She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg. She stated Resident #2 wasn't trying to engage in anything. She further stated she had no suspicion of ANE because she did not see him try to grab at nothing or try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time. She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that. She stated she did not report the incident as ANE because they weren't naked and didn't have their hands in each other pants - nothing like that going one, they were fully clothed and weren't trying to do anything. LVN C further stated she notified the DON but was not sure if she notified the ADM. During an interview on 9/26/2025 at 3:28 pm, LVN E stated she worked the evening of 9/24/2025 and received a call from CNA B around 7:30 pm or 7:45 pm about two residents found having sex. She stated she went to the memory care unit and assessed both residents and did not find any physical injuries[. She stated she called the ADON around 9:20 pm and told her what happened. She said the ADON stated to do an incident report but there was no discussion about ANE or reporting to the ADM. She called the DON and told her what happened, and the DON said to complete a head-to-toe, put in a progress note in the system and notify families. She stated there was no discussion or guidance from the DON to call ADM or notify the abuse coordinator about the incident, so she was not sure how to handle it. She stated she did not have any suspicion of ANE because neither the ADON nor DON discussed it with her, so she did not think there was any ANE. She stated she had multiple in-services on ANE and they were supposed to report all incidents of ANE to the ADM who was the AC. She did not report it because no one said it was ANE. During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together. She stated it was her expectation that staff would follow the facility policy and report any ANE to her immediately. She stated she was aware of the incident on 9/24/2025; but she was not notified until the next morning when she went to work. The ADM stated she immediately began an investigation and reported it to the state agency. She stated staff should have notified her the night before right after it happened and not waited until the next day. During an interview on 10/1/2025 at 12:07 pm, the ADON stated LVN E called her on 9/24/2025 between 9:22 pm and 9:25 pm and told her about the incident with Resident #1 and Resident #2. She stated she told LVN E to separate the residents, assess them and notify the DON. She stated she had not discussed the possibility of ANE or reporting to the ADM with LVN E at that time; she just told her to call the DON and get guidance. She stated she had been trained to report any ANE immediately to the ADM and was not sure why this was not reported. 3. Record review of Resident #4's admission record, dated 10/02/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included unspecified dementia (loss of memory, language, problem solving and other thinking abilities), muscle weakness (lack of physical or muscle strength), and major depressive disorder(feeling of sadness, hopelessness, and loss of interest or pleasure in activities). Record review of Resident #4's Quarterly MDS assessment, dated 09/01/25, revealed the resident had a BIMS score of 0 indicating severe cognitive impairment. Record review of Resident #4's care plan, dated 09/29/25, revealed Resident #4 was care planned for impaired communication r/t often just mumbled, yelled, growled, or shook head for communication and episodes of adverse behaviors physically aggressive, hitting, pinching, kicking, and throwing objects. Review of Resident #4's progress notes written by the ADON, dated 09/03/25 at 5:45 pm, reflected, RP notified by this nurse and DON of incident of abuse reported. Skin assessment and head to toe completed by this nurse all normal. No s/s of distress. An attempted interview with Resident #4 on 10/01/25 at 12:24pm, Resident #4 made a growling noise several times. The interview was not completed. Resident #4 was nonverbal. An attempted interview with Resident # 4's FM was unsuccessful. Left Resident #4's FM voice messages on 10/02/25 at 4:18pm, 10/03/25 at 9:40pm, and 10/03/25 at 6:00pm. Resident #4's FM did not return the call by facility exit on 10/03/25. During an interview on 10/01/25 at 12:39 pm, the PT stated she reported to the ADM on 09/03/25 immediately after she witnessed the incident with Resident #4 and CNA D. The PT stated she was in Resident #4's room helping her get ready for therapy. The PT stated CNA D entered Resident #4's room loudly saying she was going to change Resident #4. The PT stated CNA D moved to Resident # 4's face and repeated that she was going to change her. The PT stated Resident #4 attempted to push CNA D away and Resident #4 slapped CNA D in the face. The PT stated CNA D grabbed Resident #4's wrists forcefully down and shook Resident #4's arm. The PT stated CNA D said to Resident #4 that they were going to get this done and you are not going to be slapping me. The PT stated that she intervened to separate CNA D and Resident #4. The PT stated she told CNA D that she could not hold Resident #4's wrist down in that manner. The PT stated after the incident Resident #4 was emotional and no longer wanted to get dressed. The PT stated Resident #4 cried and did not want to go to therapy. Resident #4 did not return to her baseline until the next day 09/04/25. An interview with CNA D on 10/01/25 at 1:53pm stated on 09/3/25 she went into Resident #4's room to change her. CNA D stated the PT was at the foot of Resident #4's bed and told her to back off and leave Resident #4 alone while she was agitated. CNA D stated she was trying to get Resident #4 changed. CNA D stated she was eye level with Resident #4 sitting Indian style in her bed and asked Resident #4 what was wrong and Resident #4 slapped her in the face and she placed her right hand over Resident #4's left hand to prevent Resident #4 from further slapping her. CNA D stated Resident #4 acted like she was going to slap her again, so she placed her left hand on Resident #4's right hand. CNA D stated she did not hold Resident #4's wrists back or shake her arm. CNA D stated she did her job and was not disrespectful to any of the residents. CNA D stated immediately after the incident the ADM told her to clock out due to the investigation and the ADM called her by phone could not recall the date and was told her they had to let her go due to the incident. An interview with the SW on 10/03/25 at 12:06 pm stated she was not aware of the incident with Resident #4 and CNA D when it occurred on 09/03/25. The SW stated she was made aware of the incident after it occurred and the ADM conducted the investigation on. An interview with the interim DON on 10/03/25 at 12:20pm stated the PT reported the incident with Resident #4 and CNA D immediately to the ADM after the incident occurred. The interim DON stated the ADM made her aware of the incident on 9/03/25. The interim DON stated she did not notice a difference with Resident #4's behavior after the incident. The interim DON stated Resident #4 was nonverbal and it was expected for her to be free from any abuse. An interview with the ADM on 10/03/25 at 12:40pm stated the PT notified her on 09/03/25 after the incident occurred with Resident #4 and CNA D. The ADM stated the PT stated CNA D pinned Resident #4's wrists back to prevent Resident #4 from slapping her. The ADM stated Resident #4 was nonverbal and it was expected for CNA D not to have pinned Resident's #4's wrist back. Review of CNA D's personnel file reflected that she was terminated on 09/03/25. Review of the facility's investigation, dated 09/03/25, reflected a thorough investigation was completed, and the allegation of physical abuse was confirmed. Review of the facility's policy, dated April 2021, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected:Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:1.Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff.b. other residents.C. consultants.d. volunteers.e. staff from other agencies.f. family members.g. legal representatives.h. friends.i. visitors; and/orj. any other individual. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. This was determined to be an Immediate Jeopardy (IJ) on 10/01/2025 at 4:53 pm. The Administrator was notified. The ADM was provided with the IJ template on 10/01/2025 at 4:53 pm .The following Plan of Removal submitted by the facility was accepted on 10/02/25 at 4:54pm Immediate Jeopardy (IJ) states as follows: 1--The facility failed to keep Resident #1 and Resident #2 from abuse and neglect when both residents were observed engaging in sexual activity on the memory care unit on 9/24/2025 about 7:30 pm.2-- Resident #5 free from misappropriation when the Business Office Manager took his benefits card and spent $3,700. The facility immediately implemented the following plans: F600- Free from Abuse/Neglect Action (Immediate): 1--Resident 1 and Resident 2 were immediately separated from each other. Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker. The social worker performed trauma informed care assessment. No adverse findings noted. Medical Director was notified, and orders obtained for psychiatric services.Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented. Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity. 2-The Business Office Manager was immediately terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds. The BOM was terminated on 09/17/25. The resident's funds were replaced by the facility on 9/18/25. Person(s) Responsible: Administrator and/or Director of Nursing Completion Date: 10/1/2025 Action (Identification): 1--All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors. If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately. Zero out of 60 incident reports reviewed showed no adverse/inappropriate behavior. Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart. Daily audits will be conducted for behavioral events for 14 days, then weekly X30 days. 2. The Regional Business Office Director completed an audit for 70 residents trust funds with no discrepancies noted. This was completed at the corporate level by the Regional Business Office, as the facility BOM was terminated. There were no discrepancies noted from this audit. Person(s) Responsible: Administrator and/or Director of NursingCompletion Date: 10/1/2025 Action (Identification): Staff assigned to the secured unit, in which there are consistent staff members, other facility staff including PRN staff and agency staff will be interviewed for any additional incidents or residents that may have been affected by resident-to-resident abuse. Person(s) Responsible Administrator and/or Designee Completion Date: 10/1/2025 Action (Prevention): 1--Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations. Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.2-One-time weekly audits over the next 30 days by the Regional Business Office Manager. Resident Fund Management Service will be audited weekly for the next 30 days. Person(s) Responsible: Regional Nurse ConsultantCompletion Date: 10/1/2025 Action (Prevention): Education provided to all staff by the Administrator:1. Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator)1. Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. All Facility staff will complete prior to working their next shift. New employees and agency staff will be educated upon hire and/or prior to working a shift. Knowledge will be verified via test and verbal discussion with affirmative feedback2. Staff that handle resident funds, Business Office and Human Resources Director will undergo retraining on financial policies, ethical standards, and proper fund management procedures. This training was completed on 9/18/25 by the Regional Business Office Director, with the Human Resources Director. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/01/25 Action (Prevention): Education provided to Nursing Staff by the Director of Nursing on:1. Resident Kardex that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. 2. Testing and verbal confirmation are utilized to assess knowledge retention.3. Annual training via Relias regarding resident's rights, theft, misappropriation and abuse. All Facility staff, new hire and agency will complete prior to working their next shift. Knowledge will be verified via test and verbal discussion with affirmative feedback. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/1/25 Action (Monitoring): 1--During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior. Will be reviewed during daily meeting x 30 days and then weekly thereafter. 2-Weekly and as needed reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager. This will be ongoing. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Completion Date: 10/1/25 Action (QAPI): Medical Director informed of this plan at the Ad Hoc QAPI. At this time no other recommendations have been made. Person(s) Responsible: Administrator Completion Date: 10/1/2025 The surveyor monitored the POR as follows: Record Review of abuse, neglect, exploitation Inservice completed by 10/03/25 Record Review of copy of cashier's check totaling in the amount of $3700 paid out to Resident #5's RP. An interview with CNA F on 10/03/25 at 12:00pm stated she completed her abuse, neglect, exploitation inservice this morning and was giving a test after completion. CNA F was able to provide types of abuse physical, sexual, financial, and gave examples such as stealing a resident's money. CNA F knew to report immediately if ever witnessed to the ADM. An interview with RN G on 10/03/25 at 12:15pm stated she was given in-service this morning over abuse, neglect, and exploitation. RN G knew to contact the ADM immediately if ever witnessed. RN G knew types of abuse such as taking funds, sexual abuse, and talking bad to residents. RN G knew the signs of abuse/neglect, gave examples of not changing the residents and not caring for them. An interview with CNA H on 10/03/25 at 1:42pm stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test. CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call light, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. An interview with I on 10/03/25 at 2:03pm stated she received her in-service on by 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. An interview with HK J on 10/03/25 at 2:36pm stated that she received the in-service over abuse, neglect, and exploitation today. HK J knows to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money). An interview with the DM on 10/02/25 at 2:53pm stated that she just had her inservice over exploitation in the DON's office. The DM stated taking a resident's magazine would be exploitation. The DM know to report immediately to the AM if she witnessed any abuse or neglect. An interview with the DA on 10/02/25 at 3:07pm stated she was in the DON's office just a while ago for in-service. The DA know who to report abuse, neglect, and exploitation to the ADM immediately. While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse and neglect for three residents (Resident #1, Resident #2 and Resident #4) of seven reviewed for abuse. The facility failed to:1) Ensure Resident #1 did not engage in sexual activity with Resident #2 on 9/24/2025.2) Ensure Resident #2 did not engage in inappropriate behavior on 9/18/2025, 9/19/2025 and 9/24/2025.3) Ensure CNA D did not grab Resident #4's wrist forcefully and shake her arm in the presence of therapy staff on 9/3/2025. On 9/26/2025 at 6:40 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/3/2025, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of abuse, injury, and psychosocial harm.Findings included: 1. Review of Resident #1's face sheet, dated 9/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), anemia (low blood iron level), insomnia (problems falling and staying asleep), hypokalemia (low blood levels of potassium), and acute respiratory failure. Review of Resident #1's admission MDS assessment, dated 9/5/2025, reflected she had a BIMS score of 4 suggesting severe cognitive impairment. Review of Resident #1's progress notes for the date of 9/18/2025, reflected no mention of her being found in bed with Resident # 1 on 9/18/2025 Review of Resident #1 's progress note dated 9/25/2025 at 4:14 am, by LVN E reflected: CNA reported that this resident was lying in bed with female resident [Resident #1] sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #1's care plan dated 9/26/2025 (the only care plan in the EMR) on 9/26/2025 , reflected the focus area initiated on 9/11/2025: I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition with interventions to Administer meds[ per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. 2. Review of Resident #2's face sheet, dated 9/26/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affect movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and benign prostatic hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2's progress note, dated 9/18/2025 at 2:30 pm, by LVN C, reflected: In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's progress note, dated 9/25/2025 at 4:14 am, by LVN E, reflected: CNA reported that this resident was lying in bed with female resident sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. During an interview on 9/26/2025 at 2:39 pm, CNA B stated she worked Wednesday night on 9/24/25 and about 7:30 pm she discovered Resident #1 and Resident #2 in Resident #2's room. Resident #2 was sitting in his wheelchair and was naked from the waist down with Resident #1 on top of him also naked from the waist down and they were engaged in sexual activity. She stated she separated and redirected residents and took female resident across the hall to her room and helped her put her clothes back on. She called LVN E, the charge nurse, and told her what happened. She stated she had not thought it was abuse at the time because both residents had dementia and did not really know what they were doing. She had no suspicion of ANE because the residents were confused. She stated she did not call ADM because she reported it to LVN E and thought LVN E would call and report this to ADM. She stated she was trained on ANE and all incidents of ANE were to be reported immediately to the ADM. She stated- she did not do that and now she realizes it was ANE and should have been reported. She thought because they were confused it could not be ANE. During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025. She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg. She stated Resident #2 wasn't trying to engage in anything. She further stated she had no suspicion of ANE because she did not see him try to grab at nothing or try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time. She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that. She stated she did not report the incident as ANE because they weren't naked and didn't have their hands in each other pants - nothing like that going one, they were fully clothed and weren't trying to do anything. LVN C further stated she notified the DON but was not sure if she notified the ADM. During an interview on 9/26/2025 at 3:28 pm, LVN E stated she worked the evening of 9/24/2025 and received a call from CNA B around 7:30 pm or 7:45 pm about two residents found having sex. She stated she went to the memory care unit and assessed both residents and did not find any physical injuries . She stated she called the ADON around 9:20 pm and told her what happened. She said the ADON stated to do an incident report but there was no discussion about ANE or reporting to the ADM. She called the DON and told her what happened, and the DON said to complete a head-to-toe, put in a progress note in the system and notify families. She stated there was no discussion or guidance from the DON to call ADM or notify the abuse coordinator about the incident, so she was not sure how to handle it. She stated she did not have any suspicion of ANE because neither the ADON nor DON discussed it with her, so she did not think there was any ANE. She stated she had multiple in-services on ANE and they were supposed to report all incidents of ANE to the ADM who was the AC . She did not report it because no one said it was ANE. During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together. She stated it was her expectation that staff would follow the facility policy and report any ANE to her immediately. She stated she was aware of the incident on 9/24/2025; but she was not notified until the next morning when she went to work. The ADM stated she immediately began an investigation and reported it to the state agency. She stated staff should have notified her the night before right after it happened and not waited until the next day. During an interview on 9/27/2025 at 1:39 pm FM of Resident #1 stated the NF called an informed them of the incident between Resident #1 and Resident #2 on 9/24/3035. FM stated they were shocked by this behavior as it was very unlike Resident #1 to engage in behaviors like that. FM stated Resident #1's cognition is impaired and that she doesn't have the capacity for true consent. FM stated her cognition was so impaired they would have to remind her to eat and make sure she would bathe. FM stated this incident was extremely upsetting as Resident #1 does not engage in this sort of behavior. During an interview on 10/1/2025 at 12:07 pm, the ADON stated LVN E called her on 9/24/2025 between 9:22 pm and 9:25 pm and told her about the incident with Resident #1 and Resident #2. She stated she told LVN E to separate the residents, assess them and notify the DON. She stated she had not discussed the possibility of ANE or reporting to the ADM with LVN E at that time; she just told her to call the DON and get guidance. She stated she had been trained to report any ANE immediately to the ADM and was not sure why this was not reported. 3. Record review of Resident #4's admission record, dated 10/02/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included unspecified dementia (loss of memory, language, problem solving and other thinking abilities), muscle weakness (lack of physical or muscle strength), and major depressive disorder(feeling of sadness, hopelessness, and loss of interest or pleasure in activities). Record review of Resident #4's Quarterly MDS assessment, dated 09/01/25, revealed the resident had a BIMS score of 0 indicating severe cognitive impairment. Record review of Resident #4's care plan, dated 09/29/25, revealed Resident #4 was care planned for impaired communication r/t often just mumbled, yelled, growled, or shook head for communication and episodes of adverse behaviors physically aggressive, hitting, pinching, kicking, and throwing objects. Review of Resident #4's progress notes written by the ADON, dated 09/03/25 at 5:45 pm, reflected, RP notified by this nurse and DON of incident of abuse reported. Skin assessment and head to toe completed by this nurse all normal. No s/s of distress. An attempted interview with Resident #4 on 10/01/25 at 12:24pm, Resident #4 made a growling noise several times. The interview was not completed. Resident #4 was nonverbal. An attempted interview with Resident # 4's FM was unsuccessful. Left Resident #4's FM voice messages on 10/02/25 at 4:18pm, 10/03/25 at 9:40pm, and 10/03/25 at 6:00pm. Resident #4's FM did not return the call by facility exit on 10/03/25. During an interview on 10/01/25 at 12:39 pm, the PT stated she reported to the ADM on 09/03/25 immediately after she witnessed the incident with Resident #4 and CNA D. The PT stated she was in Resident #4's room helping her get ready for therapy. The PT stated CNA D entered Resident #4's room loudly saying she was going to change Resident #4. The PT stated CNA D moved to Resident # 4's face and repeated that she was going to change her. The PT stated Resident #4 attempted to push CNA D away and Resident #4 slapped CNA D in the face. The PT stated CNA D grabbed Resident #4's wrists forcefully down and shook Resident #4's arm. The PT stated CNA D said to Resident #4 that they were going to get this done and you are not going to be slapping me. The PT stated that she intervened to separate CNA D and Resident #4. The PT stated she told CNA D that she could not hold Resident #4's wrist down in that manner. The PT stated after the incident Resident #4 was emotional and no longer wanted to get dressed. The PT stated Resident #4 cried and did not want to go to therapy. Resident #4 did not return to her baseline until the next day 09/04/25. An interview with CNA D on 10/01/25 at 1:53pm stated on 09/3/25 she went into Resident #4's room to change her. CNA D stated the PT was at the foot of Resident #4's bed and told her to back off and leave Resident #4 alone while she was agitated. CNA D stated she was trying to get Resident #4 changed. CNA D stated she was eye level with Resident #4 sitting Indian style in her bed and asked Resident #4 what was wrong and Resident #4 slapped her in the face and she placed her right hand over Resident #4's left hand to prevent Resident #4 from further slapping her. CNA D stated Resident #4 acted like she was going to slap her again, so she placed her left hand on Resident #4's right hand. CNA D stated she did not hold Resident #4's wrists back or shake her arm. CNA D stated she did her job and was not disrespectful to any of the residents. CNA D stated immediately after the incident the ADM told her to clock out due to the investigation and the ADM called her by phone could not recall the date and was told her they had to let her go due to the incident. An interview with the SW[ on 10/03/25 at 12:06 pm stated she was not aware of the incident with Resident #4 and CNA D when it occurred on 09/03/25. The SW stated she was made aware of the incident after it occurred and the ADM conducted the investigation on. An interview with the interim DON on 10/03/25 at 12:20pm stated the PT reported the incident with Resident #4 and CNA D immediately to the ADM after the incident occurred. The interim DON stated the ADM made her aware of the incident on 9/03/25. The interim DON stated she did not notice a difference with Resident #4's behavior after the incident. The interim DON stated Resident #4 was nonverbal and it was expected for her to be free from any abuse. An interview with the ADM on 10/03/25 at 12:40pm stated the PT notified her on 09/03/25 after the incident occurred with Resident #4 and CNA D. The ADM stated the PT stated CNA D pinned Resident #4's wrists back to prevent Resident #4 from slapping her. The ADM stated Resident #4 was nonverbal and it was expected for CNA D not to have pinned Resident's #4's wrist back. Review of CNA D's personnel file reflected that she was terminated on 09/03/25. Review of the facility's investigation, dated 09/03/25, reflected a thorough investigation was completed, and the allegation of physical abuse was confirmed. Review of the facility's policy, dated April 2021, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected:Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:1.Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff.b. other residents.C. consultants.d. volunteers.e. staff from other agencies.f. family members.g. legal representatives.h. friends.i. visitors; and/orj. any other individual. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. This was determined to be an Immediate Jeopardy (IJ) on 10/01/2025 at 4:53 pm. The Administrator was notified. The ADM was provided with the IJ template on 10/01/2025 at 4:53 pm .The following Plan of Removal submitted by the facility was accepted on 10/02/25 at 4:54pm Immediate Jeopardy (IJ) states as follows: 1--The facility failed to keep Resident #1 and Resident #2 from abuse and neglect when both residents were observed engaging in sexual activity on the memory care unit on 9/24/2025 about 7:30 pm.2-- Resident #5 free from misappropriation when the Business Office Manager took his benefits card and spent $3,700. The facility immediately implemented the following plans: F600- Free from Abuse/Neglect Action (Immediate): 1--Resident 1 and Resident 2 were immediately separated from each other. Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker. The social worker performed trauma informed care assessment. No adverse findings noted. Medical Director was notified, and orders obtained for psychiatric services.Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented. Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity. 2-The Business Office Manager was immediately terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds. The BOM was terminated on 09/17/25. The resident's funds were replaced by the facility on 9/18/25. Person(s) Responsible: Administrator and/or Director of Nursing Completion Date: 10/1/2025 Action (Identification): 1--All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors. If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately. Zero out of 60 incident reports reviewed showed no adverse/inappropriate behavior. Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart. Daily audits will be conducted for behavioral events for 14 days, then weekly X30 days. 2. The Regional Business Office Director completed an audit for 70 residents trust funds with no discrepancies noted. This was completed at the corporate level by the Regional Business Office, as the facility BOM was terminated. There were no discrepancies noted from this audit. Person(s) Responsible: Administrator and/or Director of NursingCompletion Date: 10/1/2025 Action (Identification): Staff assigned to the secured unit, in which there are consistent staff members, other facility staff including PRN staff and agency staff will be interviewed for any additional incidents or residents that may have been affected by resident-to-resident abuse. Person(s) Responsible Administrator and/or Designee Completion Date: 10/1/2025 Action (Prevention): 1--Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations. Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.2-One-time weekly audits over the next 30 days by the Regional Business Office Manager. Resident Fund Management Service will be audited weekly for the next 30 days. Person(s) Responsible: Regional Nurse ConsultantCompletion Date: 10/1/2025 Action (Prevention): Education provided to all staff by the Administrator:1. Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator)1. Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. All Facility staff will complete prior to working their next shift. New employees and agency staff will be educated upon hire and/or prior to working a shift. Knowledge will be verified via test and verbal discussion with affirmative feedback2. Staff that handle resident funds, Business Office and Human Resources Director will undergo retraining on financial policies, ethical standards, and proper fund management procedures. This training was completed on 9/18/25 by the Regional Business Office Director, with the Human Resources Director. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/01/25 Action (Prevention): Education provided to Nursing Staff by the Director of Nursing on:1. Resident Kardex that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. 2. Testing and verbal confirmation are utilized to assess knowledge retention.3. Annual training via Relias regarding resident's rights, theft, misappropriation and abuse. All Facility staff, new hire and agency will complete prior to working their next shift. Knowledge will be verified via test and verbal discussion with affirmative feedback. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/1/25 Action (Monitoring): 1--During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior. Will be reviewed during daily meeting x 30 days and then weekly thereafter. 2-Weekly and as needed reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager. This will be ongoing. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Completion Date: 10/1/2025Action (QAPI): Medical Director informed of this plan at the Ad Hoc QAPI. At this time no other recommendations have been made. Person(s) Responsible: Administrator Completion Date: 10/1/2025 The surveyor monitored the POR as follows: Record Review of abuse, neglect, exploitation Inservice completed by 10/03/25 Record Review of copy of cashier's check totaling in the amount of $3700 paid out to Resident #5's RP. An interview with CNA F on 10/03/25 at 12:00pm stated she completed her abuse, neglect, exploitation inservice this morning and was giving a test after completion. CNA F was able to provide types of abuse physical, sexual, financial, and gave examples such as stealing a resident's money. CNA F knew to report immediately if ever witnessed to the ADM. An interview with RN G on 10/03/25 at 12:15pm stated she was given in-service this morning over abuse, neglect, and exploitation. RN G knew to contact the ADM immediately if ever witnessed. RN G knew types of abuse such as taking funds, sexual abuse, and talking bad to residents. RN G knew the signs of abuse/neglect, gave examples of not changing the residents and not caring for them. An interview with CNA H on 10/03/25 at 1:42pm stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test. CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call light, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. An interview with MA I on 10/03/25 at 2:03pm stated she received her in-service on by 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. An interview with HK J on 10/03/25 at 2:36pm stated that she received the in-service over abuse, neglect, and exploitation today. HK J knows to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money). An interview with the DM on 10/02/25 at 2:53pm stated that she just had her in-service over exploitation in the DON's office. The DM stated taking a resident's magazine would be exploitation. The DM know to report immediately to the AM if she witnessed any abuse or neglect. An interview with the DA on 10/02/25 at 3:07pm stated she was in the DON's office just a while ago for in-service. The DA know who to report abuse, neglect, and exploitation to the ADM immediately. While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to evaluate the effectiveness of the corrective systems

Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #3) reviewed for accidents and hazards.The facility failed to ensure Resident #3 did not elope from the facility on 09/10/25. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 09/10/25 and ended on 09/15/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for falls, injuries, and hospitalization.Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #3) reviewed for accidents and hazards. The facility failed to ensure Resident #3 did not elope from the facility on 09/10/25. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 09/10/25 and ended on 09/15/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for falls, injuries, and hospitalization. Findings included: Record review of Resident #3's admission recorded dated 10/02/25 documented an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses including: unspecified dementia (loss of memory, language, problem solving and other thinking abilities), muscle weakness (lack of physical or muscle strength), and history of falling. Record review of Resident #3's Quarterly MDS assessment, dated 09/02/25, revealed the resident had a BIMS score of 3 indicating the resident had severe cognitive impairment. Record review of Resident #3's care plan, dated 09/29/25, revealed Resident #3 was care planned for impaired cognitive function/dementia or impaired thought processes r/t dementia, at risk for falls r/t confusion, cognitive impairment, gait/balance problems, and unaware of safety needs. Resident #3's care plan did not reflect to routinely monitor the resident. Review of an initial “Elopement Risk Assessment” dated 06/03/24, reflected Resident #3 was not at risk for elopement and care plan interventions of routinely monitor resident. Review of elopement incident report dated 09/10/25 at 6:10pm written by LVN C reflected “This nurse received a phone call that there was a possible resident of ours walking down the highway. This nurse went outside and resident was walking up with a male person. A lady in a car told me that she is bringing one of our residents back that was off the property. This nurse walked with the resident back into the facility. The resident sat down in the front lobby and was given some water to drink. Vital signs stable. Keeping the resident within sight at this time. No injuries observed at the time of the incident.” Review of Resident #3's nursing progress note dated 09/10/25 written by LVN Cat 6:17pm reflected “This nurse received a phone call of a possible resident outside. This nurse went outside and there was a male walking up the sidewalk with the resident. The lady in the car stated that our resident was walking outside and they are bringing her back. This nurse notified the ADON while we are walking back into the facility because she is here at this time. Assisted the resident back in the facility and gave her some water. VS stable 167/52(blood pressure) 98(oxygen) 97.2(temperature) 98(pulse) O2 sat. She denies any pain and said that she did not fall while she was out. States that she just wanted to get away. She has no control over anything and needed to get away. This nurse was directed to send her back to the secure until to room [ROOM NUMBER] at this time. Notified the responsible party that she would be moving back there and what room she would be in. He states that he will be calling tomorrow and speaking with management”. In an interview with the former DON on 09/29/25 at 2:59pm, she stated she had received a call from the ADON on 09/10/25 around 6:00pm and could not recall the exact time that Resident # 3 was found outside at the road to the right of the facility by someone that passed by in their car. LVN C assessed Resident #3 with no injuries and Resident #3 was placed on the secured unit. The former DON stated there was no camera footage of Resident #3 when she had exited the facility as the cameras did not work. The former DON was advised by the ADON that Resident #3 went out of the facility when a visitor was holding the door open for CNA B to come into the facility. The former DON stated that CNA B did not recognize Resident #3 because she had worked the secured unit. CNA B stated Resident #3 did not reside on the secure unit. The former DON stated CNA B thought that Resident #3 was a visitor because she was dressed like a visitor and had a purse . The former DON stated it was expected for CNA B to recognize Resident #3, and the incident could have resulted in Resident #3 possibly being hit by a car while outside the facility. The former DON stated immediately after the incident on 09/10/25 the facility was trained on the missing resident policy, what to do when a resident elope, and to prevent elopement. In an interview with LVN C on 09/29/25 at 3:14pm, she stated on 09/10/25 she had received a call around 6:00pm during shift change from a lady whom she did not know to let her know there was an elderly person out at the road. LVN C stated at the same time the ADON was on the line with another facility in the area asking if they had a resident that was missing. LVN C stated when she got off the phone she and the ADON immediately went outside the facility. LVN C stated a lady was sitting in a blue car and a young man was bringing Resident #3 to the facility door. LVN C stated Resident # 3 was not outside the facility more than five minutes. LVN C stated she asked Resident #3 where she was going, and Resident #3 told her she just needed a break. LVN C gave Resident #3 some water and assessed her for any injuries, and none were noted. Resident # 3 was placed on the secured unit. LVN C stated anything could have happened to Resident #3 that could have caused harm while outside the facility. LVN C stated inservice on preventing elopement was completed after the incident on what to do in case of elopement. In an interview with CNA B on 09/29/25 at 4:08pm, she stated on 9/10/25 after 6:00PM (the exact time could not be recalled), as she was coming in the facility, a visitor that was leaving out of the facility had held the door open as she was coming in to work. CNA B stated shortly after she was on the secured unit an unidentified staff member had stated to her that Resident #3 went out of the facility earlier. CNA B stated she asked the unidentified person what did Resident #3 look like, and the unidentified person said the resident was dressed up and had a purse. CNA B then stated to the unidentified staff member “Oh My Gosh Resident #3 was coming out of the facility as she was coming into the facility”. CNA B stated Resident #3 did not look like a facility resident. CNA B stated she did not know Resident #3 was a facility resident because she had a dressy colorful dress on, and had a purse, with big hair. CNA B stated she had never seen Resident #3 as she worked the secured unit. CNA B stated that she will take the blame for not recognizing it was Resident #3 coming out of the facility as she was coming in. CNA B expressed she was very sorry for that. CNA B received elopement training to prevent elopement after the incident over elopement procedures and the protocol to follow when there is an elopement. In an attempted interview with Resident #3 on 09/30/25 at 3:22pm, Resident #3 was sitting in the secured unit at the dining table, and she was not able to say if she was safe or not. Resident # 3 was not able to elaborate on if she had left the facility or how she got outside when she was found in the road. Resident #3 she was not able to recall the elopement incident, and she stated she was here and said she did not know. In an interview with Resident #3's RP on 10/01/25 at 9:25am he stated that he received a call on 9/10/2025 around 6:00pm that evening from a female (name unknown) at the facility advised that Resident #3 had been found outside at the road walking on the highway. Resident #3's RP stated the facility never told him how Resident #3 was let out of the facility. Resident #3's RP stated he had a problem with Resident #3 being let out of the facility and that Resident #3 was let out of the facility by staff. Resident #3's RP was very concerned because Resident #3 had dementia and that someone had let Resident #3 out and there was no way Resident #3 could have pushed that heavy door leading to the outside open. Resident #3's RP stated Resident #3 would not have known to return back to the facility if she was not found outside the facility. Resident #3's RP stated the Highway is a very busy highway and anything could have happened (possibly hit by a car) with Resident #3 being on the Highway if no one had found her. Resident #3's RP stated the problem he had was the facility door was not secured, and Resident #3 was able to get out of the facility. Resident #3's RP stated that residents could be able to walk out with employees because no staff was at the front area watching the door. Resident #3's RP stated he wanted the security to the door to be enforced for the safety of all the residents and to ensure this incident would not ever happen again. In an interview with the ADON on 10/01/25 at 11:55am she stated she was on the phone around 6:00pm (could not recall the exact time) on 09/10/25 talking with another facility in the area, and they were asking if they had a resident that was missing. The ADON stated while she was on the phone speaking with the other facility LVN C was on the line with the people that had Resident #3 outside the facility. The ADON stated once she and LVN C both got off the phone they went outside to the parking lot of the facility. The ADON stated there was a lady that was sitting in a blue car and a male gentleman was escorting Resident #3 back to the door of the facility. The ADON stated Resident #3 was back inside the facility by 6:15 pm. The ADON stated that Resident #3 may have gotten out of the facility with visitors. The ADON stated that Resident #3 dressed up every day and would not be recognized as a resident. The ADON stated when Resident # 3 was brought back inside the facility, Resident #3 sat in a chair, and was given water. The ADON stated that Resident #3 told LVN C that she just needed a break. The ADON stated Resident #3 was fully assessed by LVN C with no injuries and escorted Resident #3 to the secured unit. The ADON stated that Resident #3 was very confused and when she went out of the facility would not have known to come back into the facility. The ADON stated the speed limit in front of the facility was 55 miles per hour and the worst thing that could have happened was Resident #3 could have gotten run over by a car. The ADON stated immediately after the elopement incident elopement training was conducted on the protocol, procedure of elopement, and to monitor residents. In an interview with the ADM and interim DON on 10/01/25 at 5:30 pm they stated that when the state surveyor came in on 09/26/25 the elopement was completed. The ADM and Interim DON stated an elopement assessment was completed on all residents, the elopement book was updated and staff were in serviced on the location to find it. Inservice on the missing resident policy procedures (what to do) was completed with all staff. Care plans were updated for all residents that were elopement risks. The sign on the front door, dining area, and any door staff exit through was placed for all resident's safety. An assessment was completed on Resident #3 and the care plan was updated. Resident #3 was moved to the secure unit and staff statements and witness statements were conducted. A root cause analysis was completed by the interim DON along with a complete report of the elopement incident. An interview with the interim DON on 10/03/25 at 12:20pm reflected that Resident #3 was not recognized by CNA B when a visitor was holding the door open for her when she came to work on 9/10/25 which resulted in Resident #3 exiting the facility. The interim DON stated this could have resulted in potential harm if Resident #3 had a fall while outside the facility. The interim DON stated it was expected for staff to make sure Resident #3 was safe. An interview with the ADM on 10/03/25 at 12:40pm stated that Resident # 3 was let out by CNA B who did not recognize she was a resident on 09/10/25 around 6:00pm. The ADM stated that Resident #3 could have experienced a negative outcome with harm if she was hit by a car on the busy highway. The ADM stated it was expected Resident #3's admit assessment completed on 06/03/24 to be followed. The ADM stated Resident #3 was not an elopement risk at the initial assessment but required care plan to be routinely monitored. Review of the facility's “Safety and Supervision of Resident” policy, dated 2001, revealed “Our facility strives to make the environment as free from accident hazards as possible, Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Policy Interpretation and Implementation Facility Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: e. unsafe wandering…” Review of the facility's “Wandering and Elopements” policy, dated 2001, revealed “The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.” This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 09/10/25 and ended on 09/15/25. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: - Review of Wandering/Elopement Assessment was conducted on all residents was completed on 09/10/25. - Review of Inservice on missing resident policy and protocol to follow was completed on 09/10/25. - Review of Elopement book and Inservice on where the book is located was completed on 09/10/25. - Review of Care plans updated on all residents that are an elopement risk was completed on 09/10/25. - Review of Signage on door in front door and any door staff exit through to make sure residents are not able to exit facility was observed on 09/10/25. - Review of Assessment on Resident #3, Reviewed Resident #3's updated care plan, moved to the secure unit on 09/10/25. - Review of Staff statements/witness statements about the elopement incident was completed on 09/11/25. - Review of Root cause analysis was completed on the elopement was completed by DON on 09/11/25 - Review of Complete incident report on the elopement was completed on 09/15/25

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 7 residents (Resident #1, Resident #2, Resident #3) reviewed for care plans. The facility failed to update Resident #1's care plan after she was seen in bed with Resident #2 on 9/18/2025[KS1] [LP2] and after a sexual activity incident on 9/24/2025. The facility failed to update Resident #2's care plan after inappropriate behaviors were noted on 9/18/2025, 9/19/2025 and 9/24/2025.[KS3] [LP4] The facility failed to care plan interventions to routinely monitor Resident #3 when an initial elopement assessment was completed 06/03/24[KS5] [LP6] . This failure placed residents at risk of not having their individualized needs met, a delay in services, and not receiving adequate care to meet their needs.Findings included: Resident #1 Review of Resident #1's face sheet dated 9/26/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Anemia (low blood iron level), Insomnia (problems falling and staying asleep), Hypokalemia (low blood levels of potassium), and acute respiratory failure. Review[KS7] [LP8] of Resident #1's admission MDS assessment dated [DATE] reflected she had a BIMS score of 4 suggesting severe cognitive impairment. No behaviors were noted in the behavior section of the MDS. Review of Resident #1's progress notes on 9/18/2025, reflected no mention of her being found in bed with Resident #2 on 9/18/2025[KS9] [LP10] Review of Resident #1's progress notes dated 9/25/2025 at 4:14 am by LVN E reflected: CNA reported that this resident was lying in bed with female resident sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #1's care plan (the only care plan in the EMR) on 9/26/2025, reflected the focus area initiated on 9/11/2025: I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition.with interventions Administer meds per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. Resident #2 Review of Resident #2's face sheet dated 9/26/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affects movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and Benign Prostatic Hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2's progress note dated 9/18/2025 at 2:30 pm by LVN C reflected: In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's progress note dated 9/19/2025 at 8:27 am by LVN K reflected: resident was noted to be kissing a female resident on her hand. resident was redirected by this nurse redirection was successful. Review of Resident #2's progress note dated 9/19/2025 at 8:44 am by LVN K reflected: resident was noted kissing a female resident in the mouth by this nurse, resident was separated from female resident. and redirected. Review of Resident #2's progress note dated 9/25/2025 at 4:14 am by LVN E reflected: CNA reported that this resident was lying in bed with female resident [Resident #1] sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #2's care plan dated 9/26/2025 reflected no entries initiated prior to 9/22/2025 and there were no entries related to his sexual behaviors.The following focus that was initiated on 9/25/2025: I have memory loss/dementia r/t dementia, difficulty making decisions, disease process, Impaired decision making, neurological symptoms.With interventions initiated on 9/25/2025 and revised on 9/26/2025: Cue, reorient and supervise or assist me as needed. Discuss concerns about confusion, disease process, transition issues, andcommunity placement with all team members. Observe for and report to the nurse any changes in cognitive function, specificallychanges in: decision-making ability, memory, recall and general awareness, difficulty, expressing self, difficulty understanding others, level of consciousness, and mentalstatus. Review of Resident #2's care plan on 10/3/2025 reflected the following focus and intervention initiated on 9/26/2025: I have episodes of adverse behavior(s): Sexually inappropriate behavior (has held hands and attempted to kiss others, shows preference to one resident); Interventions:Anticipate behavior(s) and redirect when in close proximity to others that mightinvoke aggression.Ensure family/MD/aware of behaviors and/or any increase in behaviors noted.Ensure staff is aware of physical/sexual behaviors and interventions.Redirect/remove when approaching/being approached by particular female residentMonitor and chart behaviors q[KS11] [LP12] shift and report to MD.Resident will be placed one to one until IDT determines one to one is no longer inneed.[KS13] [LP14] During[KS15] [LP16] an interview on 10/3/2025 at 4:48 pm, the DON stated the former DON had been responsible for updating care plans. She stated when the state agency had been in the facility at the beginning of September 2025, they knew care plans needed to be updated, and she had been working through them but had not completed all of them yet. She stated she had not gotten to Resident #1 or Resident #2's care plans yet. During an interview on 10/3/2025 at 4:30 pm, the ADM stated she was unaware the care plans for Residents#1 and Resident #2 had not been updated[KS17] [LP18] . She stated her expectation was that nursing staff would update care plans to reflect changes in the residents per the facility policy. Resident #3 Record review of Resident #3's admission recorded dated 10/02/25 documented an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses including: unspecified dementia (loss of memory, language, problem solving and other thinking abilities), muscle weakness (lack of physical or muscle strength), and history of falling. Record[KS19] review of Resident #3's Quarterly MDS assessment, dated 09/02/25, revealed the resident had a BIMS score of 3 indicating the resident had severe cognitive impairment. Record review of Resident #3's care plan, dated 09/29/25, revealed Resident #3 was care planned for impaired cognitive function/dementia or impaired thought processes r/t dementia, at risk for falls r/t confusion, cognitive impairment, gait/balance problems, and unaware of safety needs. Review of an initial Elopement Risk Assessment dated 06/03/24[KS20] , reflected Resident #3 was not at risk for elopement and care plan interventions of routinely monitor resident. Record review of Resident #3's care plan, dated 09/29/25, revealed that there was no care plan interventions to routinely monitor Resident #3. In an interview with the MDS Coordinator on 10/03/25 at 4:25pm, she stated the agency nurse who no longer worked at the facility would have been responsible for letting her know that Resident #4 had care plan interventions once the initial elopement assessment was completed on 06/03/24[KS21] . The MDS coordinator stated it was expected for the agency nurse to let her know the care plan interventions so she could have entered on the care plan. The MDS Coordinator stated without the care plan interventions updated the staff would not have known to follow the intervention. In an interview with the ADM on 10/03/25 at 4:34pm, she stated she was not aware that the care plan did not reflect care plan interventions from the initial assessment completed on 06/03/24 to reflect to routinely monitor Resident #4[KS22] . The ADM stated it was expected for the MDS Coordinator to place the care plan intervention immediately after the elopement assessment was completed on 06/03/24[KS23] . The ADM stated with interventions not noted there would not have been anything to follow. Review of Facility Policy Care Planning - Interdisciplinary Team with revision date 12/2024, reflected: The interdisciplinary team is responsible for the development of resident care plans.1. Resident care plans are developed according to the timeframes and criteria established by S483.21.2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

Based on interview and record review, the facility failed to conduct an initial comprehensive, accurate, standardized reproducible assessment of the resident's functional capacity within 14 days of admission for 1 (Resident #2) of 7 residents reviewed for Comprehensive Assessments being completed timely. The facility failed to complete a comprehensive assessment for Resident #2 within 14 days of admission. This failure placed newly admitted residents at risk of not having care and treatment needs assessed to ensure necessary care and services were provided to meet these needs.Findings included: Review of Resident #2's face sheet dated 9/26/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affects movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and Benign Prostatic Hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. During an interview on 10/3/2025 at 4:17 pm, the MDS Coordinator stated Resident #2 did not have an MDS assessment done yet. She stated she was running late in getting assessments done. She further stated the facility has 14 days from admission to complete MDS assessments and Resident #2's did not get done. She stated she was the one responsible for making sure they got done. She stated she initially thought Resident #2 was respite because he was admitted on hospice services. During an interview on 10/3/2025 at 4:30 pm, the ADM stated she was unaware the MDS assessments were late and not getting done and unaware that Resident #2 did not have any MDS assessments done since his admission. She stated the MDS coordinator reported up to regional MDS staff but that at the local level the MDS coordinator reported directly to the ADM. She stated her expectation was that the MDS coordinator will complete MDS assessments on time per the facility policy. Review of Facility Policy Comprehensive Assessments with revision date February 2025 reflected: Comprehensive assessments are conducted to assist in developing person-centered care plans.1. Comprehensive assessments are conducted in accordance with criteria and time frames established in the Resident Assessment Instrument (RAI) User Manual.2. admission Assessment -The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if:a. this is the resident's first time in this facility, ORb. the resident has been admitted to this facility and was discharged return not anticipated, ORc. the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

Based on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 1 of 6 (Resident #5) reviewed for misappropriation and exploitation, in that: The facility failed to ensure Resident #5 was free from exploitation when the BOM took Resident #5's net spend credit card and used the card for personal use. The BOM used Resident #5's credit card and withdrew funds totaling $3700. This failure could place residents at risk of financial hardships and a decrease in resident's quality of life.Findings included: Record review of Resident #5's admission record dated 10/02/25 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses included major depressive disorder (sadness), cognitive communication deficit (inability to communicate effective), and hypertension (high blood pressure). Record review of Resident #5's Quarterly MDS assessment, dated 09/23/25, revealed the resident had a BIMS score of 0 indicating the resident had severe cognitive impairment. Record review of Resident #5's care plan, dated 09/29/25, revealed Resident #5 was care planned for visually impaired and required secure storage of personal items/medications in a lock box to ensure safety and prevent misuse or loss. An attempted interview with the BOM was made 10/02/25 at 4:30pm, 10/03/25 at 11:49am, and 10/03/25 at 3.37pm. A voice message was left and the BOM did not return call prior to facility exit 10/03/25. An interview with the Marketing Director on 10/01/25 at 10:44am stated on 09/15/25 Resident # 5's RP came to the facility to pick up Resident #5's wallet and the RP noticed there was a credit card missing. The Marketing Director stated she was a witness with the BOM to count out the large amount of cash that was in Resident #5's wallet. Resident #5's RP told the BOM there was a card missing and the BOM asked what card. The Marketing Director stated it was alerted to staff that Resident #5's card may have been misplaced and to be on the lookout. Resident #5's RP stated there was no activity on the card because they had not received any alerts on the card. The Marketing Director stated the next day, 09/16/25,she was speaking with the BOM over the phone and she asked her what was going on because she had given short responses. The Marketing Director stated the BOM asked her if they could meet and they met around 6:08pm. The Marketing Director stated when she opened the BOM's car door she was sobbing and told her she “fucked up” with Resident #5's money and she took Resident #5's card. The Marketing Director stated the BOM stated she received a fraud notification claim and she Resident #5's card. The Marketing Director stated the BOM initially told her she used $2,000 then she went to $3,000 and told her she could not get the money back to Resident #5. The Marketing Director asked what she used Resident #5's card for and she stated on things she could not get back. The BOM stated once she started using the card she could not stop and she had set up a pin for the card. The Marketing Director stated the BOM stated she would be shown on camera using Resident #5's card at locations and she gave her the office key as she was not going back to work because the police would be there. The Marketing Director stated the next morning 09/17/25 around 9:00am when she went to work she reported the incident to the ADM. The Marketing Director stated she did not report to the ADM immediately after it happened because she was trying to process what the BOM told her. The Marketing Director stated it was expected for her to contact the ADM immediately after the BOM confessed to taking Resident #5's credit card and used it for her personal use. An interview with Resident #5 on 10/02/25 at 4:00pm stated his RP told him someone had taken his card out of his wallet and spent $3,700. Resident #5 stated he did not know who took his card and used it but the person who used the card had paid the $3,700 back to him. Resident #5 stated his RP did not tell him who used his credit card but he was upset about it Resident #5 stated he spoke with police and did not press charges because he received the money back. An interview with Resident #5's RP on 10/02/25 at 4:49pm stated she was told by the ADM the BOM took Resident #5's card out of his wallet and spent $3,700. Resident #5's RP stated the wallet was locked up in the business office when Resident #5 was in the hospital. Resident #5's RP stated when Resident #5 returned from the hospital on [DATE] he told his RP that his wallet was in the business office. Resident #5's RP stated she went to the business office to retrieve the wallet from the BOM. Resident #5's RP stated the BOM and another unidentified woman counted the money out to her that was in Resident #5's wallet. Resident #5's RP stated that she had noticed a credit card was missing. Resident #5's RP stated they had not received any card alerts that Resident #5 had used the card. Resident #5 ‘s RP stated when the account was checked it was a total of $3,700 that was used. Resident #5's RP stated Resident #5 did not want to press charges because he received the money back. Resident #5 stated if it was up to her she would have pressed charges on the BOM. Resident #5's RP stated Resident #5 in his right mind, and he had received the $3700 back and did not want to file charges. Resident #5's RP stated the check for $3,700 was written out to her An interview with the SW on 10/03/25 at 12:06pm stated she was not aware of the incident with the BOM using Resident #5's credit card. The SW stated that she did not know the exact date she found out, but it was after the incident had occurred when she and the ADM went to Resident #5's room to return the credit card along with a cashier's check. The SW stated it was expected for the BOM to have not used Resident #5's credit card for her personal use. The SW stated the negative outcome of the BOM using Resident #5's credit card would cause financial hardship to the resident. An interview with the interim DON on 10/03/25 at 12:20pm stated she was not made aware that the BOM had used Resident #5's credit card for her personal use until 09/17/25. The interim DON stated the negative outcome would be loss of control of Resident #5's credit card that would affect Resident #5 emotionally. An interview with the ADM on 10/03/25 at 12:40pm stated she did not find out until 09/17/25 around 10:30am that the BOM confessed to the Marketing Director that she had taken Resident #5's credit card and spent $3700 for her personal use. The ADM stated on 09/15/25 Resident's #5's RP reported the credit card missing from Resident #5's wallet. The ADM stated it was expected that the Marketing Director's reported to her immediately when the BOM confessed of taking and using Resident #5's card. The ADM stated the Marketing Director met with the BOM the evening on 09/16/25 and she had confessed to the Marketing Director that she had taken the card and used the card for personal use. The ADM stated the police were called out to the facility on [DATE] and the resident did not want to press charges because the $3700 was returned back to him . The ADM stated the police did not make any reports due to Resident #5 not wanting to press charges with the credit card being used. The Adm stated the negative outcome with the incident would cause debt to Resident #5 and could effect Resident #5 emotionally and financially. The ADM stated it was expected for the BOM not have took Resident #5's credit card and used it for her personal use. Review of the BOM's personnel file reflected she was terminated on 09/17/25. Review of cashier's check pay to the order of Resident #5's RP with remitter BOM in the amount of $3700 dated 09/18/25. Review of facility's investigation dated 09/18/25 reflected a thorough investigation was completed, and the allegation of misappropriation was confirmed. Review of facility's policy, dated April 2021, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff. b. other residents. c. consultants. d. volunteers. e. staff from other agencies. f. family members. g. legal representatives. h. friends. i. visitors; and/or j. any other individual. Develop and implement policies and protocols to prevent and identify theft, exploitation, or misappropriation of property”.

Based on interview and record review, the facility failed to immediately notify the resident's representative of the change] in the resident's physical, mental, or psychosocial status for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure Resident #1's RP was notified when she was found lying in bed with Resident #2 on 9/18/2025. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.Findings included: 1. Review of Resident #1's face sheet, dated 9/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including d[dementia (group of brain disorders that cause progressive cognitive decline), anemia (low blood iron level), insomnia (problems falling and staying asleep), hypokalemia (low blood levels of potassium), and acute respiratory failure. Review of Resident #1's admission MDS assessment, dated 9/5/2025, reflected that she had a BIMS score of 4 suggesting severe cognitive impairment. Review of Resident #1's MDS assessment (type not noted), dated 9/12/2025, reflected a BIMS score of 3 suggesting severe cognitive impairment. Review of Resident #1's progress notes, dated 9/18/2025, reflected no mention of Resident #1 found in bed with Resident #2 and no mention that her RP was notified of the incident on 9/18/2025. Review of Resident #1's care plan dated 9/26/2025 (the only care plan in the EMR) on 9/26/2025, reflected the focus area initiated on 9/11/2025: I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un-safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition with interventions, Administer meds per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. 2. Review of Resident #2's face sheet, dated 9/26/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affect movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and benign prostatic hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2 progress note, dated 9/18/2025, at 2:30 pm by LVN C reflected, In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's care plan, dated 9/26/2025, reflected no entries prior to 9/22/2025 and there were no entries related to his sexual behaviors.The following focus was initiated on 9/25/32025: I have memory loss/dementia r/t dementia, difficulty making decisions, disease process, impaired decision making, neurological symptoms.With interventions initiated on 9/25/2025 and revised on 9/26/2025: Cue, reorient and supervise or assist me as needed. Discuss concerns about confusion, disease process, transition issues, andcommunity placement with all team members. Observe for and report to the nurse any changes in cognitive function, specificallychanges in: decision-making ability, memory, recall and general awareness, difficulty, expressing self, difficulty understanding others, level of consciousness, and mentalstatus. Review of Resident #2's care plan, dated 09/26/2025 reflected the following focus: I have episodes of adverse behavior(s): Sexually inappropriate behavior (has held hands and attempted to kiss others, shows preference to one resident);Interventions:Anticipate behavior(s) and redirect when in close proximity to others that mightinvoke aggression.Ensure family/MD/aware of behaviors and/or any increase in behaviors noted.Ensure staff is aware of physical/sexual behaviors and interventions.Redirect/remove when approaching/being approached by particular female residentMonitor and chart behaviors q shift and report to MD.Resident will be placed one to one until IDT determines one to one is no longer inneed. During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025. She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg. She stated Resident #2 wasn't trying to engage in anything. She stated she had no suspicion of ANE because she did not see him try to grab at nothing or try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time[ . She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that. She stated she did not] report the incident as ANE because they weren't naked and didn't have their hands in each other's pants - nothing like that going on, they were fully clothed and weren't trying to do anything. LVN C stated she notified the DON but did not remember if she called either resident's RP. During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together. She stated it was her expectation that staff would report it immediately to her and notify the RPs of both residents. She was unaware that the RP's had not been notified. During an interview on 9/27/2025 at 1:39 pm, the FM for Resident #1 stated he was notified about an incident of sexual behavior that occurred on 9/24/2025 but never received a call about a previous incident on 9/18/2025. He stated when he was contacted by the facility on 9/24/2025 there was no indication there were any previous incident between [Resident #1} and {Resident #2] or any other male residents. The FM stated he was Resident #1's POA and it was very upsetting that they had not notified him about the incident on 9/18/2025. Review of facility Policy Resident Rights, dated February 2021, reflected: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include tl1e resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;k. appoint a legal representative of his or her choice, in accordance with state law;o. be notified of his or her medical condition and of any changes in his or her condition;p. be informed of, and participate in, his or her care planning and treatment;

Based on observation, interviews and record reviews, the facility failed to use services of a Registered Nurse for at least 8 consecutive hours, 7 days a week. The facility failed to have an RN at the facility on 8/11 to 8/15/2025, 8/18 to 8/22/2025, 8/25 to 8/28/2025, and 9/1/2025, 9/2/2025. This failure could place residents at risk of not receiving adequate care and services of an RN, and decreased quality of life. Findings included: An observation on 9/3/2025 at 11:22 am of the Daily Nurse Staffing Report posting reflected zero scheduled RN hours. Further observation on the 9/3/2025 at 11:22 am of the Daily Nurse Staffing Report reflected zero schedule RN hours. During an interview on 9/3/2025 at 12:15 pm, the DON stated she was not aware that her RN hours could not be used to fulfill the RN staffing hours requirement. She stated she was not familiar with the average daily census requirement and thought her RN hours in addition to the weekend RNs that worked would cover all the required RN hours. The DON stated she was responsible for nurse staffing hours but was not aware her hours could not be used to meet the required RN coverage hours. During an interview on 9/3/2025 at 2:20 pm, the SC stated she had run the RN staffing report and there was no RN coverage for the dates of 8/11 to 8/15/2025, 8/18 to 8/22/2025, 8/25 to 8/28/2025, and 9/1/2025, 9/2/2025. During an interview on 9/3/2025 at 3:34 pm, the SC stated the RN the facility used for covering RN staffing hours went out on leave 8/11/2025 and was not replaced. During an interview on 9/3/25 at 4:51 pm, the RNC stated the ADM was responsible for making sure there was RN coverage. RNC stated she was not aware the RN hours could not be the same as the DON hours and was not aware of the average daily census of 60 criteria. She stated she was aware the facility was using the DON's hours for RN coverage but was not aware that was not allowed. She stated their average daily census was over 60. RNC stated she had provided RN coverage on 9/3 and 9/4/2025 as she had been in the building. During an interview on 9/3/2025 at 5:15 pm, the ADM stated she was not aware the facility needed RN coverage hours other than what the DON provided. The ADM stated it was the DON's responsibility to see that nurse staffing was correct. She stated she was the interim ADM and did not know if their average daily census was over 60, they needed additional RN coverage hours. In an email on 9/3/2025 at 12:54 pm the ADM was asked to provide proof of RN coverage for 8 hours a day for the last 7 days. The ADM replied via email on 9/3/2025 at 2:39 pm that the [DON] was in the building on 8/25/2-025 through 8/29/2025. The ADM was asked via return email on 9/3/2025 at 2:41 pm if there were other RNs in the building for coverage at that time and ADM replied via email on 9/3/2025 at 2:47 pm Unfortunately, no. Record review of Daily Nurse Staffing sheets for 9/2/2025, 9/3/2025 and 9/4/2025: For shift: 6a-6p, category: RN, total staff scheduled: 0, scheduled hours: 0. For shift: 6p-6a, category: RN, total staff scheduled: 0 scheduled hours: 0. Record Review of facility census sheet dated 9/3/2025 reflected the current census was 72 residents. Review of facility policy Staffing, Sufficient and Competent Nursing, revised August 2022, reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 1.Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including:a. assuring resident safety;b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident;c. assessing, evaluating, planning and implementing resident care plans; andd. responding to resident needs.2. A licensed nurse is designated as a charge nurse on each shift.A. A licensed nurse may be a licensed practical nurse (LPN), licensed vocational nurse (L VN), or registered nurse (RN).b. A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care.c. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring and administering of medications to meet the needs for 35 out of 72 residents reviewed for pharmacy services, in that:The facility failed to provide morning medications for 35 out of 72 residents on 8/31/2025 resulting in 305 medication errors. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Resident #1 Review of Resident #1's face sheet dated 9/4/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Cerebral Infarction (Stroke - brain attack), history of falling, Dementia (progressive cognitive disease), and Major Depressive Disorder (behavioral health disorder). Review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 14 suggesting no cognitive impairments. Review of Resident #1's progress note by LVN A on 8/31/2025 at 4:20 pm reflected: N/O per Dr , to monitor VSS for 12 hours x 1 day d/t med error missed dose of medication. VSS WNL. No s/s of distress noted. DON , ADON, and Administrator notified. Resident is own RP and aware of situation d/t staffing. Resident #2 Review of Resident #2's face sheet dated 9/4/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Schizoaffective Disorder (behavioral health disorder), Huntington's Disease (breakdown of nerve cells), Gastroenteritis and Colitis (inflammation of the stomach and intestines) and Vitamin deficiency. Review of Resident #2's quarterly MDS dated [DATE], reflected a BIMS score of 8 suggesting mild cognitive impairment. Review of Resident #2's progress note by LVN B on 8/31/2025 at 3:27 pm reflected: new order per Dr to monitor VS for 12 hours x 1 day d/t med error missed dose of medication. VS WNL no s/s of distress. DON ADON, Administrator, RP attempted to be made aware of situation d/t staffing. Resident #3 Review of Resident #3's face sheet dated 9/4/202 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Atrial Fibrillation (irregular heart beat), anxiety disorder, Scoliosis (curvature of the spine), Gastro-esophageal reflux disease (stomach acid reflux disorder) and malignant neoplasm of the testis (cancer of the male testicular organ). Review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 5 suggesting severe cognitive impairment. Review of progress note by LVN B on 8/31/2025 at 2:42 pm reflected: new order per Dr [name] to monitor VS for 12 hours x 1 day d/t med error missed dose of medication. VS WNL no s/s of distress. DON ADON, Administrator, RP aware of situation d/t staffing. During an interview on 9/3/2025 at 10:28 am, MA - A stated she was called at 10:00 am on 8/31/25 to come into the facility and pass meds because the MA for the 100 and 400 halls called in sick. MA-A stated she arrived at the facility at 11:00 and discovered none of the morning meds for the 100 and 400 hall had been passed. She stated she notified the nurse, LVN-B who called the MD for orders. MA-A stated there were no adverse outcomes due to the missed medications. During an interview on 9/3/2025 at 10:31 am, LVN-B stated she called the medical director on 8/31/2025 to inform him of the missed medications for the residents on the 100 and 400 hall and get orders for how to proceed. LVN-B stated she received orders to leave the missed medications as missed and start passing medications according to the current schedule. LVN-B stated she was given orders to monitor the vitals from all residents with missed medication for 12 hours and notify MD of any adverse reactions. She stated the MD informed her that all missed medications would be a medication error, and each would need to be reported. She stated she also called RPs of the residents and informed them of the missing medications. She stated there were no adverse outcomes due to the missed medications. During an interview on 9/3/2025 at 10 40 am, LVN A stated she was working on 8/31/2025 and was assigned the 200 and 300 halls. She stated LVN B told her about the medications for the 100 hall residents had been missed because the MA had called in sick, and no one had known. She stated she had been working with a resident that had a fall that morning and did not realize MA B had not come to work. She stated she helped LVN B make calls to RPs and assess residents by completing vital signs. She stated the residents VS were WNL and she did not see or get report of any adverse outcomes. She stated she had been with LVN B with MD on speaker phone when he gave them instructions to notify the DON, take VS, monitor residents for changes and just give the meds that were due now, but not go back and give any missed medications. During an interview on 9/3/2025 at 11:58 am, the interim ADM stated she had only been at the facility for 1.5 weeks. She stated a nurse called her around 10:10 am on 8/31/2025 and informed her of the missing medications. The ADM stated another MA came in to pass medications. The MD was notified and told them not to give the late meds and to write up med errors for all missed medications. During an interview on 9/3/2025 at 12:15 am, the DON stated she was aware the 100 hall residents missed their morning medications on 8/31/2025. She stated a MA had called in sick after the shift had started. She stated the MA has texted her that morning to let her know she was sick and asked who was on call, so she assumed she had gotten ahold of the staff on call and notified them she was sick. The DON stated she did not notify anyone at the facility that the MA had notified her after 7 am on 8/31/2025 that she was sick and could not come into work. During an interview on 9/3/2025 at 1:52 pm, the MD stated he was aware of the missed medications on 8/31/2025. He stated he was notified about 11:30 on the morning of 8/31/2025 that a MA has called in sick and that morning meds were missed. He stated it was inappropriate for residents to have missed their morning medications and he informed the nurse that called him that all missed medications would be med errors. He stated he gave orders for all residents that missed medications to have their vital signs checked for 12 hours and to be monitored for any changes in condition. He stated to his knowledge there were no adverse outcomes from the medications being missed and no residents had any change sin conditions. He stated he could not comment on the protentional adverse outcomes because he had not yet received a complete list of all the residents and the missed medications. During an interview on 9/3/2025 at 4:51 pm RNC stated she was aware of the missed medications on 8/31/2025 for the 100 hall residents that resulted in over 300 medication errors. She stated a MA had called in sick and by the time anyone realized it the morning med pass had been missed. She stated the MA had texted the DON at 7:09 that morning, but the DON did not contact anyone at the facility and let them know she was sick. She stated LVN B reached out to the MD for orders and was told not to give the morning meds, but to monitor the residents for any changes in conditions. She stated to her knowledge there were no adverse outcomes from the 100 hall residents missing their morning medications. She stated they will be making changes to ensure this does not happen again that included changing the MA schedules, so their shift starts the same time as the nurses, making the charge nurses responsible to ensure the MAs were at the facility for work and completing in-services with all nursing staff. During an interview on 9/4/2025 at 11:59 am, MA B stated she was sick on 8/31/2025 and unable to work. She stated she texted the DON at 7:09 am and told her I don't know who's on call but I cannot work I'm sick. She stated the DON's response was [staff name] I think and nothing more. She stated she also contacted another department head, and they told her they would let the on-call staff know so she assumed it was handled. She stated she found out when she came back to work that all the morning medications for the resident son the 100 hall had been missed. The MD was provided a complete, 82-page report Medication Admin Audit Report on 9/4/2025 at 9:58 am via email. Repeated calls and texts to MD to discuss report and get his statement were not returned. Review of facility report Medication Admin Audit Report dated 9/3/2025 at 11:58 am reflected 82 pages of missed medications. Review of facility policy Administering Medications, revised April 2019, reflected: Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions.4. Medications are administered in accordance with prescriber orders, including any required time frame.5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:a. enhancing optimal therapeutic effect of the medication;b. preventing potential medication or food interactions; andc. honoring resident choices and preferences, consistent with his or her care plan.6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.7. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concern.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 5 halls reviewed for environment. The facility did not address moisture damage and discoloration in the ceiling on the hallway in the secure unit. This failure could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.The findings included: During on observation on 09/03/2025 at 11:37am, the ceiling in the hallway in the secure unit had water stains and a black substance in the ceiling. During an interview with LVN C on 09/03/2025 at 11:40am, LVN C stated that the ceiling has been like that for a while. LVN C stated the water stains and black substance were cause by an air condition leak in the ceiling. LVN C stated that black substance appeared to be mold to her. LVN C stated a negative outcome would be respiratory issues from the mold. During an interview with the Maintenance Director on 09/03/2025 at 11:45am, Maintenance Director stated that he was aware of the water stains in the ceiling but had not been notified of any black substance in the ceiling. The Maintenance Director stated the air condition unit in the secure had a leak a few weeks back but that had been fixed. The Maintenance Director stated he was waiting for the ceiling to completely dry before fixing it. The Maintenance Director stated that the company requires him to get three estimates before he could proceed to have the work completed. The Maintenance Director stated that a negative outcome would be the ceiling would look less appealing, and the black substance could be mold. The Maintenance Director stated if the black substance was mold, then that could cause respiratory issues for the residents on the secure unit. During an interview with the DON on 09/04/2025 at 2:48pm, the DON stated she was aware that the ceiling had water stains and there was a black substance in the ceiling of the secure unit. The DON stated that the Maintenance Director had recently fixed air condition leak in the attic on the secure unit. The DON stated that the water stains and black substance in the ceiling would make the facility look less homelike. The DON stated that she considered the black substance to be mold. The DON stated that mold could cause respiratory issues for the residents and staff on the secure unit. During an interview with the ADM on 09/04/2025 at 2:55pm, the ADM stated she was not aware of any water stains or black substance in the ceiling of the secure unit. The ADM stated she was aware that air condition on the secure unit had a leak but had been fixed. The ADM stated that she could not give any negative outcomes due to not knowing what the black substance was. Review of the facility's Homelike Environment policy, revised dated 2021, reflected Policy StatementResidents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible Policy Interpretation and Implementation1. Staff provides person-centered care that emphasized the residents' comfort, independence and personal needs and preferences.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. Clean, sanitary and orderly environment;.

Based on interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Residents #4) reviewed for accident prevention. The facility failed to ensure that bleach was not attainable for Resident #4 on 08/26/2025. This failure could place residents at risk for accidents and hazards.Findings include: Record review of Resident #4's Face Sheet, dated 09/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #4 has the following diagnoses: anxiety disorder (feelings of worry or fear are so intense and constant that they don't go away), unspecified dementia (loss of normal brain function that makes it hard to remember, think, speak, and do other everyday tasks), schizophrenia (brain disorder where a person has trouble telling what's real from what's not, leading to a disconnect from reality), and cognitive communication deficit (difficulties with communication that stem from a problem with one or more cognitive processes, such as attention, memory, reasoning, problem solving, or executive functions). Record review of Resident #4's Annual MDS, dated [DATE], reflected the resident was unable to complete the interview to determine the BIMS score. Resident #4 was dependent in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on taking off footwear, and personal hygiene. Resident #4 required supervision or touching assistance in the area of eating. Record review of Resident #4's Care Plan, dated 09/04/2025, reflected the resident was care planned for memory loss/dementia r/t delusional behaviors, dementia, difficulty making decisions, end stages memory loss, and impaired decision making. Record review of Resident #4's Nursing Progress Note, dated 08/26/2025, reflected kitchen staff notified DON and charge nurse she seen resident drinking her cleaning solution of bleach diluted water with soap in it about 30cc. VS taken immediately 97.7, 124/72bp, 0-10 pain. Resident alert and oriented. Resident # 4 was observed but could not be interviewed due to her cognitive impairment. Record review of Resident #4's Discharge Instructions, dated 08/26/2025, reflected discharge instructions: nontoxic ingestions. Findings: lungs appear clear, the heart and mediastinum unremarkable. No evidence of acute intrathoracic disease. During an interview with the KS on 09/03/2025 at 5:05pm, KS stated that she was washing dishes when she noticed Resident #4 had removed a cup from the dirty cups cart that was in the kitchen's doorway. The KS stated she did not see Resident #4 drink from the cup but knew the cup had bleach and soap water in it. The KS stated she put about one fourth of a cap of bleach in the soapy water. The KS stated that cups were soaked in soapy bleach water to remove hard stains such as coffee and tea. The KS stated when she saw Resident #4 with the cup, she immediately took it and assisted the resident to the nurse. The KS stated the DON and LVN B were at the nurse station. The KS stated she was told that Resident #4's toxicology screen came back negative. The KS stated if Resident would have drank the bleach soap water she could have gotten During an interview with the LVN B on 09/03/2025 at 4:50pm, LVN B stated she was not aware if the kitchen staff saw Resident #4 drink the bleach soap water. LVN B stated that the resident VS's were within normal limits at the time of her assessment. LVN B stated that the NP gave order for the resident to be sent to the ER. LVN B stated that the Resident returned from the ER the same day and there was no trace of toxins, and her labs were normal. During an interview with the DON on 09/04/2025 at 2:48pm, DON stated that the kitchen staff stated she was not aware if Resident #4 had drank from the cup with bleach soap water. The DON stated that Resident #4 was given water per the bleach label instructions. The DON stated Resident #4 was sent to the ER per the NP. The DON stated that the paperwork from the hospital did not reflect Resident had drank the bleach soap water and her lab were all normal. The DON stated there would not be a negative outcome due to the hospital lab work showing Resident #4 did not have toxic chemicals in her system. During an interview with the ADM on 09/04/2025 at 2:55pm, ADM that she was notified by the DON that a kitchen staff stated that Resident #4 had possibility drank bleach soap water. The ADM stated that the only departments that use bleach were dietary and housekeeping. The ADM stated after the incident, bleach would be securely kept in the offices of the DM and housekeeper supervisor. The ADM stated that the resident was sent to the ER and her labs were all normal. The ADM stated there would not be a negative outcome due to the resident not having an adverse effect. Review of the facility's Safety and Supervision of Residents policy, revised dated July 2017, reflected Policy StatementPolicy Interpretation and ImplementationFacility-Oriented Approach to Safety1. Our facility-oriented approach to safety addresses risks for group of residents. Individualized, Resident-Centered Approach to Safety

Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for 2 of 8 residents (Resident #1 and Resident #2) reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility on [DATE]. The facility failed to ensure Resident #2 did not elope from the facility [DATE]. An Immediate Jeopardy (IJ) existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, dehydration, and hospitalization . Findings included: Record review of Resident #1's admission recorded dated [DATE] documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses included: unspecified dementia (loss of memory, language, problem solving and other thinking abilities), mild protein-calorie malnutrition (protein intake that is insufficient to meet bodily demands for protein synthesis and tissue repair) and muscle weakness (lack of physical or muscle strength). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed the resident had a BIMS score of 06 indicating the resident had severe cognitive impairment. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was care planned for neurocognitive disorder with Lewy bodies, risk for injury from wandering in an unsafe environment, cognitive loss/dementia, and falls. Review of Resident #1's nursing progress note dated [DATE], reflected resident told staff he wanted the manager to know he was not eating anything anymore and he hated living here. Review of an Elopement Risk Assessment date [DATE], reflected Resident #1 was a risk for elopement. No interview could be conducted with Resident #1 due to the Resident #1 being discharged to the VA hospital for behavioral support and elopement risks. Record review of Resident #2's admission recorded dated [DATE] documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses included: vascular dementia (chronic condition that affects the brain's ability to function by damaging blood vessels and reducing blood flow and oxygen supply), memory deficit (issue with forming, storing, or recalling memories), and anxiety (feeling of fear, dread, and uneasiness that can be a normal reaction of stress). Record review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed the resident had a BIMS score of 05 indicating the resident had severe cognitive impairment. Record review of Resident #2's care plan, dated [DATE], revealed Resident #2 was care planned for episodes of anxiety, psychotropic drug use, dehydration/fluid maintenance, communication, visual function, cognitive loss/dementia, delirium, and elopement. Review of Resident #2's nursing progress note dated [DATE], reflected spoke Resident #2's and she said his worked at the hospital and that is probably why he went over there. Review of an Elopement Risk assessment dated [DATE], reflected Resident #2 was a risk for elopement. During an interview with Resident #2 on [DATE] at 12:45pm, Resident #2 stated that he climbed over the fence with the chairs. Resident #2 did not state why he eloped but stated he felt safe and was ok. An interview with RN A on [DATE] at 10:00am, revealed RN A stated Resident #2 was outside in the courtyard a few minutes before smoke time. RN A stated that Resident #2 liked to go sit in the gazebo. RN A stated that Resident #2 was only outside for about ,d+[DATE] minutes. RN A stated that she was giving resident on the secure unit fluids when LVN A brought Resident #2 back in the secure unit and stated that he was found in the hospital parking lot across the street by a prn facility staff. RN A stated that Resident #2 did not let her assess lower body but only his upper body. RN A stated Resident #2 did not have any injuries from the elopement. RN A stated that since the incident no resident was allowed in the courtyard alone. RN A stated that Resident #2 was placed on 15-minute check. RN A stated when resident was allowed in the courtyard alone staff checked on the resident every ,d+[DATE] minutes while outside. RN A stated round inside the secure unit were done at least every two hours. RN A stated that Resident #2 could have been hit by a car, died from heat exhaustion, been injured or been abducted due to his elopement. An interview with the CNA A on [DATE] at 12:55pm, revealed she was an agency staff, and she was in-serviced on the visual check log, missing person policy, rounds and supervision. CNA A stated no resident can be left alone in the courtyard, elopement drill will be performed twice a week for the next five weeks, window alarms were installed on the windows in the secure unit, and window and window alarms checks will be done twice a week for the next five weeks. An interview with the DON on [DATE] at 1:55pm, revealed the DON stated that the facility in-serviced facility staff as well as agency staff on the visual check log, missing person policy, rounds and supervision. DON stated no resident could be left alone in the courtyard, elopement drill will be performed twice a week for the next five weeks, window alarms were installed on the windows in the secure unit, and window and window alarms check will be done twice a week for the next five weeks. DON stated that both Resident #1 and Resident #2 two used objects to get over the fence around the secure unit. DON stated that both residents could have been hit by cars, passed out, or gotten injured during the elopement incidents. An interview with ADM on [DATE] at 4:10pm, revealed that ADM stated in-services were done on visual check log, missing person policy, rounds, and supervision. ADM stated facility staff and agency were in-serviced on those topics of concern. ADM stated no resident can be left alone in the courtyard, elopement drill will be performed twice a week for the next five weeks, window alarms were installed on the windows in the secure unit, and window and window alarms check would be done twice a week for the next five weeks. ADM stated that both Resident #1 and Resident #2 two used objects to get over the fence around the secure unit. ADM stated that both residents could have been dehydrated, picked up by a stranger, fallen and gotten injured or hit by a car due to the elopement incidents. ADM stated she expected for staff to follow through with the invention put in place to ensure all residents were present and safe. Review of the facility's Safety and Supervision of Resident policy, dated 2001, revealed Our facility strives to make the environment as free from accident hazards as possible, Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Policy Interpretation and Implementation Facility Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: e. unsafe wandering . This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: - A Wandering/Elopement Assessment was conducted on all residents. - Resident #1 received 1:1 supervision until he was discharged to the VA hospital on [DATE]. - Observation on [DATE] at 12:45pm of window alarms were installed to all windows and were working properly on the secure unit. - On [DATE] Resident #1 was sent to the VA Hospital for elopement risk and behavioral support. - All staff were in-serviced on their Missing Person Policy, Rounds, and 1:1 supervision. - On [DATE] at 2:55pm reviewed Elopement Drills were conducted ([DATE] and [DATE]). Elopement drills are being conducted twice a week for the next five weeks. - On [DATE] reviewed the facility head count sheet. The facility was conducting a head count on all residents daily. - Visual check logs were being completed on residents in secure unit by the Nurse at the being of each shift and turned in to the DON daily. - On [DATE] at 3:00pm reviewed the window and window alarm checklist. The window and window alarm checks were being conducted five times a week (conducted by maintenance and weekend supervisor) - Resident #2 received 15-minute supervision checks implemented on [DATE]. The 15-minute checks were completed for 72 hours. Observed the 15-minute checks documentation on [DATE] at 11:15am. - Both Resident #1 and Resident #2 care planned were updated with elopement risk interventions. - Resident #1 and Resident #2 received nursing assessments no injuries noted from elopements. Resident #2 was seen by the NP, no med changes and had a follow up visit in two weeks. - On [DATE] QAPI meeting was conducted. - The facility and VA hospital will coordinate a safe placement for Resident #1.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 6 residents (Residents #1 and #4) reviewed for abuse. 1. The facility failed to ensure Resident #1 was protected from verbal and physical abuse by MA C. 2. The facility failed to ensure Resident #4 was protected from verbal abuse which included verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group and intimidating from CNA A. An Immediate Jeopardy (IJ) situation was identified on 04/23/23. While the IJ was removed on 04/25/23 at 4:40 PM, the facility remained out of compliance at a scope of pattern with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for physical harm and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: 1. Record review of Resident #1's, undated, face sheet indicated a [AGE] year-old female who was last admitted to the facility on [DATE]. Her diagnoses included epilepsy (recurrent seizures), Parkinson's (a progressive disorder that affects the nervous system), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Bipolar (a mental health condition that causes extreme mood swings that include emotional highs known as mania or hypomania and lows such as depression, Anxiety (a group of mental illnesses that cause constant fear and worry), and mixed receptive-expressive disorder (a communication disorder in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe). Record review of a Resident #1's quarterly MDS, dated [DATE], indicated a BIMS of 4, which indicated a severe cognitive impairment. Her bed mobility, transfer, dressing, eating, and personal hygiene functional status was 01, which indicated she required supervision for self-performance and support level for each was 01, which indicated setup help only. Record review of Resident #1's care plan, last reviewed/revised on 04/17/23, indicated she had a behavior of yelling and cussing at staff that started 04/13/23 and the approach was staff to calm and redirect resident when she became agitated. Record review of the facility event report, created 04/13/23, at 6:40 PM, by LVN I, stated Resident #1 attacked Medication Aide C. Record review of Resident #1's progress notes, printed 04/19/23, reflected no progress note, dated 04/13/23; no progress note documented the incident between Resident #1 and MA C Record review of Resident #2, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses which included fracture of the spine, and back pain. Record review of Resident #2 quarterly MDS, dated [DATE], revealed a BIMs of 15, which indicated the resident was cognitively intact. Record review of Resident #2's undated progress notes revealed no progress notes on 04/13/23 and no incident reports. During an interview on 04/19/23 at 4:00 pm with Resident #1 she began sobbing immediately and the DON arrived to comfort the resident, she was not interviewable. During an interview on 04/20/23 at 1:00 PM, MAINT B stated on 04/13/23 during a normal smoke break at 3:30 PM, Resident #1 was out of cigarettes and only had cigars. The resident got upset, stood up to staff and called her a fat bitch, Resident #1 was down the ramp a bit, he went to back her away the from road. MA C came in, numerous times Resident #1 stood up and MA C grabbed her by the pants and pulled her down. MA C grabbed Resident #1 by the head. MAINT B stated he froze up and walked away from situation, it diffused then he turned and saw the wheelchair at an angle with resident in it, almost tilted so Maint B went to Resident #1 and stabilized her wheelchair. MAINT B stated MA C said she could have used that rod in his hand a little while ago (during incident). Maint B told the ADON and DON immediately that Maint B witnessed MA C in a confrontation with Resident #1 because he was uncomfortable. MA C was sent home that day. He stated MA C went in and claimed Resident #1 scratched her and the Administrator leaned towards self defense. MA C said Resident #1 tried to burn her with a cigarette, Resident #1 was highly upset after the incident, asked them to call the cops and was crying. Even after the incident when everyone was back in the building, Resident #1 was screaming and hollering at MA C to get out. Resident #2, was very upset by the situation and told MAINT B that he needed to report it. During an interview on 04/20/23 at 1:30 PM with the DON, she stated MA C worked Saturday in the kitchen (after the incident with Resident #1 on Thursday (04/13/23) without contact with residents, then worked with residents on Monday as a medication aid, but due to new information MA C was then re-suspended Monday (04/17/23) evening at the end of her shift; she was originally suspended Thursday afternoon after the event (MA C abusing Resident #1) during the 3:30 PM smoke break. During an interview and observation on 04/20/23 at 1:55 PM with Resident #2, he stated Resident #1 was trying to go down the ramp in the smoking area and MA C grabbed her by the arm and they grappled. MA C grabbed Resident #1 by the head and twisted Resident #1's hair. Resident #1 hit her head on the bar by the ramp because she was upset with the situation. MA C made the MAINT B, who was out there at the time, leave (by upsetting him). Resident #1 was trying to go down the ramp. Resident #2 said he felt terrible about it (MA C abusing Resident #1), I couldn't do anything about it. He stated staff could put their hands on residents when they wanted and nothing happened (referring to staff being allowed to hit and grab residents abusively), he understood the resident had no choice when staff provided care. He stated Resident #1 was often crying constantly and no staff tried to comfort her or intervene with her (Resident #1 has behaviors of verbally crying and calling out, often tied to smoking). He stated the Adm won't listen to residents and always took the staff member's side (believed what staff said and ignored resident concerns). He was visibly upset when recounting the abuse of Resident #1 by MA C; his voice trembled and he got loud when he conveyed his frustration at not being able to intervene on behalf of Resident #1. He stated he felt helpless when he witnessed the abuse. During an interview on 04/20/23 at 2:22 PM, CNA K stated she did not witness the incident on Thursday (04/13/23), but was assigned to Resident #1's hall that day. Resident #1 was very upset and acted out a lot on Thursday (04/13/23) after the incident. She stated Resident #1 was upset, rocking back and forth and stated she wanted a cigarette and had other behaviors (crying often, hollering out) throughout the evening. During an interview on 04/20/23 at 2:24 PM with the DON, she stated MAINT B reported, around 3:45 PM, on Thursday (04/13/23), MA C tried to get Resident #1 to sit, and MA C could have had Resident #1 by the hair (DON said MANT B was not certain at that moment). The DON took MAINT B to the ADM. The ADM talked to MA C and got the DON, she said Resident #1 tried to burn MA C with a cigarette, was clawing at MA C, and MA C's ring may have caught in Resident #1's hair when she was defending herself from being burned by Resident #1. MA C was sent home at that time and ADM was investigating. During an interview on 04/20/23 at 3:00 PM with the ADM, she stated she talked to Maint B more about it on Monday which was when he said some things he did not mention on Thursday (04/13/23). MAINT B said Resident #1 was outside, upset, and went down the slope of the sidewalk. MA C grabbed Resident #1 by the pants and put her back in the chair, Resident #1 had got combative. MA C said to ADM that she tried to get Resident #1 to stop her from walking down the ramp. It was said Resident #1's hair was pulled, MA C denied pulling Resident #1's hair, MA C stated her ring may have gotten caught in it. The ADM stated she talked to Resident #1 on Thursday (04/13/23) around supper time, before 5 PM. There were no marks on Resident #1. MA C said she pulled the resident by the pants to get her to sit and not walk down the ramp. Resident #1 was fighting MA C; Resident #1 was angry that day. On Monday (04/17/23) MAINT B mentioned hair pulling, he wasn't sure what happened. CNA G came in and said something Monday (04/17/23), MA C was suspended in evening time. Staff were not trained to pull pants to get residents to sit down. The ADM said MA C had scratches on her and got them when she was trying to get Resident #1 to sit back down. MA C told her she did it because he did not want the resident to fall and it was the only way to keep her from falling. Resident #1 tried to burn her with her cigarette and the resident clawed MA C until she drew blood and almost knocked them both over. MA C was sent home Thursday, I thought it was the right thing to do at the time but she did not feel it was reportable at the time but she was investigating. In a confidential staff interview, staff stated one of the housekeepers came in and asked who they should report something to. Confidential Staff said Adm was in kitchen, notify DON. Confidential Staff member stated she went out smoke, a few residents were still outside, Resident #1 was upset and crying, Resident #1 was saying Mama that bitch pulled my hair, mama that bitch snatched me and she was telling that to LVN H. MA C said, she was tired of bringing them out to smoke because every time there was an issue with Resident #1. She was telling LVN H that, LVN H was trying to calm Resident #1. MA C said she was tired of it (Resident #1's behavior). Resident #1 said I'm tired of it too (MA C's arguing); arguing back and forth. MA C went closer to Resident #1. Resident #1 said again Mama she pulled my hair. MA C stated Resident #1 tried to burn her with a cigarette. Resident #1 jumped up from her wheelchair Resident #1 said Mama move I am going to whip that Bitch. The Confidential Staff member got between Resident #1 and MA C. MA C stated, yeah you scratched me, you had a hold of my arm, I bet you let go of my arm then Resident #1 got more upset. MA C said she was not going to allow the resident to hit her, and she was going to defend herself. The DON and ADON came out and grabbed Resident #1. Maint B had a stick in his hand, MA C said next time you need to let me have that (rod), Maint B said he had nothing to do with that and went back inside. MA C continued inflaming the other residents. Another resident offered her a cigarette (menthol), but MA C would not let the resident give Resident #1 a cigarette. MA C said she tried to burn her with a cigar. Confidential Staff stated what she witnessed verbal abuse of Resident #1 and mental abuse of Resident #1. She stated Resident #2 said that's wrong, she didn't have to do her like that, she was pulling her hair and everything. In a confidential staff interview staff stated she did not witness the incident but residents were upset and talked about it. After the incident on 04/13/23, staff was at the nurse's station and MA C sat down and said I am tired of this shit (said at the nurses station in front of staff and referring to Resident #1 having behaviors that revolved around smoking and MA C did not like taking Resident #1 out to smoke). Resident #1 arrived at the nurses station while that comment was said and Resident #1 tried to come into nursing station and said she (Resident #1) was going to get that bitch because she (MA C) pulled her hair. MAINT B calmed the resident down and took Resident #1 to the break room, got Resident #1 a soda, and Maint B pushed Resident #1 back to her room in her wheelchair. Confidential Staff stated that Maint B was supportive of Resident #1 and Resident #1 had a trusting relationship with Maint B; Maint B was often able to calm Resident #1. In a confidential resident interview of a resident stated resident was late to smoke on Thursday at the 3:30 PM smoke time, so they did not witness what occurred. However, they saw Resident #1 had MA C's arm behind her head. MA C was above Resident #1 and Resident #1 was in her wheelchair. She said she saw MA C put her hands on Resident #1's neck. In an interview on 04/21/23 at 4:35 PM, HK D via phone stated, she was out the entire time in the smoking area and Resident #1 was throwing a fit because she had no cigarettes, which was odd and it seemed her cigarettes were going missing, but there was a pack of donated cigars that were the size of cigarettes so Resident #1 was given one of those. Resident #1 called MA C a Fat Bitch and Resident #1 was going down the ramp (standing) and MA C moved several feet to where Resident #1 was and grabbed Resident #1 by her pants and pulled her down into her wheelchair twice. Resident #1 was upset and cussing, MA C pulled Resident #1's hair. MA C held Resident #1 in the chair for about 1 minute against Resident #1's will and was pulling the chair with Resident #1 in it toward the trash cans, still holding her down by the pant loop. Resident #1 was yelling you pulled my hair. She heard Resident #1 say she was going to call the police on MA C and MA C said they would take you (Resident #1) to jail. HK D went and told the ADON. She stated the ADM told HK D she should not say that she saw MA C pull Resident #1's hair if she spoke to the state. In an interview on 04/23/23 at 12:30 PM with MA C, she stated Resident #1 was upset there were no menthol cigarettes, in the can there were free cigars so she gave Resident #1 a cigar and lit it. Resident #1 started to cuss rant and [NAME] and she wanted another resident to give her a cigarette because she had menthol like Resident #1 liked. MA C stated she did not approve of a resident giving a cigarette to another resident. Resident #1 called her names we went further in the smoking area down the ramp she said no don't go further Resident #1 turned and slapped MA C. Resident #1 started to stand up he told her she had to sit because she had seizures and was not wearing her helmet. She grabbed her side to sit her down she had MA C's arm and was punching then reached out with the other hand to burn MA C. MA C stated she had a ring on her finger that was heart-shaped and it grabbed in the residents hair when she reached out so she didn't burn her with the cigar in her hand she got caught in the residents hair while she was trying to get her in her chair. A staff member from housekeeping got her up the ramp Resident #1 grabbed the rail to the ramp and dumped the trash can over. Resident #1 then calmed down and was fine it was all over a cigarette. A nurse came out, the DON or the ADON got her and took her back in she washed blood and stuff off of my arm. She was trying to stop her from burning herself. She did not want her disappearing She went inside and told the DON, and the administrator what happened. She took the residents out for the 11:00 AM smoke break on Monday. Resident #1 came up and apologized, said Mama, she am sorry and she told her she needed to control her temper. When the residents went out at 1:00 pm on Monday someone bought menthol cigarettes for Resident #1. MA C stated her last training on abuse was one month ago the facility did not train staff to touch residents or hold residents down by their pants. Resident #1 had fallen and hit her head in the past when she walked away when she got mad so she was protecting Resident #1. Around 6:55 PM, the DON went and said she was suspended again. She had my arm around her waist for 10 seconds each time and it happened twice during the incident. MAINT B got her to sit down. When asked if there was an incident when she and Resident #1 were back in the building on Thursday at the nurse's station she said Resident #1 screamed at her at the nurse's station, she walked off at the time Record review of the facility work schedule for 04/17/23 revealed MA C was scheduled to work from 7 AM to 7 PM on the 200 and 300 hall and her name was not crossed out for that shift. 2. Record review of Resident #4's, undated, face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, depression, and anemia (low red blood cell count). Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMs score of 4, which indicated the resident had severely impaired cognition. Resident #4 used a walker for mobility and she did not exhibit any behaviors of physical or verbal aggression toward others or self. Record review of Resident #4's care plan, last updated 04/10/23, revealed falls were a problem area, with a start date of 09/28/22, and showed she suffered a fall on 12/20/22 related to confusion and self-transfers. The care plan approach included call bell in reach and explain/encourage use and answer promptly; another approach was don't rush the resident. Record review of Resident #4's medical record, from her visit to the emergency roiagnom on [DATE] at 4:12 PM, revealed ambulance medical technicians relayed to the emergency room staff Resident #4 had a witnessed fall at a nursing home and a CNA told the resident to turn around and get her walker and the resident fell in her doorway. Resident #4 told EMS a black girl beat her up and pushed her into the wall, she tore me up. The record further revealed the resident complained of 10 out of 10 pain in her right shoulder; there was a small laceration to the right cheek and lip area. A chest x-ray revealed a right anterior shoulder dislocation which was confirmed by a shoulder x-ray. The facility contacted adult protective services (APS) and provided both versions of the incident. The resident was transferred from the local hospital to another hospital because her dislocated shoulder had attempted reduction (put back in socket), multiple times,. Record review of Resident #4's medical record, from hospital #2, revealed she was admitted on [DATE] and discharged [DATE]. Resident #4 was treated for a right shoulder dislocation, pain management and increased blood pressure. The resident had urinary retention that required placement of a foley catheter while in hospital #2. There were small abrasions and ecchymosis (bruising) to right lower lip and right cheek. Resident #4 told staff at hospital #2 a girl cursed at her, hit her with a heavy object, and pushed her to the ground where she fell on her right shoulder and hip. During an interview and observation on 04/19/23 at 10:20 AM with Resident #4's family member, family member stated that on the day of Resident #4's fall, 04/06/23, Resident #4 stated she was hit and then fell to the floor. Resident #4 suffered a dislocated shoulder, her teeth were chipped and face was bloody. The Family Member said Resident #4 had no history of claiming assault; but she kept saying she hit me in my face several days in a row, and she kept saying she was scared. Family Member subsequently had Resident #4 removed from the secure unit on the 300 hall to the 400 hall because Resident #4 kept expressing fear related to the 300 hall. During an interview on 4/19/23 at 11:57 AM, CNA A, who was at work at the time of this interview, she stated she was the only direct care staff on the secure unit when 2 residents set off the alarm by pushing the door, so she went intervene. CNA A stated Resident #4 was upset that Resident #9 had urinated and defecated in her room, so CNA cleaned it up and then the door alarm went off again. CNA A said Resident #4 was yelling at Resident #9, who was by the door that was alarming. CNA A told Resident #4 to please go get your walker, three times, then turned back to the door alarm and heard Resident #4 hit the ground. She saw Resident #4 with her arm behind her back, face first on floor; arm ended tucked up under her, she doesn't walk off without walker often, she was in room when she fell . During an interview on 04/24/23 at 3:00 PM with HK D, she stated she was on the secure unit at the time when Resident #4 fell . She heard CNA A yelling and cussing at the residents and she pulled out her phone and recorded the audio of what CNA A was saying at the time Resident #4 fell . She provided a copy of the recording to the State Surveyor, which revealed CNA A saying yo mama, yo mama, Senorita then yelling at Resident #4 you go away, and Resident #4 was heard quietly saying shut up, CNA A said you are a mean old lady and I will call the law, Resident #4 could be heard saying I I I will call the nurse, then CNA A said something inaudible and then said not your conversation (twice), go about your work then her voice got louder and she said go away, this is me and him talking not you, go away, then a creaking noise could be heard and 2 squeaks and a scream from Resident #4 as she fell and at least one male voice saying Oh, then staff saying oh shit and then footsteps and the alarm sounded for the door to bring help to the secure unit. HK D stated she felt the way and what CNA A was saying to Resident #4 was verbal abuse and HK D immediately took the recording and played it for DON, but no one else asked to hear it and no follow up was done In an interview on 04/26/23 at 1:27 pm with ADM she stated she was unaware of the audio recording of the verbal abuse of Resident #4 and that the DON did not inform her that HK D played an audio recording of verbal abuse by CNA A to Resident #4. She stated CNA A would be terminated immediately. She also stated she would report the allegation of abuse immediately. Record review of the facility's schedule revealed that CNA A worked on 4/16/23, 4/17/23, 4/18/23, 4/19/23, and 4/20/23. Record review of the facility's, undated, nursing home resident rights policy stated the resident has a right to be free from abuse, neglect, exploitation, and misappropriation of property. Record review of the facility's preventing resident abuse policy, revised in January 2011, revealed the facility will not condone any form of resident abuse or neglect. This was determined to be an Immediate Jeopardy (IJ) on 04/23/23 at 2:35 PM. The Administrator and the Regional Director of Operations were notified. The ADM was provided with the IJ template on 04/23/23 at 2:35 pm. The following Plan of Removal submitted by the facility was accepted on 04/25/23 at 4:40 PM: Impact Statement: F600- Abuse The facility failed to keep residents free from abuse resulting in the abuse of one resident. All residents have the potential to be affected. [Residents #1 and #2] were assessed by RN and support was provided as accepted, physician was notified of the deficiency on 4/23/23. There were no new orders obtained. The affected resident's responsible party was notified by Administrator of alleged deficiencies and a plan of correction. On 4/23/2023 the Administrator, Director of Nursing Assistant Director of Nursing, and Social Worker interviewed all residents in the facility to determine if any other residents were affected by this event or had any physical or psychosocial distress. No residents had any concerns regarding the identified citation of abuse. The interviews were completed on 4/24/23. Ad-Hoc Quality Assurance and Performance Improvement meeting was held on 4/23/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the deficiencies, Abuse prevention, abuse investigations, unexplained injuries, preventing abuse, protecting residents during abuse, identifying signs of abuse, reporting abuse to facility management, reporting resident to resident abuse, policy and procedure, and the plan for removal of immediacy. On 4/23/2023 the RDO completed 1:1 in-service on Abuse with the Administrator, Director of Nursing, and Assistant Director of Nursing. Starting on 4/23/2023, the facility leadership (Administrator, Director of Nursing, and Regional Director) will complete education with all staff on abuse, to ensure that each resident receives services consistent with the professional standards of practice, comprehensive person-centered care plan, and the resident's goals and preferences. The training was initiated on 4/23/2023 and will be completed on 4/24/2023. Staff will sign in for the in-service. If they are not able to attend in person, then the DON/designee will complete a 1 on 1 in-service due to having to complete the in-service via phone. Staff will be reminded of who the abuse coordinator is in the facility. Staff will not be allowed to work until they receive the training. RDO will verify the completion of the training and in servicing. The policy pertaining to Abuse was reviewed on 4/23/2023 by the NHA (Nursing Home Administrator), Director of Nursing, RDO (Regional Director of Operations), and Medical Director. No changes made to the abuse policy Starting on 4/23/2023, IDT (Interdisciplinary team), including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Activity Director, HR, and BOM will meet with all residents daily from Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any allegations of abuse arise for 4 weeks, then PRN. The findings will be brought up to the Administrator for further action within 24 hours if necessary. Grievances will be reviewed during the morning meetings with the Administrator and IDT team members for any follow-up needed. All grievances will be entered into the Grievance log by the Administrator starting 4/23/2023 and the investigation form will be filled out by the Administrator accordingly as an ongoing process. On 4/23/2023 the RDO will start reviewing the Grievance log and investigation forms weekly for four (4) weeks followed by monthly reviews after this will be ongoing. 4/23/2023 RDO will provide physical oversight at the facility weekly x4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance that the IDT team is meeting with the residents regarding their grievances or any alleged abuse by completing an audit of ten (10) residents per week for four (4) weeks. This was initiated on 4/24/2023. Any identified concern will be addressed within 24 hours and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI via phone meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 4/24/2023. The RDO will provide oversight of the Administrator to ensure that the items on the plan of removal are reviewed and completed for 2 months or until cleared of cited deficiencies. POR monitoring included the following: In an observation on 04/24/23 at 3:30 PM in the 200 hall walk through revealed no concerns. In an observation on 04/24/23 at 3:52 PM in the 300 hall secure unit revealed Staff interacting with residents appropriately. In an interview on 04/24/23 at 4:40 PM the COO stated MA C, the staff from the altercation incident, was terminated yesterday (04/23/23), once they completed their interviews with witnesses. There was additional information that had come to light so they made the decision to terminate her. Record review of in-service sheets, dated 04/23/23 and 04/24/23, revealed facility training of recognition of abuse, neglect and exploitation and reporting of events for all staff and administration. Record review on 05/19/23 of the sign-in sheets revealed 91 staff members had been in-serviced on abuse and 8 staff were trained via telephone. Record review of the sign-in sheet dated 04/23/23 for the Quality Assurance and Performance Improvement committee revealed that the RDO, ADM, DON, Medical Director, and ADON attended the meeting. Record review of in-service sheet dated 04/23/23 from 3:00 pm - 3:15 pm revealed one-on-one instruction related to abuse, neglect, and reporting provided by the RDO and signed by the DON and ADM; no mention of the ADON was documented on this form. In an interview on 05/19/23 at 4:45 pm ADM stated the one-on-one training with the RDO discussed the following topics: Abuse, types of abuse, when to report, abuse investigations, injuries of unknown, abuse prevention, protecting resident during abuse investigations, recognizing signs and symptoms of abuse/neglect, and reporting abuse to facility management. She confirmed the DON resigned 05/16/23. In an interview on 05/19/23 at 5:00 pm ADON stated the one-on-one training with the RDO discussed the follow topics: Abuse, types of abuse, when to report, abuse investigations, injuries of unknown origin, abuse prevention, protection of the resident during abuse investigations, recognizing signs and symptoms of abuse/neglect, and reporting abuse to facility management. Record review of the Termination Record dated 04/23/23 for MA C confirmed she was terminated on 04/23/23 and her last day worked was 04/17/23. Record review of the Employee Status List for the facility revealed MA C's name with a line drawn through it and term under Employee Status. Record review revealed safe survey for all resident at the facility has been completed. Further POR monitoring revealed: In an observation on 05/19/23 at 1:25 PM signage was posted on the facility entrance and hand sanitizer was available. The halls appeared neat, clean, and free of odor. All residents appeared neat and well groomed. In an interview on 05/19/23 at 1:55 with CNA L, she stated she has been working at the facility for 5 years and worked the 6am - 6pm shift and her job duties were grooming, shaving, showering and toileting residents. She stated she had not witnessed any abuse or neglect but stated she would stop it, then make sure the resident was safe then report to the abuse coordinator (ADM) or ADON. CNA L stated she had been in-serviced on abuse and neglect and gave the example of physical (hitting a resident) and verbal abuse (talk to resident in a mean tone or cursing a resident). In an interview on 05/19/23 at 2:00 pm with CNA M, she stated she had worked at the facility for 1 year and worked the 6am-6pm shift. CNA M stated that her job duties were to feed residents, showering residents, and keeping residents safe. She had not witnessed any abuse or neglect but stated she would stop the incident, make sure the resident was safe, and notify the abuse coordinator (ADM). CNA M stated she had been in-serviced on abuse and neglect and gave an example for physical abuse (hitting or pushing a resident) and verbal abuse (yelling at a resident or cursing at a resident). In an interview on 05/19/23 at 2:20 pm with CNA N, she stated she had worked at the facility for 5 years and worked the 6pm-6am shift. CNA N's job duties were to help residents with daily routines, and check and change residents. She had not witnessed any abuse or neglect but stated she would ensure the resident was safe then report the incident to the abuse coordinator (ADM), ADON or charge nurse. CNA N had been in-serviced on abuse and neglect, and she gave the example of physical (hitting a resident) and verbal abuse (yelling or screaming at a resident). In an interview on 05/19/23 at 2:30 pm with CNA O, she stated she had worked here for 2 years and worked the 6pm-6am shift. She stated her job duties were to change residents, assist with toileting, assisting residents in getting ready for bed and making sure the resident's needs are being met. CNA O had not witnessed any abuse or neglect but stated she would stop the incident, make sure the resident was safe, and immediately notify the abuse coordinator (ADM), ADON, or the charge nurse. CNA O gave examples of physical

Based on interview and record review the facility failed to ensure that, based on their comprehensive assessment, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for four residents (Residents #1,2,3,5,) of twenty-nine residents reviewed for quality of care. LVN A failed to ensure residents received treatment and care in accordance with professional standards of practice on 07/07/19, 07/08/19, 07/10/19 , and 07/11/19 when she allowed an [AGE] year old child, her daughter, to crush and mix residents' medications, respond to residents' request for assistance, pass ice water, be present in a resident's room during a medical procedure, and deliver over the counter pain medication to a resident who complained of pain. An Immediate Jeopardy (IJ) was identified on 07/13/19 at 8:51 P.M. While the IJ was removed on 07/14/19, the facility remained out of compliance at the severity level of potential harm that is more than minimal harm and at the scope of pattern because the facility was still monitoring the plan of removal. These failures could place residents at risk of a delay in receiving necessary care and services or not receiving care at all, receiving the wrong medication, or choking and/or aspiration from receiving the incorrect consistency of liquids, and could result in serious injury, harm, and a decline in condition. Findings included: 1. Review of Resident #1's comprehensive Minimum Data Set (MDS) assessment, dated 07/01/19 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and was not able to make daily decisions and required assistance with ADLs. Review of Resident #1's Nurses Notes revealed an entry dated 07/07/19 at 7:06 P.M. that indicated LVN A called the ambulance to send the resident to the emergency room . Review of Resident #1's physician's orders [REDACTED]. 2. Review of Resident #2's quarterly MDS assessment, dated 05/13/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. She required assist from staff for ADLs 3. Review of Resident #3's quarterly MDS assessment, dated 04/09/19, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. She was alert and oriented, cognitively intact, was able to make daily decisions, and did not have any long term or short-term memory deficits. She required assistance from the staff for ADLs. 4. Review of Resident #5's quarterly MDS assessment, dated 05/15/19, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was alert and oriented, cognitively intact, was able to make daily decisions and did not have long term or short-term memory deficits. He required assistance with ADLs. An interview on 07/13/19 at 3:00 P.M. with CNA Q revealed LVN A brought her [AGE] year-old child to work with her on 07/07/19, 07/08/19, 07/10/19, and 07/11/19. She stated LVN A allowed her [AGE] year old child to crush and pass medications to residents on hall 400. She observed on 07/10/19 at approximately 7:00 P.M.LVN A was on hall 400 passing medication when her 11-year daughter was at the nurse's station with a different medication cart crushing medications. She and CNA C observed the [AGE] year old child taking a pill from a plastic cup, putting it into a small plastic bag, crushing the medication, pouring the crushed medication back into the plastic cup, adding chocolate pudding to the medication, and mixing it all together. Then the child pushed the cart from the nurse's station toward Hall 400 with the medication in the cups on top of the cart. She said on 07/07/19 saw the child in Resident #1's room on hall 100, when paramedics were attending to her during a medical emergency. She said she had observed the [AGE] year old child answering residents' call lights and passing ice water to residents and she did not knock on the residents' doors before entering. She heard the child asking a staff member which bed Resident #3 was in when passing ice water. She said on 07/10 /19 CNA C notified the administrator via text message. She said the DON called and spoke with LVN A over the phone. When LVN A hung up, LVN A said can you believe someone took a picture of my daughter pushing the medication cart and sent it to the Administrator and said she was crushing and passing medications, answering call lights and passing ice water to residents CNA Q said LVN A said DON told her to watch her back. In an interview on 07/13/19 at 6:00 P.M. LVN A revealed she worked halls 100 and 400. She brought her [AGE] year-old child to work with her on 07/07/19, 07/08/19, 07/10/19 and 07/11/19. She stated she allowed the child to answer call lights and pass ice water to keep her busy. She also allowed her to be in Resident #1's room for education purposes on 07/07/19 while the paramedics were assessing, evaluating, and preparing the resident for transport to the hospital during a medical crisis. LVN A stated on 07/10/19 she allowed the child to sit on the foot of Resident #1's bed while the Intravenous Technician inserted a peripheral central catheter (PICC) line into the resident's arm. She stated she thought it would be educational. LVN A stated her daughter wanted to be a pediatric physician, and if her daughter couldn't handle seeing the procedure, she wouldn't spend money on college. LVN A stated she had instructed the child on the procedure to crush medications but denied allowing her to pass medication to residents. She stated she had permission from the DON to bring the child to work with her if she kept the child with her. When ask if she seen anything wrong with this, she stated NO, why don't you enlighten me. According to the U.S. National Library of Medicine a peripherally inserted central catheter (PICC) is a long, thin tube that goes into your body through a vein in your upper arm. The end of this catheter goes into a large vein near your heart. The U.S. National Library of Medicine indicated the following steps are taken to insert a PICC line: . Ultrasound pictures are used to choose the vein and guide the needle into your vein . The area where the needle is inserted is cleaned. You get a shot of medicine to numb your skin. This may sting for a moment. A needle is inserted, then a guide wire and the catheter. The guide wire and catheter are moved through your vein to the proper spot. During this process, the needle puncture site is made a little larger with a scalpel. One or two stitches close it up afterward . (accessed from https://medlineplus.gov/ency/patientinstructions/ 1.htm on 07/24/19) In an Interview on 07/13/19 at 5:45 P.M. the Administrator revealed she received a text message from CNA C on 07/10/19 around 7:30 P.M requesting the Administrator her to call her. The Administrator stated she texted her back, asked what was wrong. The Administrator stated CNA C replied that LVN A was allowing her [AGE] year old daughter to crush and pass medications on Hall 400. She stated that CNA C then sent a picture of LVN A's daughter pushing the medication cart. The Administrator said she forwarded the text message and the photo from CNA C to the DON, and then she called the DON. She stated the DON told her she had called the facility and informed LVN A that the child could not be in the facility and to send her home. The Administrator stated during her investigation on 07/13/19, after the surveyor entered the facility she was informed the child was back in the facility on 07/11/19, passing ice water and answering residents call lights, and was in Resident #1's room during a PICC line insertion and on 07/07/19 the child was in Resident #1's room while paramedics prepared the resident for emergency medical transport. The Administrator stated she did not investigate or follow up on 07/11/19, why the child had access to the medication cart and if she was crushing and passing medications. She said she should have followed -up with CNA C on 07/11/19 about the text message and photo she sent her on 07/10/19. She would have found out that the child was back in the facility on 07/11/19 and that LVN A was allowing the child to be in resident room while emergency care was being performed, and that she was passing ice water, answering call lights and the child had access to the medication and was pushing the medication cart. She stated LVN A would have been terminated before her next assignment on the 10-6 shift on 07/11/19. She said, she could not believe any professional nurse would bring a child to work while on duty. In an interview on 07/13/19 at 6:40 P.M. the DON revealed on 07/10/19 around 7:30 P.M. the Administrator forwarded her the text message from CNA C stating LVN A's [AGE] year-old child was at the facility crushing and passing medication on Hall 400. The DON stated she also received the picture of the [AGE] year old pushing the medication cart. The DON stated she called the facility around 7:40 P.M. and informed LVN A that the child could not be pushing the cart up and down the hall ways. The DON stated she informed LVN A the child needed to be sitting in a common area or the employee's break room, or LVN A needed to send the child home. The DON stated on 07/11/19 Resident #2's family member complained to her that a child was answering Resident #2's call light and passing ice water. The DON stated the family member reported Resident #2 was upset and did not want the child back in her room. The DON said during the facility's investigation on 07/13/19 she was told the child was back in the facility on 07/11/19, and that the [AGE] year old child was in the room during Resident #1's PICC insertion. The DON stated she did not investigate or follow up on the reason the child had access to the medications and medication carts, and she was crushing and passing medication. She was upset that LVN A was insubordinate by bringing her child back to work with her on 07/11/19 after she was told not to bring her to work. She stated she should have looked into the complaint when Resident #2's family member made the allegation of LVN A's daughter answering the call light, that LVN A would have been suspended on 07/11/19 and some of this would not have occurred. In an interview on 07/13/19 at 3:25 P.M. CNA C stated on 07/10/19 around 7:00 P.M. she observed LVN A's [AGE] year-old daughter standing at the medication cart at the nurse's station crushing residents' medications. She observed four plastic medication cups with pills in each cup on top of the medication cart. She observed the child take the pill from the cup, put it into a plastic bag, crush the medication, put the crushed medication back into the plastic cup, and then add chocolate pudding to the crushed medications and mix it together. Then the child pushed the medication cart toward hall 400. She stated she took a photo of the child pushing the medication cart down the hall. She texts a message to the Administrator on 07/10/19 around 7:30 PM to ask the Administrator to call her. The Administrator texted her asking what was wrong, and she texted the Administrator that LVN A was allowing her [AGE] year old daughter to crush and pass medication on hall 400. In an interview on 07/13/19 at 2:45 P.M. CNA F stated on 07/07/19 he was working on the hall 100 and saw LVN A 's daughter in the room when LVN A and the paramedics were attending to Resident #1 and getting her ready to transport to the hospital. In an interview on 07/13/19 at 3:35 P.M. CNA D worked on hall 100 stated she saw LVN A's daughter answering call lights and passing ice water to residents. She saw the child getting ice out of the ice chest. She asked her what she was doing, she stated, she was passing ice water to the residents. She did not inform the administrator or DON because she did not realize it was a problem. In an interview on 07/13/19 at 4:41 P.M. CNA E stated she observed LVN A handing Tylenol to her [AGE] year old daughter and telling her to go give it to a resident but could not recall the residents name. CNA E said she saw LVN A hand a cup of icy hot to her daughter and told her to take it to Resident #2. CNA E stated when she returned from her breaks the child informed her of which resident had called for assistance and what they needed. CNA E stated she and Resident #5 observed the child crushing medication at the nurse's station, and Resident#5 asked CNA E if the child should be crushing medications. CNA E told Resident #5, she guessed because LVN A was aware that child was crushing the medications. CNA E stated she did not report the child's or LVN A's actions to the DON or Administrator because the DON was aware of the [AGE] year old daughter was coming to work with LVN A. CNA E stated on 07/11/19 LVN A handed a blood pressure cuff to the child told her to put it back in the medication cart .Her daughter replied someone might take a photo again. LVN A grabbed the blood pressure cuff away from her daughter and threw it in the drawer of the cart. CNA E stated she felt like LVA A allowing her daughter to answer call lights was a HIPAA (Health Insurance Portability and Accountability Act) violation. In an interview on 07/13/19 at 3:45 P.M. Resident #5 stated he observed LVN A's daughter at the nurse's station take pills from a plastic cup, put the pills into a plastic bag, crush the pills, put the crushed pills back into the cup, and then add pudding to the cup and mix it together. Then she put the cup on the other side of the cart. In an interview on 07/13/19 at 4:10 P.M. Resident #2 stated she turned on her call light because she needed pain medication for her knee. Resident #2 stated LVN A's daughter came into her room and asked her what she needed. Resident #2 stated she told the child to go get her mother. Resident #2 stated LVN A came to the room and Resident #2 told LVN A she needed some pain medication for her knee. Resident #2 stated after her conversation with LVN A the daughter came back with a cup of salve. Resident #2 stated she refused to use it and told the child to have her mother come to the room. Resident #2 stated the daughter asked the resident if she needed help, and Resident #2 told the child if her mother didn't want to help her, she would do it herself. She said it made her angry and upset that a child was answering her call light when she needed the nurse. Resident #2 stated she told LVN A not to send her daughter back into her room, and that she did not want a child responding when she called when she needed for help. Resident #2 stated LVN A told her that the DON had given her permission for her daughter to be in the facility. In an interview on 07/13/19 at 4:20 P.M. Resident #3 stated LVN A's daughter had answered her call light and had brought her fresh ice water. Resident #3 stated she would rather have the regular staff answer her call light than a child. On 07/13 19 the Administrator provided a list of Residents residing in the facility with physicians' orders for thickened fluids or NPO. Review of Physician orders [REDACTED]. Resident #9's physician order [REDACTED]. nectar liquids Resident #10's physician order [REDACTED]. nectar liquids Resident #11's physician order [REDACTED]. nectar liquids Resident #13's physician order [REDACTED]. NPO Resident #14's physician order [REDACTED]. NPO Review of facility's policy Administering Medications, dated December 2012, reflected: Only persons licensed or permitted by this state to prepare, administer . may do so. Safety of Medication. No medications are kept on top of the cart. The Administrator and DON were notified on 07/13/19 at 8:51 P.M. that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 07/14/19 at 6:34 P.M. and included: 1.DON and Administrator were in serviced by Administor R on 07/14/19 at 10:00 am on Quality of Life related to child passing water /ice and answering call lights, HIPPA, Quality of Care related to minor child answering call lights, Medication safety related to minor child pushing medication carts and resident rights. 2. all staff on duty on 07/13/19 including LVN, RN, and CNA were in serviced by the DON and Administrator regarding not having anyone in the facility answering call lights or passing water unless they are an employee of the facility. 3. All staff on duty on 07/13/18 including LVN, RN, and CNA, Med Aid, Housekeeping staff, laundry staff, Maintenance and Management staff were in serviced on not allowing non staff members or staff members who are not licensed watching or participating in nursing care of residents, except for call lights and answer passing water based on the liquid consistency book at the nurse station. Only licensed nurses or med aids shall push med carts. Only licensed nurses and med aid are allowed to dispense medications, crush medications or deliver any type of ointments or creams to residents. 4. LVN, RN and CNA, Med Aid, Housekeeping staff, laundry staff, Maintenance and Management staff will be in serviced by the DON/designee on the above information before they take their assignment. Any staff who are on leave or vacation will be in serviced on the above before they take their assignment. 5. All alert and oriented residents will be reassured and given a form that no one will be answering call lights, passing ice water, watching care, or pushing med carts unless they are an employee of the facility. Families or guardians of non-alert residents /non interviewable residents are being notified on 07/14/19 and 07/15/19 if they see a non-employee providing any type of care or answering call lights they are to contact the Administrator or DON. 6. A sign was posted in the breakroom on 07/14/19 with a phone number to contact the Administrators if anyone is in the facility that is not an employee participating in residents care to include passing ice water, answering call lights, watching care and anything to do with medication safety and medication administration. 7. The Administrator/designee will ensure that there are no non-staff members providing care Monday thru Friday by having management team ask alert and oriented residents if any non-staff were participating in or providing care to them. Families of non-alert /interviewable residents will be contacted as well to ensure non-employees are not providing care /answering call lights. 8. The RN supervisor /designee will ensure that no non-staff providing care on Saturday and Sunday by making rounds and randomly asking alert and oriented residents and families of non-alert residents if any non-staff members had been watching or providing any care to them in the facility. 9. Charge Nurse at night and /or nurse aids will contact the Administrator if any employee brings a child to work. If at any time it is discovered that a child is in the facility on employee's shift and was not reported, both employees are subject to disciplinary action. 10. Facility in-serviced all staff on 07/14/19 that no child under the age of 16 are allowed in the facility while a staff member is working their assigned shift. 11. Volunteers will be in serviced prior to beginning their volunteer service on Abuse, Neglect ,and reporting requirements to the administrator and will know who the abuse coordinator is, HIPPA, and that they cannot provide any type of direct care to a resident or be present while any direct care is occurring and that their services will be limited to those involving activities ,completion date 07/15/19. 12. The Administrator/designee will also make random visits to the facility on e time weekly after regular business hours for 4 weeks to verify only staff members providing care for the residents. The management team and the RN supervisor will conduct audits daily for 1 week, weekly for 3 weeks then PRN. 13. A dietary list of liquid consistency will be posted at the nurses' station so that all facility employees will be aware of dietary requirements. 14. LVN A that allowed minor to pass water, answer call lights, and push medication cart has been suspended pending investigation and will be terminated no later than Wednesday, July 15,19. The facility's implementation of their Plan of Removal was verified through the following: Interviews on 07/14/19 at 3:00 PM with the Administrator and Director of Nurses revealed they were in-serviced on Quality of Life related to child passing water/ice and answering call lights, HIPAA as related to minor child/non-employees in room during any type of resident care, Quality of Care related to child answering call lights of residents, medication safety as minor child giving bio-freeze and resident Rights. Interviews on 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed RN G, LVN H Charge Nurses representing all shifts including week-ends were in serviced on only licensed staff were to access to the medications and medication cart, HIPAA related to privacy of residents, non-staff providing care such as answering call lights, passing ice water, and watching care The Administrators should be called immediately. If they observe anyone other than employees performing any of these activities, and it's not report both employees are subject to disciplinary action. Interviews 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed five CNA's representing all three shifts and week-ends (CNA I, CNA J, CNA K, CNA L, and CNA M) all were in serviced on HIPAA privacy, Non-staff answering call lights, passing ice water, watching care, and only licensed staff had access to the medications, medication cart. The Administrators should be called immediately if they observe anyone other than employees performing any of these activities. Interviews on 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed one Housekeeper N, one Dietary Manager O, one Staffing Coordinator P representing all three shifts and week-ends all had training on HIPAA, non-staff providing care such as answering call lights, passing ice water, watching care. Only licensed staff were to access to the medications, medication cart. The Administrator should be called immediately if they observe anyone other than employees performing any of these activities. Interviews 07/16/17 from 10:00 A.M. to 3:15 P.M. revealed four alert Residents (Residents #2, 3,6, and 7,) stated they did not see any children in the facility the last two days passing ice water, answering call lights and they were to notify the Administrator if anyone other than staff member was preforming any of these activities. In an interview on 07/13/19 at 9:30 P.M. the Administrator revealed she supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting, by going over all reports, attending care plan meetings. She understood the IJ occurred related to a child passing ice/water, answering call lights, child having access to medication and medication cart and medication safety. She stated the facility has put in place a policy and check off list for all volunteers and they will receive training on Abuse, and Neglect, reporting to her. She stated the facility also put in place a policy on children in the work place. In an interview on 07/13/19 at 9:00 P.M. the Director of Nurses stated she ensured the facility's policies and procedures were followed by reviewing reports such as the 24-hour report, incident and accident reports, and attending Care Plan meetings. She understood the IJ occurred related to a child passing ice/water, answering call lights, child having access to medication and medication cart and medication safety. Review of the facility's Volunteer Policy, instituted on 07/15/19, revealed all volunteers for the facility will be in-serviced on Abuse, Neglect, and Exploitation and reporting, and that the Administrator is the Abuse Coordinator. Volunteers will also be trained on HIPAA regulations, Resident Rights and what limitation they have in the facility regarding patient care, such as, but not limed to, assisting with ADLs, observing care or assisting with feeding. Review of the facility's Children at The Workplace policy, dated 07/15/19, reflected (Epic Nursing and Rehabilitation ) policy is that no child under the age of 16 is allowed to stay at the facility while the staff member is on duty. A child of an employee may come to the facility with a sitter or family member but may not stay the entire shift. While the Administrator was informed the IJ was removed on 07/14/19, the facility remained out of compliance at the severity level of no actual harm with a potential for more than minimal harm and at the scope of pattern because the facility was still monitoring the plan of removal.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals for 4 (Residents 1,2,3 and 5) of 29 residents reviewed for pharmacy services. 1. The Administrator failed to investigate and follow up on 07/10/19 when reported an unlicensed and untrained [AGE] year old child having access to the medication cart. 2. The Director of Nurses failed to investigate and follow up on 07/10/19 when reported an unlicensed and untrained [AGE] year old child having access to the medication cart. 3.LVN A failed to provide pharmacy services that ensure the accurate, acquiring and dispensing of drugs when she allowed her [AGE] year-old daughter to crush and mix medications, deliver over the counter medications (ointment and pain medications) to a resident who complained of pain. An Immediate Jeopardy (IJ) was identified on 07/13/19 at 8:51PM. While the IJ was removed on 07/14/19, the facility remained out of compliance at the severity level of potential harm that is more than minimal harm and at the scope of pattern because the facility was monitoring the plan of removal. This failure placed residents at risk of receiving incorrect doses of medications and/or receiving medications intended for other residents and not receiving full therapeutic benefits of prescribed medications. Findings included: 1. Review of Resident #1's comprehensive Minimum Data Set (MDS) assessment, dated 07/01/19 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and was not able to make daily decisions and required assistance with ADLs. Review of Resident #1's Nurses Notes revealed an entry dated 07/07/19 at 7:06 P.M. that indicated LVN A called the ambulance to send the resident to the emergency room . Review of Resident #1's physician's orders [REDACTED]. 2. Review of Resident #2's quarterly MDS assessment, dated 05/13/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. She required assist from staff for ADLs 3. Review of Resident #3's quarterly MDS assessment, dated 04/09/19, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. She was alert and oriented, cognitively intact, was able to make daily decisions, and did not have any long term or short-term memory deficits. She required assistance from the staff for ADLs. 4. Review of Resident #5's quarterly MDS assessment, dated 05/15/19, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was alert and oriented, cognitively intact, was able to make daily decisions and did not have long term or short-term memory deficits. He required assistance with ADLs. An interview on 07/13/19 at 3:00 P.M. with CNA Q revealed LVN A brought her [AGE] year-old child to work with her on 07/07/19, 07/08/19, 07/10/19, and 07/11/19. She stated LVN A allowed her [AGE] year old child to crush and pass medications to residents on hall 400. She observed on 07/10/19 at approximately 7:00 P.M.LVN A was on hall 400 passing medication when her 11-year daughter was at the nurse's station with a different medication cart crushing medications. She and CNA C observed the [AGE] year old child taking a pill from a plastic cup, putting it into a small plastic bag, crushing the medication, pouring the crushed medication back into the plastic cup, adding chocolate pudding to the medication, and mixing it all together. Then the child pushed the cart from the nurse's station toward Hall 400 with the medication in the cups on top of the cart. She said on 07/07/19 saw the child in Resident #1's room on hall 100, when paramedics were attending to her during a medical emergency. She said she had observed the [AGE] year old child answering residents' call lights and passing ice water to residents and she did not knock on the residents' doors before entering. She heard the child asking a staff member which bed Resident #3 was in when passing ice water. She said on 07/10 /19 CNA C notified the administrator via text message. She said the DON called and spoke with LVN A over the phone. When LVN A hung up, LVN A said can you believe someone took a picture of my daughter pushing the medication cart and sent it to the Administrator and said she was crushing and passing medications, answering call lights and passing ice water to residents CNA Q said LVN A said DON told her to watch her back. In an interview on 07/13/19 at 6:00 P.M. LVN A revealed she worked halls 100 and 400. She brought her [AGE] year-old child to work with her on 07/07/19, 07/08/19, 07/10/19 and 07/11/19. She stated she allowed the child to answer call lights and pass ice water to keep her busy. She also allowed her to be in Resident #1's room for education purposes on 07/07/19 while the paramedics were assessing, evaluating, and preparing the resident for transport to the hospital during a medical crisis. LVN A stated on 07/10/19 she allowed the child to sit on the foot of Resident #1's bed while the Intravenous Technician inserted a peripheral central catheter (PICC) line into the resident's arm. She stated she thought it would be educational. LVN A stated her daughter wanted to be a pediatric physician, and if her daughter couldn't handle seeing the procedure, she wouldn't spend money on college. LVN A stated she had instructed the child on the procedure to crush medications but denied allowing her to pass medication to residents. She stated she had permission from the DON to bring the child to work with her if she kept the child with her. When ask if she seen anything wrong with this, she stated NO, why don't you enlighten me. According to the U.S. National Library of Medicine a peripherally inserted central catheter (PICC) is a long, thin tube that goes into your body through a vein in your upper arm. The end of this catheter goes into a large vein near your heart. The U.S. National Library of Medicine indicated the following steps are taken to insert a PICC line: . Ultrasound pictures are used to choose the vein and guide the needle into your vein . The area where the needle is inserted is cleaned. You get a shot of medicine to numb your skin. This may sting for a moment. A needle is inserted, then a guide wire and the catheter. The guide wire and catheter are moved through your vein to the proper spot. During this process, the needle puncture site is made a little larger with a scalpel. One or two stitches close it up afterward . (accessed from https://medlineplus.gov/ency/patientinstructions/ 1.htm on 07/24/19) In an Interview on 07/13/19 at 5:45 P.M. the Administrator revealed she received a text message from CNA C on 07/10/19 around 7:30 P.M requesting the Administrator her to call her. The Administrator stated she texted her back, asked what was wrong. The Administrator stated CNA C replied that LVN A was allowing her [AGE] year old daughter to crush and pass medications on Hall 400. She stated that CNA C then sent a picture of LVN A's daughter pushing the medication cart. The Administrator said she forwarded the text message and the photo from CNA C to the DON, and then she called the DON. She stated the DON told her she had called the facility and informed LVN A that the child could not be in the facility and to send her home. The Administrator stated during her investigation on 07/13/19, after the surveyor entered the facility she was informed the child was back in the facility on 07/11/19, passing ice water and answering residents call lights, and was in Resident #1's room during a PICC line insertion and on 07/07/19 the child was in Resident #1's room while paramedics prepared the resident for emergency medical transport. The Administrator stated she did not investigate or follow up on 07/11/19, why the child had access to the medication cart and if she was crushing and passing medications. She said she should have followed -up with CNA C on 07/11/19 about the text message and photo she sent her on 07/10/19. She would have found out that the child was back in the facility on 07/11/19 and that LVN A was allowing the child to be in resident room while emergency care was being performed, and that she was passing ice water, answering call lights and the child had access to the medication and was pushing the medication cart. She stated LVN A would have been terminated before her next assignment on the 10-6 shift on 07/11/19. She said, she could not believe any professional nurse would bring a child to work while on duty. In an interview on 07/13/19 at 6:40 P.M. the DON revealed on 07/10/19 around 7:30 P.M. the Administrator forwarded her the text message from CNA C stating LVN A's [AGE] year-old child was at the facility crushing and passing medication on Hall 400. The DON stated she also received the picture of the [AGE] year old pushing the medication cart. The DON stated she called the facility around 7:40 P.M. and informed LVN A that the child could not be pushing the cart up and down the hall ways. The DON stated she informed LVN A the child needed to be sitting in a common area or the employee's break room, or LVN A needed to send the child home. The DON stated on 07/11/19 Resident #2's family member complained to her that a child was answering Resident #2's call light and passing ice water. The DON stated the family member reported Resident #2 was upset and did not want the child back in her room. The DON said during the facility's investigation on 07/13/19 she was told the child was back in the facility on 07/11/19, and that the [AGE] year old child was in the room during Resident #1's PICC insertion. The DON stated she did not investigate or follow up on the reason the child had access to the medications and medication carts, and she was crushing and passing medication. She was upset that LVN A was insubordinate by bringing her child back to work with her on 07/11/19 after she was told not to bring her to work. She stated she should have looked into the complaint when Resident #2's family member made the allegation of LVN A's daughter answering the call light, that LVN A would have been suspended on 07/11/19 and some of this would not have occurred. In an interview on 07/13/19 at 3:25 P.M. CNA C stated on 07/10/19 around 7:00 P.M. she observed LVN A's [AGE] year-old daughter standing at the medication cart at the nurse's station crushing residents' medications. She observed four plastic medication cups with pills in each cup on top of the medication cart. She observed the child take the pill from the cup, put it into a plastic bag, crush the medication, put the crushed medication back into the plastic cup, and then add chocolate pudding to the crushed medications and mix it together. Then the child pushed the medication cart toward hall 400. She stated she took a photo of the child pushing the medication cart down the hall. She texts a message to the Administrator on 07/10/19 around 7:30 PM to ask the Administrator to call her. The Administrator texted her asking what was wrong, and she texted the Administrator that VN A was allowing her [AGE] year old daughter to crush and pass medication on hall 400. In an interview on 07/13/19 at 2:45 P.M. CNA F stated on 07/07/19 he was working on the hall 100 and saw LVN A 's daughter in the room when LVN A and the paramedics were attending to Resident #1 and getting her ready to transport to the hospital. In an interview on 07/13/19 at 3:35 P.M. CNA D worked on hall 100 stated she saw LVN A's daughter answering call lights and passing ice water to residents. She saw the child getting ice out of the ice chest. She asked her what she was doing, she stated, she was passing ice water to the residents. She did not inform the administrator or DON because she did not realize it was a problem. In an interview on 07/13/19 at 4:41 P.M. CNA E stated she observed LVN A handing Tylenol to her [AGE] year old daughter and telling her to go give it to a resident but could not recall the residents name. CNA E said she saw LVN A hand a cup of icy hot to her daughter and told her to take it to Resident #2. CNA E stated when she returned from her breaks the child informed her of which resident had called for assistance and what they needed. CNA E stated she and Resident #5 observed the child crushing medication at the nurse's station, and Resident#5 asked CNA E if the child should be crushing medications. CNA E told Resident #5, she guessed because LVN A was aware that child was crushing the medications. CNA E stated she did not report the child's or LVN A's actions to the DON or Administrator because the DON was aware of the [AGE] year old daughter was coming to work with LVN A. CNA E stated on 07/11/19 LVN A handed a blood pressure cuff to the child told her to put it back in the medication cart .Her daughter replied someone might take a photo again. LVN A grabbed the blood pressure cuff away from her daughter and threw it in the drawer of the cart. CNA E stated she felt like LVA A allowing her daughter to answer call lights was a HIPAA (Health Insurance Portability and Accountability Act) violation. In an interview on 07/13/19 at 3:45 P.M. Resident #5 stated he observed LVN A's daughter at the nurse's station take pills from a plastic cup, put the pills into a plastic bag, crush the pills, put the crushed pills back into the cup, and then add pudding to the cup and mix it together. Then she put the cup on the other side of the cart. In an interview on 07/13/19 at 4:10 P.M. Resident #2 stated she turned on her call light because she needed pain medication for her knee. Resident #2 stated LVN A's daughter came into her room and asked her what she needed. Resident #2 stated she told the child to go get her mother. Resident #2 stated LVN A came to the room and Resident #2 told LVN A she needed some pain medication for her knee. Resident #2 stated after her conversation with LVN A the daughter came back with a cup of salve. Resident #2 stated she refused to use it and told the child to have her mother come to the room. Resident #2 stated the daughter asked the resident if she needed help, and Resident #2 told the child if her mother didn't want to help her, she would do it herself. She said it made her angry and upset that a child was answering her call light when she needed the nurse. Resident #2 stated she told LVN A not to send her daughter back into her room, and that she did not want a child responding when she called when she needed for help. Resident #2 stated LVN A told her that the DON had given her permission for her daughter to be in the facility. In an interview on 07/13/19 at 4:20 P.M. Resident #3 stated LVN A's daughter had answered her call light and had brought her fresh ice water. Resident #3 stated she would rather have the regular staff answer her call light than a child. On 07/13 19 the Administrator provided a list of Residents residing in the facility with physicians' orders for thickened fluids or NPO. Review of Physician orders [REDACTED]. Resident #9's physician order [REDACTED]. nectar liquids Resident #10's physician order [REDACTED]. nectar liquids Resident #11's physician order [REDACTED]. nectar liquids Resident #13's physician order [REDACTED]. NPO Resident #14's physician order [REDACTED]. NPO Review of facility's policy Administering Medications, dated December 2012, reflected: Only persons licensed or permitted by this state to prepare, administer . may do so. Safety of Medication. No medications are kept on top of the cart. The Administrator and DON were notified on 07/13/19 at 8:51 P.M. that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 07/14/19 at 6:34 P.M. and included: 1.DON and Administrator were in serviced by Administor R on 07/14/19 at 10:00 am on Quality of Life related to child passing water /ice and answering call lights, HIPPA, Quality of Care related to minor child answering call lights, Medication safety related to minor child pushing medication carts and resident rights. 2. all staff on duty on 07/13/19 including LVN, RN, and CNA were in serviced by the DON and Administrator regarding not having anyone in the facility answering call lights or passing water unless they are an employee of the facility. 3. All staff on duty on 07/13/18 including LVN, RN, and CNA, Med Aid, Housekeeping staff, laundry staff, Maintenance and Management staff were in serviced on not allowing non staff members or staff members who are not licensed watching or participating in nursing care of residents, except for call lights and answer passing water based on the liquid consistency book at the nurse station. Only licensed nurses or med aids shall push med carts. Only licensed nurses and med aid are allowed to dispense medications, crush medications or deliver any type of ointments or creams to residents. 4. LVN, RN and CNA, Med Aid, Housekeeping staff, laundry staff, Maintenance and Management staff will be in serviced by the DON/designee on the above information before they take their assignment. Any staff who are on leave or vacation will be in serviced on the above before they take their assignment. 5. All alert and oriented residents will be reassured and given a form that no one will be answering call lights, passing ice water, watching care, or pushing med carts unless they are an employee of the facility. Families or guardians of non-alert residents /non interviewable residents are being notified on 07/14/19 and 07/15/19 if they see a non-employee providing any type of care or answering call lights they are to contact the Administrator or DON. 6. A sign was posted in the breakroom on 07/14/19 with a phone number to contact the Administrators if anyone is in the facility that is not an employee participating in residents care to include passing ice water, answering call lights, watching care and anything to do with medication safety and medication administration. 7. The Administrator/designee will ensure that there are no non-staff members providing care Monday thru Friday by having management team ask alert and oriented residents if any non-staff were participating in or providing care to them. Families of non-alert /interviewable residents will be contacted as well to ensure non-employees are not providing care /answering call lights. 8. The RN supervisor /designee will ensure that no non-staff providing care on Saturday and Sunday by making rounds and randomly asking alert and oriented residents and families of non-alert residents if any non-staff members had been watching or providing any care to them in the facility. 9. Charge Nurse at night and /or nurse aids will contact the Administrator if any employee brings a child to work. If at any time it is discovered that a child is in the facility on employee's shift and was not reported, both employees are subject to disciplinary action. 10. Facility in-serviced all staff on 07/14/19 that no child under the age of 16 are allowed in the facility while a staff member is working their assigned shift. 11. Volunteers will be in serviced prior to beginning their volunteer service on Abuse, Neglect ,and reporting requirements to the administrator and will know who the abuse coordinator is, HIPPA, and that they cannot provide any type of direct care to a resident or be present while any direct care is occurring and that their services will be limited to those involving activities ,completion date 07/15/19. 12. The Administrator/designee will also make random visits to the facility on e time weekly after regular business hours for 4 weeks to verify only staff members providing care for the residents. The management team and the RN supervisor will conduct audits daily for 1 week, weekly for 3 weeks then PRN. 13. A dietary list of liquid consistency will be posted at the nurses' station so that all facility employees will be aware of dietary requirements. 14. LVN A that allowed minor to pass water, answer call lights, and push medication cart has been suspended pending investigation and will be terminated no later than Wednesday, July 15,19. The facility's implementation of their Plan of Removal was verified through the following: Interviews on 07/14/19 at 3:00 PM with the Administrator and Director of Nurses revealed they were in-serviced on Quality of Life related to child passing water/ice and answering call lights, HIPAA as related to minor child/non-employees in room during any type of resident care, Quality of Care related to child answering call lights of residents, medication safety as minor child giving bio-freeze and resident Rights. Interviews on 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed RN G, LVN H Charge Nurses representing all shifts including week-ends were in serviced on only licensed staff were to access to the medications and medication cart, HIPAA related to privacy of residents, non-staff providing care such as answering call lights, passing ice water, and watching care The Administrators should be called immediately. If they observe anyone other than employees performing any of these activities, and it's not report both employees are subject to disciplinary action. Interviews 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed five CNA's representing all three shifts and week-ends (CNA I, CNA J, CNA K, CNA L, and CNA M) all were in serviced on HIPAA privacy, Non-staff answering call lights, passing ice water, watching care, and only licensed staff had access to the medications, medication cart. The Administrators should be called immediately if they observe anyone other than employees performing any of these activities. Interviews on 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed one Housekeeper N, one Dietary Manager O, one Staffing Coordinator P representing all three shifts and week-ends all had training on HIPAA, non-staff providing care such as answering call lights, passing ice water, watching care. Only licensed staff were to access to the medications, medication cart. The Administrator should be called immediately if they observe anyone other than employees performing any of these activities. Interviews 07/16/17 from 10:00 A.M. to 3:15 P.M. revealed four alert Residents (Residents #2, 3,6, and 7,) stated they did not see any children in the facility the last two days passing ice water, answering call lights and they were to notify the Administrator if anyone other than staff member was preforming any of these activities. In an interview on 07/13/19 at 9:30 P.M. the Administrator revealed she supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting, by going over all reports, attending care plan meetings. She understood the IJ occurred related to a child passing ice/water, answering call lights, child having access to medication and medication cart and medication safety. She stated the facility has put in place a policy and check off list for all volunteers and they will receive training on Abuse, and Neglect, reporting to her. She stated the facility also put in place a policy on children in the work place. In an interview on 07/13/19 at 9:00 P.M. the Director of Nurses stated she ensured the facility's policies and procedures were followed by reviewing reports such as the 24-hour report, incident and accident reports, and attending Care Plan meetings. She understood the IJ occurred related to a child passing ice/water, answering call lights, child having access to medication and medication cart and medication safety. Review of the facility's Volunteer Policy, instituted on 07/15/19, revealed all volunteers for the facility will be in-serviced on Abuse, Neglect, and Exploitation and reporting, and that the Administrator is the Abuse Coordinator. Volunteers will also be trained on HIPAA regulations, Resident Rights and what limitation they have in the facility regarding patient care, such as, but not limed to, assisting with ADLs, observing care or assisting with feeding. Review of the facility's Children at The Workplace policy, dated 07/15/19, reflected (Epic Nursing and Rehabilitation) policy is that no child under the age of 16 is allowed to stay at the facility while the staff member is on duty. A child of an employee may come to the facility with a sitter or family member but may not stay the entire shift. While the Administrator was informed the IJ was removed on 07/14/19, the facility remained out of compliance at the severity level of no actual harm with a potential for more than minimal harm and at the scope of pattern because the facility was still monitoring the plan of removal.

Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resource effectively and efficiently to attain or maintain the highest practicable physical, mental and psychocoial well being for 4 (Residents #1,2,3,5) of 29 residents reviewed for administration. The Administrator failed to take immediate action in a matter when it was reported an unlicensed, untrained [AGE] year old child had access, crush and pass medications, and observe care which resulted in the child performing the acts on multiple occasions. An Immediate Jeopardy (IJ) was identified on 07/13/19 at 8:51 P.M. While the IJ was removed on 07/14/19, the facility remained out of compliance at the severity level of potential harm that is more than minimal harm and at the scope of pattern because the facility was still monitoring the plan of removal. These failures could place residents at risk of a delay in receiving necessary care and services or not receiving care at all, receiving the wrong medication, or chocking and/or aspiration from receiving the incorrect consistency of liquids, and could result in serious injury, harm, and a decline in condition. Findings included: 1. Review of Resident #1's comprehensive Minimum Data Set (MDS) assessment, dated 07/01/19 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and was not able to make daily decisions and required assistance with ADLs. Review of Resident #1's Nurses Notes revealed an entry dated 07/07/19 at 7:06 P.M. that indicated LVN A called the ambulance to send the resident to the emergency room . Review of Resident #1's physician's orders [REDACTED]. 2. Review of Resident #2's quarterly MDS assessment, dated 05/13/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. She required assist from staff for ADLs 3. Review of Resident #3's quarterly MDS assessment, dated 04/09/19, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her primary [DIAGNOSES REDACTED]. She was alert and oriented, cognitively intact, was able to make daily decisions, and did not have any long term or short-term memory deficits. She required assistance from the staff for ADLs. 4. Review of Resident #5's quarterly MDS assessment, dated 05/15/19, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was alert and oriented, cognitively intact, was able to make daily decisions and did not have long term or short-term memory deficits. He required assistance with ADLs. An interview on 07/13/19 at 3:00 P.M. with CNA Q revealed LVN A brought her [AGE] year-old child to work with her on 07/07/19, 07/08/19, 07/10/19, and 07/11/19. She stated LVN A allowed her [AGE] year old child to crush and pass medications to residents on hall 400. She observed on 07/10/19 at approximately 7:00 P.M.LVN A was on hall 400 passing medication when her 11-year daughter was at the nurse's station with a different medication cart crushing medications. She and CNA C observed the [AGE] year old child taking a pill from a plastic cup, putting it into a small plastic bag, crushing the medication, pouring the crushed medication back into the plastic cup, adding chocolate pudding to the medication, and mixing it all together. Then the child pushed the cart from the nurse's station toward Hall 400 with the medication in the cups on top of the cart. She said on 07/07/19 saw the child in Resident #1's room on hall 100, when paramedics were attending to her during a medical emergency. She said she had observed the [AGE] year old child answering residents' call lights and passing ice water to residents and she did not knock on the residents' doors before entering. She heard the child asking a staff member which bed Resident #3 was in when passing ice water. She said on 07/10 /19 CNA C notified the administrator via text message. She said the DON called and spoke with LVN A over the phone. When LVN A hung up, LVN A said can you believe someone took a picture of my daughter pushing the medication cart and sent it to the Administrator and said she was crushing and passing medications, answering call lights and passing ice water to residents CNA Q said LVN A said DON told her to watch her back. In an interview on 07/13/19 at 6:00 P.M. LVN A revealed she worked halls 100 and 400. She brought her [AGE] year-old child to work with her on 07/07/19, 07/08/19, 07/10/19 and 07/11/19. She stated she allowed the child to answer call lights and pass ice water to keep her busy. She also allowed her to be in Resident #1's room for education purposes on 07/07/19 while the paramedics were assessing, evaluating, and preparing the resident for transport to the hospital during a medical crisis. LVN A stated on 07/10/19 she allowed the child to sit on the foot of Resident #1's bed while the Intravenous Technician inserted a peripheral central catheter (PICC) line into the resident's arm. She stated she thought it would be educational. LVN A stated her daughter wanted to be a pediatric physician, and if her daughter couldn't handle seeing the procedure, she wouldn't spend money on college. LVN A stated she had instructed the child on the procedure to crush medications but denied allowing her to pass medication to residents. She stated she had permission from the DON to bring the child to work with her if she kept the child with her. When ask if she seen anything wrong with this, she stated NO, why don't you enlighten me. According to the U.S. National Library of Medicine a peripherally inserted central catheter (PICC) is a long, thin tube that goes into your body through a vein in your upper arm. The end of this catheter goes into a large vein near your heart. The U.S. National Library of Medicine indicated the following steps are taken to insert a PICC line: . Ultrasound pictures are used to choose the vein and guide the needle into your vein . The area where the needle is inserted is cleaned. You get a shot of medicine to numb your skin. This may sting for a moment. A needle is inserted, then a guide wire and the catheter. The guide wire and catheter are moved through your vein to the proper spot. During this process, the needle puncture site is made a little larger with a scalpel. One or two stitches close it up afterward . (accessed from https://medlineplus.gov/ency/patientinstructions/ 1.htm on 07/24/19) In an Interview on 07/13/19 at 5:45 P.M. the Administrator revealed she received a text message from CNA C on 07/10/19 around 7:30 P.M requesting the Administrator her to call her. The Administrator stated she texted her back, asked what was wrong. The Administrator stated CNA C replied that LVN A was allowing her [AGE] year old daughter to crush and pass medications on Hall 400. She stated that CNA C then sent a picture of LVN A's daughter pushing the medication cart. The Administrator said she forwarded the text message and the photo from CNA C to the DON, and then she called the DON. She stated the DON told her she had called the facility and informed LVN A that the child could not be in the facility and to send her home. The Administrator stated during her investigation on 07/13/19, after the surveyor entered the facility she was informed the child was back in the facility on 07/11/19, passing ice water and answering residents call lights, and was in Resident #1's room during a PICC line insertion and on 07/07/19 the child was in Resident #1's room while paramedics prepared the resident for emergency medical transport. The Administrator stated she did not investigate or follow up on 07/11/19, why the child had access to the medication cart and if she was crushing and passing medications. She said she should have followed -up with CNA C on 07/11/19 about the text message and photo she sent her on 07/10/19. She would have found out that the child was back in the facility on 07/11/19 and that LVN A was allowing the child to be in resident room while emergency care was being performed, and that she was passing ice water, answering call lights and the child had access to the medication and was pushing the medication cart. She stated LVN A would have been terminated before her next assignment on the 10-6 shift on 07/11/19. She said, she could not believe any professional nurse would bring a child to work while on duty. In an interview on 07/13/19 at 6:40 P.M. the DON revealed on 07/10/19 around 7:30 P.M. the Administrator forwarded her the text message from CNA C stating LVN A's [AGE] year-old child was at the facility crushing and passing medication on Hall 400. The DON stated she also received the picture of the [AGE] year old pushing the medication cart. The DON stated she called the facility around 7:40 P.M. and informed LVN A that the child could not be pushing the cart up and down the hall ways. The DON stated she informed LVN A the child needed to be sitting in a common area or the employee's break room, or LVN A needed to send the child home. The DON stated on 07/11/19 Resident #2's family member complained to her that a child was answering Resident #2's call light and passing ice water. The DON stated the family member reported Resident #2 was upset and did not want the child back in her room. The DON said during the facility's investigation on 07/13/19 she was told the child was back in the facility on 07/11/19, and that the [AGE] year old child was in the room during Resident #1's PICC insertion. The DON stated she did not investigate or follow up on the reason the child had access to the medications and medication carts, and she was crushing and passing medication. She was upset that LVN A was insubordinate by bringing her child back to work with her on 07/11/19 after she was told not to bring her to work. She stated she should have looked into the complaint when Resident #2's family member made the allegation of LVN A's daughter answering the call light, that LVN A would have been suspended on 07/11/19 and some of this would not have occurred. In an interview on 07/13/19 at 3:25 P.M. CNA C stated on 07/10/19 around 7:00 P.M. she observed LVN A's [AGE] year-old daughter standing at the medication cart at the nurse's station crushing residents' medications. She observed four plastic medication cups with pills in each cup on top of the medication cart. She observed the child take the pill from the cup, put it into a plastic bag, crush the medication, put the crushed medication back into the plastic cup, and then add chocolate pudding to the crushed medications and mix it together. Then the child pushed the medication cart toward hall 400. She stated she took a photo of the child pushing the medication cart down the hall. She texts a message to the Administrator on 07/10/19 around 7:30 PM to ask the Administrator to call her. The Administrator texted her asking what was wrong, and she texted the Administrator that VN A was allowing her [AGE] year old daughter to crush and pass medication on hall 400. In an interview on 07/13/19 at 2:45 P.M. CNA F stated on 07/07/19 he was working on the hall 100 and saw LVN A 's daughter in the room when LVN A and the paramedics were attending to Resident #1 and getting her ready to transport to the hospital. In an interview on 07/13/19 at 3:35 P.M. CNA D worked on hall 100 stated she saw LVN A's daughter answering call lights and passing ice water to residents. She saw the child getting ice out of the ice chest. She asked her what she was doing, she stated, she was passing ice water to the residents. She did not inform the administrator or DON because she did not realize it was a problem. In an interview on 07/13/19 at 4:41 P.M. CNA E stated she observed LVN A handing Tylenol to her [AGE] year old daughter and telling her to go give it to a resident but could not recall the residents name. CNA E said she saw LVN A hand a cup of icy hot to her daughter and told her to take it to Resident #2. CNA E stated when she returned from her breaks the child informed her of which resident had called for assistance and what they needed. CNA E stated she and Resident #5 observed the child crushing medication at the nurse's station, and Resident#5 asked CNA E if the child should be crushing medications. CNA E told Resident #5, she guessed because LVN A was aware that child was crushing the medications. CNA E stated she did not report the child's or LVN A's actions to the DON or Administrator because the DON was aware of the [AGE] year old daughter was coming to work with LVN A. CNA E stated on 07/11/19 LVN A handed a blood pressure cuff to the child told her to put it back in the medication cart .Her daughter replied someone might take a photo again. LVN A grabbed the blood pressure cuff away from her daughter and threw it in the drawer of the cart. CNA E stated she felt like LVA A allowing her daughter to answer call lights was a HIPAA (Health Insurance Portability and Accountability Act) violation. In an interview on 07/13/19 at 3:45 P.M. Resident #5 stated he observed LVN A's daughter at the nurse's station take pills from a plastic cup, put the pills into a plastic bag, crush the pills, put the crushed pills back into the cup, and then add pudding to the cup and mix it together. Then she put the cup on the other side of the cart. In an interview on 07/13/19 at 4:10 P.M. Resident #2 stated she turned on her call light because she needed pain medication for her knee. Resident #2 stated LVN A's daughter came into her room and asked her what she needed. Resident #2 stated she told the child to go get her mother. Resident #2 stated LVN A came to the room and Resident #2 told LVN A she needed some pain medication for her knee. Resident #2 stated after her conversation with LVN A the daughter came back with a cup of salve. Resident #2 stated she refused to use it and told the child to have her mother come to the room. Resident #2 stated the daughter asked the resident if she needed help, and Resident #2 told the child if her mother didn't want to help her, she would do it herself. She said it made her angry and upset that a child was answering her call light when she needed the nurse. Resident #2 stated she told LVN A not to send her daughter back into her room, and that she did not want a child responding when she called when she needed for help. Resident #2 stated LVN A told her that the DON had given her permission for her daughter to be in the facility. In an interview on 07/13/19 at 4:20 P.M. Resident #3 stated LVN A's daughter had answered her call light and had brought her fresh ice water. Resident #3 stated she would rather have the regular staff answer her call light than a child. On 07/13 19 the Administrator provided a list of Residents residing in the facility with physicians' orders for thickened fluids or NPO. Review of Physician orders [REDACTED]. Resident #9's physician order [REDACTED]. nectar liquids Resident #10's physician order [REDACTED]. nectar liquids Resident #11's physician order [REDACTED]. nectar liquids Resident #13's physician order [REDACTED]. NPO Resident #14's physician order [REDACTED]. NPO Review of facility's policy Administering Medications, dated December 2012, reflected: Only persons licensed or permitted by this state to prepare, administer . may do so. Safety of Medication. No medications are kept on top of the cart. The Administrator and DON were notified on 07/13/19 at 8:51 P.M. that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 07/14/19 at 6:34 P.M. and included: 1.DON and Administrator were in serviced Administor R on 07/14/19 at 10:00 am on Quality of Life related to child passing water /ice and answering call lights, HIPPA, Quality of Care related to minor child answering call lights, Medication safety related to minor child pushing medication carts and resident rights. 2. all staff on duty on 07/13/19 including LVN, RN, and CNA were in serviced by the DON and Administrator regarding not having anyone in the facility answering call lights or passing water unless they are an employee of the facility. 3. All staff on duty on 07/13/18 including LVN, RN, and CNA, Med Aid, Housekeeping staff, laundry staff, Maintenance and Management staff were in serviced on not allowing non staff members or staff members who are not licensed watching or participating in nursing care of residents, except for call lights and answer passing water based on the liquid consistency book at the nurse station. Only licensed nurses or med aids shall push med carts. Only licensed nurses and med aid are allowed to dispense medications, crush medications or deliver any type of ointments or creams to residents. 4. LVN, RN and CNA, Med Aid, Housekeeping staff, laundry staff, Maintenance and Management staff will be in serviced by the DON/designee on the above information before they take their assignment. Any staff who are on leave or vacation will be in serviced on the above before they take their assignment. 5. All alert and oriented residents will be reassured and given a form that no one will be answering call lights, passing ice water, watching care, or pushing med carts unless they are an employee of the facility. Families or guardians of non-alert residents /non interviewable residents are being notified on 07/14/19 and 07/15/19 if they see a non-employee providing any type of care or answering call lights they are to contact the Administrator or DON. 6. A sign was posted in the breakroom on 07/14/19 with a phone number to contact the Administrators if anyone is in the facility that is not an employee participating in residents care to include passing ice water, answering call lights, watching care and anything to do with medication safety and medication administration. 7. The Administrator/designee will ensure that there are no non-staff members providing care Monday thru Friday by having management team ask alert and oriented residents if any non-staff were participating in or providing care to them. Families of non-alert /interviewable residents will be contacted as well to ensure non-employees are not providing care /answering call lights. 8. The RN supervisor /designee will ensure that no non-staff providing care on Saturday and Sunday by making rounds and randomly asking alert and oriented residents and families of non-alert residents if any non-staff members had been watching or providing any care to them in the facility. 9. Charge Nurse at night and /or nurse aids will contact the Administrator if any employee brings a child to work. If at any time it is discovered that a child is in the facility on employee's shift and was not reported, both employees are subject to disciplinary action. 10. Facility in-serviced all staff on 07/14/19 that no child under the age of 16 are allowed in the facility while a staff member is working their assigned shift. 11. Volunteers will be in serviced prior to beginning their volunteer service on Abuse, Neglect ,and reporting requirements to the administrator and will know who the abuse coordinator is, HIPPA, and that they cannot provide any type of direct care to a resident or be present while any direct care is occurring and that their services will be limited to those involving activities ,completion date 07/15/19. 12. The Administrator/designee will also make random visits to the facility on e time weekly after regular business hours for 4 weeks to verify only staff members providing care for the residents. The management team and the RN supervisor will conduct audits daily for 1 week, weekly for 3 weeks then PRN. 13. A dietary list of liquid consistency will be posted at the nurses' station so that all facility employees will be aware of dietary requirements. 14. LVN A that allowed minor to pass water, answer call lights, and push medication cart has been suspended pending investigation and will be terminated no later than Wednesday, July 15,19. The facility's implementation of their Plan of Removal was verified through the following: Interviews on 07/14/19 at 3:00 PM with the Administrator and Director of Nurses revealed they were in-serviced on Quality of Life related to child passing water/ice and answering call lights, HIPAA as related to minor child/non-employees in room during any type of resident care, Quality of Care related to child answering call lights of residents, medication safety as minor child giving bio-freeze and resident Rights. Interviews on 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed RN G, LVN H Charge Nurses representing all shifts including week-ends were in serviced on only licensed staff were to access to the medications and medication cart, HIPAA related to privacy of residents, non-staff providing care such as answering call lights, passing ice water, and watching care The Administrators should be called immediately. If they observe anyone other than employees performing any of these activities, and it's not report both employees are subject to disciplinary action. Interviews 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed five CNA's representing all three shifts and week-ends (CNA I, CNA J, CNA K, CNA L, and CNA M) all were in serviced on HIPAA privacy, Non-staff answering call lights, passing ice water, watching care, and only licensed staff had access to the medications, medication cart. The Administrators should be called immediately if they observe anyone other than employees performing any of these activities. Interviews on 07/16/19 from 10:00 A.M. to 3:15 P.M. revealed one Housekeeper N, one Dietary Manager O, one Staffing Coordinator P representing all three shifts and week-ends all had training on HIPAA, non-staff providing care such as answering call lights, passing ice water, watching care. Only licensed staff were to access to the medications, medication cart. The Administrator should be called immediately if they observe anyone other than employees performing any of these activities. Interviews 07/16/17 from 10:00 A.M. to 3:15 P.M. revealed four alert Residents (Residents #2, 3,6, and 7,) stated they did not see any children in the facility the last two days passing ice water, answering call lights and they were to notify the Administrator if anyone other than staff member was preforming any of these activities. In an interview on 07/13/19 at 9:30 P.M. the Administrator revealed she supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting, by going over all reports, attending care plan meetings. She understood the IJ occurred related to a child passing ice/water, answering call lights, child having access to medication and medication cart and medication safety. She stated the facility has put in place a policy and check off list for all volunteers and they will receive training on Abuse, and Neglect, reporting to her. She stated the facility also put in place a policy on children in the work place. In an interview on 07/13/19 at 9:00 P.M. the Director of Nurses stated she ensured the facility's policies and procedures were followed by reviewing reports such as the 24-hour report, incident and accident reports, and attending Care Plan meetings. She understood the IJ occurred related to a child passing ice/water, answering call lights, child having access to medication and medication cart and medication safety. Review of the facility's Volunteer Policy, instituted on 07/15/19, revealed all volunteers for the facility will be in-serviced on Abuse, Neglect, and Exploitation and reporting, and that the Administrator is the Abuse Coordinator. Volunteers will also be trained on HIPAA regulations, Resident Rights and what limitation they have in the facility regarding patient care, such as, but not limed to, assisting with ADLs, observing care or assisting with feeding. Review of the facility's Children at The Workplace policy, dated 07/15/19, reflected (Epic Nursing and Rehabilitation ) policy is that no child under the age of 16 is allowed to stay at the facility while the staff member is on duty. A child of an employee may come to the facility with a sitter or family member but may not stay the entire shift. While the Administrator was informed the IJ was removed on 07/14/19, the facility remained out of compliance at the severity level of no actual harm with a potential for more than minimal harm and at the scope of pattern because the facility was still monitoring the plan of removal.

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 (Resident #1) of 3 reviewed for abuse. 1. The facility failed to protect residents by allowing CNA A, alleged perpetrator to work and have contact with residents after allegation of hitting Resident #1. The allegation was reported on 07/01/18, the CNA was not suspended until 07/03/18 and returned to work 07/07/18. CNA A continued to work and have contact with residents from 07/07/18 to 08/03/18 without monitoring by the facility to ensure that the residents were protected. 2. ADON W failed to report suspected abuse to the Administrator and DON after the alleged abuse of Resident #1 was reported to her by multiple staff. An Immediate Jeopardy (IJ) was identified on 07/19/18. While the IJ was removed on 08/07/18, 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 immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. This failure could affect 18 residents with behaviors on the secured unit. The findings included: Review of the Admission Record dated 07/03/18 for Resident #1 reflected an admission date of [DATE]. Review of the MDS assessment dated [DATE] for Resident #1 revealed he was severely impaired cognitively, with physical behaviors directed towards others e.g. hitting, kicking, pushing, scratching, and grabbing. Resident #1 had active [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 05/08/18 reflected Resident #1 resides in a secured unit due to wondering, elopement risk, and need for controlled environment. Resident #1 required staff assistance for all ADLs. The Resident displayed physically aggressive behavior at times with a history of hitting staff. Review of Progress Notes dated 07/01/18 at 5:26 PM, written by LVN E, reflected Resident #1 had sclera of left eye. No swelling or drainage noted. Wife aware of areas to face. At 4:05 PM LVN E documented during incontinent care today (07/01/18) redness noted to left cheek. Resident #1 continued to have combative episodes during ADL care. Review of Progress Notes dated 07/02/18 at 12:26 PM written by LVN G reflected incident to left eye. Redness and slight swelling noted to left eye. Review of Progress Notes dated 07/03/18 at 1:09 AM written by LVN F reflected incident to left eye. Bruising and slight swelling around left eye noted. Scratch to left cheek and bruise to the left side of resident's chin. Review of Progress Notes dated 07/04/18 1:22 PM (time entered written by LVN T) reflected LVN T assessed the bruise to Resident #1's left side of face at 6:30 AM There was no further documentation of the redness and bruising in any of the above progress notes. Observation of Resident #1's face on 07/11/18 at 12:00 PM revealed all his injuries had healed and there was no bruising noted. Interview on 07/11/18 at 10:26 AM with CNA B revealed when she and CNA A went to change Resident #1 on 07/01/18 The resident was being combative hit CNA A. She stated CNA A then hit the resident back. After CNA A hit Resident #1 CNA A yelled down the hall for LVN E. CNA B said she told LVN E that CNA A hit Resident #1 and LVN E did nothing. She stated when they left the room she also told the ADON W, the ADON who was on-call, about what happened. She stated she did not think to walk down the hall to get the Administrators telephone number. She stated on 07/03/18 she had a meeting with the Administrator over the phone. The DON, and both ADONs were in the office. She told them again that CNA A hit Resident #1. CNA B also wrote that in her statement on 07/03/18 after the meeting. Interview with CNA A on 07/12/18 at 3:40 PM stated she was helping CNA B change Resident #1 and Resident #1 swung at her and hit her on the chin and she fell back and bit her lip. She denied hitting Resident #1. She stated she was not aware the resident had a scratch or bruise on his face. She stated on 07/01/18 she worked a double shift. She stated she left the unit at 2:00 PM to work the hall and she worked the 100 hall until 7:00 PM. She stated she did not see CNA B scratch the resident's face when they were in the room together. She stated RN I came to her and asked her to write a statement about what she saw because the family said someone hit Resident #1. She stated this was about 5:30-6:00 PM on 07/01/18. She stated after she wrote her statement RN I did not say anything else to her and she went back working on the 100 hall. She stated if she knew somebody hit Resident #1 she would tell the nurse and call the abuse coordinator right away. Interview with Resident #1's Responsible Party on 07/11/18 at 3:21 PM stated she came in on Sunday 07/01/18 and saw Resident #1's face was all messed up. She stated LVN E told her she noticed it that morning. The family member stated LVN E told her it did not happen on her shift 6:00 AM-6:00 PM. The family member stated she knew the resident was hit but did not know what happened. She stated she overheard CNA C and CNA D talking about the incident in the hall and one of them said CNA A hit Resident #1. She stated when she brought it to LVN E's attention that Resident #1 had a blood shot left eye, bruising/redness around his left eye, under his eye and cheek bone was red, and a bruise so dark on his chin that she thought it was a marker LVN E had no explanation. She stated this all occurred on 07/01/18. She stated she was upset that no one called her about it. Interview with CNA D on 07/11/18 at 4:50 PM stated CNA C had asked her what happened to Resident #1's face when she got to work for the 2-10 shift. She told CNA C she did not know and that is when CNA C told her to go look at him. She stated when she looked at Resident #1's face he had a bruise near his mouth and his eye. She stated he looked like someone punched him in the eye and it did not look like a scratch at first. She stated the eye was red and turning to be like a bruise. She told CNA C that did not happen on her shift (10:00 PM-6:00 AM) the previous day. CNA D stated when Resident #1's Responsible Party came in that evening LVN E tried to tell her that it happened on the 10:00 PM-6:00 AM shift and CNA D told LVN E in front of the Responsible Party that information was a lie. Interview with LVN F on 07/11/18 at 2:00 PM stated he worked 07/02/18 and on the 24-hour report it said Resident #1 had a scratch on his cheek. He stated when he went back to check on Resident #1 he noticed Resident #1 had a black eye and a bruise on his jaw. He stated he thought he was following up on a scratch because that is what was written on the 24-hour report. That night Resident #1's family member came in and asked him what happened, and he told her he did not know because no one told him anything. He stated he was never told Resident #1 was hit but to him that was what it looked like, the resident was hit. Interview with LVN G on 07/11/18 at 2:15 PM stated she was aware of an incident with Resident #1 She stated she knew that the resident had an incident with two CNAs and the resident got scratched. She learned of the incident from LVN E, but she never got the full story she just knew it involved CNA A and CNA B. She stated when she worked on 07/02/18 she noticed Resident #1 had redness and swelling to his left eye. She stated at that time, she did not see a black eye, but later it became present. She was asked if it was the resident's eye or his cheek and she took her finger and pointed to her eye and circled the entire eye area that was red (bruised). She stated it was also red on is cheek bone area. Interview with resident #1's family member on 07/11/18 at 9:34 AM stated she found out about the incident when the Responsible Party visited Resident #1 at 5:00 PM on Sunday 07/01/18. The facility failed to contact her or the Responsible Party who visited to the facility twice a day. When the Responsible Party visited the resident, on 07/01/18, he had bruises on his chin and face. She stated there were scratches as well. When the Responsible Party asked what happened no one could tell her. When the family member arrived at the facility on 07/03/18 LVN F was on duty. She asked LVN F what happened, and he could not tell her what happened. She asked if an incident report was done. He stated it had just been noted that an incident had happened on 07/03/18. She stated she spent the night with Resident #1 that night. She stated on the Responsible Part's lunch break she and the Responsible Party met with the DON and the DON could not tell them what happened. The DON stated ADON W called the doctor, the DON, and the Administrator. The DON stated the incident report had not been entered due to training as they just started using a new computer system. When she asked for a hard copy of the report, the DON refused to give it to her because she was still investigating the incident. When she told the DON that if she did not get corporate or the Administrator on the phone right then, she was calling the state agency, the DON called Administration and the Administration did not know about the incident. On 07/04/18 she met with the Administrator and the Administrator told her she was sorry about the incident. The day they met the Administrator she stated she was there to discuss the scratch on the resident's face. She stated that did not sit well with her because the Administrator had gotten all the pictures of the bruising and to say it was only a scratch did not sit well with her. Reviewed family member personal cell phone on 07/20/18 revealed there were several pictures on the phone with the date and time the picture was taken. Picture dated 07/01/18 at 5:53 PM of Resident #1 revealed resident had a scratch on the left side of his face that went from his cheek bone to his mustache and his cheek was bruised. Resident's left eye was reddish purple. Picture dated 07/02/18 at 7:42 PM of Resident #1 (side view) lying down reflected Resident's left eye was reddish purple. Resident had a scratch on the left side of his cheek that went from his cheek bone to his mustache. Resident had a dark purple circular bruise on the left side of his chin. Picture dated 07/02/18 at 7:43 PM of Resident #1 (front View) lying down with two dark purple bruises on his chin. Resident's left cheek was swollen with reddish purple bruising. Resident's left eye was also bruised and red. Picture dated 07/03/18 at 11:04 AM of Resident #1 (front view) with a reddish/purple eye, a scratch on his cheek, and a bruise on resident's chin. Interview with the Administrator on 07/11/18 at 10:45 AM stated she learned about the incident on 07/03/18. The DON called her with Resident #1's family in the office. She stated prior to that none of the nurses had called her about an incident. She stated other than Resident #1 being combative and the resident hitting CNA A there was no incident. She stated CNA B never told them CNA A hit Resident #1 until 07/03/18. She stated there was an incident report done on 07/01/18 concerning Resident #1. She stated when she learned CNA A was alleged to hit Resident #1 she suspended both, CNA A and CNA B. When CNA B told her CNA A hit Resident #,1 she asked CNA B why she did not tell someone that day and CNA B told her she did not have the Administrator's number. She stated her number was kept in the CNA book at the nurse's station. She stated as far as she knew CNA B never told ADON W that CNA A hit Resident #1. She stated CNA B was terminated on 7/5/18 due to failure to report abuse. CNA B did not report the abuse that occurred on 07/01/18 until 07/03/18. The Administrator stated she reported the incident (to HHS) on 07/03/18 when she found out about the incident. Reviewed of the incident report dated 07/01/18 and revised on 07/03/18 revealed Resident #1 had redness to his left cheek under his eye on 07/01/18 at 10:30 AM. The incident report also reflected there were no post incident injuries observed, no witnesses found, and no one was notified of the injury. Interview with the Nurse Practitioner (NP) on 07/11/18 at 12:05 PM stated no one called her about injuries involving Resident #1. She stated all the information she got was from the Family Member. The Family Member told her it happened on Sunday (07/01/18). She stated she would not be on call on the weekend. She stated she saw resident on 07/04/18 and assessed his face and eye. She stated he had bruising on his eye and chin. The bruising on the resident's chin was circular and more purple. The bruise on the lower part of resident's eye was fading and was greenish in color. Interview with LVN H on 0712/18 at 12:30 PM stated RN I asked her to write a statement because something had happened, but she never said what. RN I told her it had to be investigated and they were trying to get a time line. She stated prior to her getting off work on 07/01/18 at 6:00 AM she helped CNA D change Resident #1 because he could be combative at times but on that night, he was not. She stated when she left the facility the resident did not have any injuries. She stated when she came back on Sunday at 6:00 PM CNA C told her that LVN E told Resident #1's family member that his injuries happened on the 10-6 shift. LVN H told CNA C that was not true because when she left the resident did not have any bruising or scratches. She stated she asked the medication aide what time she gave Resident #1 his medication and she said around 7:30-8:00 AM and the resident did not have any scratches or bruises. At that time CNA A walked up to her and said Resident #2 and Resident #3 were in Resident #1's room fighting over a cord. She stated she knew that was not true because they do not have cords in resident's room. She stated while she was talking to CNA A she noticed CNA A had a busted lip. CNA A told her that she busted her lip herself but did not say how. She stated CNA A did not know that she already heard that Resident #1 had hit her, and she had punched him. LVN H stated she then heard that CNA B scratched the resident and her nail ended up broken. LVN H stated when she came in LVN E told her Resident #1 had scratches on him, but she had not noticed it until the afternoon because he kept swinging his arms. She stated she was told that CNA A hit Resident #1, but she did not tell anyone. She was asked why she did not tell anyone and she said she heard the investigation had already started plus it was hearsay. LVN H was asked why she did not say anything to RN I, even though it was hearsay, and she stated she thought they already knew about it. Interview with the DON on 07/11/18 at 12:25 PM stated she first found out about the alleged abuse on 07/03/18 when CNA B made her statement that CNA A hit Resident #1. When she was notified Resident #1 was combative with the CNAs she told ADON W to get statements from all who were involved with the resident within that day. She stated the information she received was that CNA A and CNA B were in the room together and Resident #1 was combative. She was asked why the incident was reported, to HHS, late and the DON said the facility did not learn of the incident until 07/03/18 when CNA B made her statement. She was shown the facility self-report where it states on 07/02/18 the family informed staff that resident was hit by an employee. She again stated they did not learn about the incident until 07/03/18. She was asked how LVN H's statement written on 07/01/18 at 6:20 PM reflect that during incontinent care there were no scratches or bruising noted to the face of Resident #1 when an incident report was initiated on 07/01/18 at 10:30 AM for redness to left cheek under eye and nurses noted dated 07/01/18 at 4:05 PM reflected redness noted to left cheek. The DON stated maybe there was not enough light in the room and she did not see it. Interview with ADON W on 07/11/18 at 1:30 PM stated she was on call the weekend of (MONTH) 30-July 2, (YEAR). She stated she was not notified by staff that an employee hit Resident #1. She stated she found out about the abuse on 07/03/18 when CNA B wrote her statement. She stated at no time did CNA B tell her CNA A hit Resident #1 prior. She stated she did not see bruising around the eye where he could have been punched on 07/02/18. She stated she went back to the unit and there was a very small scratch on resident's cheek. On a subsequent interview with CNA D on 07/12/18 at 1:50 PM she stated she called ADON W on 07/01/18 because she was upset that LVN E was trying to say the injury happened on her shift. She stated at that time she told ADON W that she heard that CNA A had hit Resident #1. Interview with CNA C on 07/12/18 at 3:40 PM stated she came to work on 07/01/18 on the 2-10 shift Resident #1 was sitting in the hall and as she walked by Resident #1 looked up and CNA C said, Oh what happened to you? She asked LVN E what happened to Resident #1 and she said she did not know. She stated when she was clocking in CNA B was clocking out, and CNA B told her that CNA A hit Resident #1 twice in the face. She stated she went and told LVN E that one of the CNAs hit Resident #1. She stated LVN E told her that did not happen on her shift it must have happened on the 10-6 shift. She stated when CNA D came in she asked CNA D what happened to Resident #1 last night and she said nothing. She told CNA D to go look at him. She told CNA D that LVN E said it happened on the 10-6 shift. She stated CNA D was upset because LVN E was trying to say it happened on her shift, so CNA D called ADON W. She stated the next thing she knew RN I had called for them to come to the office for a statement. RN I told her ADON W said it was hearsay and she had nothing to do with it, so RN I sent her back to the unit. CNA C told LVN E she had better get it together because when Resident #1's wife got to the facility she will want to know what happened to her husband. CNA C stated if CNA D never called the ADON W to tell her Resident #1 had an accident and it looked like someone hit him the incident would have never been reported. Interview with LVN E on 07/12/18 at 10:50 PM stated on 07/01/18 she noticed a scratch on Resident #1's face. She stated she tried to look at the scratch, but she could not see it clearly because the resident kept swinging his arms. She stated she called ADON W to report the scratch. The residents spouse asked her what happened, and she stated she did not know. She stated when she first saw it she did not call the spouse because she did not want her to get upset about anything, so she did not talk to the spouse until she came to the facility. She stated she told the family member she was not aware of anything happening on the morning of 07/01/18. She stated CNA A never told her resident hit her, CNA A only told her she bit her lip. She stated she did not call ADON W because she did not have anything to report. She stated CNA D came in to work on the 6-2 shift on 07/01/18. She stated she had not seen Resident #1's eye swollen or any redness until resident's family member came in. On a subsequent interview with ADON W on 07/12/18 at 5:00 PM she stated she did not remember if she was called by CNA D on the weekend 07/01/18. She was asked again if CNA D had called her and she said she might have called and said something about the work schedule. She was asked again if CNA D called her concerning Resident #1 and ADON W said Oh yes now that you say that . She stated CNA D called her and told her LVN E told Resident #1's Responsible Party the injuries happened on the 2-10 shift and it did not. She stated she told CNA D the incident happened on the morning shift, so she did not know why LVN E would tell the residents family member anything different. She also denied that CNA D told her that CNA A had hit Resident #1. She stated she did not call RN I because from the information that she was given it was only a small scratch on resident's cheek. Interview with RN I on 07/16/18 at 9:17 AM stated she was the Weekend supervisor for 07/01/18. She stated she went back on the unit about four times on 07/01/18 and each time she went on the unit she asked LVN E if there was anything happening. She asked if LVN E had anything to report, any falls, accidents, behaviors and each time LVN E said no. She stated CNA A told her around dinner time, at 5-5:30 PM that Resident #1 had hit her on the chin and she fell back and bit her lip. She stated she talked to LVN E and she stated she was working on an incident report. She stated she got a call from the on-call supervisor, ADON W, stating that Resident #1's family member called about the resident's injury. She stated at that time she asked for statements from everyone that worked the unit on 07/01/18. She asked for just the facts and what they did with the resident that day. She never talked to Resident #1's Responsible Party. She stated CNA C came to her and said she heard that CNA A hit Resident #1. She stated she told CNA C that was hearsay because she was not working at that time. CNA C told her she wanted to make sure she told someone, so she did not get in trouble. She thanked CNA C and told her she would carry it higher. She stated she reported what CNA C told her to ADON W, the on-call supervisor. ADON W told her she would take care of it. RN I stated CNA B did not tell her or the ADON W directly that CNA A had hit Resident #1. She stated CNA C was not on that shift and was not in the building until the evening shift so what she told her was hearsay. She was asked when she gets a report of abuse what was she supposed to do according to facility policy and she said notify the abuse coordinator. She was asked if the policy stated the report had to come from an employee that was in the facility at the time of the alleged abuse and she said, no, she used her judgement. When asked about Resident #1's injuries she stated the injury was underneath his eye by the cheekbone. She stated she did not see a dark purple bruise on resident's chin. Interview with Medical Director on 07/20/18 at 10:15 AM revealed any events of bruising or falls he would get notified. He stated how he is notified depends on the injury. Skin tears/bruising went on a report/communication form. He stated he was at the facility on 07/13/18 and he was not made aware of any injuries with Resident #1. Review of daily staffing schedules revealed CNA A continued to work at the facility after the allegation of abuse was reported. Time sheet for CNA A reflected she worked 07/01/18 thru 07/03/18. Review of the statements written by CNA D dated 07/01/18 at 6:15 PM reflected Resident 1's injuries were not present at 5:30 AM when she and LVN H changed him on 07/01/18. Review of the statements written by CMA Q dated 07/01/18 reflected Resident #1 had no noted scratches or injuries on his face at 7:45 AM when he was given his medication. Review of the statements written by LVN E 07/01/18 with no time indicated revealed she observed and assessed redness to left cheek of Resident #1 at 11:30 AM she could not do a full assessment because resident was combative. Review of Resident #1's Medication Administration Record [REDACTED]. Review of the facility Provider Investigation Report revealed the incident was not reported to HHSC until 07/03/18 at 11:48 AM. In the Investigation summary the facility reported the family reported on Tuesday 07/02/18 that Resident #1 had been hit in the eye by a facility employee and the resident had a black eye. Interview with the Administrator on 07/19/18 at 4:00 PM revealed when she started the investigation on 07/03/18 it was on abuse. She stated she was not in the facility on 07/03/18 but on 07/04/18 she saw Resident #1 and he did not have a black eye. She stated she was in the facility on 07/02/18 but she did not see Resident #1. She stated it was not treated as abuse initially only a scratch. She stated CNA A was in-serviced when she returned to work but on an in-service dated 07/09/18 for abuse/neglect CNA A's name was not on the sign in sheet. She stated the family made the allegation of abuse about 9:30 AM on 07/03/18, and at that time she was not in the building she was at home. She stated on 07/03/18 she also talked to CNA B at about 10:00-10:15 AM, that was a conference call along with ADON W and DON. She stated after the meeting with the family and CNA B was when she started the investigation. She stated at that time both CNA A and B were suspended. She stated she delegated her abuse coordinator duties to the DON when she is not at the facility. She was asked would she expect her nurses to report the black eye, and she said no, because of how it happened. She stated the resident was scratched and the black eye came from that scratch. She stated she would expect a nurse to call her if a CNA came to them and said a CNA abused a resident. She felt it was appropriate for a CNA to go to the nurse and report abuse. She stated she did not care who called so long as the call was made. She was asked if there was any reason why two different CNAs and a nurse would say they called the ADON W when they had not. She stated she had no idea why a CNA or a nurse would say they called the ADON W and they did not unless they did not like ADON W. She stated the nurses that worked the weekend stated they had no reason to report abuse. She stated if a CNA said abuse happened regardless if the CNA was in the building or not she would investigate. The statements written on 07/01/18 was about the scratch. There was only one statement written on the abuse allegation because there was only one person that alleged the abuse and that was CNA B. She stated her investigation consisted of an interview with the family who was the reporter and a statement from CNA B. She stated she did not document anything from the interview with the family. She stated the only statement from CNA A was on 07/01/18 and that was concerning the scratch not the abuse allegation. She stated when CNA A came back to work she was told if she saw or heard of any abuse she was to report or if she had trouble with other staff she was to report it. She stated CNA A had been working on the 100 hall. CNA A had not had any follow-up meetings with CNA A nor had she had any further concerns. Interview with the DON on 07/19/18 at 5:29 PM revealed the staff knew that if there was an allegation of abuse and there is an alleged perpetrator (AP) the AP is suspended until the investigation is completed. If unfounded they bring the AP back, but they do not bring the AP back to the unit. CNA A was put on the 100 hall. they monitor CNA A in the hall and watch the residents to ensure they are cared for. She stated they monitor CNA A as they would any other staff as well as the residents. She stated she monitored for signs of burnout or if they need help talk to the CNA. She stated she would monitor their residents more closely for skin tears or injury that had not occurred. She stated if she though staff were abusing a resident they would not be working at the facility. She stated after she met with the family it was about 11:30-11:45 AM then she met with CNA B. After the meeting both CNAs were suspended. She was asked once when the family notified her about the staff hitting the resident why the investigation did not switch to an abuse investigation and she said it did. She was asked what interviews were conducted after the investigation went from a scratch to abuse. She stated she spoke with CNA A again, but she did not document it because she had her statement from 07/01/18. She stated there were no additional interviews once the investigation turned to an abuse investigation she just used the statements from the 07/01/18 that pertained to the scratch assuming that is how they injury occurred. She stated when she was told by the family about the abuse to Resident #1 she still went down the road of a scratch. She stated they would have done the same thing either way. She did not feel she needed another statement from staff about the abuse. She stated outside of the statements she got on 07/01/18 there were no other statements to get. She stated all she saw was a scratch and redness on 07/02/18, there were no bruising or swelling other than the scratched area. She was asked what she would expect her nurses to do and she stated she would expect the nurse to report it if they looked at the resident and thought the resident was hit. She stated all the staff know to call her and she answers the phone. She stated the staff know to report everything but if they did not than that is another problem. When the family made her aware that the resident had a black eye the only person that looked at resident was LVN G who was assigned to that hall. She stated she was physically in the building and she did not go look at Resident #1 on 07/03/18 when the abuse was reported. Review of the undated facility abuse policy reflected it is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process .when an abuse identifies a perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility pending outcome of the investigation The administrator or his/her designee will report this allegation of abuse within 2 hours to the state agency (HHSC) and the proper local authorities The administrator was notified that an Immediate Jeopardy (IJ) was identified on 07/19/18 at 2:45 PM. On 08/03/18 the facility was notified the Immediate Jeopardy (IJ) still existed because the alleged perpetrator was still working at the facility. There was no evidence CNA A had been monitored while working at the facility since the 07/19/18 visit. The Plan of Removal reflected the following: .The notification of the alleged immediate jeopardy states as follows: 1. Failure to act on an abuse allegation immediately (reporting) 2. Break in the system leaving the resident at risk for the potential of further abuse 3. Clear evidence of thorough investigation The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: a. Facility administrator will begin education for facility staff to include RNs, LVNs, CNAs, CMAs, department heads, dietary, and housekeeping staff on the definition of abuse and neglect and the different types of abuse. The education will also include the reporting of any allegation of abuse or neglect to the abuse prevention coordinator immediately. The abuse prevention coordinator's phone number is posted in the facility. If the abuse prevention coordinator/administrator, is not immediately available then notification will be made to the director of nursing or the next available in charge. INITIATED: 7.19.18- TO BE COMPLETED: 7.20.18. b. Facility administrator, suspended, until further notice/investigation completion, ADON W, on 7.19.18. as it was alleged that she was made aware of an abuse allegation but did not report it to the abuse coordinator immediately and did not protect the resident. ADON W, returned to work on 7/21/18 after receiving abuse in-service and a written disciplinary action. ADON W, was re-suspended on 8.3.18. until further notice/investigation completion. CNA A was suspended on (MONTH) 3,2018 at and did not return to work until (MONTH) 7, (YEAR). CNA B was suspended on (MONTH) 3, (YEAR) and was terminated on (MONTH) 5, 2

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents for 1 (Resident #1) of 3 reviewed for abuse. 1. The facility failed to protect residents by allowing CNA A, alleged perpetrator to work and have contact with residents after allegation of hitting Resident #1. The allegation was reported on 07/01/18, the CNA was not suspended until 07/03/18 and returned to work 07/07/18. CNA A continued to work and have contact with residents from 07/07/18 to 08/03/18 without monitoring by the facility to ensure that the residents were protected. 2. ADON W failed to report suspected abuse to the Administrator and DON after the alleged abuse of Resident #1 was reported to her by multiple staff. An Immediate Jeopardy (IJ) was identified on 07/19/18. While the IJ was removed on 08/07/18, 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 immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. This failure could affect 18 residents with behaviors on the secured unit. The findings included: Review of the Admission Record dated 07/03/18 for Resident #1 reflected an admission date of [DATE]. Review of the MDS assessment dated [DATE] for Resident #1 revealed he was severely impaired cognitively, with physical behaviors directed towards others e.g. hitting, kicking, pushing, scratching, and grabbing. Resident #1 had active [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 05/08/18 reflected Resident #1 resides in a secured unit due to wondering, elopement risk, and need for controlled environment. Resident #1 required staff assistance for all ADLs. The Resident displayed physically aggressive behavior at times with a history of hitting staff. Review of Progress Notes dated 07/01/18 at 5:26 PM, written by LVN E, reflected Resident #1 had sclera of left eye. No swelling or drainage noted. Wife aware of areas to face. At 4:05 PM LVN E documented during incontinent care today (07/01/18) redness noted to left cheek. Resident #1 continued to have combative episodes during ADL care. Review of Progress Notes dated 07/02/18 at 12:26 PM written by LVN G reflected incident to left eye. Redness and slight swelling noted to left eye. Review of Progress Notes dated 07/03/18 at 1:09 AM written by LVN F reflected incident to left eye. Bruising and slight swelling around left eye noted. Scratch to left cheek and bruise to the left side of resident's chin. Review of Progress Notes dated 07/04/18 1:22 PM (time entered written by LVN T) reflected LVN T assessed the bruise to Resident #1's left side of face at 6:30 AM There was no further documentation of the redness and bruising in any of the above progress notes. Observation of Resident #1's face on 07/11/18 at 12:00 PM revealed all his injuries had healed and there was no bruising noted. Interview on 07/11/18 at 10:26 AM with CNA B revealed when she and CNA A went to change Resident #1 on 07/01/18 The resident was being combative hit CNA A. She stated CNA A then hit the resident back. After CNA A hit Resident #1 CNA A yelled down the hall for LVN E. CNA B said she told LVN E that CNA A hit Resident #1 and LVN E did nothing. She stated when they left the room she also told the ADON W, the ADON who was on-call, about what happened. She stated she did not think to walk down the hall to get the Administrators telephone number. She stated on 07/03/18 she had a meeting with the Administrator over the phone. The DON, and both ADONs were in the office. She told them again that CNA A hit Resident #1. CNA B also wrote that in her statement on 07/03/18 after the meeting. Interview with CNA A on 07/12/18 at 3:40 PM stated she was helping CNA B change Resident #1 and Resident #1 swung at her and hit her on the chin and she fell back and bit her lip. She denied hitting Resident #1. She stated she was not aware the resident had a scratch or bruise on his face. She stated on 07/01/18 she worked a double shift. She stated she left the unit at 2:00 PM to work the hall and she worked the 100 hall until 7:00 PM. She stated she did not see CNA B scratch the resident's face when they were in the room together. She stated RN I came to her and asked her to write a statement about what she saw because the family said someone hit Resident #1. She stated this was about 5:30-6:00 PM on 07/01/18. She stated after she wrote her statement RN I did not say anything else to her and she went back working on the 100 hall. She stated if she knew somebody hit Resident #1 she would tell the nurse and call the abuse coordinator right away. Interview with Resident #1's Responsible Party on 07/11/18 at 3:21 PM stated she came in on Sunday 07/01/18 and saw Resident #1's face was all messed up. She stated LVN E told her she noticed it that morning. The family member stated LVN E told her it did not happen on her shift 6:00 AM-6:00 PM. The family member stated she knew the resident was hit but did not know what happened. She stated she overheard CNA C and CNA D talking about the incident in the hall and one of them said CNA A hit Resident #1. She stated when she brought it to LVN E's attention that Resident #1 had a blood shot left eye, bruising/redness around his left eye, under his eye and cheek bone was red, and a bruise so dark on his chin that she thought it was a marker LVN E had no explanation. She stated this all occurred on 07/01/18. She stated she was upset that no one called her about it. Interview with CNA D on 07/11/18 at 4:50 PM stated CNA C had asked her what happened to Resident #1's face when she got to work for the 2-10 shift. She told CNA C she did not know and that is when CNA C told her to go look at him. She stated when she looked at Resident #1's face he had a bruise near his mouth and his eye. She stated he looked like someone punched him in the eye and it did not look like a scratch at first. She stated the eye was red and turning to be like a bruise. She told CNA C that did not happen on her shift (10:00 PM-6:00 AM) the previous day. CNA D stated when Resident #1's Responsible Party came in that evening LVN E tried to tell her that it happened on the 10:00 PM-6:00 AM shift and CNA D told LVN E in front of the Responsible Party that information was a lie. Interview with LVN F on 07/11/18 at 2:00 PM stated he worked 07/02/18 and on the 24-hour report it said Resident #1 had a scratch on his cheek. He stated when he went back to check on Resident #1 he noticed Resident #1 had a black eye and a bruise on his jaw. He stated he thought he was following up on a scratch because that is what was written on the 24-hour report. That night Resident #1's family member came in and asked him what happened, and he told her he did not know because no one told him anything. He stated he was never told Resident #1 was hit but to him that was what it looked like, the resident was hit. Interview with LVN G on 07/11/18 at 2:15 PM stated she was aware of an incident with Resident #1 She stated she knew that the resident had an incident with two CNAs and the resident got scratched. She learned of the incident from LVN E, but she never got the full story she just knew it involved CNA A and CNA B. She stated when she worked on 07/02/18 she noticed Resident #1 had redness and swelling to his left eye. She stated at that time, she did not see a black eye, but later it became present. She was asked if it was the resident's eye or his cheek and she took her finger and pointed to her eye and circled the entire eye area that was red (bruised). She stated it was also red on is cheek bone area. Interview with resident #1's family member on 07/11/18 at 9:34 AM stated she found out about the incident when the Responsible Party visited Resident #1 at 5:00 PM on Sunday 07/01/18. The facility failed to contact her or the Responsible Party who visited to the facility twice a day. When the Responsible Party visited the resident, on 07/01/18, he had bruises on his chin and face. She stated there were scratches as well. When the Responsible Party asked what happened no one could tell her. When the family member arrived at the facility on 07/03/18 LVN F was on duty. She asked LVN F what happened, and he could not tell her what happened. She asked if an incident report was done. He stated it had just been noted that an incident had happened on 07/03/18. She stated she spent the night with Resident #1 that night. She stated on the Responsible Part's lunch break she and the Responsible Party met with the DON and the DON could not tell them what happened. The DON stated ADON W called the doctor, the DON, and the Administrator. The DON stated the incident report had not been entered due to training as they just started using a new computer system. When she asked for a hard copy of the report, the DON refused to give it to her because she was still investigating the incident. When she told the DON that if she did not get corporate or the Administrator on the phone right then, she was calling the state agency, the DON called Administration and the Administration did not know about the incident. On 07/04/18 she met with the Administrator and the Administrator told her she was sorry about the incident. The day they met the Administrator she stated she was there to discuss the scratch on the resident's face. She stated that did not sit well with her because the Administrator had gotten all the pictures of the bruising and to say it was only a scratch did not sit well with her. Reviewed family member personal cell phone on 07/20/18 revealed there were several pictures on the phone with the date and time the picture was taken. Picture dated 07/01/18 at 5:53 PM of Resident #1 revealed resident had a scratch on the left side of his face that went from his cheek bone to his mustache and his cheek was bruised. Resident's left eye was reddish purple. Picture dated 07/02/18 at 7:42 PM of Resident #1 (side view) lying down reflected Resident's left eye was reddish purple. Resident had a scratch on the left side of his cheek that went from his cheek bone to his mustache. Resident had a dark purple circular bruise on the left side of his chin. Picture dated 07/02/18 at 7:43 PM of Resident #1 (front View) lying down with two dark purple bruises on his chin. Resident's left cheek was swollen with reddish purple bruising. Resident's left eye was also bruised and red. Picture dated 07/03/18 at 11:04 AM of Resident #1 (front view) with a reddish/purple eye, a scratch on his cheek, and a bruise on resident's chin. Interview with the Administrator on 07/11/18 at 10:45 AM stated she learned about the incident on 07/03/18. The DON called her with Resident #1's family in the office. She stated prior to that none of the nurses had called her about an incident. She stated other than Resident #1 being combative and the resident hitting CNA A there was no incident. She stated CNA B never told them CNA A hit Resident #1 until 07/03/18. She stated there was an incident report done on 07/01/18 concerning Resident #1. She stated when she learned CNA A was alleged to hit Resident #1 she suspended both, CNA A and CNA B. When CNA B told her CNA A hit Resident #,1 she asked CNA B why she did not tell someone that day and CNA B told her she did not have the Administrator's number. She stated her number was kept in the CNA book at the nurse's station. She stated as far as she knew CNA B never told ADON W that CNA A hit Resident #1. She stated CNA B was terminated on 7/5/18 due to failure to report abuse. CNA B did not report the abuse that occurred on 07/01/18 until 07/03/18. The Administrator stated she reported the incident (to HHS) on 07/03/18 when she found out about the incident. Reviewed of the incident report dated 07/01/18 and revised on 07/03/18 revealed Resident #1 had redness to his left cheek under his eye on 07/01/18 at 10:30 AM. The incident report also reflected there were no post incident injuries observed, no witnesses found, and no one was notified of the injury. Interview with the Nurse Practitioner (NP) on 07/11/18 at 12:05 PM stated no one called her about injuries involving Resident #1. She stated all the information she got was from the Family Member. The Family Member told her it happened on Sunday (07/01/18). She stated she would not be on call on the weekend. She stated she saw resident on 07/04/18 and assessed his face and eye. She stated he had bruising on his eye and chin. The bruising on the resident's chin was circular and more purple. The bruise on the lower part of resident's eye was fading and was greenish in color. Interview with LVN H on 0712/18 at 12:30 PM stated RN I asked her to write a statement because something had happened, but she never said what. RN I told her it had to be investigated and they were trying to get a time line. She stated prior to her getting off work on 07/01/18 at 6:00 AM she helped CNA D change Resident #1 because he could be combative at times but on that night, he was not. She stated when she left the facility the resident did not have any injuries. She stated when she came back on Sunday at 6:00 PM CNA C told her that LVN E told Resident #1's family member that his injuries happened on the 10-6 shift. LVN H told CNA C that was not true because when she left the resident did not have any bruising or scratches. She stated she asked the medication aide what time she gave Resident #1 his medication and she said around 7:30-8:00 AM and the resident did not have any scratches or bruises. At that time CNA A walked up to her and said Resident #2 and Resident #3 were in Resident #1's room fighting over a cord. She stated she knew that was not true because they do not have cords in resident's room. She stated while she was talking to CNA A she noticed CNA A had a busted lip. CNA A told her that she busted her lip herself but did not say how. She stated CNA A did not know that she already heard that Resident #1 had hit her, and she had punched him. LVN H stated she then heard that CNA B scratched the resident and her nail ended up broken. LVN H stated when she came in LVN E told her Resident #1 had scratches on him, but she had not noticed it until the afternoon because he kept swinging his arms. She stated she was told that CNA A hit Resident #1, but she did not tell anyone. She was asked why she did not tell anyone and she said she heard the investigation had already started plus it was hearsay. LVN H was asked why she did not say anything to RN I, even though it was hearsay, and she stated she thought they already knew about it. Interview with the DON on 07/11/18 at 12:25 PM stated she first found out about the alleged abuse on 07/03/18 when CNA B made her statement that CNA A hit Resident #1. When she was notified Resident #1 was combative with the CNAs she told ADON W to get statements from all who were involved with the resident within that day. She stated the information she received was that CNA A and CNA B were in the room together and Resident #1 was combative. She was asked why the incident was reported, to HHS, late and the DON said the facility did not learn of the incident until 07/03/18 when CNA B made her statement. She was shown the facility self-report where it states on 07/02/18 the family informed staff that resident was hit by an employee. She again stated they did not learn about the incident until 07/03/18. She was asked how LVN H's statement written on 07/01/18 at 6:20 PM reflect that during incontinent care there were no scratches or bruising noted to the face of Resident #1 when an incident report was initiated on 07/01/18 at 10:30 AM for redness to left cheek under eye and nurses noted dated 07/01/18 at 4:05 PM reflected redness noted to left cheek. The DON stated maybe there was not enough light in the room and she did not see it. Interview with ADON W on 07/11/18 at 1:30 PM stated she was on call the weekend of (MONTH) 30-July 2, (YEAR). She stated she was not notified by staff that an employee hit Resident #1. She stated she found out about the abuse on 07/03/18 when CNA B wrote her statement. She stated at no time did CNA B tell her CNA A hit Resident #1 prior. She stated she did not see bruising around the eye where he could have been punched on 07/02/18. She stated she went back to the unit and there was a very small scratch on resident's cheek. On a subsequent interview with CNA D on 07/12/18 at 1:50 PM she stated she called ADON W on 07/01/18 because she was upset that LVN E was trying to say the injury happened on her shift. She stated at that time she told ADON W that she heard that CNA A had hit Resident #1. Interview with CNA C on 07/12/18 at 3:40 PM stated she came to work on 07/01/18 on the 2-10 shift Resident #1 was sitting in the hall and as she walked by Resident #1 looked up and CNA C said, Oh what happened to you? She asked LVN E what happened to Resident #1 and she said she did not know. She stated when she was clocking in CNA B was clocking out, and CNA B told her that CNA A hit Resident #1 twice in the face. She stated she went and told LVN E that one of the CNAs hit Resident #1. She stated LVN E told her that did not happen on her shift it must have happened on the 10-6 shift. She stated when CNA D came in she asked CNA D what happened to Resident #1 last night and she said nothing. She told CNA D to go look at him. She told CNA D that LVN E said it happened on the 10-6 shift. She stated CNA D was upset because LVN E was trying to say it happened on her shift, so CNA D called ADON W. She stated the next thing she knew RN I had called for them to come to the office for a statement. RN I told her ADON W said it was hearsay and she had nothing to do with it, so RN I sent her back to the unit. CNA C told LVN E she had better get it together because when Resident #1's wife got to the facility she will want to know what happened to her husband. CNA C stated if CNA D never called the ADON W to tell her Resident #1 had an accident and it looked like someone hit him the incident would have never been reported. Interview with LVN E on 07/12/18 at 10:50 PM stated on 07/01/18 she noticed a scratch on Resident #1's face. She stated she tried to look at the scratch, but she could not see it clearly because the resident kept swinging his arms. She stated she called ADON W to report the scratch. The residents spouse asked her what happened, and she stated she did not know. She stated when she first saw it she did not call the spouse because she did not want her to get upset about anything, so she did not talk to the spouse until she came to the facility. She stated she told the family member she was not aware of anything happening on the morning of 07/01/18. She stated CNA A never told her resident hit her, CNA A only told her she bit her lip. She stated she did not call ADON W because she did not have anything to report. She stated CNA D came in to work on the 6-2 shift on 07/01/18. She stated she had not seen Resident #1's eye swollen or any redness until resident's family member came in. On a subsequent interview with ADON W on 07/12/18 at 5:00 PM she stated she did not remember if she was called by CNA D on the weekend 07/01/18. She was asked again if CNA D had called her and she said she might have called and said something about the work schedule. She was asked again if CNA D called her concerning Resident #1 and ADON W said Oh yes now that you say that . She stated CNA D called her and told her LVN E told Resident #1's Responsible Party the injuries happened on the 2-10 shift and it did not. She stated she told CNA D the incident happened on the morning shift, so she did not know why LVN E would tell the residents family member anything different. She also denied that CNA D told her that CNA A had hit Resident #1. She stated she did not call RN I because from the information that she was given it was only a small scratch on resident's cheek. Interview with RN I on 07/16/18 at 9:17 AM stated she was the Weekend supervisor for 07/01/18. She stated she went back on the unit about four times on 07/01/18 and each time she went on the unit she asked LVN E if there was anything happening. She asked if LVN E had anything to report, any falls, accidents, behaviors and each time LVN E said no. She stated CNA A told her around dinner time, at 5-5:30 PM that Resident #1 had hit her on the chin and she fell back and bit her lip. She stated she talked to LVN E and she stated she was working on an incident report. She stated she got a call from the on-call supervisor, ADON W, stating that Resident #1's family member called about the resident's injury. She stated at that time she asked for statements from everyone that worked the unit on 07/01/18. She asked for just the facts and what they did with the resident that day. She never talked to Resident #1's Responsible Party. She stated CNA C came to her and said she heard that CNA A hit Resident #1. She stated she told CNA C that was hearsay because she was not working at that time. CNA C told her she wanted to make sure she told someone, so she did not get in trouble. She thanked CNA C and told her she would carry it higher. She stated she reported what CNA C told her to ADON W, the on-call supervisor. ADON W told her she would take care of it. RN I stated CNA B did not tell her or the ADON W directly that CNA A had hit Resident #1. She stated CNA C was not on that shift and was not in the building until the evening shift so what she told her was hearsay. She was asked when she gets a report of abuse what was she supposed to do according to facility policy and she said notify the abuse coordinator. She was asked if the policy stated the report had to come from an employee that was in the facility at the time of the alleged abuse and she said, no, she used her judgement. When asked about Resident #1's injuries she stated the injury was underneath his eye by the cheekbone. She stated she did not see a dark purple bruise on resident's chin. Interview with Medical Director on 07/20/18 at 10:15 AM revealed any events of bruising or falls he would get notified. He stated how he is notified depends on the injury. Skin tears/bruising went on a report/communication form. He stated he was at the facility on 07/13/18 and he was not made aware of any injuries with Resident #1. Review of daily staffing schedules revealed CNA A continued to work at the facility after the allegation of abuse was reported. Time sheet for CNA A reflected she worked 07/01/18 thru 07/03/18. Review of the statements written by CNA D dated 07/01/18 at 6:15 PM reflected Resident 1's injuries were not present at 5:30 AM when she and LVN H changed him on 07/01/18. Review of the statements written by CMA Q dated 07/01/18 reflected Resident #1 had no noted scratches or injuries on his face at 7:45 AM when he was given his medication. Review of the statements written by LVN E 07/01/18 with no time indicated revealed she observed and assessed redness to left cheek of Resident #1 at 11:30 AM she could not do a full assessment because resident was combative. Review of Resident #1's Medication Administration Record [REDACTED]. Review of the facility Provider Investigation Report revealed the incident was not reported to HHSC until 07/03/18 at 11:48 AM. In the Investigation summary the facility reported the family reported on Tuesday 07/02/18 that Resident #1 had been hit in the eye by a facility employee and the resident had a black eye. Interview with the Administrator on 07/19/18 at 4:00 PM revealed when she started the investigation on 07/03/18 it was on abuse. She stated she was not in the facility on 07/03/18 but on 07/04/18 she saw Resident #1 and he did not have a black eye. She stated she was in the facility on 07/02/18 but she did not see Resident #1. She stated it was not treated as abuse initially only a scratch. She stated CNA A was in-serviced when she returned to work but on an in-service dated 07/09/18 for abuse/neglect CNA A's name was not on the sign in sheet. She stated the family made the allegation of abuse about 9:30 AM on 07/03/18, and at that time she was not in the building she was at home. She stated on 07/03/18 she also talked to CNA B at about 10:00-10:15 AM, that was a conference call along with ADON W and DON. She stated after the meeting with the family and CNA B was when she started the investigation. She stated at that time both CNA A and B were suspended. She stated she delegated her abuse coordinator duties to the DON when she is not at the facility. She was asked would she expect her nurses to report the black eye, and she said no, because of how it happened. She stated the resident was scratched and the black eye came from that scratch. She stated she would expect a nurse to call her if a CNA came to them and said a CNA abused a resident. She felt it was appropriate for a CNA to go to the nurse and report abuse. She stated she did not care who called so long as the call was made. She was asked if there was any reason why two different CNAs and a nurse would say they called the ADON W when they had not. She stated she had no idea why a CNA or a nurse would say they called the ADON W and they did not unless they did not like ADON W. She stated the nurses that worked the weekend stated they had no reason to report abuse. She stated if a CNA said abuse happened regardless if the CNA was in the building or not she would investigate. The statements written on 07/01/18 was about the scratch. There was only one statement written on the abuse allegation because there was only one person that alleged the abuse and that was CNA B. She stated her investigation consisted of an interview with the family who was the reporter and a statement from CNA B. She stated she did not document anything from the interview with the family. She stated the only statement from CNA A was on 07/01/18 and that was concerning the scratch not the abuse allegation. She stated when CNA A came back to work she was told if she saw or heard of any abuse she was to report or if she had trouble with other staff she was to report it. She stated CNA A had been working on the 100 hall. CNA A had not had any follow-up meetings with CNA A nor had she had any further concerns. Interview with the DON on 07/19/18 at 5:29 PM revealed the staff knew that if there was an allegation of abuse and there is an alleged perpetrator (AP) the AP is suspended until the investigation is completed. If unfounded they bring the AP back, but they do not bring the AP back to the unit. CNA A was put on the 100 hall. they monitor CNA A in the hall and watch the residents to ensure they are cared for. She stated they monitor CNA A as they would any other staff as well as the residents. She stated she monitored for signs of burnout or if they need help talk to the CNA. She stated she would monitor their residents more closely for skin tears or injury that had not occurred. She stated if she though staff were abusing a resident they would not be working at the facility. She stated after she met with the family it was about 11:30-11:45 AM then she met with CNA B. After the meeting both CNAs were suspended. She was asked once when the family notified her about the staff hitting the resident why the investigation did not switch to an abuse investigation and she said it did. She was asked what interviews were conducted after the investigation went from a scratch to abuse. She stated she spoke with CNA A again, but she did not document it because she had her statement from 07/01/18. She stated there were no additional interviews once the investigation turned to an abuse investigation she just used the statements from the 07/01/18 that pertained to the scratch assuming that is how they injury occurred. She stated when she was told by the family about the abuse to Resident #1 she still went down the road of a scratch. She stated they would have done the same thing either way. She did not feel she needed another statement from staff about the abuse. She stated outside of the statements she got on 07/01/18 there were no other statements to get. She stated all she saw was a scratch and redness on 07/02/18, there were no bruising or swelling other than the scratched area. She was asked what she would expect her nurses to do and she stated she would expect the nurse to report it if they looked at the resident and thought the resident was hit. She stated all the staff know to call her and she answers the phone. She stated the staff know to report everything but if they did not than that is another problem. When the family made her aware that the resident had a black eye the only person that looked at resident was LVN G who was assigned to that hall. She stated she was physically in the building and she did not go look at Resident #1 on 07/03/18 when the abuse was reported. Review of the undated facility abuse policy reflected it is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process .when an abuse identifies a perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility pending outcome of the investigation The administrator or his/her designee will report this allegation of abuse within 2 hours to the state agency (HHSC) and the proper local authorities The administrator was notified that an Immediate Jeopardy (IJ) was identified on 07/19/18 at 2:45 PM. On 08/03/18 the facility was notified the Immediate Jeopardy (IJ) still existed because the alleged perpetrator was still working at the facility. There was no evidence CNA A had been monitored while working at the facility since the 07/19/18 visit. The Plan of Removal reflected the following: .The notification of the alleged immediate jeopardy states as follows: 1. Failure to act on an abuse allegation immediately (reporting) 2. Break in the system leaving the resident at risk for the potential of further abuse 3. Clear evidence of thorough investigation The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: a. Facility administrator will begin education for facility staff to include RNs, LVNs, CNAs, CMAs, department heads, dietary, and housekeeping staff on the definition of abuse and neglect and the different types of abuse. The education will also include the reporting of any allegation of abuse or neglect to the abuse prevention coordinator immediately. The abuse prevention coordinator's phone number is posted in the facility. If the abuse prevention coordinator/administrator, is not immediately available then notification will be made to the director of nursing or the next available in charge. INITIATED: 7.19.18- TO BE COMPLETED: 7.20.18. b. Facility administrator, suspended, until further notice/investigation completion, ADON W, on 7.19.18. as it was alleged that she was made aware of an abuse allegation but did not report it to the abuse coordinator immediately and did not protect the resident. ADON W, returned to work on 7/21/18 after receiving abuse in-service and a written disciplinary action. ADON W, was re-suspended on 8.3.18. until further notice/investigation completion. CNA A was suspended on (MONTH) 3,2018 at and did not return to work until (MONTH) 7, (YEAR). CNA B was suspended on (MONTH) 3,

Based on interview and record review the facility was not administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Resident #1) of 3 reviewed for abuse. 1. The Administrator, DON, ADON W, LVN F, LVN E, and RN I failed to appropriately identify Resident #1's facial injuries as those of alleged abuse in order to implement the written policy and procedures that prohibited and prevented abuse/neglect. As a result of the misidentification, the residents's facial injuries were investigated as only a scratch, and he alleged perpetrator of abuse, CNA A, continued working with other residents. 2. The Administrator and DON failed to protect the residents at the facility by not thoroughly investigating an allegation of abuse. 3. ADON W failed to report suspected abuse to the Administrator and DON after the alleged abuse of Resident #1 was reported to her by multiple staff. An Immediate Jeopardy (IJ) was identified on 07/19/18. While the IJ was removed on 08/07/18, 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 immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. This failure could affect 18 residents with behaviors on the secured unit. The findings included: Review of the Admission Record dated 07/03/18 for Resident #1 reflected an admission date of [DATE]. Review of the MDS assessment dated [DATE] for Resident #1 revealed he was severely impaired cognitively, with physical behaviors directed towards others e.g. hitting, kicking, pushing, scratching, and grabbing. Resident #1 had active [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 05/08/18 reflected Resident #1 resides in a secured unit due to wondering, elopement risk, and need for controlled environment. Resident #1 required staff assistance for all ADLs. The Resident displayed physically aggressive behavior at times with a history of hitting staff. Review of Progress Notes dated 07/01/18 at 5:26 PM, written by LVN E, reflected Resident #1 had sclera of left eye. No swelling or drainage noted. Wife aware of areas to face. At 4:05 PM LVN E documented during incontinent care today (07/01/18) redness noted to left cheek. Resident #1 continued to have combative episodes during ADL care. Review of Progress Notes dated 07/02/18 at 12:26 PM written by LVN G reflected incident to left eye. Redness and slight swelling noted to left eye. Review of Progress Notes dated 07/03/18 at 1:09 AM written by LVN F reflected incident to left eye. Bruising and slight swelling around left eye noted. Scratch to left cheek and bruise to the left side of resident's chin. Review of Progress Notes dated 07/04/18 1:22 PM (time entered written by LVN T) reflected LVN T assessed the bruise to Resident #1's left side of face at 6:30 AM There was no further documentation of the redness and bruising in any of the above progress notes. Observation of Resident #1's face on 07/11/18 at 12:00 PM revealed all his injuries had healed and there was no bruising noted. Interview on 07/11/18 at 10:26 AM with CNA B revealed when she and CNA A went to change Resident #1 on 07/01/18 The resident was being combative hit CNA A. She stated CNA A then hit the resident back. After CNA A hit Resident #1 CNA A yelled down the hall for LVN E. CNA B said she told LVN E that CNA A hit Resident #1 and LVN E did nothing. She stated when they left the room she also told the ADON W, the ADON who was on-call, about what happened. She stated she did not think to walk down the hall to get the Administrators telephone number. She stated on 07/03/18 she had a meeting with the Administrator over the phone. The DON, and both ADONs were in the office. She told them again that CNA A hit Resident #1. CNA B also wrote that in her statement on 07/03/18 after the meeting. Interview with CNA A on 07/12/18 at 3:40 PM stated she was helping CNA B change Resident #1 and Resident #1 swung at her and hit her on the chin and she fell back and bit her lip. She denied hitting Resident #1. She stated she was not aware the resident had a scratch or bruise on his face. She stated on 07/01/18 she worked a double shift. She stated she left the unit at 2:00 PM to work the hall and she worked the 100 hall until 7:00 PM. She stated she did not see CNA B scratch the resident's face when they were in the room together. She stated RN I came to her and asked her to write a statement about what she saw because the family said someone hit Resident #1. She stated this was about 5:30-6:00 PM on 07/01/18. She stated after she wrote her statement RN I did not say anything else to her and she went back working on the 100 hall. She stated if she knew somebody hit Resident #1 she would tell the nurse and call the abuse coordinator right away. Interview with Resident #1's Responsible Party on 07/11/18 at 3:21 PM stated she came in on Sunday 07/01/18 and saw Resident #1's face was all messed up. She stated LVN E told her she noticed it that morning. The family member stated LVN E told her it did not happen on her shift 6:00 AM-6:00 PM. The family member stated she knew the resident was hit but did not know what happened. She stated she overheard CNA C and CNA D talking about the incident in the hall and one of them said CNA A hit Resident #1. She stated when she brought it to LVN E's attention that Resident #1 had a blood shot left eye, bruising/redness around his left eye, under his eye and cheek bone was red, and a bruise so dark on his chin that she thought it was a marker LVN E had no explanation. She stated this all occurred on 07/01/18. She stated she was upset that no one called her about it. Interview with CNA D on 07/11/18 at 4:50 PM stated CNA C had asked her what happened to Resident #1's face when she got to work for the 2-10 shift. She told CNA C she did not know and that is when CNA C told her to go look at him. She stated when she looked at Resident #1's face he had a bruise near his mouth and his eye. She stated he looked like someone punched him in the eye and it did not look like a scratch at first. She stated the eye was red and turning to be like a bruise. She told CNA C that did not happen on her shift (10:00 PM-6:00 AM) the previous day. CNA D stated when Resident #1's Responsible Party came in that evening LVN E tried to tell her that it happened on the 10:00 PM-6:00 AM shift and CNA D told LVN E in front of the Responsible Party that information was a lie. Interview with LVN F on 07/11/18 at 2:00 PM stated he worked 07/02/18 and on the 24-hour report it said Resident #1 had a scratch on his cheek. He stated when he went back to check on Resident #1 he noticed Resident #1 had a black eye and a bruise on his jaw. He stated he thought he was following up on a scratch because that is what was written on the 24-hour report. That night Resident #1's family member came in and asked him what happened, and he told her he did not know because no one told him anything. He stated he was never told Resident #1 was hit but to him that was what it looked like, the resident was hit. Interview with LVN G on 07/11/18 at 2:15 PM stated she was aware of an incident with Resident #1 She stated she knew that the resident had an incident with two CNAs and the resident got scratched. She learned of the incident from LVN E, but she never got the full story she just knew it involved CNA A and CNA B. She stated when she worked on 07/02/18 she noticed Resident #1 had redness and swelling to his left eye. She stated at that time, she did not see a black eye, but later it became present. She was asked if it was the resident's eye or his cheek and she took her finger and pointed to her eye and circled the entire eye area that was red (bruised). She stated it was also red on is cheek bone area. Interview with resident #1's family member on 07/11/18 at 9:34 AM stated she found out about the incident when the Responsible Party visited Resident #1 at 5:00 PM on Sunday 07/01/18. The facility failed to contact her or the Responsible Party who visited to the facility twice a day. When the Responsible Party visited the resident, on 07/01/18, he had bruises on his chin and face. She stated there were scratches as well. When the Responsible Party asked what happened no one could tell her. When the family member arrived at the facility on 07/03/18 LVN F was on duty. She asked LVN F what happened, and he could not tell her what happened. She asked if an incident report was done. He stated it had just been noted that an incident had happened on 07/03/18. She stated she spent the night with Resident #1 that night. She stated on the Responsible Part's lunch break she and the Responsible Party met with the DON and the DON could not tell them what happened. The DON stated ADON W called the doctor, the DON, and the Administrator. The DON stated the incident report had not been entered due to training as they just started using a new computer system. When she asked for a hard copy of the report, the DON refused to give it to her because she was still investigating the incident. When she told the DON that if she did not get corporate or the Administrator on the phone right then, she was calling the state agency, the DON called Administration and the Administration did not know about the incident. On 07/04/18 she met with the Administrator and the Administrator told her she was sorry about the incident. The day they met the Administrator she stated she was there to discuss the scratch on the resident's face. She stated that did not sit well with her because the Administrator had gotten all the pictures of the bruising and to say it was only a scratch did not sit well with her. Reviewed family member personal cell phone on 07/20/18 revealed there were several pictures on the phone with the date and time the picture was taken. Picture dated 07/01/18 at 5:53 PM of Resident #1 revealed resident had a scratch on the left side of his face that went from his cheek bone to his mustache and his cheek was bruised. Resident's left eye was reddish purple. Picture dated 07/02/18 at 7:42 PM of Resident #1 (side view) lying down reflected Resident's left eye was reddish purple. Resident had a scratch on the left side of his cheek that went from his cheek bone to his mustache. Resident had a dark purple circular bruise on the left side of his chin. Picture dated 07/02/18 at 7:43 PM of Resident #1 (front View) lying down with two dark purple bruises on his chin. Resident's left cheek was swollen with reddish purple bruising. Resident's left eye was also bruised and red. Picture dated 07/03/18 at 11:04 AM of Resident #1 (front view) with a reddish/purple eye, a scratch on his cheek, and a bruise on resident's chin. Interview with the Administrator on 07/11/18 at 10:45 AM stated she learned about the incident on 07/03/18. The DON called her with Resident #1's family in the office. She stated prior to that none of the nurses had called her about an incident. She stated other than Resident #1 being combative and the resident hitting CNA A there was no incident. She stated CNA B never told them CNA A hit Resident #1 until 07/03/18. She stated there was an incident report done on 07/01/18 concerning Resident #1. She stated when she learned CNA A was alleged to hit Resident #1 she suspended both, CNA A and CNA B. When CNA B told her CNA A hit Resident #,1 she asked CNA B why she did not tell someone that day and CNA B told her she did not have the Administrator's number. She stated her number was kept in the CNA book at the nurse's station. She stated as far as she knew CNA B never told ADON W that CNA A hit Resident #1. She stated CNA B was terminated on 7/5/18 due to failure to report abuse. CNA B did not report the abuse that occurred on 07/01/18 until 07/03/18. The Administrator stated she reported the incident (to HHS) on 07/03/18 when she found out about the incident. Reviewed of the incident report dated 07/01/18 and revised on 07/03/18 revealed Resident #1 had redness to his left cheek under his eye on 07/01/18 at 10:30 AM. The incident report also reflected there were no post incident injuries observed, no witnesses found, and no one was notified of the injury. Interview with the Nurse Practitioner (NP) on 07/11/18 at 12:05 PM stated no one called her about injuries involving Resident #1. She stated all the information she got was from the Family Member. The Family Member told her it happened on Sunday (07/01/18). She stated she would not be on call on the weekend. She stated she saw resident on 07/04/18 and assessed his face and eye. She stated he had bruising on his eye and chin. The bruising on the resident's chin was circular and more purple. The bruise on the lower part of resident's eye was fading and was greenish in color. Interview with LVN H on 0712/18 at 12:30 PM stated RN I asked her to write a statement because something had happened, but she never said what. RN I told her it had to be investigated and they were trying to get a time line. She stated prior to her getting off work on 07/01/18 at 6:00 AM she helped CNA D change Resident #1 because he could be combative at times but on that night, he was not. She stated when she left the facility the resident did not have any injuries. She stated when she came back on Sunday at 6:00 PM CNA C told her that LVN E told Resident #1's family member that his injuries happened on the 10-6 shift. LVN H told CNA C that was not true because when she left the resident did not have any bruising or scratches. She stated she asked the medication aide what time she gave Resident #1 his medication and she said around 7:30-8:00 AM and the resident did not have any scratches or bruises. At that time CNA A walked up to her and said Resident #2 and Resident #3 were in Resident #1's room fighting over a cord. She stated she knew that was not true because they do not have cords in resident's room. She stated while she was talking to CNA A she noticed CNA A had a busted lip. CNA A told her that she busted her lip herself but did not say how. She stated CNA A did not know that she already heard that Resident #1 had hit her, and she had punched him. LVN H stated she then heard that CNA B scratched the resident and her nail ended up broken. LVN H stated when she came in LVN E told her Resident #1 had scratches on him, but she had not noticed it until the afternoon because he kept swinging his arms. She stated she was told that CNA A hit Resident #1, but she did not tell anyone. She was asked why she did not tell anyone and she said she heard the investigation had already started plus it was hearsay. LVN H was asked why she did not say anything to RN I, even though it was hearsay, and she stated she thought they already knew about it. Interview with the DON on 07/11/18 at 12:25 PM stated she first found out about the alleged abuse on 07/03/18 when CNA B made her statement that CNA A hit Resident #1. When she was notified Resident #1 was combative with the CNAs she told ADON W to get statements from all who were involved with the resident within that day. She stated the information she received was that CNA A and CNA B were in the room together and Resident #1 was combative. She was asked why the incident was reported, to HHS, late and the DON said the facility did not learn of the incident until 07/03/18 when CNA B made her statement. She was shown the facility self-report where it states on 07/02/18 the family informed staff that resident was hit by an employee. She again stated they did not learn about the incident until 07/03/18. She was asked how LVN H's statement written on 07/01/18 at 6:20 PM reflect that during incontinent care there were no scratches or bruising noted to the face of Resident #1 when an incident report was initiated on 07/01/18 at 10:30 AM for redness to left cheek under eye and nurses noted dated 07/01/18 at 4:05 PM reflected redness noted to left cheek. The DON stated maybe there was not enough light in the room and she did not see it. Interview with ADON W on 07/11/18 at 1:30 PM stated she was on call the weekend of (MONTH) 30-July 2, (YEAR). She stated she was not notified by staff that an employee hit Resident #1. She stated she found out about the abuse on 07/03/18 when CNA B wrote her statement. She stated at no time did CNA B tell her CNA A hit Resident #1 prior. She stated she did not see bruising around the eye where he could have been punched on 07/02/18. She stated she went back to the unit and there was a very small scratch on resident's cheek. On a subsequent interview with CNA D on 07/12/18 at 1:50 PM she stated she called ADON W on 07/01/18 because she was upset that LVN E was trying to say the injury happened on her shift. She stated at that time she told ADON W that she heard that CNA A had hit Resident #1. Interview with CNA C on 07/12/18 at 3:40 PM stated she came to work on 07/01/18 on the 2-10 shift Resident #1 was sitting in the hall and as she walked by Resident #1 looked up and CNA C said, Oh what happened to you? She asked LVN E what happened to Resident #1 and she said she did not know. She stated when she was clocking in CNA B was clocking out, and CNA B told her that CNA A hit Resident #1 twice in the face. She stated she went and told LVN E that one of the CNAs hit Resident #1. She stated LVN E told her that did not happen on her shift it must have happened on the 10-6 shift. She stated when CNA D came in she asked CNA D what happened to Resident #1 last night and she said nothing. She told CNA D to go look at him. She told CNA D that LVN E said it happened on the 10-6 shift. She stated CNA D was upset because LVN E was trying to say it happened on her shift, so CNA D called ADON W. She stated the next thing she knew RN I had called for them to come to the office for a statement. RN I told her ADON W said it was hearsay and she had nothing to do with it, so RN I sent her back to the unit. CNA C told LVN E she had better get it together because when Resident #1's wife got to the facility she will want to know what happened to her husband. CNA C stated if CNA D never called the ADON W to tell her Resident #1 had an accident and it looked like someone hit him the incident would have never been reported. Interview with LVN E on 07/12/18 at 10:50 PM stated on 07/01/18 she noticed a scratch on Resident #1's face. She stated she tried to look at the scratch, but she could not see it clearly because the resident kept swinging his arms. She stated she called ADON W to report the scratch. The residents spouse asked her what happened, and she stated she did not know. She stated when she first saw it she did not call the spouse because she did not want her to get upset about anything, so she did not talk to the spouse until she came to the facility. She stated she told the family member she was not aware of anything happening on the morning of 07/01/18. She stated CNA A never told her resident hit her, CNA A only told her she bit her lip. She stated she did not call ADON W because she did not have anything to report. She stated CNA D came in to work on the 6-2 shift on 07/01/18. She stated she had not seen Resident #1's eye swollen or any redness until resident's family member came in. On a subsequent interview with ADON W on 07/12/18 at 5:00 PM she stated she did not remember if she was called by CNA D on the weekend 07/01/18. She was asked again if CNA D had called her and she said she might have called and said something about the work schedule. She was asked again if CNA D called her concerning Resident #1 and ADON W said Oh yes now that you say that . She stated CNA D called her and told her LVN E told Resident #1's Responsible Party the injuries happened on the 2-10 shift and it did not. She stated she told CNA D the incident happened on the morning shift, so she did not know why LVN E would tell the residents family member anything different. She also denied that CNA D told her that CNA A had hit Resident #1. She stated she did not call RN I because from the information that she was given it was only a small scratch on resident's cheek. Interview with RN I on 07/16/18 at 9:17 AM stated she was the Weekend supervisor for 07/01/18. She stated she went back on the unit about four times on 07/01/18 and each time she went on the unit she asked LVN E if there was anything happening. She asked if LVN E had anything to report, any falls, accidents, behaviors and each time LVN E said no. She stated CNA A told her around dinner time, at 5-5:30 PM that Resident #1 had hit her on the chin and she fell back and bit her lip. She stated she talked to LVN E and she stated she was working on an incident report. She stated she got a call from the on-call supervisor, ADON W, stating that Resident #1's family member called about the resident's injury. She stated at that time she asked for statements from everyone that worked the unit on 07/01/18. She asked for just the facts and what they did with the resident that day. She never talked to Resident #1's Responsible Party. She stated CNA C came to her and said she heard that CNA A hit Resident #1. She stated she told CNA C that was hearsay because she was not working at that time. CNA C told her she wanted to make sure she told someone, so she did not get in trouble. She thanked CNA C and told her she would carry it higher. She stated she reported what CNA C told her to ADON W, the on-call supervisor. ADON W told her she would take care of it. RN I stated CNA B did not tell her or the ADON W directly that CNA A had hit Resident #1. She stated CNA C was not on that shift and was not in the building until the evening shift so what she told her was hearsay. She was asked when she gets a report of abuse what was she supposed to do according to facility policy and she said notify the abuse coordinator. She was asked if the policy stated the report had to come from an employee that was in the facility at the time of the alleged abuse and she said, no, she used her judgement. When asked about Resident #1's injuries she stated the injury was underneath his eye by the cheekbone. She stated she did not see a dark purple bruise on resident's chin. Interview with Medical Director on 07/20/18 at 10:15 AM revealed any events of bruising or falls he would get notified. He stated how he is notified depends on the injury. Skin tears/bruising went on a report/communication form. He stated he was at the facility on 07/13/18 and he was not made aware of any injuries with Resident #1. Review of daily staffing schedules revealed CNA A continued to work at the facility after the allegation of abuse was reported. Time sheet for CNA A reflected she worked 07/01/18 thru 07/03/18. Review of the statements written by CNA D dated 07/01/18 at 6:15 PM reflected Resident 1's injuries were not present at 5:30 AM when she and LVN H changed him on 07/01/18. Review of the statements written by CMA Q dated 07/01/18 reflected Resident #1 had no noted scratches or injuries on his face at 7:45 AM when he was given his medication. Review of the statements written by LVN E 07/01/18 with no time indicated revealed she observed and assessed redness to left cheek of Resident #1 at 11:30 AM she could not do a full assessment because resident was combative. Review of Resident #1's Medication Administration Record [REDACTED]. Review of the facility Provider Investigation Report revealed the incident was not reported to HHSC until 07/03/18 at 11:48 AM. In the Investigation summary the facility reported the family reported on Tuesday 07/02/18 that Resident #1 had been hit in the eye by a facility employee and the resident had a black eye. Interview with the Administrator on 07/19/18 at 4:00 PM revealed when she started the investigation on 07/03/18 it was on abuse. She stated she was not in the facility on 07/03/18 but on 07/04/18 she saw Resident #1 and he did not have a black eye. She stated she was in the facility on 07/02/18 but she did not see Resident #1. She stated it was not treated as abuse initially only a scratch. She stated CNA A was in-serviced when she returned to work but on an in-service dated 07/09/18 for abuse/neglect CNA A's name was not on the sign in sheet. She stated the family made the allegation of abuse about 9:30 AM on 07/03/18, and at that time she was not in the building she was at home. She stated on 07/03/18 she also talked to CNA B at about 10:00-10:15 AM, that was a conference call along with ADON W and DON. She stated after the meeting with the family and CNA B was when she started the investigation. She stated at that time both CNA A and B were suspended. She stated she delegated her abuse coordinator duties to the DON when she is not at the facility. She was asked would she expect her nurses to report the black eye, and she said no, because of how it happened. She stated the resident was scratched and the black eye came from that scratch. She stated she would expect a nurse to call her if a CNA came to them and said a CNA abused a resident. She felt it was appropriate for a CNA to go to the nurse and report abuse. She stated she did not care who called so long as the call was made. She was asked if there was any reason why two different CNAs and a nurse would say they called the ADON W when they had not. She stated she had no idea why a CNA or a nurse would say they called the ADON W and they did not unless they did not like ADON W. She stated the nurses that worked the weekend stated they had no reason to report abuse. She stated if a CNA said abuse happened regardless if the CNA was in the building or not she would investigate. The statements written on 07/01/18 was about the scratch. There was only one statement written on the abuse allegation because there was only one person that alleged the abuse and that was CNA B. She stated her investigation consisted of an interview with the family who was the reporter and a statement from CNA B. She stated she did not document anything from the interview with the family. She stated the only statement from CNA A was on 07/01/18 and that was concerning the scratch not the abuse allegation. She stated when CNA A came back to work she was told if she saw or heard of any abuse she was to report or if she had trouble with other staff she was to report it. She stated CNA A had been working on the 100 hall. CNA A had not had any follow-up meetings with CNA A nor had she had any further concerns. Interview with the DON on 07/19/18 at 5:29 PM revealed the staff knew that if there was an allegation of abuse and there is an alleged perpetrator (AP) the AP is suspended until the investigation is completed. If unfounded they bring the AP back, but they do not bring the AP back to the unit. CNA A was put on the 100 hall. they monitor CNA A in the hall and watch the residents to ensure they are cared for. She stated they monitor CNA A as they would any other staff as well as the residents. She stated she monitored for signs of burnout or if they need help talk to the CNA. She stated she would monitor their residents more closely for skin tears or injury that had not occurred. She stated if she though staff were abusing a resident they would not be working at the facility. She stated after she met with the family it was about 11:30-11:45 AM then she met with CNA B. After the meeting both CNAs were suspended. She was asked once when the family notified her about the staff hitting the resident why the investigation did not switch to an abuse investigation and she said it did. She was asked what interviews were conducted after the investigation went from a scratch to abuse. She stated she spoke with CNA A again, but she did not document it because she had her statement from 07/01/18. She stated there were no additional interviews once the investigation turned to an abuse investigation she just used the statements from the 07/01/18 that pertained to the scratch assuming that is how they injury occurred. She stated when she was told by the family about the abuse to Resident #1 she still went down the road of a scratch. She stated they would have done the same thing either way. She did not feel she needed another statement from staff about the abuse. She stated outside of the statements she got on 07/01/18 there were no other statements to get. She stated all she saw was a scratch and redness on 07/02/18, there were no bruising or swelling other than the scratched area. She was asked what she would expect her nurses to do and she stated she would expect the nurse to report it if they looked at the resident and thought the resident was hit. She stated all the staff know to call her and she answers the phone. She stated the staff know to report everything but if they did not than that is another problem. When the family made her aware that the resident had a black eye the only person that looked at resident was LVN G who was assigned to that hall. She stated she was physically in the building and she did not go look at Resident #1 on 07/03/18 when the abuse was reported. Review of the undated facility abuse policy reflected it is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process .when an abuse identifies a perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility pending outcome of the investigation The administrator or his/her designee will report this allegation of abuse within 2 hours to the state agency (HHSC) and the proper local authorities The administrator was notified that an Immediate Jeopardy (IJ) was identified on 07/19/18 at 2:45 PM. On 08/03/18 the facility was notified the Immediate Jeopardy (IJ) still existed because the alleged perpetrator was still working at the facility. There was no evidence CNA A had been monitored while working at the facility since the 07/19/18 visit. The Plan of Removal reflected the following: .The notification of the alleged immediate jeopardy states as follows: 1. Failure to act on an abuse allegation immediately (reporting) 2. Break in the system leaving the resident at risk for the potential of further abuse 3. Clear evidence of thorough investigation The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: a. Facility administrator will begin education for facility staff to include RNs, LVNs, CNAs, CMAs, department heads, dietary, and housekeeping staff on the definition of abuse and neglect and the different types of abuse. The education will also include the reporting of any allegation of abuse or neglect to the abuse prevention coordinator immediately. The abuse prevention coordinator's phone number is posted in the facility. If the abuse prevention coordinator/administrator, is not immediately available then notification will be made to the director of nursing or the next available in charge. INITIATED: 7.19.18- TO BE COMPLETED: 7.20.18. b. Facility administrator, suspended, until further notice/investigation completion, ADON W, on 7.19.18. as it was alleged that she was made aware of an abuse allegation but did not report it to the abuse coordinator immediately and did not protect the resident. ADON W, returned to work on 7/21/18 after receiving abuse in-service and a wri

Based on observation, interview, and record review, it was determined the facility failed to provide each resident with adequate supervision and assistance devices to prevent accidents for one (Resident #9) of nine residents reviewed for falls. The facility failed to supervise Resident #9, who was at high risk for falls, in the dining room on 10/23/13. Resident #9 fell and sustained a 5.0 cm by 5.0 cm hematoma to the left side of his head, a laceration to the left side of his head, a skin tear to his left shoulder, a laceration to his left shoulder, a laceration to his left index finger, and was complaining of pain to his left knee, his left shoulder, and back pain. The facility failed to develop and implement new interventions to keep Resident #9 from standing up out of his wheelchair and falling. These failures could affect the 36 residents, including Resident #9, who had Dementia and/or Alzheimer's Disease and the seven residents, who experienced falls and falls with major injury, by placing them at risk for injuries resulting in skin tears, bruising, lacerations, concussions, hematomas, head injuries and fractures. Findings included: Resident #9's Face Sheet, dated 08/08/13, reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's MDS assessment, dated 09/30/13, reflected he was severely impaired cognitively and sometimes understood. He required extensive physical assistance of two staff for transfers, dressing, and toileting and was incontinent of bowel and bladder. The MDS assessment also reflected Resident #9 required limited physical assistance of one staff while up in his wheelchair, and he was not steady during surface-to-surface transfers, was only able to stabilize with staff assistance. [DIAGNOSES REDACTED]. Further review of Resident #9's MDS assessment revealed he had falls since admit/reentry/prior assessment and two or more falls that had injury. Resident #9's Care Plan, dated 08/14/13 reflected, "Resident has a history of falls and is at risk for potential falls. Resident has limited safety awareness. Will not experience any injuries from falls over the next 90 days 11/14/13. Assist with transfers Remind to ask for assist (sic) for all transfers Use bed and chair alarms for reminders and make sure they are on and in working condition - Nurse & CNA checks freq (frequently) Referral for PT (Physical Therapy) evaluation if ordered Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician Ensure bed is in low position at all times - Nurse & CNA checks freq Ensure blue safety mats are at bedside when resident is in bed - Nurse & CNA checks freq * Restorative program - see individualized POC (Plan Of Care)...." The Care Plan reflected a handwritten note, dated 08/16/13, which indicated the resident fell out of bed, and chair/bed alarm, mats on floor, and resident out of bed more frequently, but family refused. The Care Plan also reflected a handwritten note, dated 08/20/13, which indicated the resident fell out of bed on floor mats and to continue plan of care. The Care Plan reflected another handwritten note, dated 08/29/13, which indicated the resident was sitting on the floor mat, bed kept in lowest position, and continue plan of care. Resident #9's Care Plan also reflected the following handwritten notes and dates: "9/6/13 -assist from bed to floor mat- (no injury) 9/18/13 f/u (follow up) fall - freq staff (checks) 9/26/13 fall w/c assisted to floor chair alarm (check) q (every) 2" Review of Resident #9's Fall Risk Evaluation, dated 09/18/13, reflected a score of 18, which indicated he was at high risk for falls. The Incident/Accident Report, dated 09/26/13, reflected Resident #9 fell in the Activity room, while trying to stand-up from his wheelchair, but did not sustain any injuries. The report also reflected, "CURRENT MOBILITY W/C - Self Wheeled MEDICAL HISTORY Fall History Incontinency Confusion/Disorientation MENTAL STATUS Alert & Oriented x (times) 3...FINAL DISPOSITION ACTIONS TAKEN TO MINIMIZE REOCCURRENCE: Ensure Alarm to chair is working appropriately. FINAL CONDITION: (No) injuries notes. Denies pain/discomfort...." The Investigation Follow-Up, dated 09/27/13, reflected, "PAST INTERVENTIONS ATTEMPTED (Include Dates) - chair alarm - low bed - bed alarm - scoop mattress - floor mats RECOMMENDATIONS/NEW INTERVENTIONS Ensure chair alarm working properly...." Interview on 11/26/13 at 3:53 p.m. with RN E revealed Resident #9 was a very anxious and busy resident. She said Resident #9 got up for dinner in the evenings after his family left, and he could be very active. She stated he was always standing up and trying to walk. RN E revealed she tried to keep him busy by offering magazines or calling his family member. She said they took him to the bathroom, even though the resident was incontinent. The staff, who worked on the evening shift, tried to keep him busy and in sight by the Nurse's Station. When asked if she was working the evening Resident #9 fell in the activities room, RN E replied she was and he was in the activities room watching a movie. She stated there was no staff in there at the time he fell . RN E revealed she was down the hall working and heard a chair alarm sounding. She said by the time she got there, Resident #9 was on the floor. RN E stated she was aware there was a list of fall interventions available for her to choose and help him, but she just thought up things at the time to keep him safe. She revealed she did not consider changing the chair alarm or the chair because the resident was going back to bed soon, and the chair alarm was appropriate. RN E stated Resident #9 just could not remember, and he was so unsteady. She revealed she thought the chair alarm was the most appropriate intervention. Resident #9's Care Plan, dated 08/14/13, reflected a handwritten note, dated 10/03/13, which indicated the resident fell out of bed onto the floor mat and the bed was in the lowest position and continue plan of care. An Incident/Accident Report, dated 10/23/13, reflected Resident #9 was found on the floor in the dining room, was assessed for injuries, and then transferred to the emergency room for evaluation and treatment. The report reflected Resident #9 was assessed with [REDACTED]. of pain to his left knee, his left shoulder, and back pain. The report also reflected Resident #9 was a transfer assist by staff, required wheelchair staff assist, had a fall history, was incontinent, confused, disoriented, and had Alzheimer's. The report indicated therapy was to evaluate and treat if indicated. The Incident/Accident Report reflected, "FINAL DISPOSITION ACTIONS TO MINIMIZE REOCCURRENCE: (blank) FINAL CONDITION: Therapy to eval (evaluate) & treat if indicated...." The Incident/Accident Investigation Worksheet reflected CNA B was interviewed and said Resident #9's chair alarm was intact and in proper working order when placed on the resident. Interview on 11/27/13 at 8:56 a.m. with CNA B revealed she got Resident #9 up for breakfast the morning he fell and went to the hospital. She stated he was placed in his wheelchair with his chair alarm working. She revealed she took Resident #9 to the dining room and placed him at the table where he normally ate. CNA B stated there was no other staff in the dining room at the time she left Resident #9 in there. She said she went to assist other residents, and she heard a chair alarm sounding. CNA B revealed she went running into the dining room and Resident #9 was already on the floor with his head bleeding. She stated he kept saying he was going home, and he was lying beside one of the back doors. CNA B said the nurse came and assessed him and then sent him to the hospital via 911 because he was complaining of pain from his legs, arms, and his head. CNA B stated she told the nurse that something needed to be done about Resident #9's wheelchair, but the nurse just said they knew Resident #9 and they would see what might need to be done to his wheelchair. She revealed she made suggestions before to the nurses, but the nurses did not seem to pay any attention. She stated she had one nurse tell her the nursing staff knew better what the residents needed because they were the nurses. CNA B revealed she stopped saying anything after that. Interview on 11/26/13 at 10:34 a.m. with LVN A revealed Resident #9 only got up for breakfast and dinner, and she only worked the day the shift. LVN A said Resident #9 was very anxious, and he had no cognitive ability. He attempted to stand, but could not remember he could not stand or walk. She revealed he was a very high risk for falls and had to be monitored very closely, so they tried to keep him near the Nurse's Station and keep his chair alarm on his wheelchair. LVN A said Resident #9 had been in therapy, but he could not remember what he was supposed to do to keep himself safe, so his family member thought it was best to stop. When asked if she was working the morning Resident #9 fell and went to the hospital, LVN A replied she was working and the CNA had gotten Resident #9 up for breakfast. She stated he was wheeling around the facility, so LVN A said she got him coffee and sat him at one of the tables in the dining room. LVN A said he knew how to lock and unlock the brakes on his wheelchair inconsistently. She said there had been times she found him dragging his wheelchair with one brake locked and the other brake unlocked. LVN A revealed she heard the chair alarm sounding, and when she got there he was near one of the back doors. Resident #9 had fallen out of his wheelchair and hit his head on a bedside table that was always by that door. LVN A stated Resident #9 was a very high risk for falls and the staff tried to monitor him as closely as possible and anticipate his needs to keep him still. She revealed he was up and down much of the time when he was in his wheelchair. She said she just tried to do any and everything she could think of to keep him still. When asked if she had a choice of interventions to try for a resident who had fallen, LVN A replied they just tried to come up with their own ideas. She stated there was not a list or book that she knew about. The Investigation Follow-Up, dated 10/23/13, reflected, "PAST INTERVENTIONS ATTEMPTED (Include Dates) Bed & Chair alarms in place & working properly. redirection RECOMMENDATIONS/NEW INTERVENTIONS monitor closely ensure alarms are in proper working order...." Resident #9's Client Transfer Form, dated 10/23/13, reflected, "...REASON FOR TRANSFER (i.e. What Happened?) fell , sluggish pupils, head trauma...." Resident #9's Emergency Department's Imaging Report, dated 10/23/13, reflected a CT of his head was taken and the results were "...SUPERFICIAL SOFT TISSUE SWELLING...." Resident #9's Emergency Department Discharge Paperwork, printed on 10/23/13, reflected he had contusions and lacerations. Resident #9's facility's Nurse's Notes, dated 10/23/13, reflected he returned to the facility from the hospital with steri strips to his left index finger. The Notes also reflected he was transferred to his bed, which was in the low position, with an alarm in working order. Resident #9's Care Plan, dated 08/14/13, reflected a handwritten note, dated 10/23/13, which indicated he had an "actual" fall 10/23/13 and Physical and Occupational Therapy to evaluate and treat as indicated. Resident #9's Interdisciplinary Care Plan Record, dated 10/24/13, reflected, "...NURSING Cont (continue) fall protocol - PT/OT eval & tx (treat) for fall prevention...." Resident #9's Care Plan, dated 10/29/13 reflected, "Resident has poor safety awareness and is at risk for falls; resident is at risk for falls; resident is at increaseed (sic) risk for fall r/t (related to) freq removes chair alarm himself by unclipping it from shirt by leaning forward & reaching behind back to pull clip loose. Resident will be free from falls or injuries from falls over the next 90 days Assist with transfers and mobility in accordance with res' (resident's) needs. Use tab alarm as a reminder if ordered and redirect res when he removes alarm. Freq monitoring by staff to ensure alarm remains attached. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician Continued education with (his family member)." The Care Plan reflected an undated handwritten note, which indicated chair and bed alarm; bed in lowest position, mats on floor at bedside x (times) 2 S/T (Skin Tear) x 2 - tx (treatment) as ordered. Another handwritten note reflected "-fall 11/3 & 11/12 - Updated...." Resident #9's Fall Risk Evaluation, dated 11/12/13, reflected a score of 18, which indicated he was at high risk for falls. An observation/interview on 11/25/13 at 9:20 a.m. revealed Resident #9 in bed. LVN A stated the resident had a history of [REDACTED]. LVN A revealed Resident #9 was assisted up for the morning meal and the evening meal and had to be monitored due to wandering while up in his wheelchair, and he would not sit in his wheelchair all the time. LVN A said Resident #9 still thought he could walk. Interview on 11/25/13 at 12:55 p.m. with CNAs F and G revealed Resident #9 only got up for breakfast and dinner meals, but when he was up, they really had to watch him, because he was always trying to stand up. When asked what they did, they replied they tried to keep him safe, but sometimes they were busy. They stated they found themselves running all the time because his chair alarm was always going off, and he was trying to stand up. CNAs F and G stated when he was in bed, he was a lot safer. When asked if they said anything to the facility regarding what they thought would keep Resident #9 safer, CNA F replied she told her nurse, but nothing happened. She stated she did not really think the nurses listened to them because she made other suggestions and nothing ever happened. Interview on 11/26/13 at 9:00 a.m. with CNAs C and D revealed Resident #9 got up for breakfast and dinner only, used a wheelchair, and wore a chair alarm. CNA C said Resident #9 was always trying to stand up, and he would wheel himself about the facility, so she would try to keep him in one place. CNA C revealed he was like a "jack in the box" always up and down. CNA D said Resident #9 was hard to keep up with and if a chair alarm sounded, it was probably him standing up. CNA D said this was how she would know where he was most of the time. When asked if they had been asked or had they made suggestions on ways to keep Resident #9 safe when he was in the wheelchair, both CNAs said no because they did not think it would make a difference. Observation on 11/26/13 at 5:12 p.m. revealed Resident #9 in the activity room sitting in front of the television, beginning to stand up. His chair alarm sounded, staff responded, and put him back in his chair. Observation on 11/26/13 at 5:32 p.m. revealed Resident #9 at a table in the dining area. His chair alarm sounded, and he was standing up at the table. Staff responded and put him back in his chair. Observation on 11/26/13 at 5:45 p.m. revealed a chair alarm sounding. Resident #9 was standing up in front of his wheelchair. When the staff got to him, he was leaning forward. Interview on 11/26/13 at 11:47 a.m. with the DOR revealed Resident #9 had been treated by therapy some time ago, and they discontinued services and referred the resident to the restorative nursing program to try and maintain the resident's strength. The DOR stated Resident #9 began to have problems related to his wheelchair and was evaluated to return back on services. When asked what kind of problems with his wheelchair, the DOR replied the resident was standing up and falling down. The DOR revealed the resident's family member wanted the therapy services discontinued following approximately two weeks of treatment, but she (the DOR) did not know why. When asked if she spoke to the family member, the DOR replied no. When asked what the DOR's involvement was when a resident fell , she responded the facility had meetings every morning, which she attended. During these meetings, each incident was reviewed, and the therapy department would then screen the resident. If the resident was appropriate for therapy, then he/she would be placed on therapy. The DOR stated sometimes the therapy would be for only two weeks, and then therapy would refer the resident to the Restorative Nursing Program. When asked if therapy was involved in other types of interventions, the DOR replied yes. She stated sometimes it could be repairing wheelchair brakes or applying a foot rest on the wheelchair. When asked about Resident #9, the DOR responded he had foot rests on his wheelchair, but the resident just stood up around them or just leaned over and pulled them up. She stated they really did not help him. When asked if she had spoken to his family about other types of mobility devices, the DOR replied she thought about a "Merry Walker" (Safety Walker) for Resident #9. She stated since the family discontinued therapy, she could not speak with them or explain how the "Merry Walker" might assist Resident #9. Interview on 11/26/13 at 1:19 p.m. with the Administrator and DON revealed the facility had a protocol and policy and procedure for falls and there was a list available for the staff to choose interventions from at the Nurse's Station. The DON stated she was unaware the staff were not utilizing the information available for interventions. The Administrator stated he learned of problems in his morning meetings, and the department head for the problem was to follow-up. When asked about Resident #9's falls, the Administrator and DON replied they were aware of his unsafe behavior. The Administrator stated Resident #9 had a right to fall, and they were a restraint free facility. Interview on 11/26/13 at 3:5 p.m. with a Family member of Resident #9's revealed the family member was told by the Administrator in October, when Resident #9 fell , the wheelchair would be reviewed for safety. The family member said nothing ever happened. Resident #9's family member was afraid to say anything. He/She thought it was best to keep Resident #9 in bed. The resident's family member thought it was wrong because Resident #9 liked to get up sometimes. Interview on 11/26/13 at 11:45 a.m. with Resident #9's family member revealed when he lived at home and fell , it was difficult to get him back up. The resident spent a lot of time in the hospital, but then it was decided the resident would come to the facility for rehabilitation to strengthen him and go home, but due to his deteriorating Alzheimer's condition, he had remained in the facility. The family member stated he/she was not against him having therapy. It just seemed like they kept doing the same things over and over, and he continued to fall. The family member revealed he/she just wanted to keep him safe, and that was why he/she wanted him in the bed most of the time because when he really hurt himself was when he got up in his wheelchair. Resident #9's Care Plan, dated 10/29/13, reflected an update on 11/26/13 after surveyor intervention. The entry reflected, "W/C (Wheelchair) replaced, added drop seat (with) anti-tippers & wedge cushion." Resident #9's Care Plan, dated 11/26/13 after surveyor intervention, reflected, "Resident has a history of falls and is at risk for potential falls. Will not experience any falls or injuries from falls over the next 90 days 2/26/14 Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician Fitted w/c with anti-tip bars, drop seat (with) scoop cushion use for mobility at all times. Staff to ensure that chair/bed alarms or (sic) on and in working order at all times. Scoop mattress to bed; bed to be in lowest position with floor mats in place at all x's (times) while resident in bed. On-going education on fall intervention and prevention with family and staff. Restorative program x 2 weeks in accordance with resident's individualized POC." The facility's current Accident/Incident P/P, dated January 2012, reflected to provide a safe and healthful environment. The Fall Management Process included in the P/P reflected: "Rationale: Successful fall management requires a thorough clinical assessment of residents who fall (or have a history of falls) and their environment. Assist staff in assessing and managing individuals who have recent history of falls or who are at risk for falling. Staff will help identify ways to modify some of the risk factors for falls, as well as identifying ways to adjust the patient's environment to minimize the risk of injury due to falls. Purpose: To promote an environment as free of accident hazards as possible and to minimize the risks of accidents through supervision and to provide alternatives to decrease injuries from falls.... General Information...The following are examples of common Intrinsic risk factors: Gait and balance disorders Muscular weakness (particularly of the lower of extremities)... Confusion Incontinence... Previous falls... Potential Approache (sic) Examples...5. Reduce or relieve physical discomforts...seating position...7. Review normal routine for consistency...24. Anti-tip attachment to wheelchair, brake extenders, or tray 25. W/c with foot rests or low seat without foot rests to promote independent w/c mobility 26. Assistive devices...merry walker...31. Self release belt, lap buddy...Interventions to reduce fall risk factors...." The facility's Form CMS-672, Residents Census and Conditions of Residents, signed by the MDS Nurse on 11/25/13, 36 residents were identified with Dementia and/or Alzheimer's Disease. The facility's Form CMS-802, Roster/Sample Matrix, provided by the Administrator on 11/25/13, reflected seven residents experienced falls, including falls with major injury.

Based on observation, interview and record review, it was determined the facility failed to ensure that residents were cared for in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life for one (Resident #6) of three residents reviewed for quality of life. Staff failed to move Resident #6 when she informed them of problems with her roommates which affected her sleep, her phone conversations, her visits with friends and family and her over all wellbeing. These failures contributed to Resident #6 feelings of anger, anxiety, hopelessness, dehumanization and depression. These failures also contributed to increases in medication. These failures could affect the the other 23 residents, who do not have a [DIAGNOSES REDACTED]. Findings included: According to the MDS assessment, dated 03/27/12, Resident #6 was a [AGE] year-old female, who was admitted on [DATE]. The MDS assessment reflected her [DIAGNOSES REDACTED]. The assessment also reflected Resident #6 was totally dependent on staff for transfers and locomotion out of her room, she has symptoms of Depression two to six days a week, but did not have behaviors or [MEDICAL CONDITION]. Resident #6's Care Plan, dated 03/17/12, relating to Depression-Potential for alteration in mood and behavior reflected she was at risk for Depression related to her placement in the facility due to her age, the severity of her physical condition, and the adjustment to a new living environment. The goals reflected were to manage the Depression through interventions; have her needs met, and to not exhibit any signs and symptoms of Depression related to placement in the facility over the next 90 days. Some approaches reflected staff were to assist her with ADLs and anticipate her needs; monitor for changes in mood and behavior; monitor for signs and symptoms of Depression; encourage the resident to participate in decision-making; encourage resident to express thoughts and feelings, and to provide a psychiatric referral as needed. Resident #6's Initial Social Assessment Patient Health Questionnaire, dated 03/17/12, reflected she had Depression. Resident #6's Behavior Tracking Form, dated 05/13/12, reflected she had expressed verbal distress, was tearful, grieving and displayed severe hopelessness. Resident #6's Psychological Evaluation, dated 05/31/12, reflected she was referred for mental health services by her primary care physician due to symptoms of Anxiety and Depression including hopelessness, restlessness, grieving, mood swings, etc. The Evaluation also reflected Resident #6 stated it was hard to relate to the other residents at the facility because she was so much younger than them. Further review of the Evaluation revealed Resident #6 stated she often felt responsible for her roommate (Resident #11) and she laid awake at night in an effort to keep her roommate (Resident #11) safe. The Evaluation reflected Resident #6's primary emotion was depression and she was tearful with a sad mood; feeling down and blue, but her impulse control was good. Resident #6's Evaluation also reflected a [DIAGNOSES REDACTED]. A fax from the psychologist to Resident #6's physician, dated 07/30/12, reflected Resident #6's psychological condition had deteriorated, and she had "increased impulsivity and mood swings." Further review of the fax revealed Resident #6 received [MEDICATION NAME] (antidepressant) Extended Release 37.5 mg twice a day; [MEDICATION NAME] (antianxiety) 1 mg daily and [MEDICATION NAME] 300 mg, the recommendation to start treatment with a mood stabilizer such as [MEDICATION NAME] 125 mg twice a day if not contraindicated by [MEDICATION NAME]. Resident #6's LPC Progress Notes dated, dated 08/23/12, reflected she stated Resident #11 snored and complained about her visitors. The Notes also reflected Resident #6 could not sleep at night, was angry and wanted to change rooms. Resident #6's LPC Progress Notes, dated 08/30/12, reflected she was "depressed and agitated in regard to many issues including loss of independence, her roommate (Resident #11), her lack of privacy and financial concerns." Resident #6's LPC Progress Notes, dated 09/06/12, reflected she "was quite depressed and frustrated as she is still unhappy with her room situation." Resident #6's LPC Progress Notes, dated 09/27/12, reflected her session was extended and the resident was distraught over the past two days because the issues seemed to have triggered unresolved issues from her past. The Notes also reflected a plan of care to fax Resident #6's primary care physician to request an increase in her dosage of [MEDICATION NAME]. Resident #6's Psychologist's fax to her physician dated 09/27/12 reflected the resident was more emotional, easily angered, and had crying spells. The fax also reflected was addressing unresolved issues that seemed to be fueling her emotional distress." The Psychologist's recommendation was to increase her [MEDICATION NAME] to 125 mg every morning and 250 milligrams at bedtime to help Resident #6 stabilize her emotions. Resident #6's October 2012 physician's orders [REDACTED]. On 10/10/12 at 12:45 p.m., Resident #6 stated since admission to the facility on [DATE], she had issues living with roommates who had [MEDICAL CONDITION] and Dementia. She revealed whenever her roommates (Residents #11 and #12) were confused, disoriented, afraid and/or emotionally distraught she (Resident #6) had to verbally calm and console them. Resident #6 stated Residents #11 and #12 did not know how to operate the call light system and could not call for staff assistance. She revealed she felt responsible to use the call light to obtain staff assistance for Residents #11's and #12's physical or emotional needs. Resident #6 stated the staff only came in the room when called and did not routinely check on Resident #11, Resident #12 or herself. Resident #6 stated there had been times when she had to lie in urine and feces or had to smell the foul odor of her roommates' stool and urine. Resident #6 stated Resident #11 would get up in the middle of the night thinking it was breakfast and start getting dressed. Resident #6 revealed she had to talk to Resident #11 almost every night just to get her to go back to bed and calm her down. Resident #6 stated she never got any sleep. Resident # 6 stated whenever she had company, Resident #11 would become afraid and fretful; wanting to leave the room or sleep in another room. Resident #6 revealed Resident #11's behavior made her guests uneasy and nervous. Resident #6 stated RN D asked her (Resident #6's) company to leave. She said her company was "put out" of the facility for no reason. Resident #6 stated Resident #11 eventually moved out of the room because Resident #11's family did not like her (Resident #6) to have company. Resident #6 revealed she thought the problem was solved, because she did not have a roommate for two weeks. Resident #6 stated she knew she would eventually have a roommate, because she could not afford a private room. She said it was not a problem. Resident #6 stated she just wanted to have a roommate she could talk to; someone who was not confused or someone she felt she had to look after. Resident #6 stated she did not think it was her responsibility to take care of her roommates, because she had her own health care issues to handle. Resident #6 revealed she felt she was working on a job without pay instead of being taken care of. Resident #6 stated she paid the same amount for her room as her roommates (Residents #11 and #12) and should have "privacy and peace." Resident #6 said her current roommate, Resident #12, was so confused that she (Resident #12) came in every night and asked if she (Resident #12) could stay the night. Resident #6 revealed Resident #12 would start crying because she (Resident #12) did not think she (Resident #12) had a place to sleep. Resident #6 stated she could not even talk on the phone, because Resident #12 was answering whenever she (Resident #6) spoke. Resident #6 said she had to stop her conversation and tell Resident #12 that she was talking on the phone. Resident #6 revealed every night she had to pretend to call Resident #12's daughter or Resident #12 would cry for her daughter and not go to sleep. Resident #6 also stated Resident #12 snored very loudly and she (Resident #6) could not get any sleep. Resident #6 revealed she did not know how much longer she could take it as the situation was driving her (Resident #6) "crazy." Resident #6 stated she could not get out of bed without help and Resident #6 could not walk very far because she had fractured her foot. Resident #6 revealed she had to endure her roommates' (Resident's #11 and #12) confusion and crying until the staff put her in the wheelchair and Resident #6 could leave the room. On 10/10/12 at 1:00 p.m., Resident #12 came in the room, during the interview with Resident #6. Resident #12 walked to the foot of Resident #6's bed and asked Resident #6 several times if she (Resident #12) could spend the night for a day or two. Resident #12 stated she did not have a place to stay. Resident #12 stated, "I wouldn't be a bother." Resident #12 was disoriented to place and time, confused, afraid and tearful. Resident #6 reassured Resident #12 and told Resident #12 this was her room too and she could stay the night. Resident #6 also told Resident #12 that she had a bed on the other side of the privacy curtain. Resident #6 suggested to Resident #12 to lie down and take a nap. Resident #12 went to the other side of the privacy curtain and started crying uncontrollably, thanking Resident #6 for letting her stay the night. On 10/10/12 at 1:10 p.m., a housekeeper came in the room and the surveyor asked the housekeeper to get a CNA or nurse to help Resident #12. Resident #12 was inconsolable although Resident #6 tried to calm her. The surveyor left the room to find assistance for Resident #12 and asked a rehabilitation therapist walking in the hallway to assist Resident #12. The rehabilitation therapist talked to Resident #12 and eventually Resident #12 calmed. On 10/10/12 at 1:15 p.m., Resident #6 stated this was what she had to go through every day. Resident #6 revealed she reported Resident #12's behaviors to Administrator E and the ADON and requested to get another roommate. Resident #6 stated Administrator E and the ADON would not change her roommate. Resident #6 stated the situation was driving her crazy. On 10/10/12 at 3:45 p.m., Administrator E revealed she moved Resident #12 into the room with Resident #6. Administrator E stated Resident #6 was complaining about Resident #11's visitors and Resident #11's family requested Resident #11 be moved to another room. Administrator E also stated she really tried to put someone in Resident #6's room who would be compatible with her. Administrator E revealed Resident #6 should have spoken to Residents #11 and #12 "kinder" and maybe this would have helped. Administrator E revealed she told Resident #6 to pull the call light whenever her roommates were confused, disoriented, asking questions, crying, upset or needed some help from the staff. Administrator E stated if Resident #6 had just pulled her call light, then the staff would have come and taken care of Residents #11 and #12. Administrator E revealed she found out Resident #6 was unhappy with Roommate #12 the week of September 23 through 29 and offered to move Resident #6 to another hall if she (Resident #6) could pay for the room. Administrator E stated Resident #6 refused to move, because she could not afford to pay $4000.00 for the room. Administrator E said Resident #6 could have moved to the other hall, if she (Resident #6) could afford it. Administrator E revealed she had two people residing on another hall, one resident, who was in a room for two residents, was dying. She stated she did not want to put another resident in the room with this resident. Administrator E revealed one resident lived in the second double occupancy room on that hall, but did not state why Resident #6 could not move into that room. She stated more staff would be required if she opened another room on that hall for Resident #6. Administrator E revealed the Corporate Office had not opened the other rooms on that hall due to the low census. She also revealed Resident #6 just wanted to have a room by herself. Administrator E stated she did not complete a Grievance Form or Complaint Form when Resident #6 reported the behaviors of her roommates, or when Resident #6 requested another room. An interview on 10/11/12 at 10:25 a.m. with Resident #6 revealed she was happy she was moved to a new room, and she was getting more attention. She stated, "Well, I came here in March and (Resident #11) was already in here. (Resident #11's family member) told me Resident #11 had Dementia, the beginning stages of Alzheimer's and would probably ask me the time; what time for breakfast. (Resident #11) couldn't read the clock anymore or read. (Resident #11's family member) said she (Resident #11) will probably ask you the same questions over and over and get up and get dressed in the middle of the night." Resident # 6 revealed, "She (Resident #11) couldn't ring the bell (call light). The only time staff came in is when I called on the light to help her or if she fell . The staff said they only come for people who can't ring the light. (Resident #11) fell four to five times in the room and I had to call the staff. She also fell a couple of times in the hallway. I didn't get any sleep with her. I was afraid she would go out in the hall or fall. I lived with (Resident #11) from March to the first part of September." Resident #6 stated, "I told my (family member) I feel so mistreated. They (Administrator E and DON H) told me if I wanted a private room I'd have to pay $4000.00 (per month). I just asked them to put someone in the room with me that I didn't feel so responsible for; be in their right mind and that I don't have to do something for." Resident #6 stated, "The only reason (Resident #11) left was because (Resident #11) didn't want me to have any company and she would say 'I'll go into the hallway or find another room to sleep in' when I had company. I would have the staff close the curtain before my company came in, so (Resident #11) wouldn't get upset. My girlfriend would close the curtain as she came in around (Resident #11's) bed. (Resident #11's) reaction was the same when my Aunt came in. My Aunt had to tell (Resident #11) it was 'Ok.'" Resident #6 revealed, "She (RN D) came in and told my company that he had to leave because (Resident #11) was sleepy and wanted to go bed. This was on a Wednesday or Thursday at 7:59 p.m. or 8:00 p.m. I could have pulled the curtain. My company got real upset and said it was not fair that he had to leave or we had to go somewhere else to visit because I pay the same amount of money for my room as (Resident #11) did. My friend is a truck driver and can only visit me when he comes into town. I thought it was unfair (Resident #11) could have four or five visitors in the room at a time, but no one would ask them to leave. Sometimes (Resident #11) would have male visitors too and I'd just close the curtain around me. I started to complain about her having visitors like that too, but (my family member) said you don't do evil for evil." Resident #6 stated, "(Administrator F) would not budge about me getting another roommate. (Administrator F) would tell me I'd have to deal with it." Resident #6 revealed, "Then we get (Administrator E) and they move (Resident #11) into another room. I was in (Room number) for two weeks by myself. Then the ADON came in and started measuring stuff. They (Administrator E and DON H) later said they were moving (Resident #12) in the room. I told them it wasn't going to work. The ADON said I'd have to talk to (DON H or Administrator E). They kept saying it's not so bad. (Administrator E) came into my room and she said, 'It's gonna happen. You're gonna get (Resident #12).' I asked her, 'What do I need to do to get out of here?" It's not fair to me." Resident #6 stated, "If I'm not happy, I don't bite my tongue. I'm very vocal. I felt I was being railroaded." Resident #6 revealed, "Nobody explained it to me or told me why (Resident #12) was moving in. They didn't really care about my sleep or my emotions. It seems that they (Administrator E and DON H) do a room switch for everybody else, except for me." Resident #6 stated, "Every time I'd go in there to talk to them (Administrator E and DON H), they would ask me if I had $4000.00 to move on the 300 Hall. They knew I didn't have $4000.00. I'd ask, well can I get another roommate." Resident #6 revealed, "So I'm losing the battle. I was to the point I was breaking down - I was in tears." Resident #6 stated, "So when they moved (Resident #12) in, I believe it was on a Thursday, I was upset. I felt I was not being listened to." Resident #6 also stated, "I spoke to someone at (name of another nursing home). I told her (representative of other facility) I was unhappy here. I just want a roommate without Dementia. She told me they had a room for me." Resident #6 revealed, "I told my friend I was moving to (other nursing home), but she (Resident #6's friend) said I wouldn't like it there. Then I spoke to my (family member) and told her I was moving to (other nursing home) nursing home. My (family member) asked me not to move to (other nursing home) nursing home. My (family member) asked me not to move because (he/she) didn't like (other nursing home) nursing home. I said (family member) you don't know what I've been going through." Resident #6 also revealed, "When (Administrator E) moved (Resident #12) into my room, she came into my room and said, 'It was a done deal.' She knew I was unhappy." Resident #6 stated, "The only time the Social Worker came in here is when she needed some paperwork. She got the church to donate a lap top for me, but that doesn't work anymore." Resident #6 stated, "I don't mind having a roommate. If they would just get me a roommate I don't have to take care of. That's not healthy for me. I've got so many grey hairs since I've been here. I got these grey specks in my hair." Resident #6 revealed, "The only relief I have is when I talk to the therapist (LPC I). That's the only thing they've done for me." On 10/11/12 at 2:00 p.m., the SW stated Resident #6 called the other nursing home on a Thursday or Friday afternoon about moving to that facility into a room without a roommate. The SW also stated Resident #6 wanted to move, because she did not want a roommate in general. The SW revealed Resident #6 had spoken to some of her friends and they told her some horror stories about the other facility. The SW stated Resident #6 changed her mind and decided to stay. The SW revealed she was aware Resident #11 and Resident #12 were "pleasantly confused." The SW stated Resident #6 told her Resident #12 was confused and was keeping her awake at night, and Resident #6 said she (Resident #6) had to take care of Resident #12, because the resident was confused. The SW did not know if she had documented Resident #6's concerns in her SS Notes. The SW also revealed Resident #6's concerns regarding Resident #12 were discussed with the Department Heads in the Focus Group meeting. The SW stated when Resident #11 moved out of the room with Resident #6, the Focus Group decided not to put another roommate in the room with Resident #6 for as long as possible. The SW said the Focus Group avoided giving Resident #6 a roommate as long as possible. The SW also stated when the Focus Group discussed moving Resident #12 into the room with Resident #6, it was decided if Resident #6 had any concerns they would move Resident #12. The SW revealed, "Because (Resident #12) was confused I figured Resident #6 would be in the same predicament as before." The SW later stated she had not heard of Resident #6's concerns until 10/10/12. On 10/11/12 at 3:30 p.m., LPC I stated, "You can only imagine with someone that young and in her condition, it would be traumatic for her. (Resident #6) talked about the roommate situation and she really wanted to have a room by herself. (Resident #6's) roommates did not like her friends. (Resident #6) felt it was invading her privacy. (Resident #6) talked about it a few times and was very reactive to the situation. (Resident #6) was overwhelmed and it was frustrating for her. (Resident #6) wanted her privacy." LPC I revealed Resident #6 occasionally complained of not being able to sleep at night, sleep deprivation could cause someone to be agitated during the day, and Resident #6 was sometimes agitated during the day. LPC I stated Resident #6 was afraid Resident #12 would fall. LPC I stated, "I think that this was the straw that broke the camel's back. I think it added to her frustration." On 10/12/12, Corporate Staff G provided the revised "Resident Involvement, Choices & Self-Determination Policy," dated 10/12/12, which reflected, "The facility shall involve the resident in choices about aspects of his/her life in the facility that are significant to that resident. This shall include activities, roommate selection/changes, and lifestyle preferences. The resident care plan will be utilized to delineate areas of resident self-determination, likes & dislikes and personal preferences. The care plan will be updated with any changes expressed by the resident...1. If a mentally intact resident has a roommate, who is confused, forgetful, anxious, etc., we should not expect the mentally intact resident to care for the confused resident. For example, we should not expect the mentally intact resident to pull the call light for the confused resident. If you are aware of this occurring, you should complete a Concern Resolution Record immediately. 2. Any complaint and/or concerns voiced to you by any resident and/or responsible party should have a concern form completed. Please inform the Charge Nurse of any complaints/concerns." The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by DON K and dated 10/09/12, reflected a census of 40 residents and 16 residents identified with Dementia: multi-infarct, Alzheimer's type, or other than Alzheimer's type.